CMS Inspection Results for REGAL HEIGHTS HEALTHCARE & REHAB CENTER

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 08/11/2008 Fire Safety Survey for REGAL HEIGHTS HEALTHCARE & REHAB CENTER

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
properly working sprinkler alarm system.	Widespread	Minimal harm or potential for actual harm
Building Service Equipment
Deficiency	Scope	Level of Harm
properly protected cooking facilities.	Widespread	Minimal harm or potential for actual harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
an approved back-up procedure for a faulty fire alarm system.	Widespread	Minimal harm or potential for actual harm
Hazardous Area
Deficiency	Scope	Level of Harm
construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Potential for minimal harm
Vertical Openings
Deficiency	Scope	Level of Harm
exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Widespread	Potential for minimal harm

 

• 08/07/2008 Health Survey for REGAL HEIGHTS HEALTHCARE & REHAB CENTER

Administration
Deficiency	Scope	Level of Harm
Train all employees on what to do in an emergency.	Widespread	Minimal harm or potential for actual harm
post nurse staffing information.	Widespread	Potential for minimal harm
Environmental
Deficiency	Scope	Level of Harm
Make sure there is a program to prevent/deal with mice, insects, or other pests.	Widespread	Minimal harm or potential for actual harm
Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Pattern	Minimal harm or potential for actual harm
Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
Give or get dental care for each resident.	Isolated	Minimal harm or potential for actual harm
Develop/implement required procedures for the administration of immunizations.	Isolated	Minimal harm or potential for actual harm
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Isolated	Minimal harm or potential for actual harm
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Pattern	Minimal harm or potential for actual harm

 

• 09/04/2007 Fire Safety Survey for REGAL HEIGHTS HEALTHCARE & REHAB CENTER

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Minimal harm or potential for actual harm
portable fire extinguishers.	Widespread	Potential for minimal harm
Building Contruction
Deficiency	Scope	Level of Harm
approved construction type or materials.	Widespread	Potential for minimal harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Widespread	Potential for minimal harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Widespread	Potential for minimal harm
Emergency Plans and Fire Drills
Deficiency	Scope	Level of Harm
did not have a written emergency evacuation plan.	Widespread	Potential for minimal harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Potential for minimal harm
properly maintained smoke detectors.	Widespread	Potential for minimal harm
an automatic smoke detection system in all hallways.	Widespread	Potential for minimal harm
Furnishings and Decorations
Deficiency	Scope	Level of Harm
exits that are free from obstructions and can be used at all times.	Widespread	Potential for minimal harm
Hazardous Area
Deficiency	Scope	Level of Harm
construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Potential for minimal harm
Illumination and Emergency Power
Deficiency	Scope	Level of Harm
properly located and lighted Exit signs.	Widespread	Potential for minimal harm
Miscellaneous
Deficiency	Scope	Level of Harm
fire safety features required by current fire safety codes.	Widespread	Potential for minimal harm
Vertical Openings
Deficiency	Scope	Level of Harm
exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Widespread	Potential for minimal harm

 

• 08/31/2007 Health Survey for REGAL HEIGHTS HEALTHCARE & REHAB CENTER

Administration
Deficiency	Scope	Level of Harm
1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides.	Widespread	Minimal harm or potential for actual harm
Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
Make sure there is a program to prevent/deal with mice, insects, or other pests.	Widespread	Minimal harm or potential for actual harm
Get rid of garbage properly.	Pattern	Minimal harm or potential for actual harm
Keep all essential equipment working safely.	Pattern	Minimal harm or potential for actual harm
Put firmly secured handrails on each side of hallways.	Pattern	Minimal harm or potential for actual harm
Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
Keep safe, clean and homelike surroundings.	Pattern	Potential for minimal harm
Mistreatment
Deficiency	Scope	Level of Harm
Protect residents from mistreatment, neglect, and/or theft of personal property.	Isolated	Actual harm
1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
Offer other nutritional food to each resident who will not eat the food served.	Pattern	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Isolated	Minimal harm or potential for actual harm
Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Minimal harm or potential for actual harm
Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm

 

• 08/21/2006 Fire Safety Survey for REGAL HEIGHTS HEALTHCARE & REHAB CENTER

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Potential for minimal harm
Building Contruction
Deficiency	Scope	Level of Harm
approved construction type or materials.	Pattern	Potential for minimal harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Pattern	Potential for minimal harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
an automatic smoke detection system in all hallways.	Widespread	Potential for minimal harm
an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Potential for minimal harm
Interior Finish
Deficiency	Scope	Level of Harm
fire-resistant room wall surfaces.	Pattern	Potential for minimal harm
Miscellaneous
Deficiency	Scope	Level of Harm
fire safety features required by current fire safety codes.	Pattern	Potential for minimal harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
proper construction of ducts through walls designed to prevent smoke passage.	Widespread	Potential for minimal harm
smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Potential for minimal harm
Vertical Openings
Deficiency	Scope	Level of Harm
exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Pattern	Potential for minimal harm

 

• 08/10/2006 Health Survey for REGAL HEIGHTS HEALTHCARE & REHAB CENTER

Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Pattern	Potential for minimal harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Make sure that all needed doctor visits are made personally by a doctor, as required.	Isolated	Minimal harm or potential for actual harm