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Deficiency Records for Regency at The Park
A list of the most recent deficiencies for Regency at The Park. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Regency at The Park. 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? |
|---|---|---|---|---|
| Observe each nurse aide's job performance and give regular training. | Health | 2024-05-22 | 2024-06-26 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-09 | 2024-03-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-18 | 2024-02-26 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-01-18 | 2024-02-26 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2024-01-18 | 2024-02-26 | 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 | 2024-01-18 | 2024-02-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-18 | 2024-02-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-18 | 2024-02-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-18 | 2024-02-26 | N |
| 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 | 2024-01-18 | 2024-02-26 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2024-01-18 | 2024-02-26 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2024-01-18 | 2024-02-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-18 | 2024-02-26 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-18 | 2024-02-26 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2024-01-18 | 2024-02-26 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-03 | 2024-02-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-03 | 2024-02-16 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-01-09 | 2024-02-13 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2024-01-09 | 2024-02-13 | N |
| Meet other general requirements. | Fire Safety | 2024-01-09 | 2024-02-13 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-01-09 | 2024-02-13 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-09 | 2024-02-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-09 | 2024-02-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-09 | 2024-02-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-09 | 2024-02-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-09 | 2024-02-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-09 | 2024-02-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-01-09 | 2024-02-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-09 | 2024-02-13 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-01-09 | 2024-02-13 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2023-11-06 | 2023-11-30 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-02-16 | 2023-03-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-02-16 | 2023-03-16 | 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 | 2023-02-16 | 2023-03-16 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-02-16 | 2023-03-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-16 | 2023-03-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-16 | 2023-03-16 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-02-16 | 2023-03-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-14 | 2023-03-07 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-02-14 | 2023-03-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-14 | 2023-03-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-14 | 2023-03-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-21 | 2022-12-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-25 | 2022-09-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-29 | 2022-07-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-29 | 2022-07-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-29 | 2022-07-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-07 | 2022-07-13 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-07 | 2022-07-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-07 | 2022-04-15 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-03-03 | 2022-04-15 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-03 | 2022-04-15 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-03-03 | 2022-04-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-03 | 2022-04-15 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-03-03 | 2022-04-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-09 | 2021-11-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-09 | 2021-11-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-26 | 2020-04-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-02-26 | 2020-04-06 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2020-02-26 | 2020-04-06 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-02-26 | 2020-04-06 | 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 | 2020-02-26 | 2020-04-06 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2020-02-26 | 2020-04-06 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-02-26 | 2020-04-06 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-02-26 | 2020-04-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-02-26 | 2020-04-06 | N |
| Respond appropriately to all alleged violations. | Health | 2020-02-26 | 2020-04-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-26 | 2020-04-06 | 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 | 2020-02-26 | 2020-04-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-26 | 2020-04-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-26 | 2020-04-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-26 | 2020-04-06 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-02-26 | 2020-04-06 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2020-02-26 | 2020-04-06 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-02-26 | 2020-04-06 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2020-02-26 | 2020-04-06 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-02-26 | 2020-04-06 | 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 | 2020-02-26 | 2020-04-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-02-26 | 2020-04-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-26 | 2020-04-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-02-26 | 2020-04-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-02-26 | 2020-04-06 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2020-02-26 | 2020-04-06 | N |
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