Regency Care Center at Monroe

Inspectors wroteBased on interview and record review, the facility failed to prevent physical abuse for 1 of 2 residents (Resident 1) reviewed for abuse. This failure placed residents at risk of injury and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure that unless the facility had a full-time Registered Dietician, that the Dietary Manager (Staff E) had completed an academic program in nutrition or dietetics accredited by an appropriate national accreditation organization. This failure placed residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services.

Inspectors wroteBased on interview and record review the facility failed to have a system in place that ensured grievances were addressed and resolved in response to residents' verbal conveyance of concerns for 6 of 6 resident council's (October 2024, December 2024, January 2025, March 2025 and April 2025), who verbalized complaints during Resident Council (RC) meeting and failed to follow the grievance process for 1 of 1 residents (Resident 47) who voiced grievances of missing pants. These failures led to residents repeatedly reporting the same issues without resolution and placed them at risk of feeling frustrated, unimportant, with diminished self-worth and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff were compliant with Infection Prevention and Control Guidelines (IPCP) and standards of practice for 1 of 3 units (Cascade Unit) reviewed for infection control practices and 1 of 2 residents (Resident 4) observed with personal care. The facility failed to follow IPCP standards during resident care activities and when handling garbage. The facility failed to ensure that staff used Personal Protective Equipment ([PPE] - specialized clothing worn to protect from infection or illness) during personal care, high contact resident care activities and handling garbage and failed to sanitize equipment after use. These failures placed all residents and staff at an increased risk for the potential transmission of infections.

Inspectors wrote<RESIDENT 273> Resident 273 admitted to the facility on [DATE]. In an interview on 05/01/2025 at 10:25 AM, Resident 273 stated they fell the day after the admission and they hurt their hip. In an interview on 05/05/2025 at 9:27 AM, Resident 273 stated they fell three months ago. Review of the electronic health record (EHR) showed Resident 273 had a fall in their room on 04/25/2025 and complained increased pain in the right hip on the next day. Review of Resident 273's fall risk evaluation on admission, dated 04/24/2025 at 1:45 PM, showed Resident 273 had one to two falls in the past three months. Review of Resident 273's admission MDS, dated [DATE], documented Resident 273 did not have a fall in the last month prior to admission, in the last two to six months prior to admission, or no fall since admission. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services to ensure residents' abilities in activities of daily living (ADLs) did not diminish. The facility failed to provide showers/bathing to 1 of 3 residents (Resident 63) reviewed for ADLs. This failure placed residents at risk for avoidable decline, unmet needs and a diminished quality of life. Findings Included . Resident 63 admitted to the facility on [DATE] with diagnoses to include fracture of the pelvis, chronic pain, and spinal stenosis (narrowing I the spinal canal which leads to compression on the spinal cord). In an interview on 05/01/2025 at 10:32 AM Resident 63 stated they would like more than one shower a week. Resident 63 stated they were admitted to the facility around Thanksgiving time and there was a time when they did not get a shower for almost two full weeks. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide proper treatment to maintain vision for 1 of 1 resident (Resident 7) reviewed for vision. This failure placed residents at risk for decline in the ability to see and diminish quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective interventions were implemented to maintain adequate nutrition for 1 of 2 sampled residents (Resident 275) reviewed for nutrition. This failure placed the residents at risk for ongoing poor oral intake, weight loss, poor nutrition and potential harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 1 resident (Resident 11) reviewed for hemodialysis (medical procedure that uses a machine to filter and clean the blood when the kidneys are failing) had consistent, completed and accurate assessments on the dialysis communication form (a form containing vital information about the resident which is sent to dialysis center for coordination of care and services) and failed to have a care plan that provided an accurate description of where their access site (a location on the resident's body in which the dialysis process is done) was located. These failures placed the resident at risk for medical complications, confusion among their medical providers, and unmet care needs. Findings Included . [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure behavioral health care and services were provided for 1 of 1 sampled resident (Resident 63) reviewed for behavioral health services. This failure placed residents at risk for increased behaviors, not receiving necessary services to meet their mental health needs and a diminished quality of life. Findings Included . Resident 63 admitted to the facility on [DATE] with diagnoses to include attention-deficit hyperactivity disorder (a condition that occurs during the development of the nervous system which affect attention and impulsivity) and bipolar disorder (a mental illness characterized by extreme shift in mood, energy and activity levels). In a review of Resident 63's monthly medication review for 02/10/2025 showed a recommendation for a psychiatric evaluation of their medications as a contributing factor to falls. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 5 sampled residents (Resident 54) reviewed for unnecessary medications. Failure to evaluate the need for continued use of an antifungal medication placed residents at risk for use of unnecessary medications and/or have adverse side effects.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a system in which residents' records were complete, accurate, and accessible, for 1 of 1 resident (Resident 4) reviewed for hospice (end of life) services. The facility failed to ensure the residents' medical records contained hospice provider's notes which placed residents at risk for medical complications, unmet care needs, and for diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment in 1 of 2 emergency carts (carts that contain needed medical equipment during an emergency) when an unlocked sharps container (a specialized, puncture-resistant, and leak-proof container designed for the safe disposal of sharp medical instruments, like needles, syringes, and scalpels, to prevent accidental injuries and ensure proper waste handling) was found to be soiled and contained five syringes. This failure placed residents and staff at risk for injury, potential exposure to diseases and lack of necessary medical equipment during an emergency. Findings Included . [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the person designated to serve as the Director of Food and Nutrition Services (Staff P) had the proper qualifications. This failure placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 4 of 5 residents (Resident 3, 6, 21, and 7) reviewed for range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM. This failure placed the residents already identified with decreased ROM risk for further decline in ROM.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual Nurse Aide Certified (NAC) performance reviews were completed for 3 of 5 employee (NAC's Q, R and T) files reviewed who had been employed longer than 1 year. This failed practice had the potential to negatively affect the competency of these NAC's and the quality of care provided to residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a system in which resident's records were complete, accurate, accessible, and systematically organized for 6 of 6 residents (Residents 6, 22, 35, 17, 50, and 61) reviewed for accurate and complete medical records. Failure to ensure that clinical records were complete and accurate placed residents at risk for medical complications, unmet care needs, and for diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 3 of 6 nurses (Staff F, Staff G, and Staff H) during medication administration, for 1 of 3 residents (Resident 17) on Enhanced Barrier Precautions (EBP), for 1 of 2 residents (Resident 17) during enteral (nutrition provided through tube inserted directly into the intestine) feeding administration, and for appropriate hand hygiene practices in 2 of 3 dining rooms (Cascade and Sky River). The facility failed to ensure staff were wearing appropriate personal protective equipment (PPE) in accordance with recommended national standards, staff followed appropriate infection control practices during medication administration, and administration of an enteral feeding. [...]

Inspectors wroteBased on record review, and interview, the facility failed to develop, implement, and maintain an in-service training program for 4 of 5 Nursing Assistants Certified (NAC's Q, R, S and T) reviewed for the required 12 hour of nurse aide training per year. The failure to ensure NAC's received 12 hour per year in-service training placed residents at risk for potential unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan that addressed the resident's medical, physical, mental, and psychosocial needs for 1 of 3 residents (Resident 50) reviewed for activities. These failures placed the residents at risk for not receiving care and services to meet their individualized needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 4 residents (Resident 55) were provided medications within physician prescribed medication parameters. These failures placed residents at risk for complications and adverse health outcomes.

Inspectors wroteBased on observation, and interview the facility failed to ensure proper storage of drugs and biologicals on 2 of 4 medication carts (Medication Carts Sky River and Cascade 2) and to ensure 1 of 4 medication carts (Sky River) was locked and not accessible to residents. This failure placed the residents, staff, and visitors at risk for medication related illness/injury due to unauthorized access to and use of medications.

Inspectors wroteBased on interview and record review the facility failed to provide the required refund for 1 of 4 sampled residents and/or their resident representative (Resident 1) within the required 30 days after the resident discharged . This failed practice placed the resident and/or resident representative at risk of financial hardship.

Inspectors wroteBased on interview and record review, the facility failed to provide Cardiopulmonary Resuscitation (CPR) for 1 of 1 sampled resident (Resident 1) for death in the facility. Failure to provide CPR for a resident who was found with no pulse and no respirations, and who had a written advance directive that indicated the resident wanted to receive life-sustaining care and services placed the resident at risk for lack of needed emergency medical interventions and unexpected death.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean homelike environment in three of three hallways observed. The failure to maintain overhead light fixtures that were free of dead insects and debris placed residents at risk for a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess five of 16 residents (21, 36, 37, 47, and 49) whose Minimum Data Sets (MDS) Assessment was reviewed. Failure to ensure accurate assessments regarding positioning (Resident 21), oxygen use (Resident 36), pressure ulcer (injury to skin from prolonged pressure) (Resident 37), blood thinner medication use (Resident 47) and hearing (Resident 49), placed residents at risk for unidentified and/or unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the staff were compliant with Infection Prevention and Control Guidelines and standards of practice for three of four halls. The facility failed to ensure oversight and management during an outbreak of the Coronavirus Disease 2019 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the infection prevention and control Antibiotic Stewardship Program (ASP, a system-wide implementation of measures for monitoring/tracking of antibiotics along with reducing the risk of unnecessary antibiotic use) was implemented for four of four residents (14, 17, 32, and 57). This failure increased the resident's risk for development of multidrug-resistant organisms (a bacteria that are resistant to many antibiotics) along with potential for unidentified nursing care trends that identify risk related to infection prevention. This failure had the potential for adverse outcomes associated with unnecessary or inappropriate antibiotic use and a decrease in quality of life for all facility residents.

Inspectors wroteBased on interview and record review, the facility failed to honor residents' rights to make choices for frequency of bathing for two of two residents (35 and 36) reviewed for choices. The failure to assess and honor resident choices placed residents at risk for impaired hygiene and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement care planned interventions for one of three residents (#32) reviewed. The facility failed to ensure safety interventions were implemented for a resident at risk for falls. This failure placed the resident at risk for unmet care needs and potential negative outcomes. Findings Included . Resident 32 was re-admitted to the facility on [DATE] with diagnoses that included delusions, hallucinations, muscle weakness, and dementia with behavioral disturbances. Review of current physician orders on 10/03/2022, showed order for Right bedside floor mat, ordered on 09/10/2022. Review of current comprehensive care plan showed Resident 32 was at risk for falls related to weakness, confusion, hallucinations, and delusions. Interventions included use of right bedside fall mat; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (26), reviewed for edema received care and services in accordance with professional standards of practice and the resident's person-centered care plan. This failure placed the resident at a risk for pain, discomfort, and unidentified decline.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of four residents (49 and 36) reviewed for respiratory care received appropriate oxygen (O2) services. Failure of the facility to ensure O2 delivery was provided according to physician ordered flow rates, monitor respiratory status, and maintain O2 equipment, placed residents at risk of discomfort and a potential negative outcome.

Inspectors wroteBased on observation and interview, the facility failed to assure food was consumed or discarded within safe time limits for one of one residents (41) reviewed for in-room food service. Allowing residents to eat foods that had sat at room temperature for extended periods of time placed resident(s) at risk for food borne illness.