Regency Care Center

In the surveyor’s words

From the most serious findings on record at Regency Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 20, 2025

  Based on observations, clinical record review, staff interview and policy review, the facility failed to supervise residents at risk for elopement for 1 of 3 residents reviewed (Resident #9). This failure resulted in the resident eloping from the facility, his whereabouts unknown for approximately an hour and 30 minutes and sustaining fractures of five ribs, therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as ofMay 8, 2025, on August 18, 2025 at 1:15 PM. […]

• Immediate jeopardy, isolatedF684Apr 17, 2023

  Based on observations, interviews and record review the facility failed to accurately assess and intervene in a timely manner for resident with change in condition for 3 of 3 residents reviewed, (Resident #82, #83 and #5). On December 4, 2022, Resident #82 was experiencing shortness of breath and coughing symptoms, nursing staff failed to provide timely assessments and on December 5th the resident passed away with cause of death being respiratory failure. This failure resulted in the death of one resident, therefore causing an Immediate Jeopardy (IJ) to the health, safety, and security of the resident. Resident #83 had an unwitnessed fall and staff failed to provide neurological assessments and Resident #5 had edema and an order for daily leg wraps, staff failed to apply the wraps. […]

• Actual harm, isolatedF600May 12, 2026

  Based on observations, interviews, and record review, the facility failed to ensure that a resident was treated with respect and dignity for 1 out of 3 residents reviewed (Resident #18). Resident #18 reported she had laid in urine for a delayed period of time without Staff X, Certified Nurse Aide (CNA), cleaning her up after asking this CNA to clean her up, causing her pain. This resident reported that she felt fearful that Staff X was going to hit her (Resident 18) and did not want Staff X to return to her room. The facility reported a census of 58 residents. Findings include:A Minimum Data Set, dated [DATE], documented that Resident #18's diagnoses included acute respiratory failure with hypoxia and cardiorespiratory conditions. […]

• Actual harm, isolatedF697May 12, 2026

  Based on record review, interview, and facility policy review, the facility failed to assess and provide pain management to adequately control residents pain for 1 of 3 residents (Resident 68) reviewed for pain management. This failure put the resident at risk of uncontrolled pain and a diminished quality of life. The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #68 documented a [DATE] admission date to the facility from an acute hospital stay. Her diagnoses included dementia, difficulty in walking, unsteadiness on feet, repeated falls, and need for assistance with personal care. […]

• No harm, potential for more than minimal, patternF725May 12, 2026

  Based on the Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Reports, staff interviews, facility assessment review, and facility record review, the facility failed to provide sufficient staff to meet resident needs for 12 of 26 weekend days during the months of October, November, and December 2025. The facility reported a census of 58 residents. Findings include: The Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report for the facility for October 1 through December 31, 2025 revealed the facility had triggered the metric for Excessively Low Weekend Staffing which required follow-up during the survey process. […]