Above 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 Regina Health Center during CMS and state inspections, most recent first.
Delayed Assistance With Transfer Back to Bed: A resident with a pelvic fracture, anorexia, and dementia, who was dependent on staff for transfers and needed a 2-person assist, did not receive timely help back to bed after activating the call light because staff delayed returning, turned off the light, and the resident was not transferred until later with a sit-to-stand lift. The resident’s daughter reported the resident was in pain and wanted to go to bed, and the DON verified the call light history showing repeated activation and delayed response.
A resident with neurocognitive disorder, seizures, and heart disease had multiple scheduled meds documented as administered on the MAR, but staff later found 14.5 pills left on a breakfast tray under the lid. A nurse confirmed the resident had no order or care plan for self-administration, and an RN stated the resident was sleeping and wanted the meds later, so they were left on the tray.
Dietary staff did not follow prescribed menu portions for residents on regular, ground, or pureed diets, resulting in meals being served with less food than required. Observations and interviews confirmed that incorrect scoop sizes were used, affecting several residents and potentially impacting all individuals served from a specific dining area.
A resident with multiple medical conditions and intact cognition repeatedly refused showers due to discomfort and expressed a preference for tub baths, which was not documented or accommodated by staff. Despite available bathtubs and communication from the resident and her family, the care plan and Kardex did not reflect her preference, and the DON was unaware of it. The resident's hygiene was affected, and facility policy allowed for different bathing methods, but her preference was not honored.
A resident's oxycodone pain medications were misappropriated by an LPN who tampered with the medication card, replacing oxycodone with Topamax. The tampering was discovered during a narcotic count, and the facility notified relevant authorities, but not the State Survey Agency. The resident had not received oxycodone since the tampering began.
A facility failed to report the misappropriation of a resident's oxycodone narcotic pain medications to the State Survey Agency. An LPN was found to have replaced the oxycodone with Topamax migraine medication by tampering with the medication card. Despite notifying other authorities, the facility did not report the incident to the State Survey Agency as required.
The facility failed to implement a comprehensive water management plan, did not alert staff about residents on Enhanced Barrier Precautions, and did not maintain proper infection control practices during medication administration.
The facility failed to ensure that a resident with dementia, diabetes, and chronic kidney disease was offered and educated about influenza and pneumonia vaccines. The medical record showed refusals without evidence of offering or education, and an RN confirmed the lack of documentation.
The facility failed to ensure that a resident with dementia, diabetes, and chronic kidney disease was offered and educated about the COVID-19 vaccine. The medical record showed a refusal but lacked evidence of the offer or education. An RN confirmed the absence of a written refusal and education documentation, contrary to the facility's vaccination policy.
Delayed Assistance With Transfer Back to Bed
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for transfers received timely assistance to be transferred back to bed. Resident #8 was admitted with diagnoses including fracture of the superior rim of the left pubis, anorexia, and dementia, and the resident’s daughter reported that the resident was in pain and wanted to go to bed. At 8:40 A.M., the daughter said the resident activated the call light and CNA #400 told her she would return after picking up breakfast trays to put the resident to bed. The call light was reactivated at 9:01 A.M., and Activities Assistant #404 answered it at 9:07 A.M. and said he would find a CNA. At 9:08 A.M., CNA #401 entered the room, turned off the call light, and stated she would be right back because the resident was a two-person assist. Resident #8 was not placed back in bed until 9:21 A.M., when CNA #401 and CNA #264 used a sit-to-stand lift. CNA #400 later verified she had turned off the light and said she would return after breakfast trays were picked up, but she got sidetracked and the resident was not on her assignment. The alarm history showed the call light was activated at 8:25 A.M. and turned off at 8:27 A.M., then reactivated at 9:00 A.M. and turned off at 9:08 A.M.; the DON verified this record.
Medications Left Unattended on Resident Tray
Penalty
Summary
The facility failed to ensure medications were not left unattended at a resident bedside. Resident #36 had diagnoses including frontotemporal neurocognitive disorder, convulsions, and heart disease, and the medical record showed no physician order or care plan for self-administration of medications. The physician’s orders for the morning included multiple medications, and the MAR showed those medications were administered to the resident on the morning of 05/11/26. During observation at 12:10 P.M., a CNA brought a breakfast tray into the dining room, and another CNA removed the lid and found pills in a medicine cup on the tray. At 12:14 P.M., a nurse verified the resident’s medications were underneath the lid and counted 14.5 pills on the tray, identifying them as Eliquis, zonisamide, pantoprazole, celecoxib, potassium chloride, thiamine, calcium-vitamin D3, metoprolol succinate, MVI, vitamin D3, folic acid, escitalopram, memantine, and furosemide. The nurse also verified the resident did not have orders or a care plan for self-administration, and the MAR had been marked that the medications were administered. An RN later stated the resident was sleeping and wanted the medications when she wanted them, so the medications were left on the breakfast tray.
Failure to Follow Prescribed Menu Portions for Specialized Diets
Penalty
Summary
The facility failed to ensure that prescribed menu portions were followed for residents on various diet textures, resulting in residents receiving less food than indicated on the menu spreadsheet. Observations in the 2B kitchenette/dining room revealed that dietary staff used incorrect scoop sizes when serving pureed chicken, pureed cauliflower, country gravy, scalloped potatoes, and ground chicken. Specifically, a two-ounce scoop was used instead of the required four-ounce scoop for pureed items, and other items were also served in smaller portions than specified. Dietary aides and the chef confirmed during interviews that incorrect serving sizes were being used, and the registered dietitian verified that staff were expected to follow the menu spreadsheet for serving sizes. This deficiency affected four identified residents and had the potential to impact all 54 residents who were served from the 2B kitchenette/dining area. The diet order report confirmed that these residents were on regular, ground, or pureed texture diets. The issue was identified through observation, menu and portion control chart review, and staff interviews, and was investigated under a specific complaint number.
Failure to Accommodate Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's bathing preferences, specifically the preference for tub baths over showers. The resident, who had diagnoses including rheumatoid arthritis, dementia, ataxia following cerebral infarction, and aneurysm, was cognitively intact and required substantial assistance for showering. Documentation showed frequent refusals of bathing, but there was no evidence that the facility investigated the reasons for these refusals or provided a tub bath as preferred. The resident's care plan and Kardex did not reflect her preference for tub baths, and shower documentation did not indicate any attempts to accommodate this preference. Interviews with the resident, her daughter, and staff confirmed that the resident disliked showers due to water spraying in her face and had repeatedly expressed a preference for tub baths. The Director of Nursing was unaware of this preference, despite the availability of bathtubs in the facility. The resident's daughter also reported concerns about her mother's hygiene, stating she had to cut her mother's hair due to it being dirty. The facility's policy allowed for various bathing methods, but there was no evidence that the resident's preference for tub baths was accommodated.
Misappropriation of Resident's Narcotic Pain Medications
Penalty
Summary
The facility failed to protect a resident's narcotic pain medications from misappropriation. A resident with moderate cognitive impairment and a history of pain, muscle weakness, rheumatoid arthritis, and dementia was prescribed oxycodone for pain management. However, a review of the medication administration records revealed that the last dose of oxycodone was administered on October 30, 2024, despite ongoing orders for the medication. An investigation conducted by the facility on December 6, 2024, uncovered that an LPN agency nurse misappropriated 14 oxycodone tablets from the resident's medication card. The nurse had tampered with the narcotic card by slitting the sides open and replacing the oxycodone with Topamax, a medication for migraines. The tampering was discovered during a routine narcotic count by two agency nurses, who noticed the card's edges pulling apart and the presence of incorrect medications in the slots. Further investigation revealed that the tampered medications matched those found in a bottle labeled with the suspect nurse's name, which was left at the nursing station. The facility notified the pharmacy, State Board of Nursing, and law enforcement about the incident. However, there was no mention of notification to the State Survey Agency. Interviews with staff confirmed the tampering and the subsequent investigation, but attempts to contact the suspect nurse were unsuccessful.
Failure to Report Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to report an allegation of misappropriation of a resident's oxycodone narcotic pain medications to the State Survey Agency as required. The incident involved a resident who was admitted with diagnoses including pain, muscle weakness, rheumatoid arthritis, and unspecified dementia. The resident had a physician's order for oxycodone to be administered as needed for pain. However, a discrepancy was identified when the last dose was recorded on 10/30/24, and it was discovered that 14 oxycodone tablets were missing from the resident's medication card. The investigation revealed that an LPN had misappropriated the oxycodone by slitting open the medication card and replacing the oxycodone with Topamax migraine medication. The facility's investigation determined that the LPN had worked four shifts at the facility and had left a bottle labeled amoxicillin at the nursing station, which contained Topamax tablets matching those found in the tampered oxycodone card. Despite notifying the pharmacy, State Board of Nursing, and Law Enforcement, the facility did not report the incident to the State Survey Agency. Interviews with facility staff confirmed the misappropriation and the lack of evidence that the incident was reported as required by the facility's policy on abuse, neglect, and misappropriation.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive water management plan, which had the potential to affect all residents. The facility's policy required a water management program, but the facility did not have a comprehensive plan in place. The facility was only assessing water temperatures and monitoring chlorine levels without establishing a water management team, developing a water system diagram, or identifying high-risk areas for Legionella growth. The Administrator confirmed the absence of a comprehensive water management plan, attributing it to a recent change in the maintenance department. The facility also failed to ensure staff were alerted that three residents were on Enhanced Barrier Precautions (EBP). These residents had conditions requiring EBP, such as urinary catheters and chemotherapy. Observations revealed that there were no signs on the doors to alert staff, and no personal protective equipment (PPE) was located near their rooms. The Infection Control Preventionist verified the absence of PPE and signs, despite the facility's policy requiring such measures for residents with indwelling medical devices or chronic wounds. Additionally, the facility failed to maintain appropriate infection control practices during medication administration. A registered nurse was observed touching medications with her hands before placing them in medication cups for two residents. This practice was confirmed by another nurse as inappropriate and against the facility's medication administration policy. The policy stated that medications should not be touched directly by hands and should be discarded if contaminated.
Failure to Offer and Educate on Vaccines
Penalty
Summary
The facility failed to ensure that Resident #9 was offered and received education regarding the influenza and pneumonia vaccines. Resident #9, who had diagnoses including dementia, diabetes mellitus, and chronic kidney disease, had a responsible party. The medical record indicated that the resident refused both vaccines, but there was no evidence that the facility offered the vaccines or provided education to the resident or her representative. An interview with RN #52 revealed that the facility did not obtain a written refusal or provide evidence of education regarding the vaccines. The facility's policy stated that vaccines were to be offered annually to all residents, coordinated by the Infection Preventionist.
Failure to Offer and Educate on COVID-19 Vaccine
Penalty
Summary
The facility failed to ensure that Resident #9 was offered and received education on the COVID-19 vaccine. Resident #9, who had diagnoses including dementia, diabetes mellitus, and chronic kidney disease, was admitted on an unspecified date and had a responsible party. The medical record indicated that the resident refused the COVID-19 vaccine, but there was no evidence that the facility offered the vaccine or provided education to the resident or her representative. An interview with RN #52 confirmed that the facility did not obtain a written refusal for the vaccine or provide evidence of education. The facility's policy stated that vaccines were to be offered annually to all residents, coordinated by the Infection Preventionist.
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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 Richfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Momentous Health At Richfield | 2.6 mi | — | 21 | 0 |
| Avenue At Broadview Heights | 2.6 mi | ★★★★★ | 14 | 0 |
| Heights Rehabilitation And Healthcare Center, The | 3.4 mi | ★★★★★ | 3 | 0 |
| The Pavilion Rehabilitation And Nursing Center | 4.3 mi | — | 0 | 0 |
| Oaks Of Brecksville | 4.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.