Regency Heritage Nursing and Rehabilitation Center

Inspectors wroteCOMPLAINT #: 2727628 Based on interviews, medical record review, and review of other pertinent facility documents on 7/9/26 and 7/10/26, it was determined that the facility failed to: a) ensure that Resident #1's pressure ulcer was consistently evaluated by wound care and b) develop a comprehensive person-centered care plan (CP) that addressed skin conditions identified in Resident #1's comprehensive assessment. The deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for wound care and was evidenced by the following:Resident #1 was not at the facility at the time of the survey. A closed medical record review was conducted. A review of Resident #1's admission Record (AR) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to: [...]

Inspectors wroteCOMPLAINT #2999892 Based on interviews, review of medical records and other pertinent facility documentation on 7/9/26 and 7/10/26, it was determined that the facility failed to maintain an accurate and complete medical record in accordance with acceptable professional standards of practice when staff failed to consistently document on the 24 Hour Vital Signs/Neuro Checks form for a resident who had an unwitnessed fall and was observed with redness on their face. This deficient practice was identified for 1 of 2 residents reviewed for falls (Resident #8) and was evidenced by the following:A review of the admission Record revealed that Resident #8 was admitted to the facility with diagnoses that included but were not limited to: [...]

Inspectors wroteBased on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) using the Resident Assessment Instrument (RAI) process on a resident who was discharged from hospice benefits. This deficient practice was identified for 1 of 3 residents reviewed for hospice (Resident #122). This deficient practice was evidenced by the following: On 6/19/25 at 9:22 AM, the surveyor observed Resident #122 lying in bed. The resident stated they were doing well today. On 6/19/25 at 11:14 AM, the surveyor reviewed the electronic medical record (EMR) which revealed orders for DNR (Do Not Resuscitate), DNI (Do Not Intubate), DNH (Do Not Hospitalize) dated 3/24/25. A physician order dated 1/25/25 was noted for [name redacted] hospice. [...]

Inspectors wroteBased on observation, interviews, review of medical records, other facility documentation, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 1 of 35 residents reviewed (Resident #122). This deficient practice was evidenced by the following: On 6/19/25 at 9:22 AM, the surveyor observed Resident #122 lying in bed. The resident stated they were doing well today. On 6/19/25 at 11:14 AM, the surveyor reviewed the electronic medical record (EMR) which revealed a physician order dated 1/25/25 for [name redacted] hospice. [...]

Inspectors wroteBased on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring a.) accurate documentation for the inventory of a controlled medication (Marinol) for one (1) of five (5) medication carts, b.) refrigerated medications for discharged residents were removed from active inventory from one (1) of two (2) medication storage room refrigerators and, c.) accountability of the shift-to-shift inventory documentation for the count of controlled medications for one (1) of five (5) medication carts inspected. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteRefer to F 881 Based on interview and review of pertinent facility documentation, the facility failed to a.) ensure the required committee members, the Infection Preventionist (IP), was present for one of four Quality Assurance and Performance Improvement (QAPI) meetings and b.) ensure antibiotic stewardship was presented for two of the four QAPI meetings. This deficient practice was evidenced by the following: On 6/18/25 at 10:57 AM, during entrance conference the surveyor requested the QAPI sign in sheets from April of 2024 to present. On 6/26/25 at 8:59 AM, the surveyor reviewed the In-Service sign in sheet;Topic: QAPI dated 8/27/24, which revealed the IP did not sign the sheet. On 6/26/25 at 11:27 AM, during the QAPI interview review, the Director of Nursing (DON) reviewed the In-Service sign in sheet; Topic: QAPI dated 8/27/24 and confirmed the IP did not sign the sign in sheet. [...]

Inspectors wroteBased on observation, interviews, record review, and review of pertinent facility documentation, it was determined that facility staff members failed to ensure infection control practices were implemented by not appropriately donning (put on) and doffing (remove) Personal Protective Equipment (PPE) and perform appropriate hand hygiene to prevent the spread of infection, in accordance with accepted national standards, Centers for Disease Control and Prevention (CDC) guidelines, before and after exiting one of one resident's room, (Resident #228), who was on Transmission Based Precautions (TBP) due to a Clostridium Difficile Infection (CDI) [infectious diarrhea that can be transmitted through direct contact], on one (1) of four (4) units. The deficient practice was evidenced by the following: According to the U.S. [...]

Inspectors wroteBased on interviews, record reviews and review of pertinent facility documents, it was determined that the facility failed to utilize an infection assessment tool prior to prescribing antibiotics and conduct an ongoing review of this process for their Antibiotic Stewardship (AS) Program. This deficient practice was identified for 2 of 3 residents reviewed for antibiotic use (Resident's #114 and #155). This deficient practice was evidenced by the following: On 6/18/25 at 9:50 AM, the surveyor interviewed the Infection Preventionist (IP) / Registered Nurse (RN) who stated that she started working at the facility in April 2025. She stated that the facility did not have a AS program in place and they were working on it. [...]

Inspectors wroteComplaint #s: NJ00185340, NJ00175616, NJ00183791 Based on interviews, record review, and review of pertinent facility documents on 04/24/2025 and 04/28/2025, it was determined that the facility failed to accurately and consistently document all the Activities of Daily Living (ADLs) of Residents #1,#2, and #3 in the Certified Nursing Assistant [CNA]Observation Sheet (COS)according to their facility's policy and procedure on ADL flow sheets. This deficient practice was observed in three out of five residents reviewed for ADLs documentation and was evidenced as follows: 1. [...]

Inspectors wroteBased on record review, interview and policy review, the facility failed to notify the resident's responsible party regarding a new diagnosis of pneumonia and a change in antibiotic for one (Residents (R) 434) of three resident reviewed for change in condition.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that an accurate Preadmission Screening and Resident Review (PASARR) Level I assessment was completed after admission for three (Resident (R)154, R61 and R84) out of 12 residents reviewed for PASARR I.

Inspectors wroteBased on observations, interviews, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 1/4/2022 from 9:53 to10:42 AM, the surveyors, accompanied by the Assistant Administrator (AA) observed the following in the kitchen: 1. In the dry storage room on a middle shelf a stack of Styrofoam bowls was removed from their original packaging. The bowls were uncovered, and the eating surface was exposed. On interview the AA stated, I'll take those. That shouldn't be like that. 2. On a middle shelf in the dry storage room a can of Cuts Hearts of Palm had a significant dent on the upper seam. The AA removed the can to the designated dented can area. 3. [...]

Inspectors wroteBased on observations, interviews, record review and review of other facility documentation, it was determined that the facility failed to implement infection control measures for the handling and storage of respiratory equipment for 2 of 4 residents reviewed for respiratory care, (Resident #34 and Resident #9). This deficient practice was evidenced by the following: 1. On 01/04/2022 at 10:32 AM, surveyor #1 observed Resident #34 lying in bed with the head of the bed elevated. Resident #34 had a tracheostomy (trach) (a surgical opening in the throat area with a tube for breathing) with a mask over the trach (used to deliver oxygen, humidification, and medications) connected to blue corrugated tubing. [...]