Regency Village

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures to ensure the accurate acquiring, receiving, dispensing, and administering of medications, to meet the needs of residents for 3 of 8 residents (Resident #1, CR #2, and CR #3) reviewed for pharmaceutical services. The facility failed to provide Resident #1 with Apixaban (anticoagulant) on 7/1/2026 and 7/2/2026, resulting in 4 missed doses. The facility failed to provide CR #2 with the following prescribed medications:Atorvastatin from 6/2/2026-6/6/2026 (6 missed doses);Flomax from 6/2/2026-6/6/2026 (6 missed doses);Pregabalin from 6/2/2026-6/6/2026 and 6/13/2026-6/19/2026 (23 missed doses);Methocarbamol from 6/11/2026-6/19/2026 (24 missed doses); andMidodrine from 6/2/2026-6/7/2026 (16 missed doses). [...]

Inspectors wroteBased on interviews and record review, the facility failed to report and investigate an incident for 1 resident of 5 residents (Resident #1) reviewed for abuse/neglect in that: The facility failed to report an allegation of staff abuse made by Resident #1 of an incident that occurred on 11/8/25 at an unknown time, to the State Agency. This failure could place residents at risk of abuse of residents. Record review of the admission record dated 1/12/26, revealed that Resident #1 was a [AGE] year-old male who was originally admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included Amyotrophic Lateral Sclerosis (also known as ALS, is a nervous system disease that affects nerve cells in the brain and spinal cord. ALS causes loss of muscle control. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #1) of 5 residents reviewed for dignity. LVN S failed to change and/or irrigate Resident #1's foley catheter on 11/28/25 when it was leaking, not flowing correctly, and there was an order to change it and irrigate it PRN, causing Resident #1 to sit in urine soaked bed linen and t-shirt. This failure could place residents at risk for embarrassment, decrease in dignity, and a decrease in quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who entered the facility with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #1) of 5 residents reviewed for catheters. LVN S failed to change and/or irrigate Resident #1's foley catheter on 11/28/25 when it was leaking, not flowing correctly, and there was an order to change it and irrigate it PRN, causing Resident #1 to call 911 and go to the ER.This failure could place residents at risk of urinary tract infections, the bladder to burst, skin break down, embarrassment, and possible hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to be free from abuse for 1 of 7 residents (Resident #2) reviewed for abuse in that:The facility failed to ensure Resident #2 was free from abuse by Resident #1 on 07/25/2025 when Resident #1 hit Resident #2 in the face. This failure could place residents at risk of abuse and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: - The facility failed to keep kitchen equipment clean and free of grease build up. - The facility failed to label foods for identification and dated with expiration date. - The facility failed to ensure that expired food items and products were not stored in the walk- in refrigerator. These failures could place residents at risk for food-borne illness and/or transmission-based infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure that assessments accurately reflected residents' status for 3 (Resident #7, #16, #22) of 10 residents reviewed for accuracy of assessments. -The facility failed to ensure that Resident #7's falls that occurred on 4/20/25 were documented on their annual MDS assessment dated [DATE]. -The facility failed to ensure that Resident # 16 's falls were documented on her Annual MDS assessment dated [DATE], quarterly MDS dated [DATE] and 12/11/24. - The facility failed to ensure that Resident # 22 's falls were documented on her Annual MDS assessment dated [DATE], quarterly MDS dated [DATE] and 12/23/24. These failures could place residents at risk of receiving inadequate care and services based on inaccurate assessments.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement comprehensive care plans with measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs identified in the comprehensive assessment for of 20 residents reviewed for care plan accuracy(Residents # 59, 123, 17) ---there were no comprehensive care plans in Resident #'s 59, 123, and 17 elctronic medical records. These failures placed residents at risk of receiving inadequate care due to incomplete care plans.

Inspectors wroteBased on interviews and record review, the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System, within 14 days, upon a resident's transfer, reentry, discharge, and death, for 1 of 18 residents (Resident #35) reviewed for transmitted MDS data to the CMS System. The facility failed to complete Resident #35's admission MDS assessment within 14 days of admission. This failure could place residents at risk of not having their assessments transmitted timely which could cause a delay in treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were unable to carry out Activities of Daily Living received the necessary services to maintain grooming and personal hygiene for 1 (Resident #7) of 5 residents reviewed for Activities of Daily Living. The facility failed to provide Resident #7 with adequate oral care. This failure could place residents at risk of diminished quality of life or decreased self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care was provided such care, consistent with professional standards of practice for 2 (Residents #27 and #32) of 4 residents reviewed for respiratory care. The facility failed to ensure Resident #27's oxygen humidifier was not empty and Resident #32's oxygen concentrator was working appropriately by not beeping. The failure could place residents at risk of developing respiratory complications or having decreased quality of care from dry nasal passages that could lead to nosebleeds or sores.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to immediately inform the resident's physician of a significant change in a resident's physical condition for one of five residents (Resident #1) reviewed for notification of change. -The facility failed to ensure Resident #1 received podiatry services on 3/29/24 and failed to ensure staff accurately and thoroughly reported Resident #1's change in condition to his third toe on his right foot, to his physician on 04/01/24. NP A was asked by Resident #1 to assess his right foot when he reported pain on 04/04/24. Resident #1 was sent to the hospital on [DATE] and had the third toe of his right foot amputated on 04/07/24 and the remaining toes on his right foot amputated on 5/12/24. Resident #1 no longer walked independently and used a wheelchair for mobility since 4/7/24. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one of five residents (Resident #1), reviewed for Quality of Care. -The facility failed to ensure Resident #1 received podiatry services on 3/29/24 and failed to ensure staff accurately and thoroughly reported Resident #1's change in condition to his third toe on his right foot, to his physician on 04/01/24. NP A was asked by Resident #1 to assess his right foot when he reported pain on 04/04/24. Resident #1 was sent to the hospital on [DATE] and had the third toe of his right foot amputated on 04/07/24 and the remaining toes on his right foot amputated on 5/12/24. Resident #1 no longer walked independently and used a wheelchair for mobility since 4/7/24. [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident # 2) reviewed for adequate supervision. --The facility failed to provide adequate supervision and put measures in place to prevent residents from eloping. Resident #2 had a history of exit seeking behaviors and wandering and eloped from the facility on 3/15/25. He was found walking on the street in front of the facility. The resident discharged to home 3/21/25. This noncompliance was identified as Past Non-Compliance. The IJ began on 3/15/25 and ended on 3/15/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to coordinate with Pre-admission and Resident Review program (PASRR) under Medicaid and initiate services within 20 days after the date that the services are agreed upon in the IDT meeting, to ensure that individuals with intellectual developmental disabilities receive the care and services they need in the most appropriate setting for 1 of 31 residents (Resident#1) reviewed for PASRR. The facility failed to complete and submit therapy evaluations for Habilitative services for PT, OT and ST services agreed upon in an IDT meeting on 10/17/24 addressing Resident #1's needs. This failure could affect residents with intellectual and developmental disabilities requiring PASRR services at risk of a delay in or not receiving specialized services that would enhance their highest level of functioning.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure a comprehensive care plan was developed within 7 days after completion of the comprehensive assessment and reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 4 (Resident #1) residents reviewed for IDT meetings/ care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #1. This deficient practice could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 residents (Resident #1) reviewed for infection control. The Administrator failed to wash or sanitize his hands and did not donn appropriate personal protective equipment (PPE) when he entered and exited Resident #1's room. Resident #1 had COVID-19 and was on droplet precautions. The facility failed to ensure the Administrator wore appropriate PPE, which included a gown, gloves, and N95 mask, when entering Resident #1's room on 3/14/2025, who was on droplet precautions (steps taken in the hospital to prevent spreading infections) for COVID-19. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident was free from abuse, neglect, and exploitation for 1 of 6 residents (Resident #27) reviewed for abuse and neglect. The facility failed to prevent and correct alleged violation of abuse regarding Resident #27 that was reported on 2/21/2024. It was alleged that on 2/20/2024 a charge nurse witnessed Resident #27's family member shaking the resident hard by her shoulders and was screaming at her. Resident #27 family member was instructed to leave the facility. The facility did not put in place a care plan or interventions to prevent the abuse from occurring again. The facility failed to thoroughly investigate the abuse allegation and mitigate further harm while they continue to investigate. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress for 1 of 6 residents (Resident #27) reviewed for abuse and neglect. The facility failed to prevent and correct alleged violation of abuse regarding Resident #27 that was reported on 2/21/2024. It was alleged that abused occurred on 2/20/2024 when a charge nurse witnessed Resident #27's family member shaking her hard by her shoulders and was screaming at her. Resident #27 was heard saying that resident #27 yelled saying her family member was trying to kill her. Resident #27 family member was instructed to leave the facility. The facility did not put in place a care plan or interventions to prevent the abuse from occurring again. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. Twenty-five opportunities were observed with a total of two errors, resulting in an eight percent medication error rate involving 2 residents (Residents #4 and #66) and 2 of 7 staff (LVN J and LVN L) reviewed for medication errors, in that: -LVN L administered the wrong dose of Prostat AWC (indicated for increased protein needs in low volume related to stages 2 to 4 pressure injuries, multiple pressure injuries, hard-to-heal wounds, unintentional muscle loss, protein-energy malnutrition, low serum proteins, and sarcopenia) to Resident #4. -LVN J administered Morphine Sulfate to Resident #66 using the wrong route. [...]

Inspectors wroteBased on interview and record review the facility failed to revise and update the comprehensive care plan for 1 of 5 residents (Resident #27) reviewed for care plans. The facility failed to put in place interventions and update the care plan that would prevent further abuse and make staff aware of the incident for Resident #27. This failure could place other residents at risk of not having their individually needs met and place them at risk of abuse and neglect.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen: The facility failed to ensure: -1. The facility failed to label and date food items stored in walk-in- refrigerator -2. The facility failed to ensure that left over food items was dated and properly stored in sealed containers with lid -3. The facility failed to remove damaged food cans from inventory. -4. The facility failed to ensure that frozen meat was thawed properly under running water or in the refrigerator. These failures could place residents at risk of food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights which included measurable objective and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs that were identified in the comprehensive assessment for 3 of 18 residents (Residents #49, #60, and #84) reviewed for care plans. 1 The facility failed to develop a care plan for Resident #49 to include the triggered care areas of communication and activities 2 The facility failed to develop a care plan for Resident #60 to include the triggered care areas of communication and activities 3 The facility failed to develop and implement care plans for Resident #84's for the triggered care area of mood and activities. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 3 of 10 residents ( Resident #16, Resident #21 and Resident #100), 1 of 4 Medication Carts( 400 Hall Medication Aide Cart and 1 of 1 Medication Rooms (Medication Room) reviewed for pharmacy services. - The facility failed to ensure the 400 Hall Med Aide Cart did not include and expired bottle of OTC iron supplement - The facility failed to ensure the Medication Storage Room did not contain expired reconstituted liquid and IV medications. - The facility failed to ensure that Resident #16 received his Memantine (a medication to treat memory deficits caused by Alzheimer's disease and dementia) as prescribed from 11/22/22 to 12/14/22. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 10 percent based on 3 errors out of 30 opportunities, which involved 3 of 9 residents (Resident #16 and Resident #27, Resident #44)reviewed for medication errors. - LVN B failed to administer medication to Resident #44 as ordered by administering Levalbuterol ( a medication to help breathing) without the use of spacer. - MA A failed to administer medication to Resident #16 as ordered by administered Memantine 5 mg ( a medication to treat memory) instead of Memantine 14 mg ER. - MA A failed to administer medication to Resident #27 as ordered by administering 2 drops of Timolol ( a medication to treat glaucoma) into the resident's right eye instead of 1 drop. [...]

Inspectors wroteBased on interview, and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 of 18 residents (Resident #84) reviewed for resident assessments. The facility failed to ensure Resident #84's admission MDS Assessment accurately reflected her mental condition. This failure could place residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview. and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 18 residents (Residents #49 and #60,) reviewed for care plan. 1 The facility failed to develop a care plan for Resident #49 to include the triggered care areas of activities 2 The facility failed to develop a care plan for Resident #60 to include the triggered care areas of communication, These failures could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided, met professional standard of quality for 2 (Resident #27, and #60) of 18 residents assessed for physician's order in that: - The facility failed to follow Resident #27, & and Resident #60's physician's orders to place a wander guard due to the resident's risk of wandering. These failures could place residents at risk of not receiving the care and services ordered by the physician and a decline in health status. Record review of Resident #27's admission face sheet revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included dementia without behavior disturbance, psychotic disturbance, mood disturbance, anxiety, restlessness, agitation, major depressive disorder, and type II diabetes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that drugs and biologicals were labeled in accordance with professional principles and stored in locked compartments under proper temperature controls for 2 of 4 medication carts. (300 Hall Nursing Cart and 400 Hall Medication Aide Cart) reviewed for medication storage. The facility failed to ensure: - The 300 Hall Nursing Cart did not include an insulin pen with no open date - The 400 Hall Medication Aide Cart did not contain medications stored outside of manufacturer specified temperature ranges. These failures could place residents at risk of adverse medication reactions and drug diversion.