Regency Manor Nursing & Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision for one (R700) out of ten residents reviewed for accident hazards, resulting in hospitalization with a hematoma (pooling of blood after damage to the blood vessels) of the right forearm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe water temperatures to reduce the risk of severe burns, having the likelihood of affecting all 35 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to have documented Registered Nurse (RN) coverage scheduled for at least eight consecutive hours, per day for seven days a week.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 5/20/26 at 9:00 AM observed the following on a tour of the basement level kitchen with dietary supervisor (DS) B:The low temperature dish machine was operating with no chlorine detected by a test strip. DS B indicated that the chlorine supply was just changed but no chlorine was being dispensed. DS B indicated she was unsure of how to prime the pump and would follow up with a service technician by phone. DS B set up and tested quaternary sanitizer in the 3-compartment sink and indicated they would use that as a sanitize step for all cleaned equipment until the automatic dish machine was properly dispensing sanitizer. [...]

Inspectors wroteBased on observation and interview, the facility failed to properly dispose of waste and maintain the dumpster area to mitigate the presence of pests, potentially affecting all residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to maintain cleanliness and ensure appropriate backflow prevention was installed at plumbing fixtures, resulting in the potential for the spread of pathogens and contamination to the water supply, affecting all 35 residents residing in the facility.

Inspectors wroteThis citation pertains to Intake number 3008091. Based on observation and interview, the facility failed to ensure an adequate supply of towels potentially affecting all 35 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide Advance Beneficiary Notice of Non-coverage (SNF ABN) and Notice of Medicare Non-coverage (NOMNC), at least 48 hours (two days) before the end of coverage for one resident (R34) of three reviewed for Beneficiary notice

Inspectors wroteBased on observation, interview and record review the facility failed to develop a care plan that addressed the complete care needs and behaviors of the residents for three residents (R13, R15, R34) of 12 sampled residents whose care plans were reviewed.

Inspectors wroteThis citation pertains to Intake 2966095. Based on observation, interview, and record review, the facility failed to implement and document a restorative exercise program for two residents (R13, R31) of three residents reviewed for restorative needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, medication and biologicals were discarded when expired and dated when opened in two of two medication carts and one of one medication rooms remained locked when not in use.

Inspectors wroteBased on interview and record review, the facility failed to maintain monthly medication regimen review (MRR) documentation (Pharmacy reviews) for nine residents (R6, R7, R11, R14, R25, R26, R32, R33 and R37) of nine reviewed for pharmacy medication review.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident food items brought in from outside were dated and failed to monitor the temperature of the resident refrigerator. This deficient practice had the potential to affect all residents that consume food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP) and failed to ensure nursing staff used appropriate Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all 37 the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a home-like environment free of offensive odors. This deficient practice had the potential to affect all residents, staff, and visitors.

Inspectors wroteBased on interview and record review the facility failed to provide eight hours of Registered Nurse (RN) coverage potentially affecting all 37 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that two of eight multi-use, single resident medications were labeled with an open date in one of two medication carts. Findings Include:On 7/16/2025 at 11:30 AM, the South medication cart was reviewed with Licensed Practical Nurse (LPN) B and revealed two ophthalmic (eye) preparations (Restasis and Atropine Sulfate) that were opened without open dates. LPN B revealed any medications for single patient use should include the resident name and date opened. At 11:45 AM, Unit Manager (UM) A was queried regarding the expectations regarding when medications should be date and confirmed, labeled medications for a single resident, should be dated when opened. At 1:30 PM, The Director of Nursing (DON) confirmed multi-use medications for single patient use should be dated when opened. [...]

Inspectors wroteThis citation pertains to Intake MI00152611. Based on observation, interview, and record review, the facility failed to provide adequate monitoring and supervision for one resident (R700) out of 14 reviewed for supervision.

Inspectors wroteThis citation pertains to Intake MI00150065. Based on observation, interview, and record review, the facility failed to maintain a homelike environment in the resident showers and ensure the ice machine on the first floor was backflow protected. This deficient practice had the potential to affect all 39 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to transport a resident from a doctors appointment in a respectful manner for one sampled resident (R901) of one reviewed for resident rights.

Inspectors wroteThis citation pertains to Intake: MI00149826. Based on observation, interview, and record review, the facility failed to ensure a wound vac (a medical device that uses negative pressure for wound healing) was consistanly applied for one sampled resident (R901) of two reviewed for skin management.

Inspectors wroteThis citation pertains to Intake: MI00150065 Based on observation, interview and record review, the facility failed to document showers for two dependent residents (R903 and R904) of four residents reviewed for complete medical records.

Inspectors wroteThis citation pertains to Intake MI00149636. Based on interview and record review, the facility failed to provide evidence of a comprehensive facility-wide infection control program encompassing outcome and process surveillance, accurate data collection/documentation/analysis, identifying, preventing, reporting, investigating and treating infections potentially affecting all 32 residents residing in the facility.

Inspectors wroteThis citation pertains to Intake: MI00143867 Based on interview and record review, the facility failed to ensure that the Quality Assurance Performance Improvement (QAPI) committee met quarterly, and was composed of the required committee members, potentially affecting all 33 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enhance barrier precautions were implemented for two residents (R17 and R12 ) identified with an indwelling urinary catheter device and skin impairment and failed to ensure infection control surveillance was documented.

Inspectors wroteBased on interview and record review, the facility failed to ensure care conferences were conducted regularly for four residents (R2, R8, R20, and R23) of five reviewed for care conferences.

Inspectors wroteBased on interview and record review the facility failed to follow up and or document physician notification of pharmacy recommendations from the medication regimen reviews for four residents (R2, R8, R15, and R23) of four reviewed for unecessary medications.

Inspectors wroteThis citation is related to Intake MI00144653. Based on observation, interview, and record review facility failed to obtain resident representative contact for one of one resident (R29) who has had multiple hospitalizations.

Inspectors wroteBased on interview and record review, the facility failed to develop an elopement baseline care plan for one (R133) of one resident reviewed for care plans.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement care plan interventions for behavioral management of individuals on psychotropic medication for one of one resident (R17) reviewed.

Inspectors wroteBased on interview and record review the facility failed to thoroughly complete a discharge summary for one resident (R32) of one resident reviewed for discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a hospital recommendation, follow a physician's order, and follow up on a dental consultation for two residents (R8 and R23) of two residents reviewed for Quality of Care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise and assess the effectiveness of interventions for one sampled resident (R23) of two residents reviewed for falls resulting in, multiple falls and transfers to the hospital.

Inspectors wroteBased on interview and record review, the facility failed to obtain orders for indwelling catheter care for one (R17) of one residents reviewed for catheters.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure as needed (PRN) psychotropic medication had adequate indication for use and a stop date for one resident (R17) of one reviewed for antipsychotic medications.

Inspectors wroteThis citation pertains to Intake: MI00143867 Based on observation, interview, and record review, the facility failed to ensure (urine) odors were limited and interventions and ventilation were adequate to resolve urine odors.

Inspectors wroteThis citation pertains to MI00142236 and MI00142614. Based on observation, interview, and record review, the facility failed to ensure food items and the kitchen were maintained in a safe and sanitary manner with the potential to affect all residents of the facility.

Inspectors wroteThis citation has two deficient practices. This citation pertains to Intakes MI00142236 and MI00142614. Based on observation, interview, and record review, the facilty failed to ensure a clean and safe environment was maintained, this practice had the potential to affect all residents that reside in the facility.

Inspectors wroteThis citation pertains to Intakes MI00142236 and MI00142614. Based on observation, interview, and record review, the facility failed to ensure handrails were firmly mounted to the wall in the upper hallway affecting five of five residents who lived in rooms along the hallway, resulting in the potential for falls.