Schulenburg Regency Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Dec 13, 2024

  Based on observations, interviews, and record reviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #109) of 4 residents reviewed for elopement on 10/27/24. The facility failed to put interventions in place to prevent Resident #109 from eloping from the facility when she walked out of the memory care unit and exited the fire alarm gate on 10/27/24. Resident #109 was found by an exit door again on 12/01/24 . Resident has history of opening the doors after pushing on them for 15 seconds allowing the door to open. An IJ was identified on 12/12/24. The IJ template was provided to the facility on [DATE] at 3:30 PM. […]

• Immediate jeopardy, isolatedF700Jan 24, 2023

  Based on observation, interview, and record review, the facility failed to assess the resident for risk of entrapment from bed rails prior to installation for one (Resident #1) of three residents reviewed for use of side or bed rails, in that: The facility failed to ensure full length bed rails were securely fastened to Resident #1's bed. She became entrapped between the rail and her mattress on 01/06/23, sustaining a femur fracture. This deficient practice could affect residents who use bed or side rails as enablers, resulting in entrapment or injury. An Immediate Jeopardy (IJ) existed from 01/06/23 - 01/07/23. […]

• No harm, potential for more than minimal, widespreadF851Oct 26, 2023

  Based on interview and record review, the facility failed to follow guidelines for mandatory electronic submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 3 quarters reviewed for payroll data information (Quarter 3 2023). The facility failed to submit PBJ staffing information to CMS for the 3rd quarter (April 1 - June 30) of fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. […]

• No harm, potential for more than minimal, patternF755Mar 11, 2026

  Based on observations, interviews, and record review the facility failed to ensure 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 each resident.The facility failed to ensure that the medications stored in the medication storage room [ROOM NUMBER] were not expired.This deficient practice could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment.The findings included:During an observation in medication room [ROOM NUMBER] on 3/9/2026 at 10:30am it was revealed that the following medications and other items were expired:Two bottles of Pro - Stat Concentrated Liquid Protein 30 fluid ounces. […]

• No harm, potential for more than minimal, patternF812Dec 10, 2025

  Based on observations, interviews and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for one of two kitchens reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary Assistant [NAME] A used proper hand hygiene during food preparation.2. The facility failed to ensure Dietary Assistant [NAME] A used appropriate oven mitt to remove food from the oven and prevent cross-contamination of the food. These failures could place residents who ate food from the kitchen at risk for foodborne illness.Findings included: 1. Observation on 11/01/2025 at 7:20 AM, reflected Dietary Assistant [NAME] A touched her shirt, the right side of her hair, and touched her face with her right hand. […]