Regency Care Center

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

two times a day for Blood Glucose -Start Date 07/29/2025 -D/C Date 08/06/2025.3. HumaLOG KwikPen Subcutaneous Solution Peninjector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 141 - 180 = 2 units; 181 - 220 = 4 units; 221 - 260 = 6 units; 261 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12 units >400 14 units and call provider, subcutaneously before meals and at bedtime for diabetes -Start Date 07/30/2025. Review of the MAR for August of 2025 revealed Resident #12 was given the following medications and had the following orders:1.Empagliflozin Oral Tablet 10 MG (Empagliflozin) Give 1 tablet by mouth in the morning for DM2 -Start Date 07/10/2025.2. Check Blood Glucose BID two times a day for Blood Glucose -Start Date 07/29/2025 -D/C Date 08/06/2025.3. HumaLOG KwikPen Subcutaneous Solution Peninjector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 141 - 180 = 2 units; 181 220 = 4 units; 221 - 260 = 6 units; 261 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12 units >400 14 units and call provider, subcutaneously before meals and at bedtime for diabetes -Start Date 07/30/2025.4. 472=16 units as one time order. one time only for high blood sugar until 08/06/2025 23:59 -Start Date08/06/2025 1245 During an interview 8/19/25 at 1:30 PM, the Director of Nursing (DON) stated when a resident has a diagnosis of diabetes, she would expect this to be in the MDS as a diagnosis. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Regency Care Center

815 High Road Norwalk, IA 50211

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm

10/23/19, documented each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Contains services provided, preference, ability, and goals for admission, desired outcomes, and care level guidelines.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Regency Care Center

815 High Road Norwalk, IA 50211

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm

resident should have been completed by or around the 20th of June 2025, and acknowledged this was not completed at that time. The DON stated they follow the Resident Assessment Instrument (RAI) Manual for completing the MDS and follow standards of practice for the Elopement Risk Evaluations. The DON stated

she started another elopement risk evaluation for Resident #7 on 8/18/25 and will submit this today, 8/20/25.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Regency Care Center

815 High Road Norwalk, IA 50211

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

At times, he would become aggressive or agitated when redirected. Resident #9 would walk up and down

the halls and go to doors. Staff P stated the resident never went out a door when she was working, she heard he did get out a door one other time, but she was not working then and only heard that he did. On the 4th of June, she believed she last saw Resident #9 at around 7:00 or 7:30 PM, he was in the 5 hallway, walking. Staff P recalled hearing a door alarm at around 7:00 PM, she thought this was the smokers going out or coming in. When she heard the door alarm, she checked the door at the end of hall 5 and by the AL entryway, and did not see any residents, the alarm was shut off, not by her. Staff P stated she was told at around 9:00 PM that the resident was missing. They looked all through the building for approximately 30 minutes and then staff went outside to look for him. He was found outside in between AL and the back of hall 6. Staff P stated she does not know how the resident got outside. Staff P stated the resident liked to go to the door at the end of hall 6, through the therapy room. She believed the door at the end of hall 6 is coded and not alarmed. 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]

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Regency Care Center

815 High Road Norwalk, IA 50211

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Regency Care Center

815 High Road Norwalk, IA 50211

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observations, staff interviews and policy review, the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections. The facility reported a census of 68 residents. Findings include: During an observation on 8/5/25 at 9:40 AM, Staff F, Certified Nursing Assistant (CNA), and Staff G, CNA, performed a mechanical lift transfer for Resident #4. After the transfer was completed, Staff F 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. 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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet