RegalCare AT HARWICH

Performance Report

ADMINISTRATION

RESULTS
Standard Survey - 37 of 39 Met Complaint Investigation Deficiencies - 0 Score after Adjustment for Scope and Severity : 37

This nursing facility met 37 out of the 39 requirements reviewed in this category in its last 3 standard surveys. The number of deficiencies not met as a result of complaint investigations was: 0 . The facility's score after adjustment for scope and severity is 37. The statewide average facility score was 36.

The following requirement(s) were not met

The regulation(s) survey date and scope and severity rating(s) are listed below.

Deficiency #1
08/13/2024 E (F 880 )
The facility must establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. Identified incidents of infection and corrective measures must be recorded and the infection control program must be reviewed yearly and updated as necessary. (F 880 )

NURSING

RESULTS
Standard Survey - 28 of 33 Met Complaint Investigation Deficiencies - 0 Score after Adjustment for Scope and Severity : 28

This nursing facility met 28 out of the 33 requirements reviewed in this category in its last 3 standard surveys. The number of deficiencies not met as a result of complaint investigations was: 0 . The facility's score after adjustment for scope and severity is 28. The statewide average facility score was 27.

The following requirement(s) were not met

The regulation(s) survey date and scope and severity rating(s) are listed below.

Deficiency #1
08/13/2024 D (F 639 )
A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan. (F 639 ) and/or; The facility develops and implements comprehensive person-centered care plans for each resident that include measurable objectives and time frames to meet each resident's medical, nursing and mental and psychosocial needs which describe services to be furnished to attain or maintain residents highest practical well-being and assess resident or resident representative goals for desired outcomes. (F 656 )
Deficiency #2
05/03/2023 D (F 675)
The facility ensures that each resident receives and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. (F 675) and/or; The facility ensures that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices (F 684) and/or; The facility ensures that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (F 697) and/or; The facility ensures that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (F 698) and/or; Resident who displays or are diagnosed with dementia, receive the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. (F 744)
Deficiency #3
05/03/2023 D (F 686 )
The facility ensures residents receive care to prevent pressure ulcers unless resident's clinical condition demonstrates that they were unavoidable and residents with pressure ulcers receive treatment and services to promote healing, prevent infection and prevent new ulcers from developing. (F 686 )
Deficiency #4
05/03/2023 D (F 690 )
The facility ensures that residents continent of bladder and bowel on admission receive services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. The facility ensures residents incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible, specifically not catheterizing residents incontinent of urine who enter the facility without an indwelling catheter and assessing residents who enter with an indwelling catheter for removal of the catheter as soon as possible. (F 690 )

RESIDENT RIGHTS

RESULTS
Standard Survey - 26 of 27 Met Complaint Investigation Deficiencies - 0 Score after Adjustment for Scope and Severity : 26

This nursing facility met 26 out of the 27 requirements reviewed in this category in its last 3 standard surveys. The number of deficiencies not met as a result of complaint investigations was: 0 . The facility's score after adjustment for scope and severity is 26. The statewide average facility score was 24.

The following requirement(s) were not met

The regulation(s) survey date and scope and severity rating(s) are listed below.

Deficiency #1
08/13/2024 D (F 583)
The facility observes resident rights to personal privacy, including personal and medical records, accommodations, medical treatment, all communications, deliveries, personal care, visits, and meetings of family and resident groups and respects residents? right to refuse the release of personal and medical records when allowed by state and federal law. (F 583) and/or; The facility maintains medical records containing required information on each resident that are complete, accurately documented, readily accessible and Systematically organized; ensures all identifiable resident records remain confidential and does not release identifiable resident information unless permitted to do so; safeguards medical record information against loss, destruction, or unauthorized use; and retains the medical records for the specified amount of time. ( F 842)

KITCHEN/FOOD SERVICES

RESULTS
Standard Survey - 11 of 12 Met Complaint Investigation Deficiencies - 0 Score after Adjustment for Scope and Severity : 11

This nursing facility met 11 out of the 12 requirements reviewed in this category in its last 3 standard surveys. The number of deficiencies not met as a result of complaint investigations was: 0 . The facility's score after adjustment for scope and severity is 11. The statewide average facility score was 11.

The following requirement(s) were not met

The regulation(s) survey date and scope and severity rating(s) are listed below.

Deficiency #1
08/13/2024 E (F 812 )
The facility procures food from sources approved or considered satisfactory by federal state or local authorities and stores, prepares, distributes and serves food in accordance with professional standards for food service safety. (F 812 ) and/or; The facility has a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. (F 813 )

ENVIRONMENT

RESULTS
Standard Survey - 19 of 21 Met Complaint Investigation Deficiencies - 0 Score after Adjustment for Scope and Severity : 19

This nursing facility met 19 out of the 21 requirements reviewed in this category in its last 3 standard surveys. The number of deficiencies not met as a result of complaint investigations was: 0 . The facility's score after adjustment for scope and severity is 19. The statewide average facility score was 18.

The following requirement(s) were not met

The regulation(s) survey date and scope and severity rating(s) are listed below.

Deficiency #1
08/13/2024 E (F 584 )
The facility provides a safe, clean, comfortable, and homelike environment, allowing residents to use their personal belongings to the extent possible by; Ensuring that the physical layout of the facility maximizes resident independence and does not pose a safety risk; Providing housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; Maintaining clean bed and bath linens that are in good condition; And providing private closet space in each resident room, adequate and comfortable lighting levels in all areas, comfortable and safe temperature levels and the maintenance of comfortable sound levels. (F 584 )
Deficiency #2
05/03/2023 D (F 921 )
The facility provides a safe, functional, sanitary and comfortable environment for residents, staff and the public. (F 921 )