Regent Park Nursing and Rehabilitation

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Pharmacy Service Deficiencies

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.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Pharmacy Service Deficiencies

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.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the backup emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110.This was evidenced by the following:1. No records or documentation for generator annual fuel testing.NFPA 110, 8.3.1 A fuel quality test shall be performed annually using tests approved by ASTM standards.This deficiency has the potential to .. Based on observation and staff interviews during the survey, it was determined that the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. This was evidenced by the following:1. Ceiling penetration and missing fire caulking around piping in the Boiler room.2. Ceiling penetration in kitchen dry storage. In part, NFPA 101, Section 8.5.1 states that smoke barriers shall be provided to subdivide building spaces to restrict the movement of s.. Based on observation and staff interviews, it was determined that the facility failed to maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. This was evidenced by the following: 1. The west exit door is difficult to open.NFPA 101, 7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.NFPA 101, 7.2.1.4.5.1 The forc.. Based on observation, it was determined that the facility failed to maintain proper electrical practices in accordance with NFPA 101, 9.1.2, and NFPA 70, National Electrical Code Section 110.12. The following deficiency evidenced this:1. The Boiler room electrical breaker panel is missing a blank cover. NFPA 101, Section 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical CodeNFPA 70, Section 110.1.. Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25,5.3.1.1.1 and NFPA 101, 19.7.6.This was evidenced by the following.1. Missing records and documentation for annual backflow inspection/testing.2. Deficiency tag on dry valve in fire sprinkler riser room.NFPA 101 Life Safety Code Standards require automatic sprinkler systems to be cont.. Based on observation, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with Life Safety Code Section 9.6 and NFPA 72.1. The Main Fire Alarm Control Panel has a deficiency tag for a power supply NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, Na.. Based on observation, it was determined that the facility failed to maintain the kitchen cooking equipment placement under the hood suppression system and the cooking appliance location as required by NFPA 96 (Chapter 12, Section 12.1.2.3.1).This was evidenced by the following:1. The kitchen deep fryer is not positioned under the kitchen hood suppression system.NFPA 96, 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking.. Based on record review and staff interviews during the survey, the facility failed to perform and document the exercising of all fire and smoke dampers at least every four years, in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems, section 3-4.7 Maintenance.This was evidenced by the following: 1. No records or documentation for smoke damper 4-year inspection and maintenance.NFPA 90A, Chapter .. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and represent the facility' s general characteristics.This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This survey was conducted on November 26, 2024, for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies."This structure is a one (1) story, Type V (000) wood frame con..

A recertification survey with complaint #CO35596 was completed on 11/3/24 to 11/7/24. Two deficiencies were cited. An Emergency Preparedness survey was conducted from 11/3/24 to 11/7/24. No deficiencies were cited. Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in accordance with professional standards in one of one medication storage rooms. Specifically, the facility failed to:-Maintain the emergency medication kit with medications that had not expired; and,-Ensure the emergency medication kit did not have two different expiration dates on individual packages which were prepared by the pharmacy.Findings include:I. Facility policy and procedureThe Medication Labeling and Storage policy, revised February 2023, was provided by the director of nursing (DON) on 11/6/24 at 3:35 p.m. The policy read in pertinent part,"The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.""If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.""The medication lab.. Based on record review and interviews, the facility failed the to report alleged violations of misappropriation of property to the proper authorities, including the police and the State Survey and Certification Agency, in accordance with state law for one (#97) of three residents reviewed for missing property out of 19 sample residents.Specifically, the facility failed to report an allegation of misappropriation of property to the State Agency, adult protective services or the local police when Resident #97 reported he was missing $750.00 from his wallet. Findings include:I. Facility policy and procedureThe Abuse policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 11/7/24 at 8:39 a.m. The policy revealed the facility did not condone resident abuse and should take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends or any oth..

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention' s (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 11/06/2023 and 11/12/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention' s (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 10/30/2023 and 11/05/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention' s (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 10/23/2023 and 10/29/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.