A list of the most recent deficiencies for Regency Healthcare and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-15 | 2024-01-23 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-12-15 | 2024-01-23 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-12-15 | 2024-01-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-15 | 2024-01-23 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-15 | 2024-01-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-15 | 2024-01-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-15 | 2024-01-23 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-12-15 | 2024-01-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-15 | 2024-01-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-15 | 2024-01-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-15 | 2023-12-15 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-12-15 | 2023-12-15 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-05-16 | 2023-06-29 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-05-16 | 2023-06-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-16 | 2023-06-29 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-05-16 | 2023-06-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-16 | 2023-06-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-16 | 2023-06-29 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-05-16 | 2023-06-29 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-05-16 | 2023-06-29 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-05-16 | 2023-06-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-16 | 2023-06-29 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-05-16 | 2023-06-29 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-05-16 | 2023-06-29 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-16 | 2023-06-29 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-05-16 | 2023-06-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-16 | 2023-06-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-16 | 2023-06-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-05-16 | 2023-06-29 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-05-16 | 2023-06-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-06 | 2023-02-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-12-06 | 2023-02-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-18 | 2023-01-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-18 | 2023-01-10 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-11-18 | 2023-01-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-18 | 2023-01-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-11-18 | 2023-01-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-18 | 2023-01-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-18 | 2023-01-10 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-11-18 | 2023-01-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-18 | 2023-01-10 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-11-18 | 2023-01-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-18 | 2023-01-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-18 | 2023-01-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-11-18 | 2023-01-10 | N |
| Provide or obtain dental services for each resident. | Health | 2022-11-18 | 2023-01-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-18 | 2023-01-10 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2022-03-15 | 2022-05-03 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-15 | 2022-05-03 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-15 | 2022-05-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-15 | 2022-05-03 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-03-15 | 2022-05-03 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-15 | 2022-05-03 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-03-15 | 2022-05-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-15 | 2022-05-03 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-25 | 2022-03-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-25 | 2022-03-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-25 | 2022-03-10 | Y |
