Regency Care

Inspectors wroteBased on observation, interview and record review the facility failed to label, store and secure medications for 5 of 5 residents (R11, R13, R18, R30 and R81) reviewed for medication storage in a sample list of 37.

Inspectors wroteBased on observation, interview, and record review, the Facility failed store and serve food and clean essential equipment (ice machine) in a manner that prevents potential contamination. This has the potential to affect all 87 residents living in the Facility.

Inspectors wroteBased on observation, interview and record review the facility failed to follow policy and procedure for infection control practices by failing to post Enhanced Barrier Precaution signs and have Personal Protective Equipment readily available (R5), and the facility failed to obtain Urinalysis Culture results to be able to monitor, analyze and track infection rates. This has the potential effect all 87 residents.1. On 5/26/2026 at 10:30am there was no Enhanced Barrier Precautions (EBP) sign on R5's door. There was no personal protective equipment (PPE) located near R5's room. On 5/26/2025 at 3:30pm V32 Certified Nursing Assistant (CNA) entered R5's room to assist R5 into bed following dialysis. V32 did not don PPE. On 5/28/2026 at 8:30am there was now an EBP sign placed on R5's door and there was also PPE now available near R5's room. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide Activities of Daily Living (ADL) assistance such as showering and nail care for 2 of 2 residents (R2 and R94) in the sample list of 37.

Inspectors wroteBased on observation, interview and record review the facility failed to provide range of motion exercises and therapeutic devices for 2 of 2 residents (R2 and R31) reviewed for positioning and mobility in the sample list of 37.1. On 5/26/2026 at 09:30 AM, R2 was lying in R2's bed with R2's hands outside of the blankets. R2 did not have a rolled washcloth in either R2's left hand or R2's right hand. On 5/26/2026 at 12:52 PM, R2 was lying in bed with no washcloths rolled up in either of R2's hands. On 5/27/2026 at 1:20 PM, V15 Certified Nurse's Assistant (CNA) was attempting to perform passive range of motion. R2 became agitated and jerked R2's hands away from V15. V15 did not attempt to reapproach. On 5/28/2026 at 10:20 AM, R2 was lying in R2's bed with R2's fisted hands on top of the blankets. R2's treatment of rolled washcloths was not in place. [...]

Inspectors wroteBased on interview and record review, the facility failed to evaluate for a root cause of a fall and implement fall interventions for 2 of 2 residents (R16, R55) reviewed for accidents in the sample list of 37.

Inspectors wroteBased on interview and record review, the facility failed to obtain urinalysis results timely for a resident symptomatic of a urinary tract infection for one (R19) of one residents reviewed for urinary tract infections in a sample list of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow transfer and fall prevention policies and did not provide adequate supervision for 2 of 2 (R2, R6) residents in the sample of 14. This failure resulted in R2 being forcefully lifted from the floor by V5, Certified Nursing Assistant, CNA, without the use of a gait belt or mechanical lift, and R6 sustaining a fall that resulted in a fracture.

Inspectors wroteBased on interview and record review, the facility failed to answer resident's call lights to address their needs and promote resident dignity for 6 of 6 residents (R9, R16, R25, R30, R33 and R285) reviewed for dignity in the sample of 42. This failure resulted in R285 becoming incontinent and feeling humiliated.

Inspectors wroteBased on interview, observation, and record review, the facility failed to serve palatable food. This failure has the potential to affect all 87 residents residing in the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to dry dishware before use. This failure has the potential to affect all 87 residents residing in the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide complete incontinent care to prevent urinary tract infection for 5 of 5 residents (R20, R40, R51, R60, R185) reviewed for urinary incontinence in the sample of 42.

Inspectors wroteBased on Interview and Observation the facility failed to properly store medications for 4 of 11 residents (R27, R30, R48, R237) observed for proper medication storage in the sample of 42. The Findings Include: 1. The 300-North Hall Medication Cart was Reviewed with V4, Registered Nurse (RN). Basaglar Insulin Pen was seen in the cart and was opened with no resident label, name, or the date it was opened. On 3/10/25 at 12:15 PM, V4 stated There are only a few residents who are on that insulin, so I'm sure I can narrow it down to who's it is. The label must have fallen off. 2. On 3/10/25 at 11:00 AM, R27 was seen lying in bed with a medicine cup sitting on his bedside table with 7 pills in the cup. R27's Medication Administration Record (MAR), dated March 2025, documents R27 received the following medications on 3/10/25 at 8:00 AM: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the resident with a written notice of why they were going to the hospital for 2 of 3 residents (R1, R185) reviewed for transfer/discharge notices in the sample of 42.

Inspectors wroteBased on interview and record review, the facility failed to provide notice regarding the bed hold policy to residents when transferred to the hospital for acute care for 2 of 3 residents (R1, R185) reviewed for notice of bed hold policy in the sample of 42.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for 1 of 16 residents (R185) reviewed for baseline Care Plan in the sample of 42.

Inspectors wroteBased on observation, interview and record review, the facility failed to have an updated resident centered Care Plan to address the current needs of the residents for 2 of 16 resident (R21, R42) reviewed for Care Plan in the sample of 42.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to ensure showers, and basic grooming assistance was provided for 1 of 24 residents (R2) reviewed Activities of Daily Living (ADLs) in the sample of 42.

Inspectors wroteBased on observations, and record reviews the facility failed to clarify pre-operative instructions and document and notify the physician a change in condition while providing medical treatment without an order for 1 of 2 residents, (R45) reviewed for quality of care in the sample of 42.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dressing to pressure sore for 1 of 5 residents (R40) reviewed for pressure sores in the sample of 42.

Inspectors wroteBased on interview, observation, and record review, the facility failed, supervise a meal, to store an oxygen cylinder and transfer residents with a full mechanical lift in a safe manner for 3 of 5 residents (R1, R42, R51) reviewed for accidents in the sample of 42.

Inspectors wroteBased on interview and record review, the facility failed to assess an dialysis access for 1 of 1 resident (R21) reviewed for dialysis in the sample of 42.

Inspectors wroteBased on interview, observation, and record review, the facility failed to do a complete assessment of bed rails, obtain a Physician Order and consent for bed rails for 3 of 3 residents (R1, R42, R185) reviewed for bed rails in the sample of 42.

Inspectors wroteBased on interview and record review, the facility failed to provide a Physician prescribed antibiotic for 1 of 18 resident (R185) reviewed for medications in the sample of 42.

Inspectors wroteBased on interview, observation, and record review, the facility failed to place residents on Enhanced Barrier Precautions, wear Personal Protective Equipment, perform hand hygiene and change gloves when needed for 3 of 16 residents (R74, R51, R60) reviewed for infection control in the sample of 42. Findings Include: 1. R74 was admitted to the facility on [DATE] with diagnosis of, in part, sepsis due to enterococcus, hydronephrosis with ureteropelvic junction obstruction, and emphysema with a history of methicillin susceptible staphylococcus aureus infection. On 3/11/25 at 12:55 PM, V5 LPN provided nephrostomy care to R74 and emptied her urine bag without a gown on. There was an enhanced barrier precautions (EBP) sign and supplies outside R74's door. V5 stated R74 is on EBP and she should have been wearing a gown while providing R74 care. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow Physician orders for 1 of 4 (R4) reviewed for indwelling catheter care in the sample of 8.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to follow R4's care plan and provide appropriate footwear during a transfer for 1 of 3 residents, (R4), reviewed for accidents in a sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to prevent physical abuse for 1 of 4 (R2) residents, reviewed for abuse in a sample of 4.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from sexual abuse for 1 of 6 (R5), reviewed for abuse in the sample of 6. This failure resulted in R5 experiencing two episodes of being sexually abused by R1 on 9/8/24, in which R5 was verbally heard yelling for help, stating that it hurt. The reasonable person concept can also be utilized, a reasonable person would experience fear, trauma, humiliation, should sexual abuse occur to them. The Immediate Jeopardy began on 9/8/2024 when R5 was sexually abused by R1. The abuse was witnessed by V5 (Certified Nurse Assistant, CNA). After removing R1 from the room, leaving R1 unsupervised, R1 again re-entered the room and sexually abused R5 for a second time. V1 (Administrator) was notified of the immediate jeopardy on 9/23/2024 at 2:27 PM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to refrigerate 4 insulin flex pens prior to opening on 1 of 2 medication carts reviewed for medication storage.

Inspectors wroteBased on observation, interview and record review, the Facility failed to ensure meals were served at acceptable temperature and a palatable texture for 4 of 4 residents (R29, R41, R52, R179) reviewed for Dietary Services, in the sample of 33.

Inspectors wroteBased on observation, interview and record review the facility failed to provide complete incontinent care for 1 of 4 residents (R4) reviewed for incontinence, in the sample of 33.

Inspectors wroteBased on observation, interview and record review, the Facility failed to ensure residents on a pureed diet were served their meal consistent with the requirements of a pureed diet consistency for 1 of 4 residents, (R62) reviewed for Diet Orders, in the sample of 33.

Inspectors wroteBased on interview, observation and record review the facility failed to store food in accordance with professional standards for food service safety. This failure has the potential to affect 78 of 79 residents living at the facility.

Inspectors wroteBased on observations, interview and record review, the facility failed to change gloves during indwelling catheter care for one of three (R11) residents, reviewed for infection control in a sample of 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect a resident from sexual abuse for 2 of 3 residents (R1 and R2) reviewed for sexual abuse in the sample of 6. Based upon a reasonable person's concept, R2 would not have wanted sexual contact without her consent and would have experienced psychosocial harm (e.g., fear, anger, depression, anxiety and humiliation) as a result of the sexual abuse since there is an expectation that R2 would not be sexually abused in the facility.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide supervision for 1 of 5 residents (R2) reviewed for dining assistance in the sample of 9.

Inspectors wroteBased on interview and record review, the facility failed to provide a palatable meal for 3 of 9 residents (R1, R5, R9) reviewed for dining services in the sample of 9.