Regency Park Nursing & Rehab Center of Carroll

In the surveyor’s words

From the most serious findings on record at Regency Park Nursing & Rehab Center of Carroll, in the surveyor’s own words.

• Actual harm, isolatedF658Aug 27, 2024

  Based on clinical record review, staff interviews, hospital record review and policy review the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 4 residents reviewed (Residents #1). The facility failed to obtain a urinalysis (UA) per Physician order in a timely manner which resulted in Resident #1 being transferred to the hospital and dying due to septic shock (bacterial infection that causes low blood pressure and organ failure) and urosepsis (untreated urinary tract infection (UTI) that spreads to the kidneys and causes sepsis). The facility received an order to obtain a UA on 8/12 and did not obtain the UA until 8/16. […]

• No harm, potential for more than minimal, patternF726Jul 10, 2023

  Based on staff interviews, facility document review and personnel file review the facility failed to provide adequate staff for the overnight shift. Several overnight staff personnel were found to be sleeping while on duty. The facility reported a census of 27 residents. Findings include: On 7/5/23 at 12:30 PM Certified Nurse Aide (CNA), Staff I, stated that in November of 2022 she worked several times with CNA Staff F on the overnight shift and Staff F would come to work very confused, out of it and often fell asleep while on duty. Staff I stated she had seen Staff F so confused that she couldn't remember how to use the Hoyer mechanical lift. Staff I stated the Director of Nursing (DON) had been notified about the concerns. […]

• No harm, potential for more than minimal, isolatedF550Aug 4, 2025

  Based on clinical record review, staff interviews and personnel file review, the facility failed to provide dignity to 2 of 4 residents (Resident #1, Resident #2) reviewed. The facility failed to provide dignity to the residents as demonstrated by residents stating they felt their care was rough due to the speed in which their care was provided. The facility reported a census of 33 residents. Findings Include: 1. The Minimum Data Set (MDS) for Resident #1, dated 6/1/25, identified a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The resident had diagnoses of atrial fibrillation, heart failure, peripheral vascular disease, diabetes mellitus, anxiety, depression, and other specified disorders of bone, ankle, and foot. […]

• No harm, potential for more than minimal, isolatedF880Oct 31, 2024

  Based on clinical record review, observations, staff interviews, CDC recommendations and policy review, the facility staff failed to follow transmission based precautions for 1 of 1 resident reviewed (Resident #34) The facility reported a census of 29 residents. Findings include: The Minimum Data Set (MDS) assessment had not been completed due to Resident #34 was admitted on [DATE]. Review of facility fax dated 10/25/24 revealed Resident #34 had a productive cough with thick yellow sputum. Lung sounds diminished with rub noted on expiratory in the lower lobe. New orders from the physician included lab work and swab for influenza and Covid. […]

• No harm, potential for more than minimal, isolatedF881Oct 31, 2024

  Based on facility policy review, staff interviews and clinical record review the facility failed to follow an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 1 resident (Resident #3). The facility failed to follow up on a urine culture. The facility reported a census of 29 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnosis of urinary tract infection, renal insufficiency, diabetes mellitus, and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. […]