Regency Care Center

F 0641

Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or potential for actual harm

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

record review, observations, staff interviews and facility policy review the facility failed to complete an accurate Minimum Data Set (MDS) for 1 of 4 residents (Resident #2) reviewed. The facility reported a census of 68 residents. Findings include:According to the Discharge-Return Not Anticipated MDS assessment tool with reference date of 11/24/2025 documented Resident #2 was admitted to the facility on [DATE REDACTED] and discharged home/community on 11/24/2025.The Care Plan Focus Area with a revision date of 11/24/2025 documented Resident #2 and responsible party choose long-term placement. Review of Resident #2's progress notes from 11/12/2025-12/1/2025 revealed no documentation of her being discharged from the facility. On 12/30/2025 at 11:45 AM Resident #2 was observed to be sitting in the dining room with her peers. On 12/30/2025 at 11:57 AM the Director of Nursing (DON) verified Resident #2 was in the building and not discharged . While reviewing the MDS that was completed on 11/24/2025 she acknowledged it documented Resident #2 was discharged but that was not accurate. At 1:30 PM she stated

the corporate staff was fixing the MDS. During the exit meeting at 2:03 PM she indicated the MDS fixed the issue. The Assistant Director of Nursing (ADON) stated around that time there was talk of Resident #2 discharging home but the family realized that was not going to be an option.The facility provided a document titled Conducting an Accurate Resident Assessment. The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Accuracy of assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (i.e. comprehensive, quarterly, significant change in status).Policy Explanation and Compliance Guidelines:2.

Qualified staff who are knowledgeable about the resident will conduct an accurate assessmentaddressing each resident's status, needs, strengths, and areas of decline. The assessment will bedocumented in the medical record. 7. A registered nurse will sign and certify that the assessment/correction request is completed. Each individual who completes a portion of the assessment will sign and certify the accuracy of that portion of the assessment. Whether the MDS assessments are manually completed, or computer-generated following data entry, each individual assessor is responsible for certifying the accuracy of responses relative to the resident's condition and discharge or entry status.

Residents Affected - Few

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 REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

12/30/2025

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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); f. Interventions will be documented in the care plan and communicated to all relevant staff. g.

Compliance with interventions will be documented in the weekly summary charting. 6. Modifications of Interventions b. Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include: i. Changes in resident's degree of risk for developing a pressure injury. ii.

New onset or recurrent pressure injury development. iii. Lack of progression towards healing. iv. Resident non-compliance. v. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights.

Event ID:

Facility ID:

If continuation sheet