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Deficiency Records for Regency Manor Nursing and Rehabilitation Center
A list of the most recent deficiencies for Regency Manor Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Regency Manor Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Address subsistence needs for staff and patients. | Fire Safety | 2024-06-11 | 2024-07-11 | N |
| Develop a communication plan. | Fire Safety | 2024-06-11 | 2024-07-11 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-06-11 | 2024-07-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-06-11 | 2024-07-11 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-06-11 | 2024-07-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-06-11 | 2024-07-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-06-11 | 2024-07-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-06-11 | 2024-07-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-06-11 | 2024-07-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-06-11 | 2024-07-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-11 | 2024-07-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-06-11 | 2024-07-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-06-11 | 2024-07-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-06-11 | 2024-07-11 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2024-06-11 | 2024-07-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-13 | 2024-07-01 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-06-13 | 2024-07-01 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-06-13 | 2024-07-01 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-06-13 | 2024-07-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-06-13 | 2024-07-01 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-06-13 | 2024-07-01 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-06-13 | 2024-07-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-13 | 2024-07-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-13 | 2024-07-01 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-06-13 | 2024-07-01 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-06-13 | 2024-07-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-06-13 | 2024-07-01 | Y |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2024-06-13 | 2024-07-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-06 | 2024-04-16 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-03-06 | 2024-04-16 | Y |
| Put firmly secured handrails on each side of hallways. | Health | 2024-03-06 | 2024-04-16 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-04-25 | 2023-06-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-25 | 2023-06-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-25 | 2023-06-06 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-04-25 | 2023-06-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-25 | 2023-06-01 | N |
| Meet other general requirements. | Fire Safety | 2023-04-25 | 2023-06-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-04-25 | 2023-06-01 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-04-25 | 2023-06-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-25 | 2023-06-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-25 | 2023-06-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-25 | 2023-06-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-25 | 2023-06-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-26 | 2023-05-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-26 | 2023-05-26 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-04-26 | 2023-05-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-26 | 2023-05-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-26 | 2023-05-26 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-04-26 | 2023-05-26 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-04-26 | 2023-05-26 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-02-01 | 2023-03-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-01 | 2023-03-17 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-01 | 2023-02-06 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-03-01 | 2022-04-18 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-03-01 | 2022-04-18 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-03-01 | 2022-04-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-03-01 | 2022-04-18 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-03-01 | 2022-04-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-03-01 | 2022-04-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-01 | 2022-04-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-01 | 2022-04-18 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-03-01 | 2022-04-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-03-03 | 2022-04-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-03 | 2022-04-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-03 | 2022-04-04 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-03-03 | 2022-04-04 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-03-03 | 2022-04-04 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-03-03 | 2022-04-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-03 | 2022-04-04 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-03-03 | 2022-04-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-03 | 2022-04-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-03 | 2022-04-04 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-03-03 | 2022-04-04 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-03-03 | 2022-04-04 | Y |
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