Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Regency Health Care And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of recurrent UTIs did not receive prompt treatment after exhibiting symptoms of a UTI. Despite a CRNP ordering a urinalysis, the urine sample was delayed, and the antibiotic was not administered in a timely manner. The resident was later hospitalized with urosepsis and septic shock, leading to their death. Facility staff failed to adhere to policies on urine sample collection and antibiotic administration, contributing to the delay in treatment.
A resident with a history of UTIs experienced symptoms such as decreased urinary output and confusion, but the facility delayed obtaining a urine specimen and administering antibiotics. The Quality Assessment and Assurance Committee failed to identify these delays as concerns, leading to the resident's hospitalization for urosepsis and septic shock.
A resident with liver disease did not receive prescribed medications, Rifaximin and Lactulose, upon admission to an LTC facility. The facility failed to order Rifaximin and did not stock Lactulose, leading to missed doses and elevated ammonia levels. The DON and CRNP acknowledged the importance of medication availability, highlighting a deficiency in pharmaceutical services.
A resident with Cerebral Atherosclerosis and Vascular Dementia was unable to access their call light on two occasions due to improper placement, contrary to facility policy. The call light was observed out of reach, first on the wall and then across the resident's abdomen. A CNA confirmed the inaccessibility, and the DON stated that call lights should always be within reach.
A resident did not receive prescribed Rifaximin medication due to unavailability, and the facility failed to notify the CRNP as required. The CRNP was only partially informed about the missed doses, and there was no documentation of notification for the second missed dose. This deficiency was identified during a complaint investigation.
A facility failed to complete and transmit a discharge MDS assessment for a resident discharged on a specified date. The facility's policy requires completion and transmission of the assessment within 14 days. The MDS Coordinator admitted the oversight, attributing it to another system in place, and acknowledged the responsibility of MDS Coordinators for timely submissions.
A facility failed to accurately code MDS assessments for two residents, one regarding CPAP use and another for continence status. A resident's long-term CPAP use was not documented, and another resident was inaccurately coded as always continent despite documented incontinence. Staff acknowledged these discrepancies, which did not accurately reflect the residents' needs.
A resident was admitted with specific medical conditions, but the facility failed to develop an accurate baseline care plan. The plan incorrectly included catheter care, despite documentation showing the resident was continent and did not have a urinary catheter. An LPN relied on hospital records without verifying information with the resident's family, leading to discrepancies in the care plan. The DON also misunderstood the resident's needs, contributing to the inaccurate documentation.
A resident's representative was not included in the care planning process, contrary to facility policy. The resident, who was cognitively impaired and had multiple diagnoses, was admitted without the representative being informed or involved in care planning. The DON confirmed the lack of documentation regarding the representative's participation.
A resident was observed with an intravenous saline lock in place for several days beyond the intended duration, despite an order for a one-time administration of normal saline. Interviews with facility staff confirmed the saline lock was not meant to remain, and there was no documentation indicating site maintenance, posing a risk for infection.
A resident with a self-care performance deficit due to a displaced fracture and impaired balance was found with long, unclean fingernails containing dried blood and dirt, posing an infection risk. Despite facility policies requiring assistance with personal hygiene, observations and interviews revealed a failure to maintain the resident's grooming, leading to a cited deficiency.
A resident with Chronic Kidney Disease was at risk of UTIs due to improper incontinent care by CNAs, who failed to follow the facility's perineal care policy. CNA #20 was observed wiping from back to front and not changing gloves or performing hand hygiene, while CNA #21, in training, was unaware of proper hand hygiene protocols. The Infection Preventionist confirmed the risk of infection due to these practices.
A resident's medical record lacked times for verbal/telephone orders and documentation for a urine specimen obtained via catheter. An LPN documented a late entry for a medication dose without indicating it was late. The DON acknowledged the absence of documentation and stated there was no place to record times for verbal orders.
A resident's clothing was improperly handled, left uncovered on a door knob outside their isolation room, contrary to facility policy and CDC guidelines. This posed a risk of cross-contamination, as confirmed by staff interviews.
Delayed Treatment of UTI Leads to Resident's Hospitalization and Death
Penalty
Summary
The facility failed to provide prompt treatment for a resident, identified as RI #180, who exhibited signs and symptoms of a urinary tract infection (UTI). Despite a Certified Registered Nurse Practitioner (CRNP) ordering a urinalysis (UA) for the resident, the urine sample was not collected and sent to the lab until several days later. The preliminary lab results were delayed, and the CRNP was not notified of the UA results until days after the initial order. Consequently, the first dose of the prescribed antibiotic was not administered until much later, despite the resident experiencing dysuria and other symptoms. RI #180 had a history of recurrent UTIs and urinary incontinence, and was admitted to the facility with multiple diagnoses, including unspecified protein-calorie malnutrition and type two diabetes mellitus. The resident's family had informed the facility staff about the resident's frequent UTIs and expressed concerns about the resident's symptoms, which included back pain and painful urination. However, the facility staff provided inconsistent reasons for the delay in testing and treatment, and the family was not included in a baseline care plan to discuss these concerns. The facility's policies on urine sample collection and antibiotic stewardship were not followed, leading to a delay in obtaining and processing the urine sample, and in administering the prescribed antibiotic. The resident was eventually transferred to the emergency room and admitted to the Intensive Care Unit with urosepsis and septic shock, where the resident later expired. Interviews with facility staff revealed a lack of adherence to the facility's policies and procedures, contributing to the delay in treatment and the resident's subsequent hospitalization and death.
Removal Plan
- The Administrator or designee notified the facility Medical Director of the incident.
- The Director of Nursing (DON) or designee used a verification checklist to ensure all abnormal urinalysis (UA) results were reported to the provider appropriately.
- The Nurse Practitioner will receive emails directly from the lab for electronic review of all lab results.
- The resident's medical record was reviewed to ensure timely treatment and recovery from infection.
- Two LPNs were provided one-on-one education on the facility's revised Urine Sample Collection policy.
- The Urine Sample Collection Policy was revised to specify actions if unable to obtain a midstream clean-catch on the first attempt.
- Notify physician if unable to obtain a urine sample within 12 hours.
- Instructions were received regarding timely medication administration, added as section 7 of the policy.
- All facility nurses were educated on the revised Urine Sample Collection Policy.
- The DON or designee will utilize a verification checklist to ensure prompt treatment.
- Arranged for the contract laboratory to email results of all lab work to CRNP for electronic review and flag physical copies for provider review.
Failure to Address UTI Symptoms Leads to Resident Hospitalization
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAAC) failed to thoroughly review all factors related to a resident's hospitalization. The resident, identified as RI #180, was admitted with a history of unspecified protein-calorie malnutrition, type two diabetes mellitus without complications, and retention of urine. The resident experienced decreased urinary output, urine odor, blood-tinged urine, and increased confusion, which were indicative of a urinary tract infection (UTI). Despite these symptoms, there was a delay in obtaining a urine specimen, notifying the Certified Registered Nurse Practitioner (CRNP) of the urinalysis results, and administering the prescribed antibiotic. The QAAC reviewed the incident report after the resident's fall and identified the need to treat the UTI. However, the committee did not identify the delay in treatment as a concern, nor did they address the systemic issues that led to the delay. The resident's urinalysis results were not promptly communicated, and the initial dose of the prescribed antibiotic, Levofloxacin, was not administered until several days later. This delay in treatment contributed to the resident's transfer to the emergency room and subsequent admission to the Intensive Care Unit (ICU) for urosepsis and septic shock. Interviews with facility staff revealed that the QAAC did not identify any concerns with the treatment of the resident's UTI. The facility's Infection Preventionist stated that urine specimens should be collected immediately, and antibiotics should be started within 24 hours unless otherwise specified. Despite these guidelines, the QAAC's documentation indicated no concerns, and the hospitalization was deemed unavoidable. The facility's failure to promptly address the resident's UTI symptoms and administer timely treatment resulted in a serious deficiency, as determined by the surveyors.
Removal Plan
- The Administrator or designee notified the facility Medical Director of the incident.
- The Director of Nursing (DON), Administrator and Assistant Director of Nursing (ADON) reviewed all Quality Assurance (QA) Committee meeting minutes, as well as reviewing rehospitalization records for months where no QAPI meeting was held.
- A Root Cause Analysis (RCA) was conducted for all rehospitalizations related to urinary tract infection (UTI) to determine if further investigation/action was needed.
- The Laboratory Services and Reporting Policy was revised by the Administrator, DON, and ADON.
- Section 7 of the Laboratory Services and Reporting Policy was revised to say, 'Immediately notify the ordering physician, or nurse practitioner of critical finding.'
- Section 8 was added to the Laboratory Services and Reporting Policy to say, 'Nurse practitioner will be notified of resulted labs for review electronically and nurse will place physical copy in chart for review at the providers next visit to the facility.'
- The DON or designee educated all RNs and LPNs that inform providers of lab results, on facility's revised Laboratory Services and Reporting policy.
- The DON or designee spoke with facility Medical Director and CRNP regarding process change for prompt notification of lab results.
- Arranged for the contract laboratory to email results of all lab work results to CRNP for electronic review.
- The Urine Sample Collection Policy was revised by the Administrator, DON, and Assistant Director of Nursing (ADON).
- Section 4-vi. of the Urine Sample Collection Policy was revised to say, 'If unable to obtain midstream clean-catch on first attempt, may obtain a catheterized specimen.'
- Section 6 of the Urine Sample Collection Policy was revised to say, 'Notify physician if unable to obtain a urine sample within 12 hours.'
- Section 7 was added to the Urine Sample Collection Policy regarding timely administration of medication.
- The DON or designee educated all facility nurses that perform urine collections on facility's revised Urine Sample Collection Policy.
- The DON or designee will continue to utilize verification checklist at least twice per week, to ensure all residents receive prompt treatment.
- The Quality Assessment and Assurance Policy was revised by the Administrator and DON.
- Section 4.d. of the Quality Assessment and Assurance Policy was revised to include contributing factors in corrective plans of action.
- Section 4.f. was added to the Quality Assessment and Assurance Policy to utilize Root Cause Analysis Tools.
- The Administrator completed an education course through Relias Online Training, titled The Use of Root Cause Analysis.
- The Administrator educated the QA Committee on F-867 Quality Assessment and Assurance, facility's revised Quality Assessment and Assurance Policy, and how to conduct an RCA.
Medication Availability and Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for a resident with liver disease, identified as RI #330, upon admission. The resident was prescribed Rifaximin and Lactulose to manage their liver condition, but missed several doses of these medications. The resident's hospital discharge summary indicated that they were to resume these medications, but the facility did not have them available, leading to missed doses on multiple occasions. Interviews and record reviews revealed that the facility did not order Rifaximin for the resident, and the Lactulose was not stocked as a backup medication. The Licensed Practical Nurse (LPN) reported that the Lactulose was not available on the medication cart, and the Director of Nursing (DON) acknowledged that the medications should have been available on the day of admission. The facility's pharmacy did not receive an order for Rifaximin, and the family was asked to bring the medication, which they did after a delay. The resident's ammonia levels were significantly elevated, which could be attributed to the missed doses of Lactulose. The facility's failure to ensure the availability and administration of the prescribed medications resulted in a deficiency, as the resident's medical needs were not adequately met. The Certified Registered Nurse Practitioner (CRNP) expressed concern over the missed doses and emphasized the importance of having medications available for residents upon admission.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as RI #15, by not ensuring the accessibility of the call light on two separate occasions during a five-day survey. The facility's policy, titled 'Call Lights: Accessibility and Timely Response,' mandates that call lights be within reach of residents at all times to ensure timely staff response. However, observations revealed that the call light for RI #15 was out of reach, first being hung on the wall and later positioned across the resident's abdomen, making it inaccessible. RI #15, who was readmitted to the facility with diagnoses including Cerebral Atherosclerosis and Vascular Dementia, was unable to reach the call light due to its improper placement. A Certified Nursing Assistant (CNA) confirmed that the resident could not access the call button in its observed locations and stated it should be clipped to the resident's shirt or blanket. The Director of Nursing (DON) also acknowledged that the call light should always be within reach and never placed behind the bed, as this would prevent the resident from alerting staff to their needs.
Failure to Notify CRNP of Unavailable Medication
Penalty
Summary
The facility failed to notify the Certified Registered Nurse Practitioner (CRNP) when medication was unavailable for administration to a resident, identified as RI #330. The resident was discharged from the hospital with a prescription for Rifaximin, to be administered twice daily. However, the medication was not available for administration on two consecutive days, and the facility did not inform the CRNP as required by their policy. The Director of Nursing acknowledged that the physician should have been notified, but there was no documentation to confirm that this notification occurred. The CRNP expected to be informed if medication was unavailable, but was only aware of the first missed dose and believed the family would provide the medication. The CRNP was not informed of the second missed dose on the same day and was only made aware of the missed doses on the following day. There was no documented evidence that the CRNP was notified about the missed doses on the second day. This deficiency was identified during the investigation of a complaint, affecting one of the 31 sampled residents.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that a discharge Minimum Data Set (MDS) Assessment was completed and transmitted for a resident who was discharged on 05/14/2024. According to the facility's policy titled MDS 3.0 Completion, a discharge assessment must be completed using the discharge date as the Assessment Reference Date (ARD) and transmitted to the designated CMS system within 14 days of completion. However, a review of the resident's MDS assessments revealed that the discharge assessment had not been completed or transmitted. During an interview on 07/30/2024, the MDS Coordinator/Registered Nurse acknowledged that the discharge assessment should have been completed on the discharge date but was overlooked due to another system being in place. The MDS Coordinators were responsible for ensuring timely submission of discharge MDS assessments.
Inaccurate MDS Coding for CPAP Use and Continence
Penalty
Summary
The facility failed to ensure accurate coding in the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in documenting their care needs. For one resident, the MDS assessment did not accurately reflect the use of a Continuous Positive Airway Pressure (CPAP) machine, despite the resident's long-term use of the device for sleep apnea. The resident confirmed the use of the CPAP machine, and the MDS Coordinator acknowledged the oversight, noting that the inaccurate coding failed to identify the resident's needs properly. Another resident's MDS assessment inaccurately documented continence status. The resident was coded as always continent of bowel and bladder, despite nursing notes indicating episodes of incontinence during the assessment period. Both the MDS Coordinator and the LPN involved in the assessment recognized the discrepancy, acknowledging that the MDS did not accurately portray the resident's continence status. The Director of Nursing also confirmed the inaccuracy, highlighting the inconsistency with the resident's admission assessment.
Inaccurate Baseline Care Plan for Resident
Penalty
Summary
The facility failed to ensure an accurate baseline care plan was developed for a resident identified as RI #180. The resident was admitted with diagnoses including unspecified protein-calorie malnutrition, type two diabetes mellitus without complications, and retention of urine. The baseline care plan summary, dated 12/13/2023, incorrectly included catheter care, despite the admission MDS indicating the resident was always continent of bowel and bladder and did not have a urinary catheter. The baseline care plan was signed by an LPN who stated he used the history and physical and discharge summary to gather information but did not communicate with the resident's family or representative about the care plans. Interviews with the LPN and the DON revealed discrepancies in the documentation and understanding of the resident's needs. The LPN admitted to not remembering if he contacted the resident's family and relied solely on hospital records and nurse reports. The DON believed the resident had a Foley catheter, which was discussed during the baseline care plan meeting, but the admission assessment documented otherwise. This miscommunication and lack of verification with the resident's representative led to the inaccurate baseline care plan, affecting the resident's immediate care needs upon admission.
Failure to Include Resident Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a care plan conference was scheduled to include the resident representative of a resident identified as RI #180. The facility's policy, titled Care Planning-Resident Participation, mandates that residents and their representatives be informed and involved in care planning and treatment decisions. However, the facility did not notify or involve RI #180's representative in the care planning process. This oversight was identified during a review of the resident's care plan and confirmed through interviews with the resident's representative and the Director of Nursing (DON). RI #180 was admitted to the facility with diagnoses including unspecified protein-calorie malnutrition, type two diabetes mellitus without complications, and retention of urine. The resident's Minimum Data Set indicated a Brief Interview for Mental Status score of five out of 15, suggesting cognitive impairment. The resident's representative reported that upon admission, they were not allowed to accompany the resident to their room and were not informed or invited to participate in a care plan meeting. The DON acknowledged the importance of family involvement in care planning but confirmed that there was no documentation of the family being invited or attending a care plan meeting for RI #180.
Failure to Remove Intravenous Saline Lock
Penalty
Summary
The facility failed to ensure that a resident, identified as RI #23, had an intravenous saline lock removed after the completion of a prescribed normal saline infusion. The resident was admitted with multiple diagnoses, including Parkinson's Disease, Chronic Obstructive Pulmonary Disease, Type Two Diabetes Mellitus, and Acute Embolism and Thrombosis of Deep veins. A review of the resident's order summary revealed an order for a one-time administration of Sodium Chloride Solution 0.9% at 100 ml/hr for dehydration, with no order for a saline lock to remain in place. Despite this, the resident was observed with the saline lock in place for several days beyond the intended duration. Interviews with facility staff, including a Registered Nurse and a Certified Registered Nurse Practitioner, confirmed that the order was only for a one-day administration of normal saline, and the saline lock was not intended to remain. The Director of Nursing acknowledged that there was no documentation on the Medication Administration Record to indicate that the site was maintained after the saline was completed, highlighting a risk for infection due to the lack of monitoring. The deficiency was identified during a recertification survey, affecting one of the 31 sampled residents.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to ensure that a resident's fingernails were kept clean and cut, which was a deficiency in providing necessary assistance for activities of daily living (ADLs). The resident, identified as having a self-care performance deficit due to a displaced fracture of the right femur and impaired balance, required partial to moderate assistance for personal hygiene. Observations revealed that the resident had long fingernails with a brown, black, and red substance underneath, identified by a registered nurse as dried blood and dirt. Additionally, the resident's toenails were thick, and there was a small red sore on the tip of a toe. Interviews with the RN and the Director of Nursing (DON) highlighted that the presence of black dirt under fingernails posed a risk for infection and that hand hygiene should be maintained before and after meals. The DON stated that if a resident refused care, it should be documented in the nurse's notes, and efforts should be made to encourage care or involve family members. The facility's policy on ADLs emphasized maintaining grooming and personal hygiene, but the observations and interviews indicated a failure to adhere to these guidelines, resulting in the cited deficiency.
Improper Incontinent Care Increases UTI Risk
Penalty
Summary
The facility failed to ensure proper incontinent care for a resident, identified as RI #335, which increased the risk of urinary tract infections (UTIs). During a survey, CNA #20 was observed wiping bowel movement from the resident's buttocks and anus area to the front of the perineal area, contrary to the facility's policy that mandates wiping from front to back. Additionally, CNA #20 did not change gloves or perform hand hygiene throughout the process, which is a breach of infection control protocols. The resident, who had a diagnosis of Chronic Kidney Disease, was at risk due to these improper care practices. Interviews with CNA #20 and CNA #21 revealed a lack of adherence to proper perineal care procedures, with CNA #20 acknowledging the risk of infection from not changing gloves and not washing hands. CNA #21, who was in training, was unaware of the necessity to wash or sanitize hands after handling soiled briefs. The facility's Infection Preventionist confirmed the risk of introducing bacteria from improper wiping techniques and lack of glove changes. The facility's policy on perineal care was not followed, leading to potential cross-contamination and infection control issues.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for Resident Identifier (RI) #180, as evidenced by several deficiencies in documentation. The medical record did not include the times for verbal or telephone orders received on three separate dates. Additionally, there was a lack of documentation regarding the collection of a urine specimen obtained via catheter, including who performed the procedure and how the resident tolerated it. Furthermore, a dose of levofloxacin was documented as administered on a later date without indicating it was a late entry, violating the facility's policy on timely and accurate documentation. Interviews with staff revealed that the Licensed Practical Nurse (LPN) responsible for documenting the late entry did so at the request of the Infection Control Nurse, several days after the medication was administered. The Director of Nursing (DON) acknowledged the absence of documentation for the urine specimen collection and stated that there was no designated place to record the time for verbal or telephone orders, which was deemed unnecessary. These lapses in documentation affected one of the 31 sampled residents, highlighting a failure to adhere to the facility's policies on maintaining accurate and timely medical records.
Improper Handling of Resident Clothing in Isolation
Penalty
Summary
The facility failed to ensure proper handling of resident clothing to prevent potential cross-contamination, specifically for a resident diagnosed with COVID-19. On the specified date, clothing was observed hanging on the door knob of the resident's room, which was in isolation, and was uncovered. This was contrary to the facility's policy and CDC guidelines, which require that clothing be stored in the resident's closet or drawers to prevent contamination. The clothing was left on the door knob by laundry staff, as confirmed by a registered nurse, who acknowledged that this practice posed a risk of contamination. Interviews with the Laundry Supervisor, Infection Preventionist, and Director of Nursing further confirmed that the clothing should have been delivered into the resident's room while wearing PPE, and stored appropriately. The clothing was supposed to remain covered until it was placed inside the room. The staff's failure to adhere to these procedures resulted in a potential risk of cross-contamination, as the clothing was left exposed on the door knob of a resident's room under isolation precautions.
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Illustrative
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Huntsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Diversicare Of Big Springs | 2.7 mi | ★★★★★ | 0 | 0 |
| Windsor House | 3.6 mi | ★★★★★ | 0 | 0 |
| Brookshire Healthcare Center | 3.8 mi | ★★★★★ | 0 | 0 |
| The Health Center At Research Park | 3.9 mi | ★★★★★ | 0 | 0 |
| Rocket City Rehabilitation And Healthcare Center | 4.5 mi | ★★★★★ | 0 | 0 |
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