Regency House of Alexandria

Inspectors wroteBased on interviews and record review, the facility failed to ensure direct care staff consulted with the Physician or Nurse Practitioner for 1 (#3) of 4 (#1, #2, #3, #4) sampled residents reviewed. The facility failed to notify the Physician or Nurse Practitioner when Resident #3 refused to go to dialysis on 06/15/2026 and 06/19/2026.

Inspectors wroteBased on record review and interview, the facility failed to develop and maintain a comprehensive, person-centered care plan with measurable goals and individualized interventions for 3 (Resident #1, Resident #2, and Resident #3) of 4 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards for food service safety by failing to document food temperatures for each meal prior to tray assembly. This deficient practice had the potential to affect all 42 residents who received meals prepared in the kitchen. Review of the facility's undated policy titled Record of Food Temperatures revealed, in part, that it is the facility's policy to record food temperatures daily to ensure foods are served at proper temperatures before trays are assembled. The policy further directed staff to measure and record the temperature of each food item and milk at every meal on a temperature log. On 07/09/2026 at 11:30 a.m., observation of the dining room during lunch service revealed two residents who reported their meals were not warm. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to food items served for 1 (Resident #1), and failed to provide a nutritional supplement as ordered for 1 (Resident #2) of 3 Sampled Residents.

Inspectors wroteBased on record review and interview, the facility failed to establish a grievance policy to ensure the prompt resolution of all grievances for 2 (#2 and #8) of 29 sampled residents. The facility failed to:Establish a grievance policy which identified a Grievance Official;Establish a grievance policy which included the contact information of the Grievance Official with whom a grievance can be filed; andMaintain evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision. This deficient practice had the potential to effect all 44 residents residing in the home. Review of the facility's policy titled, Resident and Family Grievances revised 09/01/2024 revealed, in part. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered plan of care for each resident and ensure that care and services were furnished to attain the resident's highest practicable physical, mental, and psychosocial needs that were identified in the comprehensive assessment for 2 (Resident #34 and #51) of 29 sampled residents by the facility failing to:1. Develop and implement a plan of care related to Resident #34's oxygen use.2. Develop and implement a plan of care related to Resident #51's Hospice service. Resident #34Review of Resident #34's medical record revealed an admit date of 01/12/2026 with diagnoses which included in part. Chronic Obstructive Pulmonary Disease, Pneumonia Unspecified Organism, Acute on Chronic Diastolic (Congestive) Heart Failure and Chronic Kidney Disease Unspecified. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's comprehensive care plan was revised after a change in the residents advance directive status for 1 (Resident #22) of 29 sampled residents.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to follow physician's orders for 1 (Resident #10) of 29 sampled residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident received adequate supervision to prevent incidents and accidents. The facility failed to ensure a resident received 1:1 supervision as ordered for 1 (Resident #7) of 1 resident reviewed for accidents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #34) of 29 sampled residents. The facility failed to ensure respiratory equipment was properly labeled.

Inspectors wroteBased on record review and interview, the facility failed to ensure nursing staff had the appropriate knowledge and skill sets to provide care and respond to each resident's individualized needs as identified in his/her assessment and care plan. The facility failed to verify the presence of a Louisiana nursing license prior to hire for 1 (S12 LPN) of 2 licensed nurses whose employee records were reviewed. Interview on 03/03/2026 at 9:50 a.m. with S12 LPN revealed she began working in the facility on 03/02/2026. S12 LPN revealed she was supposed to be orienting with the nurse who was pulled to do treatments. S12 LPN revealed she had been orienting with S6 RN, but S6 RN had been reassigned to perform resident treatments. S12 LPN revealed she was assigned residents and was waiting for a login for the computer. Review of S12 LPN's employee record revealed a hire date of 03/02/2026. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure an annual performance review was completed for 1 (S11 CNA) of 3 CNAs whose employee records were reviewed. Review of S11 CNA's employee record revealed a hire date of 09/16/2024. Further review failed to reveal an annual performance review. Interview with S8 HR on 03/04/2026 at 8:23 a.m. revealed S11 CNA had an initial performance review on 02/24/2025. S8 HR confirmed S11 CNA did not have an annual performance review, but should have.

Inspectors wroteBased on observation and interview, the facility failed to post the required nurse staffing data for licensed and unlicensed nursing staff directly responsible for resident care on a daily basis at the beginning of each shift. Observation on 03/03/2026 at 9:32 a.m. revealed a Staff Reporting Form dated 03/02/2026 posted on a clipboard at the nurse's station. Interview with S2 ADON on 03/03/2026 at 9:34 a.m. revealed the Staff Reporting Form was to be posted on a daily basis, at the beginning of each shift. S2 ADON confirmed the Staff Reporting Form for 03/03/2026 had not been posted, but should have been. Observation on 03/03/2026 4:02 p.m. revealed a Staff Reporting Form dated 03/02/2026 posted on a clipboard at the nurse's station. A Staff Reporting Form dated 03/03/2026 was not posted. Observation on 03/04/2026 8:11 a.m. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that the planned menus were followed to meet the nutritional needs of the residents requiring a pureed diet. The facility failed to follow the established recipe during the preparation of pureed foods, which did not ensure the nutritional adequacy of the meals provided to residents who required a pureed diet. This had the potential to affect a total of two residents who received pureed diets.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure open food items stored in the pantry and refrigerator were dated with an open date. This deficient practice had the potential to affect 43 residents who received meals served from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development of communicable diseases and infection for 1 (Resident #49) of 1 resident reviewed for infection control. The facility failed to ensure:EBP were utilized as ordered; andA peripheral IV site was changed every 3 days. Review of the facility's policy titled Enhanced Barrier Precautions revised 09/01/2024 revealed, in part. 2b) An order for enhanced barrier precautions will be obtained for residents with.feeding tubes. 3a) Implementation of Enhanced Barrier Precautions: make gowns and gloves available immediately near or outside of the resident's room. Face protection may also be needed if performing activity with risk of splash or spray. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care and services that met professional standards of quality for 1(Resident #1) of 3 residents by failing to ensure controlled medications that were ordered for Resident R1 were not administered to Resident #1. The facility census was 47.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services to ensure procedures that assure the acquiring and dispensing of a controlled medication (Hydrocodone-Acetaminophen) to meet the needs of the resident for 1 (Resident #1) of 3 sampled residents. Total facility census was 47.

Inspectors wroteBased on record review and interview the facility failed to ensure an injury of unknown origin and a serious bodily injury of an unknown origin were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 2 (#1 and #2) of 3 (#1, #2 and #3) sampled residents reviewed for accidents. The facility failed to: 1. Ensure injury of unknown origin of Resident #1 was reported within 2 hours in accordance with State law through established procedures. 2. Ensure serious bodily injury and injury of unknown origin of Resident #2 was reported within 2 hours in accordance with State law through established procedures. Findings Review of the facility undated policy titled Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation read in part . [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive person-centered care plan for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to ensure a CNA staff reported Resident #1's complaint of pain to the nurse as indicated in the plan of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services that met professional standards of quality by failing to ensure medications were administered and accurately documented on the MAR for 1 (#44) of 4 sampled residents (#44,#155,#157,#159) observed during medication administration. The facility had a total census of 54 residents according to the Resident List Report provided by the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services to ensure procedures that assure acquiring, receiving, dispensing and administration of a non-controlled medication (Sacubitril-Valsartan) to meet the needs of the resident for 1 (Resident #44) of 4 sampled residents (#44, #155,#157 and #159) observed during medication administration. The facility had a total census of 54 residents according to the Resident List Report provided by the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure their medication error rate was not 5 percent or greater. The facility had 4 medication errors (11.76%) out of 34 opportunities for errors observed. The facility had a total census of 54 residents according to the Resident List Report provided by the facility. Findings Review on 02/12/2025 of the facility's policy and procedure dated 09/01/2024, and titled Medication Administration read in part . Policy: Medications are administered by licensed nurses . as ordered by the physician and in accordance with professional standards of practice . Policy Explanation and Compliance Guidelines: 10. Ensure that the six rights of medication administration are followed: f. Right documentation 11. Review MAR to identify medication to be administered. 12. [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to follow infection control practices to prevent the development and transmission of infection. The facility failed to: (1) Implement Enhanced Barrier Precautions for Resident #206. (2) Ensure staff wore proper PPE while providing incontinent care to Resident #155. (3) Ensure that the facility's water management system was tested for Legionella.

Inspectors wroteBased on interview and record review the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, by failing to honor a resident's right to request an incontinent wipe.

Inspectors wroteBased on observation and interview the facility failed to ensure each resident was treated with respect and dignity for 1 (Resident # 205) out 19 sampled residents. The facility failed to ensure Resident #205 had adequate clothing.

Inspectors wroteBased on interview and record review, the facility failed to promptly notify the physician and responsible party after a change in resident's condition for 1 (Resident #49) of 3 (Resident #49, Resident #13, and Resident #158) residents investigated for accidents. The facility failed to notify the physician and responsible party in a timely manner after an unwitnessed fall.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that services provided or arranged in accordance with the resident's plan of care are delivered by individuals who have the skills, experience and knowledge to do a particular task or activity. This includes proper licensure or certification, if required. The facility failed to ensure that S6 CNA did not apply Zinc Oxide cream to Resident #206's stage 3 Sacral pressure sore.

Inspectors wroteBased on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #156) of 2 (Resident #13 and Resident #156) sampled residents reviewed for respiratory care. The facility failed to ensure equipment was properly labeled and stored. Total sample size was 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in a secure manner by failing to ensure medications were not left at the bedside for 1 (Resident #25) of 19 sampled residents.

Inspectors wroteBased on observation and interviews the facility failed to ensure garbage and refuse were disposed of properly.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program to prevent and control the spread of COVID-19 by failing to ensure proper signage was utilized for 2 of 2 (Resident #2 and #R1) residents on Transmission Based Precautions out of a total sample of 4 (Resident #1, Resident #2, Resident #3, and #R1) residents.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident's person-centered plan of care was implemented for monitoring side effects and effectiveness of an anticoagulant medication, for 1 (Resident #3) of 3 sampled residents. (Resident #1, Resident #2, and Resident #3).

Inspectors wroteBased on record review and interview, the facility failed to ensure services were provided to meet professional standards of practice for 1 (#3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to: 1. Ensure Physician's orders for obtaining labs for a medication that required a drug level were followed for Resident #3; and 2. Ensure Resident #3's physician was notified of and immediately responded to abnormal lab test results for an anticoagulant.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were stored and labeled properly in accordance with currently accepted professional principles on 1 (Hall B) of 2 (Hall A and Hall B) medication carts and 1 of 1 medication storage rooms

Inspectors wroteBased on record review and interview the facility failed to provide evidence that ongoing monitoring or evaluations were being done to ensure the corrective actions put in place after identification of an increase in the number of residents with weight loss, falls, and wounds.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections. The facility failed to ensure the following: 1. Proper hand hygiene during wound care for Resident # 14. 2. [NAME] gloves prior to administration of eye drops for Resident #251. This failed practice had the potential to affect all residents who receive medications and treatments that are managed by the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain dignity for 1 (Resident #24) of 20 sampled residents by failing to ensure resident was free of facial hair.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide nail care for 1 (#24) of 3 (#4, #24 and #102) residents reviewed for ADL care.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure a resident received the necessary care and services in accordance with the resident's comprehensive assessment and professional standards of practice by failing to provide wound care as ordered for 1 (Resident #7) of 2 (#7, #14) residents reviewed for skin conditions.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure that a resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary tract infections for 1 (#39) of 1 resident reviewed for urinary catheters. The facility failed to change Resident #39's catheter every 30 days as ordered by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 1 (Resident #32) of 1 sampled residents reviewed for respiratory care.

Inspectors wroteBased on interview and record review the facility failed to include the Medical Director or Medical Director designee in the Quality Assessment & Assurance (QAA) process. The facility's total census was 53 as per information provided by S7 Administrator.