F-F760
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 42 225474 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225474 B. Wing 05/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Regalcare at Taunton 68 Dean Street - Rear Taunton, MA 02780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760 Ensure that residents are free from significant medication errors.
Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50740 jeopardy to resident health or safety Based on document review and interviews, the facility failed to ensure for one Resident (#40), out of a total sample of 18 residents, to ensure he/she was free from a significant medication error when the Resident's Residents Affected - Few immunosuppressant medication was discontinued in error. As a result, Resident #40 missed 40 doses of tacrolimus (Prograf, an immunosuppressant medication used to prevent transplanted organ rejection) and required emergent hospitalization and medication adjustments during and after hospitalization .
Findings include:
Review of the facility's policy titled Reconciliation of Medications on Admission, revised 3/22, indicated, but was not limited to, the following:
-Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes
the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care.
-Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process.
-Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team.
-Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (Medication Administration Record) (if applicable), and
the admitting orders (sources).
-List the dose, route, and frequency for all medications.
-Review the list carefully to determine if there are discrepancies/conflicts.
Review of the facility's policy titled Aftercare of Heart Transplant, effective 4/17, indicated, but was not limited to, the following:
-After a heart transplant, a comprehensive aftercare plan is crucial for long-term success and involves ongoing monitoring for rejection, infection, and medication side effects, as well as adherence to lifestyle modifications and regular follow-up appointments. This includes taking immunosuppressant medications, adhering to a prescribed exercise program, and maintaining a healthy diet.
-This policy applies to all adult patients who have undergone a heart transplant and are currently more than three years post-transplant.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 42 225474 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225474 B. Wing 05/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Regalcare at Taunton 68 Dean Street - Rear Taunton, MA 02780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760 -All heart transplant recipients post-transplant must receive individualized, evidence-based follow-up care focusing on immunosuppressive management, cardiovascular health, infection surveillance, malignancy Level of Harm - Immediate screening, and psychosocial well-being. jeopardy to resident health or safety -Immunosuppressive Management
Residents Affected - Few *Maintain lowest effective dose of maintenance immunosuppression (e.g. tacrolimus, mycophenolate, prednisone)
*Monitor for long-term side effects: nephrotoxicity (deterioration in kidney function due to toxic substances), hypertension (high blood pressure), diabetes, dyslipidemia (abnormal levels of fats in the blood)
*Evaluate for medication adherence at every visit
-Documentation and Communication
*All assessments and interventions must be documented in the patient's electronic health record (EHR).
*Coordinate care with primary care providers and other specialists.
-Quality Assurance
*Annual review of resident outcomes (graft survival, complications, hospitalization s)
*Compliance audits on follow-up scheduling and lab monitoring
Resident #40 was admitted to the facility in January 2024 with diagnoses including stroke, heart failure, and heart transplant.
Review of the Minimum Data Set (MDS) assessment, dated 3/3/25, indicated Resident #40 was cognitively intact, as evidenced by a Brief Interview for Mental Status score of 15 out of 15, was dependent on staff for activities of daily living, and had diagnoses including heart failure and organ transplant.
Review of Resident #40's medical record indicated that Resident #40 was hospitalized in February 2025.
Review of the hospital After Visit Summary, dated 2/27/25, indicated, but was not limited to, the following:
-Resident #40 was admitted to the hospital in February 2025 for heart failure exacerbation and some of his/her medications had changed, including tacrolimus.
-Upon discharge, the Resident should start taking tacrolimus 2 milligrams (mg) each day at 9 A.M. and 3 mg each day at 9 P.M. The dosing was reduced from the Resident's previous dosing (3 mg twice daily) due to elevated tacrolimus levels noted during his/her hospital stay.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 42 225474 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225474 B. Wing 05/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Regalcare at Taunton 68 Dean Street - Rear Taunton, MA 02780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760 Review of Resident #40's Medication Reconciliation, dated 2/27/25, indicated the Resident's list of medications from the facility prior to hospitalization (his/her home medication list) and the Discharge Level of Harm - Immediate Summary were reviewed and indicated that potential clinically significant medication issues were identified. jeopardy to resident health or The document failed to indicate what the discrepancies were or the provider's resolutions for the safety discrepancies.
Residents Affected - Few Review of Resident #40's Physician's Orders indicated on 2/27/25, an order was obtained from the physician via phone for Tacrolimus 1 mg oral capsule - Give 3 capsule [sic] by mouth at bedtime AND Give 2 capsule by mouth one time a day. The order was transcribed on 2/27/25 at 4:03 P.M. Further review of the Physician's Orders indicated the order was subsequently discontinued on 2/27/25 at 6:05 P.M. No tacrolimus was prescribed to the Resident from 2/28/25 until 3/19/25.
Review of Resident #40's February 2025 and March 2025 Medication Administration Record indicated the Resident missed 40 doses of tacrolimus that he/she should have received in the facility from 2/27/25 through 3/19/25.
Review of Resident #40's Progress Notes indicated but was not limited to:
-On 2/27/25, an Order Note entered by nursing indicated an order for Tacrolimus 1 mg - Give 3 capsules by mouth at bedtime and 2 capsules by mouth one time a day was entered and was outside of the recommended dose or frequency (the usually dosing regimen per the note is 3 to 46.5386 capsules two times per day)
-On 2/27/25, a progress note was entered by the physician assist (PA). The medication list, included in the PA's progress note, indicated the Resident was taking tacrolimus 1 mg two capsules in the morning. The PA's note failed to identify the change in the Resident's tacrolimus regimen to include the additional 3 mg each day at 9 P.M.
-On 2/27/25 at 11:48 P.M., the nurse at the facility documented that the Resident had been treated at the hospital for altered mental status and his/her medications were confirmed by the PA.
-On 2/27/25 at 11:56 P.M., the nurse at the facility indicated the Resident's medication list was faxed to the hospital and receipt was confirmed.
-On 2/28/25, a progress note was entered by the physician. The physician documented in her note that the Resident was transferred to the hospital on February 22 and returned to the facility on [DATE REDACTED]. The physician indicated the Resident was hospitalized due to change in mental status, nausea, and tremors and was treated with antibiotics for a urinary tract infection. The physician indicated the Resident was on immunosuppression with prednisone and tacrolimus and was at high risk of complications and infections.
The medication list, included in the physician's note, indicated the Resident was taking tacrolimus 1 mg two capsules in the morning. The physician's note failed to identify the change in the Resident's tacrolimus regimen to include the additional 3 mg each day at 9 P.M.
-On 3/8/25, the Resident's medication regimen was reviewed by the pharmacy consultant and no irregularities were noted.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 42 225474 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225474 B. Wing 05/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Regalcare at Taunton 68 Dean Street - Rear Taunton, MA 02780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760 -On 3/19/25, a progress note was entered by the physician. The physician's note indicated the nursing notes, vital signs, and medications available in the Resident's electronic health record (EHR), prior external notes, Level of Harm - Immediate and hospital discharge summary were reviewed. The physician documented that the Resident had received jeopardy to resident health or an organ transplant in 2021 and that she was contacted by the hospital's Transplant Coordinator in regard to safety his/her low tacrolimus level of 1.2 ng/ml. The note indicated the Transplant Coordinator had discussed the Resident's medication regimen with staff at the facility and it appeared that the Resident had missed his/her Residents Affected - Few tacrolimus since he/she was readmitted to the facility on [DATE REDACTED] and was supposed to receive tacrolimus twice daily. The physician confirmed with nursing staff that the Resident had not received the tacrolimus and was later informed that the Transplant Coordinator had called the facility and recommended the Resident be transferred to the hospital for intravenous steroid treatment. Despite the documentation written in the physician's progress note, the medication list again indicated the Resident was only taking tacrolimus 1 mg two capsules in the morning.
-On 3/19/25 at 3:05 P.M., the facility nurse documented that the Resident's cardiologist requested the Resident be transferred to the emergency room at the hospital affiliated with the consulting heart failure team due to the Resident not having immunosuppressant drugs for the last two weeks. The Progress Note indicated the Resident was stable at the time of transfer.
Further review of Resident #40's Progress Notes failed to indicate that the physician's order for tacrolimus was discontinued on 2/27/25 or why the medication was discontinued.
Review of documentation received from Resident #40's consulting heart failure team indicated, but was not limited to, the following:
-At time of discharge from the hospital back to the facility on [DATE REDACTED], the Resident was prescribed tacrolimus 1 mg - Take 2 mg daily at 9 A.M. and take 3 mg daily at 9 P.M. The Resident's tacrolimus level on 2/26/25 was 6.4 ng/ml (goal level was 4-6 ng/ml). A tacrolimus level drawn 2/27/25 remained pending at time of discharge and the facility was to send a tacrolimus level on 3/3/25 to the heart failure team follow-up and dosing recommendations.
-On 2/27/25, 3/4/25, 3/5/25, and 3/18/25 the Cardiology Registered Nurse (RN) documented that she called
the facility to request the Resident's medication list and lab results be faxed to the cardiology office. The Cardiology RN indicated that she had difficulty reaching a nurse or provider at the facility
-On 3/19/25, the Cardiology RN documented that the Resident's labs and medication list were faxed on 3/18/25. The Cardiology RN noted that the labs were drawn on 3/6/25 and the tacrolimus level was 1.2 ng/ml
after the dose had been decreased to 2 mg in the A.M. and 3 mg in the P.M. The Cardiology RN reviewed
the medication list and no tacrolimus was noted.
-On 3/19/25, the Cardiology RN documented that she contacted the Resident's physician at the facility and
the physician was unaware of the critical value and discontinuation of tacrolimus and would call back with confirmation.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 42 225474 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225474 B. Wing 05/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Regalcare at Taunton 68 Dean Street - Rear Taunton, MA 02780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760 -On 3/19/25 the consulting cardiologist requested to coordinate a hospital admission for the Resident for further testing (transthoracic echocardiogram - a non-invasive test that uses ultrasound to create images of Level of Harm - Immediate the heart, and possible biopsy - a procedure that involves taking a sample of tissue to examine it more jeopardy to resident health or closely). safety
Review of Resident #40's hospital Discharge Summary, dated 3/26/25, indicated, but was not limited to, the Residents Affected - Few following:
-The Resident presented to the hospital from the facility with recent history of missed immunosuppression doses and was admitted for rejection surveillance.
-The Resident was found to have tacrolimus trough (the lowest level of the drug in the body) of 1.5 ng/ml. TTE and blood work for rejection was reassuring and the heart failure team deferred inpatient heart biopsy.
-The Resident was discharged with his/her tacrolimus dosing increased to achieve tacrolimus trough to goal level of 4-6 ng/ml, recommendations for weekly labs including tacrolimus level every Friday for two weeks, prednisone taper for empiric transplant rejection therapy, and changes to his/her insulin regimen due to high blood sugar levels while on prednisone.
Review of a Medication Incident and Discrepancy Report Form, dated 3/19/25, indicated that on 2/27/25, Resident #40's tacrolimus had been discontinued in error by a previous employee at the facility. The Form indicated that the Resident's transplant clinic had noted the medication was missing from the Resident's medication list. In the section of the Form titled Outcome of Investigation, it is noted that the medication was not administered and was entered as a one-time administration.
During an interview on 5/7/25 at 7:58 A.M., Resident #40 said that he/she had been sent to the hospital at
the end of March because he/she had missed doses of his/her anti-rejection medication and the transplant doctor wanted him/her to be monitored. Resident #40 said he/she underwent testing at the hospital and everything was okay and he/she returned to the facility. Resident #40 said he/she did not know how much medication was missed or why.
During an interview on 5/7/25 at 12:24 P.M., the Staff Development Coordinator (SDC) said that on 3/19/25, former First Floor Unit Manager #2 approached her and informed her that the hospital had called asking about the Resident's tacrolimus regimen and that he/she was supposed to be on tacrolimus two times daily because he/she had received an organ transplant. The SDC said she was not familiar with the Resident's medication regimen at the time but reviewed his/her record and confirmed that the order for tacrolimus was initially entered but then was discontinued. The SDC said the hospital instructed the facility to monitor the Resident's tacrolimus level and ensure the Resident received his/her medications. The SDC said she did not have further involvement in the situation and that former First Floor Unit Manager #2 handled all further communication with the hospital and the Resident's providers. The SDC said former First Floor Unit Manager #2 was new to the position at the time and no longer worked at the facility.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 42 225474 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225474 B. Wing 05/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Regalcare at Taunton 68 Dean Street - Rear Taunton, MA 02780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760 During a telephonic interview on 5/7/25 at 1:01 P.M., the Physician said the Resident's tacrolimus didn't make it onto his/her medication list at the facility. The Physician said the medication was to be used to Level of Harm - Immediate prevent organ rejection as the Resident had received an organ transplant. The Physician said she was made jeopardy to resident health or aware of the omission on 3/19/25 when she was informed by the Cardiology RN at the hospital. safety
During an interview on 5/7/25 at 1:25 P.M., Regional Nurse Consultant #1 said she had been acting as Residents Affected - Few Director of Nursing at the facility from 12/24/24 until the new Director of Nursing started at the facility on 3/14/25. Regional Nurse Consultant #1 said that when a resident is admitted /readmitted to the facility, the nurse entering the resident's physician's orders reviews the hospital discharge records and reviews the medications and then reviews those medications with the resident's provider at the facility. Regional Nurse Consultant #1 said there is a Medication Reconciliation assessment completed in the electronic health record by the nurse after the medications have been reviewed with the provider. Regional Nurse Consultant #1 said
the pharmacy also completes a medication review when a resident is admitted /readmitted to the facility. Regional Nurse Consultant #1 said that when a medication error is identified, an incident report is completed and a root cause analysis is done. Regional Nurse Consultant #1 said that in regard to this specific medication error, former First Floor Unit Manager #2 was notified of the error first and then she notified Regional Nurse Consultant #1. Regional Nurse Consultant #1 said she spoke with the Cardiology RN who reported that a medication list had been sent to her and that tacrolimus was not on the Resident's medication list. Regional Nurse Consultant #1 said the Cardiology RN requested to know when the Resident had last received the medication and that his/her tacrolimus level was below goal range. Regional Nurse Consultant #1 said she had reviewed Resident #40's record and identified that the order entered on 2/27/25 was entered as a one-time dose, maybe due to a glitch, and he/she had not received the medication since then. Regional Nurse Consultant #1 said that staff at the facility had not identified the medication error prior to being notified by the Cardiology RN on 3/19/25. Regional Nurse Consultant #1 said that the Cardiology RN notified the facility that the Resident should be transferred to the hospital for admission for rejection surveillance. Regional Nurse Consultant #1 said as a result of the medication error, staff at the facility were reeducated on
the process for medication reconciliation and that if there is a medication that they recognize a resident is no longer prescribed, they need to make note of it.
During a telephonic interview on 5/7/25 at 1:39 P.M., the Physician Assistant (PA) said he was aware of the medication error and had seen Resident #40 in between his/her readmission to the facility on [DATE REDACTED] and transfer back to the hospital on 3/19/25. The PA said he could not recall when he was made aware of the medication error but if he had been aware of it before the Resident was transferred back to the hospital, he would have restarted the medication at that time. The PA said he did not recall giving an order to discontinue
the Resident's tacrolimus on 2/27/25. The PA said he was unaware if the results had been sent to the cardiologist because that is something the nursing staff would do and he did not follow up with nursing to ensure the results were communicated to the Resident's cardiologist. The PA further said he was unaware
the Resident had not received the medication at the time the lab value was obtained. The PA said that he was aware the Resident's tacrolimus level had resulted low on 3/11/25, but was not aware the Resident had not received the medication.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 42 225474 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225474 B. Wing 05/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Regalcare at Taunton 68 Dean Street - Rear Taunton, MA 02780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760 During an interview on 5/7/25 at 1:59 P.M., the Regional Director of Operations said that when a medication error is discovered, the Director of Nursing at the facility would oversee the investigation, education, Level of Harm - Immediate follow-up, and any disciplinary action that may occur as a result. The Regional Director of Operations said jeopardy to resident health or that when there is no Director of Nursing at the facility, a Regional Nurse Consultant would be assigned to safety the position until a new Director of Nursing is hired. The Regional Director of Operations said that he was not aware of the medication error before being informed by the survey team on 5/7/25. Residents Affected - Few
During a telephonic interview on 5/7/25 at 2:03 P.M., the Cardiology RN said that Resident #40 has been followed by the cardiology team at the hospital since receiving an organ transplant years prior. She said that Resident #40 is seen every three to six months for routine clinic visits and the cardiology team communicates with the facility to obtain an updated medication list periodically, such as when the Resident returns to the facility after a hospitalization . The Cardiology RN said that after Resident #40 was discharged from the hospital on 2/27/25, she reached out to the facility that day to request an updated medication list and labs. The Cardiology RN said she ran into extensive hurdles when trying to contact a nurse or provider at the facility and attempted calls on 3/4/25, 3/5/25, and 3/18/25. The Cardiology RN said she had reviewed
the medication list and tacrolimus level on 3/19/25 and noted that the Resident's tacrolimus level was virtually undetectable at 1.2 ng/ml and that the lab had been drawn on 3/6/25 and resulted on 3/11/25, but
she had not been notified of the abnormal result prior. The Cardiology RN said she placed a call to the facility
on [DATE REDACTED] and spoke with a nurse who reported the medication had been discontinued on 2/27/25. The Cardiology RN said the Resident had gone a significant amount of time without the anti-rejection medication
before she was able to speak with someone at the facility. The Cardiology RN said there was no follow-through by the facility staff and she encountered many barriers when trying to get an updated medication list from the facility. The Cardiology RN said the reason a medication list is requested is so the cardiology team can ensure the Resident is taking the anti-rejection medication and that the medication error would have been caught sooner and avoided a hospital admission if the information had been sent to her sooner. The Cardiology RN said that the medication error could have caused organ transplant rejection, which can be irreversible and could have resulted in a severe outcome. The Cardiology RN said that as a result of the medication error, the Resident required a weeklong hospital admission, testing, and intravenous steroid infusions.
The surveyor attempted to contact former First Floor Unit Manager #2, but she was unable to be reached and was no longer employed at the facility.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 42 225474 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225474 B. Wing 05/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Regalcare at Taunton 68 Dean Street - Rear Taunton, MA 02780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41065 potential for actual harm Based on records reviewed and interviews, the facility failed to ensure it provided appropriate administrative Residents Affected - Some oversight specific to clinical management when a Resident (#40) did not receive his/her tacrolimus (Prograf,
an immunosuppressant medication used to prevent transplanted organ rejection) after readmission from the hospital in February 2025, resulting in abnormally low laboratory results and the Resident required emergent hospitalization and medication adjustments during and after hospitalization . Specifically, the facility administration failed to:
1. Ensure the use of laboratory services and pharmacy services, which provide ongoing support and oversight to the facility was addressed in the Facility Assessment;
2. Ensure effective systems were in place for education, and training for licensed staff to ensure competent, safe, and effective resident care related to medication reconciliation, laboratory result reporting and communication with consulting providers;
3. Ensure an Admission Medication Regimen Review (AMRR) was completed for Resident #40 upon return to the facility after a hospitalization , resulting in Resident #40 missing a total of 40 doses of tacrolimus; and
4. Ensure a medication error was fully investigated and brought all components of the error, including missed laboratory values and AMRR, to the Quality Assurance Performance Improvement Committee.
Findings include:
1. Review of the Facility Assessment, most recently updated on 4/25/25 and reviewed with the QAPI committee on 2/28/25 and 4/28/25, indicated the following:
-[The facility] has established a clinical grid that outlines what our clinical capabilities are. Our admission and field liaisons staff use this grid to determine if we can meet a resident's continuing needs. The clinical team along with the corporate office are responsible for validating a competency before a new clinical competency is added to the Grid.
-[The facility] accepts and cares for patients that its staff is competent to care for. The facility must be able to meet the medical, nursing, therapy and equipment needs to meet the requirements of the patients admitted .
The DNS updates the Clinical Service Level of Care grid quarterly and as clinical capabilities are added under the direction of the clinical team and of the corporate office. Reviews are done throughout the year regarding whether a clinical capability needs to be added to ensure the staff is prepared.
-The staff is provided with regular in-servicing opportunities and evaluations
-The Staff Development Coordinator tracks required in-service to monitor compliance with requirements.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 42 225474 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225474 B. Wing 05/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Regalcare at Taunton 68 Dean Street - Rear Taunton, MA 02780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0835 Further review of the Facility Assessment indicated the facility offers services and care related to medications including awareness of any limitations of administering medications and the administration of Level of Harm - Minimal harm or medications that residents need. potential for actual harm
The Facility Assessment failed to indicate the use of Laboratory Services or Pharmacy Services, including Residents Affected - Some how discrepancies and concerns are brought to the Administration.
2. Resident #40 was admitted to the facility in January 2024 with diagnoses including stroke, heart failure, and heart transplant.
Review of Resident #40's medical record indicated that Resident #40 was hospitalized in February 2025 for heart failure exacerbation and some of his/her medications had changed, including tacrolimus. A tacrolimus level should be obtained and sent to the hospital's heart failure team on 3/3/25 and the heart failure team would provide recommendations for ongoing dosing of tacrolimus.
Further review of the medical record for Resident #40 indicated the following:
-Resident #40's Medication Reconciliation, dated 2/27/25, indicated potential clinically significant medication issues were identified. The document failed to indicate what the issues were or the provider's resolutions for
the issues.
-Review of Resident #40's February 2025 and March 2025 MAR indicated the Resident missed 40 doses of tacrolimus that he/she should have received in the facility from 2/27/25 through 3/19/25.
-Resident #40's laboratory results indicated that on 3/6/25 (3 days after the recommended lab draw date),
the Resident had a tacrolimus level drawn. The tacrolimus level resulted low at 1.2 ng/ml (nanograms per milliliter) on 3/11/25 at 4:06 P.M. The results were reviewed by the cardiology office on 3/19/25, 8 days after
the results were reported to the facility.
-Review of Resident #40's medical record failed to indicate an AMRR had been completed by a Consultant Pharmacist after the Resident returned to the facility from the hospital on 2/27/25.
During an interview on 5/7/25 at 1:25 P.M., Regional Nurse Consultant #1 said she had been acting as Director of Nursing at the facility from 12/24/24 until the new Director of Nursing started at the facility on 3/14/25. Regional Nurse Consultant #1 said when a resident is admitted /readmitted to the facility, the nurse entering the resident's physician's orders reviews the hospital discharge records and medications and then reviews those medications with the resident's provider at the facility. Regional Nurse Consultant #1 said there is a Medication Reconciliation assessment completed in the electronic health record by the nurse after
the medications have been reviewed with the provider. Regional Nurse Consultant #1 said nursing staff are supposed to call and report labs to the Attending Physician or their designee and that specifically for Resident #40, the labs are also reported to the cardiology office.
Review of the facility's education binder on 5/8/25 failed to indicate there was in-service education conducted
on medication reconciliation, provider notification of abnormal lab results or communication with consulting providers before 3/18/25.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 42 225474 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225474 B. Wing 05/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Regalcare at Taunton 68 Dean Street - Rear Taunton, MA 02780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0835 During an interview on 5/08/25 at 11:36 A.M., the surveyor reviewed the facility's education binder with the Staff Development Coordinator (SDC). The SDC said that medication reconciliation in-servicing was Level of Harm - Minimal harm or conducted on 3/20/25 after discovery of a medication error but failed to provide evidence of medication potential for actual harm reconciliation training conducted prior.
Residents Affected - Some 3. Review of Resident #40's medical record indicated that Resident #40 was hospitalized in February 2025 for heart failure exacerbation and some of his/her medications had changed, including tacrolimus.
During a telephonic interview on 5/08/25 at 9:00 A.M., the Regional Pharmacy Manager said when he was doing an audit for the facility at the end of March, he noted that the AMRRs had not been completed as required in February and March 2025. The Regional Pharmacy Manager said the facility's Corporate nursing leadership (Regional Nurse #3) was notified of the issue at the beginning of April 2025 by his supervisor.
During an interview on 5/7/25 at 1:25 P.M., Regional Nurse Consultant #1 said she was unaware of any MRR or AMRR discrepancies or concerns back in March or April, despite her being in the acting role of Director of Nurses.
During an interview on 5/7/25 at 11:35 A.M., the Consultant Pharmacist said communication with the facility had been challenging lately because there has been a lot of turnover in management. The Consultant Pharmacist said he usually includes Regional Nurse Consultant #1 on the email that includes his report and recommendations because he is not sure who is covering. The Consultant Pharmacist said the facility's responsiveness to recommendations fluctuates from month to month. The Consultant Pharmacist said that readmissions are reviewed by another pharmacist who completes the AMRR. The Consultant Pharmacist said he could not say that he had been notified of medication errors at the facility.
The surveyor attempted to contact the Regional Nurse #3, but she was unable to be reached.
4. Review of a Medication Incident and Discrepancy Report Form, dated 3/19/25, indicated on 2/27/25, Resident #40's tacrolimus had been discontinued in error by a previous employee at the facility. A Performance Improvement Plan (PIP) was attached to the Medication Incident and Discrepancy Form and indicated medication was not administered for a resident on tacrolimus and the root cause was the medication was entered in the electronic health record incorrectly as it was entered as a one-time order. Recommendation/Action Steps on the PIP indicated all other residents on medication were reviewed to ensure that no medications were entered incorrectly, the physician and patient were aware, the transplant clinic was aware, education was provided to nursing staff, an interdisciplinary team (IDT) meeting was held to review new admission medications vs. discharge summary or new orders to ensure medications were not missed, the Resident was sent to the emergency room for evaluation, and medication errors would be tracked.
The PIP failed to identify that an Admission Medication Regimen Review had not been completed by the pharmacy after the Resident returned from the hospital on 2/27/25 or that the facility staff failed to ensure the Resident's cardiology office was aware of the abnormal tacrolimus level results prior to the Cardiology RN's request for information on 3/18/25.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 42 225474 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225474 B. Wing 05/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Regalcare at Taunton 68 Dean Street - Rear Taunton, MA 02780
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0835 During an interview on 5/7/25 at 1:08 P.M., the Regional Pharmacy Manager said he had conducted an audit and concluded that the AMRRs were not being completed consistently in February and March 2025. The Level of Harm - Minimal harm or Regional Pharmacy Manager said that the AMRRs should be completed within 72 hours of a resident's potential for actual harm admission/readmission to the facility. The Regional Pharmacy Manager said Resident #40 had returned to
the facility on [DATE REDACTED], but no AMRR had been completed within 72 hours of his/her readmission. The Residents Affected - Some Regional Pharmacy Manager said that had an AMRR been completed, this discrepancy would have been identified at that time. The Regional Pharmacy Manager said Resident #40 had missed 20 days of his/her twice daily tacrolimus doses and that this put the Resident at higher risk for organ rejection.
During an interview on 5/7/25 at 1:25 P.M., Regional Nurse Consultant #1 said after the medication error had been identified, she had reviewed Resident #40's record and identified that the order entered on 2/27/25 was entered as a one-time dose, maybe due to a glitch. Regional Nurse Consultant #1 further said the pharmacy should complete a medication review when a resident is admitted /readmitted to the facility. Regional Nurse Consultant #1 said staff at the facility had not identified the medication error prior to being notified by the Cardiology RN on 3/19/25. Regional Nurse Consultant #1 said nursing staff are supposed to call and report labs to the Attending Physician or their designee, and that specifically for Resident #40, the labs are also reported to his/her cardiology office.
During an interview on 5/7/25 at 1:59 P.M., the Regional Director of Operations said when a medication error is discovered, the Director of Nursing at the facility would oversee the investigation, education, follow-up, and any disciplinary action that may occur as a result. The Regional Director of Operations said when there is no Director of Nursing at the facility, a Regional Nurse Consultant would be assigned to the position until a new Director of Nursing is hired. The Regional Director of Operations said he was not aware of the medication error before being informed by the survey team on 5/7/25.
During a subsequent interview on 5/8/25 at 1:29 P.M., Regional Nurse Consultant #1 said that she did not report Resident #40's medication error to the governing body because she had handled the situation as a part of the governing body.
Refer to