Regency Care Center
Regency Care Center in Norwalk, IA — inspection on August 20, 2025.
Found 6 citations. 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
During an interview 8/20/25 at 11:30 AM, the MDS coordinator acknowledged the alarm section of the MDS for Residents #6, #7 and #9 should have been marked for using the wander alarm, as all three residents had a wander guard.
The MDS coordinator acknowledged she did not mark this section accurately.
The MDS coordinator stated Section E for behaviors is completed by the Social Worker, the facility has a newly hired social worker.
During an interview 8/20/25 at 12:35 PM, the DON acknowledged the MDS assessments should have been coded for alarms for Resident #6, #7 and #9, and should have been marked for behaviors if they were exhibited.
The DON stated the facility follows the Resident Assessment Instrument (RAI) Manual for completing the MDS and follows standards of practice.
The facility does not have a specific policy for MDS assessments.
165399 08/20/2025
Regency Care Center 815 High Road Norwalk, IA 50211
care level guidelines.
165399 08/20/2025
Regency Care Center 815 High Road Norwalk, IA 50211
elopement risk evaluation for Resident #7 on 8/18/25 and will submit this today, 8/20/25.
165399 08/20/2025
Regency Care Center 815 High Road Norwalk, IA 50211
During an observation 8/6/25 at 4:20 PM, observed the door at the end of hall 6, the door was alarmed.
The door is located through the therapy room, at the back of the therapy room.
During an interview 8/11/25 at 6:50 AM, Staff Q, LPN, stated she did work the night of 6/4/25, from 6:00 PM to 6:00 AM.
She worked on the Ambassador side, the back halls.
Staff Q stated Resident #9 was a resident who wandered, he would wander through the building the majority of the day. He was not aggressive, but he would get frustrated when redirected and would be verbally aggressive. He would wander into other resident's rooms and up and down the hallways, he would go to the doors to try to get outside.
There were numerous times he would go into the therapy room at the end of hall 6 and try to get out the door in the ther[TRUNCATED]
165399 08/20/2025
Regency Care Center 815 High Road Norwalk, IA 50211
During an interview on 8/7/25, at 12:30 PM, Staff E, CNA, noted unit staffing is good some days and a struggle others.
Staff E believes it takes longer to get to residents and provide the requested cares.
During an interview on 8/7/25 at 1:35 PM, the DON explained they will go through the monthly schedule to monitor for needed coverage.
The facility's scheduler oversees the daily staffing sheets and will make necessary calls to cover any open positions.
The DON noted the Assistant Director of Nursing (ADON) and the Minimum Data Set (MDS) Assessment nurse will cover both nursing and non-nursing areas, such as a CNA position, to ensure resident needs are met.
Facilty RNs and LPNs will also cover non-nursing areas as needed.
The DON voiced the facility is adequately staffed with the number of available positions.
Facility staff have voiced concerns regarding the number of call-in's.
The DON noted no resident concerns have been brought to their attention with regards to staffing.
Review of the facility document Fall Scene Investigation, completed 5/15/25 at 8:05 PM, detailed Resident #1's fall.
The document explained Resident #1 had been sitting in a wheelchair in the Ambassador Dining Room.
When the CNA was ready to assist the resident to bed, the wheelchair Resident #1 was sitting in was empty and the resident was no longer in the Dining Room. Resident #1 was found on the floor in their room on Hall 4.
The document noted the root cause of the fall was limited staff (2 CNAs for 51 residents). On 8/4/25, the facility reported an in-house census of 68 (22 residents on the Royal nursing unit and 46 residents on the Ambassador nursing unit).
The DON indicated a total of 9 residents in the Royal nursing unit require a mechanical lift (3 on Hall One, 2 on Hall Two, and 4 on Hall Three).
The DON indicated a total of 18 residents in the Ambassador nursing unit require a mechanical lift (0 on Hall Four, 9 on Hall Five, and 9 on Hall Six).
Two staff members are required to be present when utilizing a mechanical lift to transfer residents.
During an interview 8/19/25 at 1:30 PM, the Director of Nursing (DON) stated she does not believe a resident has waited longer than 20-minutes for a call light response.
The DON stated the expectation for staff to respond to call lights is as soon as possible and within 15 minutes.
The DON stated for the facility to function minimally and meet resident needs they would need during the day at least 2 CNAs, 1 nurse and 1 CMA for the up front halls (halls 1, 2 and 3) and at least 3 CNA's and two nurses for the back halls (halls 4, 5 and 6).
The DON stated on 8/5/25, they did have staff call ins for the back three halls and had 1 CNA for hall 6 and 1 CNA for hall 5 with a floater aid to assist with showers and cares, the two CNA's would split hall 4.
From 6 am to right around lunch time, they only had the 2 CNA's and the float, the DON then found another CNA to assist in the back halls.
The DON does not believe any resident waited longer than 20 minutes for a call light response that day.
The DON stated the facility does not have a policy for staffing or call lights, the facility follows standards of practice for call light response time, which should be within 15-minutes.
The facility document titled Regency Care Center Facility Assessment 2025, revised 11/2024, outlined the following staffing guidelines: 2-4 nurses working 12-hour shifts on the day shift or a combination of nurses and Certified Medication Aides (CMA)2 nurses are scheduled on the night shift with additional staff for treatment and medication pass from 6:00 PM to 10:00 PM3 Certified Nurses Aide (CNA) for the Royal nursing unit and 4-5 CNAs for the Ambassador nursing unit during the day shift (6:00 AM to 2:00 PM). A bath aide and restorative aide may be additional2-3 CNAs for the Royal nursing unit and 4-5 CNAs for the Ambassador nursing unit during the evening shift (2:00 PM to 10:00 PM)No staffing assignments documented for the night shift (10:00 PM to 6:00 AM)
165399 08/20/2025
Regency Care Center 815 High Road Norwalk, IA 50211
During an interview 8/5/25 at 9:50 AM, Staff F, CNA, stated during training, no one trained her on cleaning the equipment after each transfer.
Staff F stated there are no cleaning/sanitizing wipes on the mechanical lift in this hallway.
Staff F stated even if a resident is on Enhanced Barrier Precautions (EBP) or Transmission Based Precautions (TBP), she had not wiped down the shared mechanical lift equipment after using it, and had used the mechanical lift equipment from resident to resident without sanitizing it.
During an observation 8/5/25 at 10:30 AM, Staff H, CNA, and Staff I, CNA, performed a mechanical lift transfer for Resident #2, a resident on EBP.
Observed the EBP signage by the door to the resident's room.
Observed fluids on the floor, dripping from the resident while he was being transferred to the bed, fluids came from his seated area which appeared to be urine.
The lift wheels went through the fluid.
After the transfer was completed, Staff I moved the mechanical lift equipment into the hallway without cleaning or sanitizing the equipment and placed it in the hallway.
The mechanical lift did not have a sanitizing agent in the basket attached to the lift.
Observed the mechanical lift in the hallway until 11:15 AM, when staff I then moved it into room [ROOM NUMBER] without sanitizing or cleaning the equipment.
During an interview 8/5/25 at 10:45 AM, Staff I, CNA, stated the shared mechanical lift equipment is not sanitized or cleaned in between resident use every time.
Staff I stated there used to be sanitizing wipes in a basket on the mechanical lifts, however now none of the lifts have sanitizer wipes.
Staff I stated she has not observed staff cleaning the shared mechanical lifts and she has not cleaned them, even if it has been used for a resident on EBP.
During an interview 8/6/25 at 8:00 AM, the Director of Nursing (DON) stated an expectation the mechanical lifts be cleaned and sanitized after each use and prior to being used for another resident.
Review of the facility policy Total Lift Transfer, with a review date of 11/28/22, and the facility Hospital Clean policy, undated, documented to disinfect lift surfaces and allow them to dry and non-critical medical equipment is cleaned and disinfected between residents.
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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.