Regency Park Nursing & Rehab Center of Jefferson

Inspectors wroteBased on clinical record reviews, facility investigation review, staff interviews, and policy review, the facility failed to provide adequate nursing supervision to prevent a resident to resident altercation for 2 of 4 residents reviewed (Resident #1 and Resident #2). The facility reported a census of 43 residents.

Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to prepare and serve food under sanitary conditions to reduce the risk of contamination and food borne illness. The facility identified a census of 43 residents.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure resident's had a safe, clean, comfortable and homelike environment, with 2 recliners showing extensive wear. The facility reported a census of 43 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, resident interviews and policy review, the facility failed to complete and document appropriate assessments and interventions for the necessary care and services, to maintain the residents' highest practical physical well-being for 2 of 13 residents reviewed (Resident #12 and #4). The facility failed to document a gastrointestinal assessment and notify the physician when indicated for Resident #12. The facility also failed to implement interventions for Resident #4 with new skin issues. The facility reported a census of 43 residents.

Inspectors wroteBased on observations, record review, staff interviews, and policy review, the facility failed to change oxygen tubing and water humidifier for 1 of 1 residents reviewed (Resident #12) for respiratory services. The facility reported a census of 43 residents. Findings Include: Resident #12's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS included diagnoses of hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD)(progressive lung condition) and congestive heart failure (heart inability to pump blood causing fluid build up). The MDS documented Resident #12 received oxygen while a resident within the last 14 days. A Physician order dated 11/7/25 directed Resident #12 to wear oxygen per nasal cannula to keep oxygen saturation above 90% as needed related to COPD. [...]

Inspectors wroteBased on observation, staff interviews, the Centers for Disease Control and Prevention (CDC) and the facility policy review, the facility staff failed to follow infection control practices in order to prevent and control the onset and spread of infection within the facility by not wearing the required personal protective equipment for 1 of 2 residents (Resident #4) reviewed for catheter care. The facility also failed to keep dirty linens off the floor. The facility reported a census of 43 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility reported a census of 42.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review the facility failed to verify the resident's advanced directive choice for 1 (Resident #46) of 12 residents reviewed. The facility reported a census of 42 residents.

Inspectors wroteBased on clinical record review, resident and staff interview the facility failed to followed a physician's order for 1 resident (Resident #1) of 12 residents reviewed. The facility reported a census of 42 residents.

Inspectors wroteBased on observation, record review, staff interviews, and facility policy review the facility failed to ensure a person that assisted a resident to eat was a certified paid feeding assistant for 1 (Resident #36) of 15 residents reviewed. The facility reported a census of 42 residents.

Inspectors wroteBased on pharmacy interview, staff interviews, policy review and clinical record review the facility failed to keep accurate account of narcotic medications for 2 of 3 residents. On 8/12/24, staff discovered that Resident #1 had 8 milliliters (ml) of morphine missing, and Resident #2 had 12 ml missing. Staff admitted that they did not always look at the bottles at shift change before documenting the amount of remaining liquid morphine. Documentation of narcotics administered was inconsistent between the paper chart and the electronic chart for Resident #1 and #2. The facility reported a census of 39 residents.

Inspectors wroteBased on observation, staff interview, policy review and clinical record review the facility failed to safely store liquid narcotic medications for 1 of 3 residents reviewed (Resident #3). Staff F left two liquid narcotic medications in the top drawer of the medication cart under a single lock. The facility reported a census of 39 residents.

Inspectors wroteBased on staff interview, record review and policy review, the facility failed to consistently count resident narcotics between shifts for 1 of 3 residents reviewed (Resident #7).

Inspectors wroteBased on staff interview, record review and policy review, the facility failed to ensure to resident narcotics were disposed of properly for 1 of 3 residents reviewed (Resident #7).

Inspectors wroteBased on clinical record reviews, observations, resident, and staff interviews, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 2 of 2 residents reviewed (Residents #18 and #10) for falls. 1. Resident #18 fell two times and the facility failed to either put an intervention in place or put an inadequate intervention in place to prevent future falls. After Resident #18 fell on 7/8/23, the facility requested a urinalysis on 7/12/23. The facility collected and received the results on 7/14/23 that revealed a urinary tract infection. The provider ordered to wait for the culture and sensitivity (C&S) results then update them with the results. Resident #18 attempted to get up on her own multiple times, with the staff intervening to prevent her from falling. [...]

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 4 out of 14 residents reviewed (Resident #29, #18, #30, #37). The facility reported a census of 38 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to label individualized insulin pens with a resident identifier, date open vial of tuberculin (TB) solution and had expired treatment supplies in the cupboard and medication cart. The facility reported a census of 38 residents.

Inspectors wroteBased on observation, policy review, and staff interview, staff failed to prepare and serve food under sanitary conditions and failed to properly thaw meat to reduce the risk of contamination and foodborne illness. The facility reported a census of 38 residents.

Inspectors wroteBased on staff interview, resident interview, and facility policy review, the facility failed to provide care for 1 of 14 residents reviewed (Resident #37) in a manner to promote dignity and respect. The facility reported a census of 38 residents.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to notify the Physician when a resident refused to take sliding scale insulin at bedtime and failed to report blood sugars below 70 mg/dl (milligrams per deciliter) for 1 of 1 resident reviewed (Resident #37) for insulin administration. The facility reported a census of 38.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to complete a significant change comprehensive assessment in a timely manner (14 days after facility identified a significant change from baseline had occurred) for 1 out of 14 resident reviewed (Resident #18). The facility reported a census of 38 residents.

Inspectors wroteBased on clinical record review, resident interviews, staff interviews and facility policy review the facility failed to provide oral hygiene per resident preference for 1 of 3 residents reviewed (Resident #26) for Activities of Daily Living.

Inspectors wroteBased on clinical record review, observations, and staff interviews, the facility failed to provide oxygen as ordered by the physician for 1 of 1 resident (Resident #3) reviewed for respiratory services.

Inspectors wroteBased on resident interviews, staff interviews and facility policy review the facility failed to provide sufficient staff to meet the needs of residents who resided in the facility. The facility reported a census of 38 residents.