Regency Healthcare & Rehab Center
REGENCY HEALTHCARE & REHAB CENTER in WILMINGTON, DE — inspection on February 4, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of R43's clinical record revealed:
7/24/24 - R43 was admitted to the facility with diagnoses including dementia.
7/25/24 - R43 was care planned for receiving antipsychotic medication (to help manage his aggressive behaviors) and is at risk for behaviors and side effects.
7/30/24 - R43 was care planned for behavior as evidenced by physical aggression and interventions included to administer meds as ordered.
11/7/24 - R43 had a physician's order for quetiapine fumarate (Seroquel) 50 mg give 1 tablet by mouth two times a day for bipolar disorder.
12/3/24 1:11 PM - A nurse progress noted documented, . quetiapine fumarate . med presently N/A (not available), reordered from pharmacy .
12/4/24 10:15 AM - A nurse progress note documented, . quetiapine fumarate . med not delivered from pharmacy despite being reordered.
Spoke to pharmacy and they stated that 'the claim was paid and it will be sent on our evening delivery'. will pass in rpeort .
12/4/24 1:37 PM - A nurse progress note documented, . quetiapine fumarate .awaiting delivery of med .
12/5/24 9:36 AM - A NP encounter note documented, .Of note, patient (sic) quetiapine (sic) 50 mg tablets not delivered by pharmacy and missed PM dose yesterday as well as AM and PM doses today, per nursing staff pharmacy reported to be delivered this evening.
Will plan to administer additional 50 mg doses at bedtime with routine 200 mg order .
1/31/25 12:34 PM - Review of R43's December 2024 MAR revealed that R43 missed three (3) doses of quetiapine fumarate 50 mg 1 tab on 12/3/24 at 2 pm.
The following day, 12/4/24, R43 missed two more doses at 8:00 AM and 2:00 PM, for a total of three missed doses.
1/31/25 2:40 PM - In an interview, E4 (LPN/UM) confirmed that R43's quetiapine fumarate 50 mg doses were not administered on 12/3/24 at 2:00 PM and on 12/4/24 at 8:00 AM and at 2:00 PM.
1/31/25 3:10 PM - During interview, E1 (NHA) confirmed that the physician was not notified right away on 12/3/24 when the quetiapine fumarate medication was not available.
085012
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 085012 B.
Wing 02/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Regency Healthcare & Rehab Center 801 N.
Broom Street Wilmington, DE 19806
The facility failed to develop and implement a person-centered activity care plan for R89 that included measurable objectives and timeframes to meet R89's medical, mental and psychosocial needs.
085012
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 085012 B.
Wing 02/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Regency Healthcare & Rehab Center 801 N.
Broom Street Wilmington, DE 19806
A review of R43's clinical records revealed the following:
7/24/24 - R43 was admitted to the facility with diagnoses including but not limited to dementia.
7/25/24 - R43 was care planned for ADL (Activities of Daily Living) deficit related cognition with interventions including assisting R43 to attend activities of choice. In addition, R43 was set up for care and supervise/verbal dues (sic) to assure he follow thru.
7/25/24 - R43 was care planned for falls related to .poor safety awareness .with interventions including offering toileting before going to bed (8/14/24) and reminding R43 not to go to the bathroom without help (10/25/24).
7/31/24 - R43's admission MDS assessment revealed that R43's cognition was severely impaired and was always continent of urine and bowel during the review period.
9/6/24 (revised 1/22/25) - R43 was care planned for behaviors as evidenced by urinating on the floor and also defecating on the AC (air condition) unit. R43's interventions included encouraging R43 to call for assistance when he is ready to use the bathroom and providing R43 with a urinal.
9/19/24 - R43 was readmitted from the psych hospital from 9/6/24 through 9/19/24
9/19/24 - A facility Bladder and Bowel Continence Evaluation - Readmission Assessment documented:
Is resident completely continent? - No
Functional Mobility, Manual Dexterity, Toileting Ability - Extensive Assist
Bowel Continence - Occasional
Bladder Continence - Occasional
Resident toileting preference - Brief
List any further important details - none
9/25/24 - a facility Bladder and Bowel Program Evaluation - Quarterly Assessment documented:
085012
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 085012 B.
Wing 02/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Regency Healthcare & Rehab Center 801 N.
Broom Street Wilmington, DE 19806
Review of R43's clinical records revealed:
9/19/24 - R43 was readmitted to the facility with diagnoses including but not limited to dementia, bipolar disorder and insomnia due to mental disorder.
1/31/25 - A review of R43's fall incident reports from August 2024 through December 2024 revealed that R43 fell six (6) times related to his need for assistance with toileting on the following dates:
- 8/13/24 11:40 PM;
- 8/14/24 12:04 AM;
- 10/17/24 12:45 PM;
- 10/17/24 1:00 PM;
- 10/18/24 5:10 AM and;
- 10/21/24 10:10 AM.
1/31/25 - A review of R43's care plan lacked evidence that person centered care plan was developed to maintain or restore bladder and bowel continence after R43's multiple falls related to his need for toileting assistance.
1/31/25 5:00 PM - During interview, E1 (NHA) confirmed that an incontinence care plan was not developed for R43 and that the clinical team will be looking into it.
2/3/25 3:52 PM - In an email correspondence, E1 sent an attached file pertaining R43's incontinence care plan initiated on 2/2/25.
The facility failed to ensure R43's person centered care plan interventions and a personalized toileting program was reviewed to address R43's falls related to R43's need to use the bathroom.
2/4/25 at 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E15 (RM), E16 (VPO), E17 (DCS), E18 (Corp. IP/SD) and E19 (RN).
085012
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 085012 B.
Wing 02/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Regency Healthcare & Rehab Center 801 N.
Broom Street Wilmington, DE 19806