WILMINGTON, DE - A February 2025 federal inspection at Regency Healthcare & Rehab Center documented significant care planning deficiencies, including the facility's failure to implement appropriate toileting interventions for a dementia resident who experienced multiple bathroom-related falls.
Toileting Program Failure for Fall-Risk Resident
Federal inspectors identified critical gaps in care planning for a resident with dementia who experienced six documented falls over a four-month period, all related to attempts to use the bathroom independently. The resident, identified as R43 in inspection records, was admitted in July 2024 with severely impaired cognition yet received no structured toileting program despite clear evidence of need.
The inspection narrative documented the resident's progression from complete continence to frequent incontinence between July 2024 and October 2024. During this period, facility assessments repeatedly noted "occasional" bladder and bowel incontinence, yet staff failed to implement a scheduled toileting program. When asked whether a toileting program had been attempted, facility documentation showed conflicting responses including "No," "Unable to determine," and "don't know."
Between August and October 2024, the resident experienced six falls, all occurring when attempting to reach the bathroom without assistance. One incident report from October 17, 2024, documented the resident "transferring self from bed to go to the bathroom without asking for assistance" and falling before reaching the bathroom, resulting in a head injury that required hospital evaluation.
The pattern of falls demonstrated a clear need for intervention. On August 13, staff found the resident sitting on the floor at the bathroom door. The following day, the resident fell from a wheelchair while attempting to use the bathroom independently. Multiple October incidents showed the same pattern: the resident attempting to transfer independently to use the toilet, then falling.
Inadequate Assessment and Care Planning
Facility assessments revealed inconsistent evaluation of the resident's continence status and needs. A September 19, 2024, continence evaluation documented the resident required "extensive assist" with toileting and had occasional bladder and bowel incontinence, with a stated preference for briefs. However, the evaluation's question about "any further important details" was marked "none," suggesting inadequate clinical analysis.
Subsequent quarterly evaluations in September and October 2024 documented that no toileting program had been attempted, yet provided no explanation for this omission despite the resident's documented incontinence and cognitive impairment. The assessments included questions about why a program was not initiated but left these responses blank.
By January 2025, facility documentation claimed the resident was continent of bladder and bowel, contradicting earlier assessments and the ongoing fall pattern. A January 3, 2025, evaluation stated no toileting program was needed because the resident was "continent of bladder and bowel," despite the resident's care plan including interventions for incontinence-related skin breakdown risk implemented just weeks earlier in November 2024.
Scheduled toileting programs represent a fundamental intervention for managing incontinence and fall risk in cognitively impaired residents. These programs involve taking residents to the bathroom at regular intervals based on their individual patterns, rather than waiting for residents to request assistance or recognize their own toileting needs. For individuals with dementia, the ability to recognize bodily signals, remember bathroom locations, or request assistance appropriately often becomes impaired before physical continence abilities decline.
The absence of such programming places residents at significant risk. Falls in older adults can result in fractures, head injuries, functional decline, and increased mortality risk. When falls occur during transfers or ambulation to the bathroom—activities that often happen urgently and without proper assistance—the risk intensifies.
Direct Observations Confirmed Ongoing Risk
On January 31, 2025, inspectors observed the resident demonstrate the exact behaviors that had led to previous falls. The resident stood up with unsteady gait, transferred independently to a wheelchair, propelled to his room, and entered the bathroom without staff assistance or supervision. The resident then returned to the hallway using the same unsafe process.
When interviewed immediately after this observation, a licensed practical nurse acknowledged the resident required staff supervision for bathroom use and had "impulsive and aggressive behaviors." The nurse stated: "We have to be careful when we are around him cause he gets agitated so easily and he is not compliant with asking for assistance when using the bathroom."
This statement revealed staff awareness of the resident's inability to safely request or wait for bathroom assistance, yet documentation showed no compensatory programming to address this known deficit. The care plan included only generic interventions such as "reminding" the resident not to use the bathroom without help—an approach that fails to account for the resident's cognitive impairment and inability to follow such reminders consistently.
Food Service Management Certification Gaps
Inspectors also identified staffing deficiencies in the facility's food service operations. Federal regulations require facilities to ensure adequate supervision by qualified food service personnel to prevent foodborne illness—a particular concern in long-term care settings where residents often have compromised immune systems.
Review of kitchen staff schedules from December 2024 through January 2025 revealed that only one staff member held a valid Food Protection Manager certificate from an accredited program. This certified manager was scheduled to work only 17 of 28 days in December 2024 and 8 of 14 days on the partial January 2025 schedule reviewed by inspectors.
The U.S. Food and Drug Administration's Food Code recommends that a certified food protection manager be present during all hours of food service operation in facilities serving high-risk populations. This presence helps ensure proper food temperatures are maintained, cross-contamination is prevented, and food safety protocols are followed consistently.
Without adequate certified supervision, facilities face increased risk of foodborne outbreaks that can cause severe illness or death among elderly residents. Common pathogens such as Salmonella, E. coli, and Listeria pose particular dangers to individuals with weakened immune systems, chronic diseases, or advanced age—characteristics common among nursing home residents.
Additional Issues Identified
Beyond the major violations, the inspection documented several other concerns:
Incontinence Care Inconsistencies: The resident's care plan added interventions for skin breakdown risk related to incontinence in November 2024, including "incontinent care after each incontinent episode." This addition contradicted subsequent January 2025 assessments claiming the resident was fully continent, revealing inconsistent clinical documentation.
Behavioral Care Planning: Documentation from September 2024 noted the resident had been "urinating on the floor and also defecating on the AC unit," prompting interventions to encourage calling for bathroom assistance and providing a urinal. However, no evidence indicated these interventions were evaluated for effectiveness or modified when the fall pattern emerged.
Care Plan Implementation Gaps: Despite October 2024 fall incident reports noting "Resident to be toileted via commode," observation four months later showed the resident continuing to ambulate independently to the bathroom without staff supervision or assistance.
The inspection findings revealed a pattern of assessment without meaningful intervention—staff documented problems but failed to implement, evaluate, or modify appropriate programs to address identified needs. For a resident with moderate to severe cognitive impairment, this represented a fundamental breakdown in the care planning process that directly contributed to preventable falls and injury risk.
Facilities are required to evaluate residents' continence status, identify factors contributing to incontinence, and provide appropriate treatment and services to restore or maintain normal bladder and bowel function to the extent possible. For residents who cannot be restored to continence, facilities must provide appropriate treatment and services to prevent complications and maintain quality of life and dignity.
The documented pattern at Regency Healthcare showed repeated assessment of incontinence and fall risk without implementation of evidence-based interventions such as scheduled toileting, environmental modifications, or staffing adjustments to accommodate the resident's cognitive limitations and unsafe behaviors.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Regency Healthcare & Rehab Center from 2025-02-04 including all violations, facility responses, and corrective action plans.
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