Regency at Bluffs Park

Inspectors wroteBased on observation, interview and record review, the facility failed to effectively clean and maintain food service equipment resulting in the potential to spread food borne illness among all residents that consume food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold prior to a transfer in one (Resident #2) out of one reviewed for bed holds.

Inspectors wroteBased on interview and record review the facility failed to ensure for one out of 15 residents (Resident #79) the Minimum Data Set (MDS) assessment accurately reflected the resident's status. Findings Included: Per the facility's face sheet Resident #79 (R79) was admitted to the facility on [DATE] with a diagnosis of pressure ulcer of unspecified site, dated 6/8/2026. Review of a physician's progress note dated 6/12/2026 revealed that the physician documented under, Assessment & Medical Plan of Care: R79 had pressure injuries to her coccyx and right heel which the physician documented both to be a stage 2 pressure wounds. The physician documented treatments for the pressure wounds and the wound nurse to follow. Review of physician orders dated 6/12/2026 revealed an order for treatment to R79's stage 2 coccyx pressure ulcer. [...]

Inspectors wroteBased on observation, interview, and review, the facility failed to revise care plans for one (R65) of 15 reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent a fall for one (R200) of three residents reviewed, resulting in major injury.

Inspectors wroteBased on interview and record review, the facility failed to follow the care plan for one (R200) of three residents reviewed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 58 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 60 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, reduced air quality, and potential cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure for 14 out of 14 residents (Resident # 5, 7, 13, 15, 18, 25, 37, 48, 51, 69, 333, 335, 340, 341) allegations of abuse were reported to the state agency. Findings Included: Resident #5 (R5): Review of the grievance log revealed that on 3/7/2025, R5 had put in a grievance that it tool one and a half hours to get assistance to use the bathroom, and she had missed her shower two times. The grievance further revealed, I (R5) was told to get a private aid. NO! Hire more help. The resolution was to continue to hire more staff. Abuse was not identified, R5 refused to sign the facility's resolution. Resident #7 (R7): Review of the grievance log revealed that on 2/10/2025, R7's daughter put in a grievance that if R7 did not take a shower then she would have a refusal. No resolution was noted regarding showers. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure for 14 out of 14 residents (Resident # 5, 7, 13, 15, 18, 25, 37, 48, 51, 69, 333, 335, 340, 341) allegations of abuse were identified and investigated. Findings Included: Resident #5 (R5): Review of the grievance log revealed that on 3/7/2025, R5 had put in a grievance that it tool one and a half hours to get assistance to use the bathroom, and she had missed her shower two times. The grievance further revealed, I (R5) was told to get a private aid. NO! Hire more help. The resolution was to continue to hire more staff. Abuse was not identified, R5 refused to sign the facility's resolution. No investigation for an allegation of abuse was conducted. Resident #7 (R7): [...]

Inspectors wroteOn 04/16/25 at 02:20 PM during an interview with Licensed Practical Nurse U and V they reported the facility was understaffed and there was not enough Certified Nursing Assistants (CNA's) to meet the needs of the residents. During this interview CNA T interrupted the interview reporting to LPN U and LPN V that she could not locate the other CNA that was assigned to the same hall. CNA T elaborated that she was fed up with the other CNA because they always hide and do not take care of their assigned residents leaving CNA T with her residents (approximately 15 residents) and the other CNA's assignment (another 15 residents) CNA T stated she cant take care of 30 residents. Based on observation, interview and record review, the facility failed to ensure sufficient nursing staff to respond to resident needs timely for five of 15 reviewed (R1, R14, R22, R48 and R62).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure dignity was maintained for one resident (resident #52) of four residents reviewed for dignity. Review of the clinical record Resident # 52 (R52) was admitted to the facility on [DATE] with diagnosis that include compression fracture and cognitive deficit. Review of the Minimum Data Set (MDS) dated [DATE] revealed R52 scored 9 out of 15 (moderate cognitive) on Brief Interview Status Score for Mental Status (BIMS) . On 04/15/25 at 10:37 AM R52 was observed resting in bed, next to the bed was a recliner chair, a pillow was on the chair and on top of the pillow was a pile of un-bagged pile of linen smeared with feces. The pile of un-bagged soiled linen sat approximately 2 to 3 feet away from R52's face. R52 was observed again 31 minutes later with the soiled linen still on the reclining chair. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain resident dignity for three of three residents (Resident 25, 48, & 51) resulting in feelings of anger, embarrassment, degrading, feeling not important. Findings Included: Resident 51 (R51): Per the facility face sheet R51 had resided at the facility since 7/23/2024. On 4/16/2025 at 2:58 PM, R51 was visited in his room. R51 stated that he wore a brief, but stated he knew when he had to urinate, and have a bowel movement. R51 said staff who put briefs on him have not ever offered to allow him to wear his own underwear, and said he was not sure if he even had underwear in his room with his own belongings. With permission R52's top dresser drawer was opened, and several pairs of underwear were observed to be in the drawer that were R51's underwear. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide advanced written notice prior to a room change for one Residents (#30), of one residents reviewed for room changes.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess a seatbelt as potential restraint for one (Resident #10) of one reviewed. Resident #10 (R10) R10 admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included muscle wasting and atrophy and anoxic brain damage. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/2/25, reflected R10 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R10's Care Plan revealed R10 was dependent on two staff members with the use of a mechanical Hoyer lift for transfers. On 4/15/25 12:35 PM, R10 was observed in his room, sitting on a motorized wheelchair. R10 had a seatbelt across his lap. R10 was unable to self release his seatbelt. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure showers were offered and completed per resident preference for one out of four residents (Resident #30).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure prevention of a fall for one (Resident #10) of two reviewed for falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide Occupational Therapy (OT) services as ordered for one (R22) of two reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) ensure appropriate use of Personal Protective Equipment (PPE) for one (R7) of three reviewed for Transmission-Based Precautions (TBP); and 2) ensure appropriate hand hygiene.

Inspectors wroteBased on interview and record review the facility failed to implement an effective Quality Assurance Performance Improvement Committee (QAPI) plan to address allegations of abuse from resident grievances. Findings Included: Review of resident concern/grievance logs revealed since June of 2024 there had been 15 grievances by 15 residents that were not identified as allegations of abuse. Per the facility's Quality Assurance Performance Improvement Committee (QAPI) policy and procedure dated 4/5/2024, revealed under Procedure #6 a list of reports and logs the committee used for improvement priorities and facility-identified concerns. Resident concern summary logs were listed. In an interview on 4/23/2025 at 1:05 PM, Administrator A stated that the QAPI committee met monthly. Administrator A stated that all required members attended all meetings. [...]

Inspectors wroteThis citation pertains to Intake MI00149652. Based on observation, interview, and record review, the facility failed to provide the necessary supplies to perform oral care for one (R5) of three reviewed.

Inspectors wroteThis citation pertains to Intake MI00149652. Based on interview and record review, the facility failed to follow-up on a change in vital signs for one (R2) of three reviewed.

Inspectors wroteThis citation pertains to Intake MI00149652. Based on interview and record review, the facility failed to completed bladder scans and intermittent straight catheterization as ordered by the physician for one (R2) of two reviewed.

Inspectors wroteThis citation pertains to Intake MI00149652. Based on interview and record review, the facility failed to notify the physician of urine culture results for one (R2) of one reviewed.

Inspectors wroteThis citation pertains to Intake MI00149652. Based on interview and record review, the facility failed to ensure urine culture results were in the medical record for one (R2) of one reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting the facility's total census of 54 residents who receive meal services (2 nothing by mouth residents, or NPO) out of the facility's total census of 56 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide sufficient staff to meet residents' needs, as voiced by 6 resident and family interviews (Resident #19, 41, 42, 50, 167, and 323), from a total sample of 14 residents, resulting in unmet needs. Resident #19 Review of the Face Sheet revealed Resident #19 (R19) was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included difficulty in walking, shortness of breath, repeated falls, and paralytic gait. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/3/24 revealed R19 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). In an observation and interview on 04/23/24 at 2:59 PM, R19 was in her room watching television. R19 reported that she felt staffing was an issue. [...]

Inspectors wroteBased on observation and interview the facility failed to provide a safe, functional, and sanitary environment for the facilities census of 56 residents and its staff resulting in an increased potential for harm.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the dignity for 2 (Resident # 42 and 50) of 2 residents reviewed resulting in anger, frustration and the potential for decreased self worth.

Inspectors wroteBased upon observation, interview and record review, the facility failed to provide repair services for a power wheelchair in a timely manner for one (R19) of one residents reviewed for adaptive equipment, resulting in resident dissatisfaction and reduced resident independence with wheelchair mobility. Findings Include: Review of the Face Sheet revealed Resident #19 (R19) was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included difficulty in walking, shortness of breath, repeated falls, and paralytic gait. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/3/24 revealed R19 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Care Plan revealed R19 required assistance of one staff member for toileting and the use of a hemi walker. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 (Resident #s 5 and #22 ) of 14 reviewed for MDS assessments, resulting in the potential for inaccurate care plans and unmet care needs. Resident 5 (R5) Review of the clinical record, including the Minimum Data Set, dated [DATE] reflected R5 was a [AGE] year old female admitted to the facility on [DATE]. MDS section B question 0200 of the MDS reflected R5 had adequate hearing - no difficulty in normal conversation, social interaction, listening to TV. (with or without use of hearing aid or hearing appliances if normally used) and did not use a hearing aid. Section B 0300 Hearing aid or other hearing appliance used was coded as No. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for 1 (Resident #42) of 14 reviewed, resulting in the potential for unmet care needs and continued falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure communication services were available and appropriately utilized by staff for one (Resident #42) of two residents reviewed for communication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate treatment and services for contracture management for one resident (#3) of one resident reviewed. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent falls for one (Resident #42) of 1 reviewed for falls, resulting in recurrent falls and the potential for serious injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pain medications were given as ordered for two (resident #45 and #269) of three reviewed, resulting in increased pain and the potential for unmanaged pain.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper storage of medications for two residents (Resident #7, 42) out of 56 residents, resulting in the potential for unauthorized access to medications, medication errors, and the potential for adverse reactions/side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to justify the use of an antipsychotic medication for one (Resident #5) of five reviewed.

Inspectors wroteThis citation pertains to intakes MI00140976, MI00140959 & MI00141121. Based on observation, interview, and record review, the facility failed to perform a through assessment after a change of condition, in 2 of 7 reviewed for assessment (Resident #1 and #5), resulting in a delay in treatment and services.

Inspectors wroteThis citation pertains to intakes MI00140976, MI00140959 & MI00141121. Based on interview and record review, the facility failed to prevent significant medication errors in 6 of 7 residents reviewed for medication errors (Resident #1, #3, #4, #5, #6, and #7), resulting in a transfer to the hospital for assessment and treatment (Resident #1 & #5), and the potential for a change in condition (Resident #3, #4, #6, and #7).