Regency Care Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that a resident was treated with respect and dignity for 1 out of 3 residents reviewed (Resident #18). Resident #18 reported she had laid in urine for a delayed period of time without Staff X, Certified Nurse Aide (CNA), cleaning her up after asking this CNA to clean her up, causing her pain. This resident reported that she felt fearful that Staff X was going to hit her (Resident 18) and did not want Staff X to return to her room. The facility reported a census of 58 residents.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to assess and provide pain management to adequately control residents pain for 1 of 3 residents (Resident 68) reviewed for pain management. This failure put the resident at risk of uncontrolled pain and a diminished quality of life. The facility reported a census of 58 residents.

Inspectors wroteBased on the Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Reports, staff interviews, facility assessment review, and facility record review, the facility failed to provide sufficient staff to meet resident needs for 12 of 26 weekend days during the months of October, November, and December 2025. The facility reported a census of 58 residents.

Inspectors wroteBased on observation, clinical record review, resident and staff interviews, the facility failed to assess if a resident was appropriate to self-administer medications for one of one residents review for self-medication administration. Resident#54 was left unsupervised with medications. The facility reported a census of 58 residents. The Minimum Data Set (MDS) dated [DATE] for Resident #54 revealed the diagnoses of a heart dysrhythmia, high blood pressure, arthritis, depression and long-term gall bladder inflammation. The MDS identified that Resident #54 was taking antidepressant medication. A Brief Interview for Mental Status (BIMS) score of 13 suggested Resident #54 was cognitively intact. The Care Plan for Resident #54 revealed the risk for pain, a potential for altered mood and was elected for Hospice care due to his terminal condition. [...]

Inspectors wroteBased on clinical record review, resident and staff interviews, and resident council meeting, the facility nursing staff failed to notify the physician of a change of condition for 1 of 3 residents were reviewed (Resident #11). During a resident council meeting, Resident #11 reported having chest pain during the night to Staff J, Activities Director. Staff J filled out a grievance form and gave it to the Director of Nursing (DON) who failed to follow up and report the episode to the physician. The facility reported a census of 58 residents.

Inspectors wroteBased on record review and interviews, the facility failed to do the assessment for an initial Brief Interview of Mental Status (MDS), for Resident #34. The facility reported a census of 58 residents.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to revise one of one resident's care plan (Resident #68) following a significant change in the resident's pain status, placing the resident at risk for uncontrolled pain and a diminished quality of life. The facility reported a census of 58 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide grooming for 1 resident reviewed (Resident #34). The facility failed to trim resident's toenails which had grown long and were snagging on his socks. The facility reported a census of 58.

Inspectors wroteBased on observation, clinical record review, resident and staff interviews, the facility failed to provide an assessment and timely intervention for the necessary care and services for 2 of 3 residents reviewed (Resident #11 and Resident #45). Resident #11 reported having chest pain over night that lasted 15 minutes. The licensed nursing staff failed to provide an assessment after receiving the information. Resident #45 had a wound requiring a wound vac (medical device that uses negative pressure to promote healing in wounds). The licensed staff failed to maintain and provide interventions to ensure proper functioning of the wound vac. The wound vac was missing several changes and was not properly secured and functioning during wound clinic visits. The facility reported a census of 58 residents.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews and policy review, the facility's licensed nursing staff failed to appropriately set and maintain oxygen devices for 1 of 2 residents reviewed for oxygen administration (Resident #20). The nursing staff reported adjusting the oxygen setting who were not licensed staff. The facility reported a census of 58 residents. The Minimum Data Set (MDS) dated [DATE] for Resident #20 revealed the diagnoses of asthma with dependence on oxygen delivery. The Care Plan for Resident #20 identified oxygen to be delivered at 2 Liters without further direction for nursing staff (Licensed Practical Nurse (LPN) and or Registered Nurse (RN)). The Physician Orders for Resident #20 revealed an order for 2 liters of oxygen and the direction for the nursing staff to change oxygen tubing every Wednesday. [...]

Inspectors wroteBased on interviews, record reviews, and policy review, the facility failed to obtain physician's orders for peritoneal dialysis, to provide initial and ongoing assessment and oversight of peritoneal dialysis (PD), and to provide consistent care and documentation per professional standards of practice for 1 of 2 residents reviewed that received peritoneal dialysis in the facility (Resident #69). Resident #69 received peritoneal dialysis in the facility which was connected and disconnected by her sons. The nurses did not provide these interventions. The facility was unable to produce provider's orders for the dialysis, documentation of assessments for this dialysis, documentation of the connecting and disconnecting of the peritoneal dialysis, and clarification for who was to turn on and shut off the dialysis. The staff at the facility allowed this to go on without seeking clarification. [...]

Inspectors wroteBased on record review, staff interviews, resident representative interviews, and policy review the facility failed to provide medically-related Social Services in assisting and obtaining Medicaid applications and Power of Attorney documents for 1 of 1 Residents (Resident #57) reviewed. The facility reported a census of 58 residents.

Inspectors wroteBased on observations, resident and staff interviews, and policy review, the facility staff failed to ensure Enhanced Barrier Precautions (EBP) were in place for residents with multidrug-resistant organisms (MDROs) (Resident #24), failure of staff to wear appropriate personal protective equipment (PPE) when providing care to residents on EBP (Resident #8), and failure to follow proper infection control practices to prevent the transmission of infection with blood sugar monitoring. The facility reported a census of 58 residents.

Inspectors wroteBased on record review, observations, staff interviews and facility policy review the facility failed to complete an accurate Minimum Data Set (MDS) for 1 of 4 residents (Resident #2) reviewed. The facility reported a census of 68 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review the facility failed to ensure 1 of 4 residents' (Resident #1) care plan was updated to include interventions to offload her heals while in bed. The facility reported a census of 68 residents.

Inspectors wroteBased on observations, clinical record review, staff interview and policy review, the facility failed to supervise residents at risk for elopement for 1 of 3 residents reviewed (Resident #9). This failure resulted in the resident eloping from the facility, his whereabouts unknown for approximately an hour and 30 minutes and sustaining fractures of five ribs, therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as ofMay 8, 2025, on August 18, 2025 at 1:15 PM. The Facility Staff removed theImmediate Jeopardy on August 20, 2025 through the following actions: Resident assessed and sent to the hospital 100% Headcount of all Residents on 6/4/2025 100% Elopement Risk assessment review completed by DON for accuracy and current on 6/5/2025. [...]

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to accurately complete a Minimum Data Set (MDS) Assessment for 4 of 8 residents reviewed (Resident #6, #7, #9 and #12). The facility reported a census of 68 residents.

Inspectors wroteBased on observations, clinical record review, resident interviews, staff interviews, and facility document review, the facility failed to ensure adequate staffing levels to meet the residents' needs safely and timely. The facility reported a census of 68.

Inspectors wroteBased on clinical record review, staff interview and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 12 residents reviewed (Resident #12). The facility reported a census of 68 residents.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure staff completed an accurate and timely resident assessment as necessary for 1 of 3 residents reviewed for elopement (Resident #7). The facility reported a census of 68 residents.

Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections. The facility reported a census of 68 residents.

Inspectors wroteBased on observations, staff interview, and policy review, the facility failed to ensure proper food equipment handling practices during meal service one of one meal service observed. The facility reported a census of 76.

Inspectors wroteBased on electronic health record review, staff interview, and policy review, the facility failed to update and revise resident Care Plans for 2 of 17 residents reviewed for personalized Care Plans (Residents #2 and #25). The facility reported a census of 76.

Inspectors wroteBased on observations, electronic heath record review, and staff interview, the facility failed to provide oxygen therapy as prescribed by the physician for 1 of 2 residents reviewed for respiratory care (Resident #43). The facility reported a census of 76.

Inspectors wroteBased on observation, staff interview, clinical record review, and policy review, the facility failed to assure a medication error rate of less than 5%. Medication errors were observed for Resident #15 & Resident #61. A total of 28 ordered medications were reviewed with two errors, an error rate of 7%. The facility reported a census of 76 residents.

Inspectors wroteBased on clinical record review, bathing documentation, interviews, and facility policy the facility failed to provide residents at least two showers or bed baths per week for 4 of 4 residents reviewed (Residents #1, #2, #5, and #6). Documentation determined residents went as long as 10 days without a shower. The facility reported a census of 79 residents.

Inspectors wroteBased on clinical record review, policy review and staff interview the facility failed to report an allegation of abuse to the Department of Inspections, Appeals and Licensing (DIAL) (state survey agency) within 24 hours of the allegation for 1 of 1 incident reviewed (Resident#1). The facility reported a census of 79 residents. Findings Include: The admission Minimum Data Set (MDS) dated [DATE] for Resident#1 documented a score of 12 out of 15 for the Brief Interview for Mental Status (BIMS), which indicated moderately impaired cognitive skills. The MDS documented that the resident had no behaviors, and diagnoses including high blood pressure, quadriplegia (paralysis of all four limbs), and anxiety. [...]

Inspectors wroteBased on observation, clinical record review, and resident and staff interviews the facility failed to provide routine perineal cares of incontinent residents for 1 of 4 residents observed for cares (Res #2). The facility reported a census of 79 residents. Findings Include: The Minimum Data Set (MDS) report dated 11/12/24 documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated no cognitive impairment. The MDS reported the resident required substantial/maximal assistance for toileting and toilet transfers. The Medical Diagnosis list initiated 10/22/24 documented diagnoses including: malignant neoplasm of colon (cancer), need for assistance with personal cares, and difficulty walking. [...]

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility reported a census of 73.

Inspectors wroteBased on clinical record review, hospital record review, guidance from The Cleveland Clinic, and staff interviews, the facility failed to draw and monitor laboratory values for one of three residents reviewed during medication administration, (Resident #81 in Stage III kidney failure who was receiving medications which had the potential to affect kidney function).

Inspectors wroteBased on observation, clinical record review, interview and drug manufacturer's administration instructions, the facility failed to administer medications at an error rate of under 5%. The survey team observed 2 errors out of the 35 medications administered. The medication error rate was 5.7%.

Inspectors wroteBased on observations, and resident and staff interviews, the facility failed to ensure staff responded and answered residents' call lights within 15 minutes, and met residents needs in a timely manner for two of two nursing units observed. The facility staff also failed to provide adequate supervision of residents during dining for 3 of 3 meal observations. The facility reported a census of 77 residents.

Inspectors wroteBased on clinical record review, observations, staff interview, and policy review, the facility failed to ensure staff changed gloves when contaminated or before touched other objects and utilized infection control practices to protect against cross contamination and potential spread of infection. The facility staff also failed to complete proper hand hygiene in-between dirty to clean tasks for 3 of 6 residents reviewed for incontinence cares and dressing changes (Resident #1, #6, and #7). The facility reported a census of 77 residents.

Inspectors wroteBased on clinical record review, observation, resident and staff interviews, and facility policy review the facility failed to assess and provide interventions for a resident who developed a skin sore for one of three residents reviewed (Resident #3), and failed to complete treatments as ordered for one of three residents reviewed (Resident # 1). The facility reported a census of 77 residents.

Inspectors wroteBased on clinical record review, observations, staff interviews, and facility policy review the facility failed to provide complete and proper incontinence care to minimize the risk of cross-contamination and infection for 3 of 3 residents observed for incontinence care (Resident #1, #6, and #7). The facility reported a census of 77 residents.

Inspectors wroteBased on clinical record review, resident and staff interviews, and facility policy review, the facility failed to ensure a system was in place to verify and track resident medications, to ensure medications administered as ordered, and ensure measures in place to prevent inadvertent duplication of medication. The facility reported a census of 77 residents.

Inspectors wroteBased on clinical record review, resident interview and staff interviews, the facility failed to ensure each resident is treated with dignity and respect. (Resident #7) The facility reported census was 77.

Inspectors wroteBased on clinical record review, resident and staff interviews, the facility failed to ensure residents are provided incontinence care for 1 of 4 residents dependent on staff (Residents #7). The facility reported a census of 77.

Inspectors wroteBased on observation, clinical record review and staff interviews the facility failed to provide a prompt response to the resident's use of the nurse call system for 2 of 7 residents reviewed (Resident #4, #7). The facility reported census was 77.