Elevate Care Regency

Inspectors wroteBased on interview and record review, the facility failed to ensure safe wheelchair transport and failed to immediately respond to a resident's complaint of pain following an incident for 1 of 4 residents (R1) reviewed for accidents and supervision in a sample of 4. This failure resulted in R1 sustaining a fracture of the left femur after R1's left foot became caught in the wheelchair during transport by staff, requiring surgical intervention. Findings Include:On 7/5/2026 at 3:15 PM, R1 was observed lying in bed with an immobilizer in place on the left leg. R1 stated that she underwent surgery after sustaining a fracture when V3 (Certified Nursing Assistant/CNA) was pushing her in a wheelchair and her foot became caught underneath the footrest, causing her left leg to bend. R1 stated that she told V3 to stop when her foot became caught; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 2 of 4 residents (R8, R98) who entered the facility without pressure ulcers received the necessary treatment and services to prevent the development of new pressure ulcers and to promote the healing of existing ulcers. Specifically, the facility failed to implement mandatory pressure-redistribution protocols and provide timely incontinence care for a ventilator-dependent resident (R8) and a quadriplegic resident (R98). This failure to provide essential clinical services resulted in the development of a facility-acquired Stage 4 sacral pressure ulcer for R8 that was observed to be actively hemorrhaging, and a facility-acquired unstageable pressure ulcer for R98, who was found in a prolonged soiled state.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions. Specifically, the facility failed to: 1. Discard expired food items. 2. Maintain current records for sanitizing solution changes. 3. Maintain required temperatures for hot and cold food items during service. This deficient practice has the potential to affect all 155 residents who receive food from the kitchen. A. Expired Food Storage: On 03/23/2026 at 10:45 AM, during the initial tour of the kitchen, the following items were observed in the first reach-in refrigerator:Six (6) plates containing Jello, mixed fruit cups, and cottage cheese, all labeled with a date of 03/20/2026. Ten (10) individual cups of chopped watermelon labeled with a date of 03/20/2026. Twelve (12) fruit cups with varying dates of 03/20/2026 and 03/21/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its water management program to prevent the growth and spread of Legionella and other opportunistic waterborne pathogens. Specifically, the facility failed to: 1. Adhere to its own internal protocol regarding weekly water flushing after receiving a moderate caution test result. 2. Repair or resolve a malfunctioning chemical dispensing system intended to mitigate pathogen growth, which has been malfunctioning for over 60 days. 3. Implement necessary clinical and environmental safeguards, including failing to relocate a resident currently residing in a room identified as a Legionella source. This deficient practice can posed a risk to the health and safety of R185 and has the potential to affect all 166 residents, staff, and visitors utilizing the facility's water system.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents' needs and preferences were reasonably accommodated by failing to: 1. Maintain functioning call lights within reach for residents with significant physical and cognitive impairments (R1, R82, R95). 2. Provide timely responses to call lights, with wait times exceeding 20 minutes for assistance with basic needs such as toileting and repositioning (R95, R98). 3. Implement a system to anticipate the needs of residents who are unable to utilize standard call lights (R95). This deficient practice affected 4 of 4 residents (R1, R82, R95, R98) reviewed for reasonable accommodations in the sample of 45 and has the potential to affect all residents residing in the facility, as evidenced by recurring Resident Council grievances regarding call light response times. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that for 4 of 4 residents (R36, R98, R1, and R81) in the sample of 45 for comprehensive care plans were developed with directive, measurable interventions and implemented as written. The facility established a pattern of drafting care plans using non-directive, permissive language (May) for high-risk clinical areas, including pressure ulcer prevention. Furthermore, the facility failed to implement mandatory care plan interventions related to incontinence care, rehabilitative nursing (Passive Range of Motion), and psychosocial monitoring. This failed practice represents a systemic failure to use the care plan as a directive clinical tool, affecting residents with high-acuity needs including Multiple Sclerosis, Quadriplegia, and Dementia. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain grooming and personal hygiene for 4 of 4 residents (R1, R4, R82, R95) reviewed for activities of daily living (ADLs) in a sample of 45. The facility failed to ensure that residents who were unable to carry out ADLs independently were kept clean, well-groomed, and in a sanitary environment. Specifically, residents were observed slumped in chairs, in soiled bed linens with dried liquids, with greasy/unkept hair, and in saturated incontinence briefs. This deficient practice represents a systemic failure to provide basic ADL support and has the potential to affect all dependent residents in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 1 of 2 residents (R36) was free from neglect in the sample of 45. The facility failed to provide necessary incontinence and ostomy care, resulting in the resident remaining in a crystallized, urine-saturated brief and an overfilled colostomy bag for approximately 18 hours. This failure resulted in the development of Moisture-Associated Skin Damage (MASD), confirmed by the facility Wound Nurse, and caused R36 significant mental anguish. R36 is an alert and oriented [AGE] year-old with diagnoses including Multiple Sclerosis, Emphysema, Cataracts, and colostomy status.1. Observation and Clinical Confirmation of Physical Harm On March 25, 2026, at 10:45 AM, Resident R36 was observed with a crystallized, heavy incontinence brief and a colostomy bag filled to maximum capacity. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that a resident received a therapeutic diet as ordered by the physician for one (R93) of six residents reviewed for dietary services in the sample of 45. Specifically, the facility provided thin liquids to a resident who had a physician's order for nectar-thick liquids.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary respiratory care and monitoring for a ventilator-dependent resident by failing to assess and respond to ventilator alarms and failing to ensure the resident's ventilator circuit and closed suction system were intact and functioning. These deficiencies affect one (R1) of four residents in the sample of nine reviewed for quality of care. These failures resulted in R1 not receiving ventilation and being found unresponsive, requiring emergency medical intervention; and expired. These failures resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on [DATE] when R1 was found unresponsive, pale and disconnected from ventilator. V1 (Administrator), V2 (Director of Nursing) and V3 (Assistant Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 10:31 AM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident received care and services in accordance with professional standards of practice to promptly intervene, monitor, and escalate treatment for severe hypoglycemia for a resident. This failure applied to one (R1) of three residents reviewed for nursing care and resulted in R1 experiencing prolonged hypoglycemia of over two hours with decreased responsiveness, requiring emergent hospital transfer. R1 subsequently expired at the hospital the same day. This failure was identified as an Immediate Jeopardy. The Immediate Jeopardy began on November 18, 2025. V1 (Administrator) was notified of the Immediate Jeopardy on December 17, 2025 at 1:07PM. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to document accurate meal intakes, offer alternative meal options, and notify the physician or nurse practitioner of significant weight loss. Additionally, the facility failed to implement the dietitian ' s recommendations and follow the physician ' s orders to increase Remeron for weight management. This deficient practice affected two of the seven residents (R62 and R103) reviewed for nutrition and unplanned weight loss prevention. As a result, Resident R62 experienced a 10% unplanned weight loss over a six-month period.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure low air loss mattress devices were on the correct weights setting for residents who are at risk in developing pressure ulcers. This failure has the potential to affect four (R28, R92, R116 and R168) out of four residents reviewed for pressure ulcer care in a final sample of 55 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively supervise one resident on a thickened liquid diet from drinking a cup of thin liquids from another resident's meal tray for a resident assessed with mild to moderate risk for aspiration. This failure affected one resident (91) out of three reviewed for mechanically altered diets in a sample of 55. Based on observation, interview and record review, the facility failed to present a smoking policy that included the safe use and how the facility would supervise residents using electronic smoking materials and failed to complete quarterly smoking assessments. This affected four of four residents (R111, R61, R8, and R161) reviewed for smoking safety and supervision.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their Call Light policy. The facility failed to place the call light within reach for one resident (R40) of three residents reviewed for call light accessibility in a total sample of 55 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its comprehensive care plans policy and accurately assess and revise care plans as changes in the residents' conditions dictate for three residents (R46, R49, and R91) out of three reviewed for care plans in a sample of 55.

Inspectors wroteBased on interview and record review, the facility failed to follow their radiology or other diagnostic ordering policy by not following physician orders to obtaining an x-ray for one resident (R60) for one of one reviewed radiology services.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its the posted infection control signage and don appropriate PPE (personal protective equipment) prior to entering one resident's room that is on enhanced barrier precautions and performing blood draw This affected one of one resident (R105) reviewed for infection control in a sample of 55.

Inspectors wroteBased on interview and record review, the facility failed to prevent and protect a resident from resident-to-resident physical abuse. This failure applied to two of two (R1, R2) residents reviewed for abuse.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively supervise and ensure one resident was seated properly in wheelchair with feet on footrests or elevated off floor prior to transporting. This affected one of three residents' (R1) reviewed for safety. This failure resulted in R1 falling from the wheelchair sustaining a laceration to forehead requiring seven sutures and a left patella fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to a) properly date opened eyedrops for two residents (R81, R14); b) properly discard insulin on expiration date for three residents (R97, R44, R185); and failed to properly secure one medication cart. These failures were found on four of five medication carts reviewed.

Inspectors wroteBased on observation, interview and record review the facility failed to store and label food items in accordance with professional standards for food service safety. This failure has the potential to affect 180 residents that eat food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a resident's dignity during lunch dining for one (R67) resident in a total sample of 35 residents.

Inspectors wroteFindings include: On 5/21/24 at 12:20 PM, Observed R30 lying in bed. Surveyor did not see a call light in place. Surveyor asked R30 where the call light was. R30 said Its behind my head. They put it so I can hardly get it. Surveyor asked R30 what's the purpose of the call light. R30 said I press the button if I need them. I have to yell out if I cannot reach the call light. Surveyor asked R30 to reach for the call light. R30 made slight movements attempting to look for the call light and said Its behind this pillow. I can't get to it. Minimum Data Set, 4/9/2024, Brief Interview for Mental Status score indicates R30 has moderate cognitive impairment. On 5/21/24 at 12:30 PM, Surveyor returned to R30's room with V27 (Certified Nursing Assistant). V27 located the call light on the floor and wrapped it around R30's left upper side rail. V27 stated the call light should not be on the floor. [...]

Inspectors wroteBased on interview and record review the facility failed to follow their policy and routinely invite resident's representative to participate in a care plan conference for 1 resident (R121) in a total sample of 35 residents.

Inspectors wroteBased on interview and record review, facility failed to ensure residents are provided with regular baths twice a week for residents for 1 (R53) out of three residents reviewed for ADL care in a sample of 35.

Inspectors wroteBased on interview and record review, facility failed to follow their policy to ensure resident's nutritional status are within acceptable parameters for 1 (R111) out of three residents reviewed for significant weight loss in a sample of 35.

Inspectors wroteBased on record review, observation, and interview, the facility failed to check the gastrointestinal tube (G-tube) infusion and water flush rate for 1 of 1 resident (R163) reviewed for G tubes in the sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide continuous oxygen therapy per physician order for 1 resident (R160) in a total sample of 35 residents.

Inspectors wroteBased on observation, interview and record, the facility failed to meet the requirement to transfer 1 (R2) of 4 residents reviewed for involuntary discharge notice in the sample. This failure resulted in R2 being refused back to the facility where he resided since May of 2023.

Inspectors wroteBased on interview and record review, the facility failed to have effective interventions in place to keep a resident free from fall related injury for a resident with a history of falls. This failure applied to one (R6) of one resident reviewed for accidents and supervision and resulted in R6 experiencing four falls in four months and sustaining a laceration to the head requiring three staples and a subdural hematoma.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate patient identifying information was provided to paramedic personnel at the time of emergency transfer and led to a resident being admitted to the hospital emergency room under another resident's information. This failure applied to one (R3) of one resident reviewed for hospital transfer.