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Complaint Investigation

Regency Park Health And Rehabilitation

August 14, 2025 · Dalton, GA · 1212 Broadrick Drive
Citations 1
CMS Rating 4/5
Beds 100
Provider ID 115663
Healthcare Facility
Regency Park Health And Rehabilitation
Dalton, GA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

REGENCY PARK HEALTH AND REHABILITATION in DALTON, GA — inspection on August 14, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0880
Infection Control Deficiencies

Review of the electronic medical record (EMR) for R3 revealed that he was admitted to the facility with diagnoses that included but were not limited to osteomyelitis of ankle and foot, methicillin resistant staphylococcus aureus infection (MRSA), acute respiratory failure with hypoxia, traumatic hemorrhage of the cerebrum, and neuromuscular dysfunction of bladder.

Review of the physician's orders revealed that there was an order for indwelling Foley catheter for diagnoses of neurogenic bladder.

Review of the Minimum Data Set (MDS) assessment dated [DATE] a Brief Interview for Mental Status (BIMS) score of 13, which means that he is cognitively intact.

Review of section H (Bladder and Bowel) revealed that he has an indwelling catheter.

Review of the care plan for R3 revealed that he is at risk for a multi-drug-resistant organism (MDRO) related to the presence of a foley catheter and Enhanced Barrier precautions (EBP) were implemented for that risk.An observation of perineal and catheter care occurred on 8/14/2025 at 11:11 am.

Certified Nursing Assistant (CNA) AA provided catheter and perineal care for R3. CNA AA removed a soiled pair of gloves after cleaning the resident's perineal area.

Without performing hand hygiene, she then put on a new pair of gloves and continued care by wiping and then disposing of the soiled cleaning wipes.

She then removed her gloves a second time and donned (put on) another pair without performing hand hygiene.

She concluded the procedure by adjusting the resident's incontinence brief and completed care without any visible hand hygiene between glove changes.An interview on 8/14/2025 at 10:25 am with CNA AA confirmed that she did not perform hand hygiene between glove changes.An interview with the Director of Nursing (DON) on 8/14/2025 at 10:35 am revealed that it was her expectation that hand hygiene was performed between glove changes.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DALTON, GA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from REGENCY PARK HEALTH AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.