Regency Healthcare & Rehab Center

Inspectors wroteBased on interview and record review, it was determined that for one (R11) out of five residents reviewed for unnecessary medications, the facility failed to have evidence of ongoing antibiotic stewardship implementation when R11's antibiotic usage was not reviewed after not meeting facility antibiotic prescribing criteria.

Inspectors wroteBased on interview, record review, and review of other facility documents, it was determined that for one (R32) out of three residents reviewed for abuse, the facility failed to ensure that R32 was free from verbal abuse from a staff member on 1/9/26. Based on review of the facility's evidence to correct the deficient practice and substantial compliance at the time of the current survey, the deficiency was determined to be past non-compliance as of 1/11/26.

Inspectors wroteBased on record review and interview, it was determined that for one (R26) out of 20 residents reviewed for care plans, the facility failed to develop a person-centered care plan for an identified need.

Inspectors wroteBased on record review and interview, it was determined that for one (R67) out of 20 residents reviewed for care plans, the facility failed to review and revise a person-centered care plan for an identified need.

Inspectors wroteBased on interview, record review, and review of other facility documents, it was determined that for two (R56, and R71) out of three residents reviewed for care and services in accordance with professional standards, it was determined that the facility failed to ensure that R56's medication pain patch was removed on the evening shift according to the physician's order. For R71, the facility failed to ensure that the bowel protocol was implemented when R71 did not have a bowel movement for 5 days.

Inspectors wroteBased on observation, interview, and record review, it was determined that for one (R4) of two residents reviewed for pressure ulcers, the facility failed to ensure that R4, a resident with a Stage IV pressure injury, received treatment and services consistent with professional standards of practice to promote wound healing and prevent infection during a wound dressing change.

Inspectors wroteBased on observations, interviews and record reviews, it was determined that for two (R4 and R56) of seven residents reviewed for infection control, the facility failed to implement an effective infection prevention and control program. Specifically, the facility failed to implement Enhanced Barrier Precautions (EBP) for R4 during incontinent care and a wound dressing change despite an active physician's order and posted EBP signage. For R56, a resident with a multidrug-resistant organism (MDRO), the facility also failed to implement Enhanced Barrier Precautions during medication patch administration. The facility's Enhanced Barrier Precautions (EBP) policy, revised February 2025, stated that Enhanced Barrier Precautions are an infection prevention measure intended to reduce the transmission of multidrug-resistant organisms (MDROs) in nursing homes. [...]

Inspectors wroteBased on observation and interview, for two (R50 and R51) out of three residents reviewed for environment, it was determined that the facility failed to ensure the call system was accessible when each residents' call bell was observed closed inside the residents' bedside table drawers.

Inspectors wroteBased on record review and interview, it was determined that for one (R11) out of two residents reviewed for ADLs (Activities of Daily Living) and one (R27) out of six residents reviewed for abuse, the facility failed to follow the plan of care. For R11, a soiled and wet dressing was not changed per the physician's order. For R27, the facility failed to ensure re-admission orders on 6/28/25 were reviewed by on call provider and transcribed accurately.

Inspectors wroteBased on interview and record review, it was determined that for one (R73) out of two residents reviewed for dental, the facility failed to provide the opportunity for follow up dental services.

Inspectors wroteBased on record review and interview, it was determined that for one (R23) out of three residents reviewed for communication, the facility failed to provide Spanish-speaking translation/interpretation services during nursing care for R23.

Inspectors wroteBased on record review and interview, it was determined that for three (R23, R89 and R43) residents reviewed for care plans the facility failed to develop and implement person-centered care plans, that included measurable objectives and timeframes, to meet each residents' needs.

Inspectors wroteBased on clinical record review and interview, it was determined that for one (R43) out of one sampled resident, the facility failed to ensure the physician's order to administer quetiapine fumarate (Seroquel) .

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure that a qualified person in charge was present during all hours of operation. The presence of a certified food protection manager reduces the risk for a foodborne outbreak especially for vulnerable populations. CMS recognizes the U.S. Food and Drug Administration's (FDA) Food Code and the Centers for Disease Control and Prevention's (CDC) food safety guidance as national standards to procure, store, prepare, distribute, and serve food in long term care facilities in a safe and sanitary manner. [...]

Inspectors wroteBased on interview, record review and review of other facility documents, it was determined that for two (R42 and R43) out of eight residents reviewed for abuse, the facility failed to ensure that R42 was free from resident - to - resident physical abuse by R43 and R43 was free from physical abuse by R42.

Inspectors wroteBased on record review and interview, it was determined that for three (R23, R53 and R89) out of three residents reviewed for communication the facility failed to ensure eash residents' MDS assessments accurately reflected their status.

Inspectors wroteBased on record review and interview, it was determined that for one (R69) out one resident reviewed for mood/behavior, the facility failed to coordinate with the PASRR program under Medicaid and refer the resident for an assessment.

Inspectors wroteBased on record review, observation and interview, it was determined that for one (R43) out of three residents reviewed for bowel and bladder, the facility failed to evaluate R43's decline in urinary continence and failed to maintain or restore continence after R43's multiple falls related to his need for toileting assistance.

Inspectors wroteBased on interview, and record review, it was determined that for one (R2) out of three residents reviewed for accidents, the facility failed to provide a safe environment by having two staff members present to assist with turning when R2 received a shower on 10/25/24. R2 sustained harm due to the traumatic removal of the nephrostomy tube during care and needed to be transported to the hospital for emergency treatment. On 10/26/24, R2 was again sent to the emergency room for evaluation of the injuries to his face, torso and lower extremeties. Based on review of the facility's evidence to correct the non-compliance and the facility's substantial compliance at the time of the current survey, this deficiency was determined to be past non-compliance as of 10/29/24.

Inspectors wroteBased on record review and interview, it was determined that for one (R5) out of three residents reviewed for pharmacy services, the facility failed to obtain and administer three ordered medications (lacosamide, clonazepam, perampanel) to R5 from 12/27/24 to 12/29/24, which resulted in multiple missed doses of each medication.

Inspectors wroteBased on record review, it was determined that for one (R5) out of three residents reviewed for Physician services, the facility failed to ensure the physician/provider completed the required Control Prescription [C2- a required form for any controlled (Drug Enforcement Administration's drug schedules II through V) medications that the pharmacy must have completed with the provider's signature and DEA number in order to release the medication to the facility)] form for three medication orders (lacosamide, clonazepam, perampanel) that were necessary for R5's immediate care.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to report R1's allegation of sexual abuse to the Administrator or the State Agency within two hours when it became known on the weekend of 10/5/24. The facility reported the allegation on 10/8/24.

Inspectors wroteBased on interview and record review, it was determined that for one (R95) out of nine sampled residents reviewed for abuse, the facility failed to protect R95 from verbal abuse.

Inspectors wroteBased on observation, record review and interview, it was determined that for one (R40) out of one resident reviewed for hearing and visioin the facility failed to ensure the MDS was accurate for one (R40).

Inspectors wroteBased on interview, record review and review of other facility documentation it was determined that for one (R37) out of twelve residents reviewed for abuse, the facility failed to prevent abuse. For R37 sexual abuse by a staff CNA (Certified Nursing Assistant). An immediate jeopardy (IJ) was identified starting on 6/5/23. Due to the facility's corrective measures following the incident, this is being cited as immediate jeopardy, past non-compliance with an abatement date of 6/10/23. R37 had sustained psychosocial harm as R37 was still affected by the abuse.

Inspectors wroteBased on record review and interview it was determined for one (R37) out of one resident reviewed for range of motion (ROM) the facility failed to ensure the resident received the ordered foot brace to prevent a decline in range of motion.

Inspectors wroteBased on record review and interview it was determined that for two (R438 & R47) out of three residents reviewed for pain, the facility failed to ensure PRN narcotic pain medications were not inappropriately diverted to an agency nurse on 8/23/23. Due to the facility's corrective measures following the incident, this is being cited as past non-compliance.