Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Regency House during CMS and state inspections, most recent first.
Two residents receiving hemodialysis did not have complete, person-centered dialysis care plans, physician orders for dialysis or vascular access site inspection, or consistently completed pre/post dialysis communication forms. One resident with ESRD and pneumonia had no care plan for hemodialysis or ESRD and missing post-dialysis assessments on multiple treatment days, while another resident with ESRD and diabetes had a nonspecific dialysis care plan and only a limited number of dialysis communication forms despite thrice-weekly treatments. Staff, including the ADON, an RN, and an LVN, reported there was no dialysis policy, the admission checklist did not address dialysis, responsibilities for completing and monitoring dialysis assessments were unclear, and the process was not being monitored, while the physician and Administrator acknowledged that standards of care and documentation expectations for dialysis were not being met.
Incomplete and inaccurate care plans for identified resident needs: The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for 3 residents. One resident with vascular dementia, repeated falls, major depressive disorder, and bilateral presbycusis had a care plan that addressed vision issues but did not include hearing loss interventions, while other residents had unmet care plan needs related to scalp cancer and ROM impairments. The MDS/Care Plan Coordinator acknowledged responsibility for accurate care plans and stated she was unsure what presbycusis was.
Failure to provide full visual privacy in dual occupancy rooms: 46 of 60 rooms reviewed had A and B beds with curtains that did not extend fully around the beds. Observations on multiple halls showed a center curtain that stopped short of the wall and side curtains with gaps, preventing total visual privacy. The ADM was informed and acknowledged the issue, and the facility policy stated that each room is designed to provide full visual privacy with ceiling-suspended curtains that extend around the bed.
Failure to Notify Physician Before Using Wheelchair Head Strap: A resident with quadriplegia and a hx of traumatic brain injury was observed in a wheelchair with a head strap across her forehead, but the physician stated he was not informed of the family’s request for the strap and did not give an order for it. Nursing notes showed the family was working on the wheelchair and getting new head gear to keep the resident’s head in place, while the DON later stated she spoke with the MD before using the strap and entered the order afterward.
A resident with quadriplegia and a history of TBI was observed using a head strap attached to her wheelchair for head support, but the device was not included in the care plan and no physician order was in place. Therapy notes described the strap as supportive positioning for swallowing and neck alignment, while the physician said he had not been informed and had not ordered it. The resident was seen with the strap across her forehead in the dining room and lobby, and the administrator stated the strap met the definition of a restraint.
A resident with an indwelling catheter and moderate cognitive impairment was observed sitting in a wheelchair with the urine collection bag hanging on the armrest above the bladder. CNA A said she normally places the bag lower on the wheelchair frame to keep it below the bladder, but on this occasion the bag remained on the armrest while she continued other tasks and later took the resident to the shower room. The DON and Administrator were informed, and the DON acknowledged the bag should be below the bladder.
The facility failed to ensure the Food Supervisor wore a mustache guard while handling uncovered food, as observed during a survey. The FS was seen with an uncovered mustache over food pots, and upon inquiry, admitted to not considering the need for a mustache covering. The facility's sanitation policy requires hair restraints but did not specifically mention mustache coverings, leading to this oversight.
The facility failed to maintain kitchen equipment in safe operating condition, as one of six stove top burners did not ignite automatically, requiring a lighter for ignition. This issue persisted for about two weeks without being reported to maintenance, posing potential risks to residents and staff. The Maintenance Supervisor was unaware of the problem until surveyors arrived, and the Administrator noted the absence of a specific policy for kitchen equipment maintenance.
The facility failed to implement comprehensive care plans for two residents, one with a pressure ulcer lacking Enhanced Barrier Protection interventions, and another with unresolved behavioral issues. These oversights risked not meeting the residents' individualized care needs.
The facility failed to secure controlled drugs and biologicals in two medication carts, which were found unlocked and unattended. A CMA admitted to leaving a cart unlocked while administering medication, contrary to the facility's policy requiring carts to be locked when not in use or unattended. The DON confirmed the policy and stated staff had been educated on it.
The facility failed to maintain an effective infection prevention and control program, as staff did not adhere to Enhanced Barrier Precautions (EBPs). Two CNAs did not wear PPE while transferring a resident with a urinary catheter, and a treatment nurse failed to don PPE during wound care for another resident. Both staff members were unaware of EBP requirements, and the facility had not provided adequate training. Interviews with the DON and Administrator confirmed the lack of training and implementation of necessary precautions.
A resident with an indwelling urinary catheter was at risk for CAUTI due to improper handling during a transfer. A CNA elevated the urine collection bag above the bladder, causing backflow of urine. The facility's policy and staff interviews confirmed the need to keep the bag below the bladder to prevent infections.
The facility failed to transmit MDS assessments for four residents within the required timeframe. The MDS Coordinator, who was responsible for the assessments, was out sick, leading to delays. The residents had various medical conditions, and the delay could impact the facility's quality measures and star rating.
Failure to Maintain Orders, Care Plans, and Assessments for Dialysis Services
Penalty
Summary
The deficiency involves the facility’s failure to provide dialysis services consistent with professional standards, physician orders, and person-centered care plans for two residents receiving hemodialysis. One resident with end stage renal disease (ESRD), dependence on renal dialysis, and lobar pneumonia had a baseline care plan that did not address hemodialysis or ESRD, and the care plan only referenced an acute infection without further specification. This resident’s PPS 5-day MDS showed severely impaired cognition but no behaviors or refusal of care. Review of the Pre/Post Dialysis Communication Report forms for this resident in December showed missing post-dialysis assessments on multiple dates, and the order summary report showed no physician orders for hemodialysis or for inspection of the vascular access site. The second resident, also with ESRD, dependence on renal dialysis, and type 2 diabetes mellitus, had an MDS indicating moderately impaired cognition and no behaviors or refusal of care. This resident’s care plan included hemodialysis but did not specify the frequency, location, or access site. Review of this resident’s Pre/Post Dialysis Communication Reports showed only a limited number of forms for December and January, despite the expectation of thrice-weekly dialysis, and the order summary report likewise showed no physician orders for hemodialysis or vascular access site inspection. Thus, for both residents, required dialysis-related assessments and orders were incomplete or absent. Interviews with facility staff further described gaps in the dialysis care process. The ADON stated there was no dialysis policy and that staff were expected to follow standards of care, confirming that both residents received dialysis three times weekly and that nurses were responsible for completing pre- and post-dialysis assessment forms, but acknowledged the process was not monitored and that nursing leadership had assumed someone else was responsible. An RN reported that the admission checklist did not include dialysis and that staff turnover and ongoing orientation contributed to uncertainty about who completed the dialysis assessment forms, while also stating that the IDT was responsible for care plans. An LVN stated she was unaware that dialysis orders were not in the computer and did not know who monitored the pre/post dialysis form process. The attending physician stated that not following standards of care for dialysis recipients could eventually lead to complications, and the Administrator confirmed there was no dialysis policy and that he expected nursing staff and management to ensure dialysis orders, care plans, and post-dialysis assessments were completed and monitored.
Incomplete and inaccurate care plans for identified resident needs
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for 3 residents reviewed for care plans. For Resident #5, the record showed diagnoses including vascular dementia, repeated falls, major depressive disorder, and bilateral presbycusis, and the MDS indicated severely impaired cognitive skills for daily decision-making and difficulty hearing. Although the care plan addressed impaired visual function related to cataracts and bilateral presbycusis, the documented interventions focused on vision-related issues and did not include a focus area or interventions for hearing loss or difficulty hearing. For Resident #41, the facility failed to implement a comprehensive person-centered care plan for scalp cancer, and for Resident #76, the facility failed to implement a comprehensive person-centered care plan for range of motion impairments. The report states that the facility failed to develop a comprehensive person-centered care plan for each resident consistent with resident rights and the comprehensive assessment, including measurable objectives and timeframes to meet identified medical, nursing, mental, and psychosocial needs. During interview, the MDS/Care Plan Coordinator stated she and the DON were responsible for the care plans and ensuring they were accurate and complete, and she said she was not sure what presbycusis was and would have to look it up.
Failure to Provide Full Visual Privacy in Dual Occupancy Rooms
Penalty
Summary
The facility failed to ensure that 46 of 60 dual occupancy rooms reviewed were designed or equipped to provide full visual privacy for residents. During observations, rooms on A hall, B hall, C hall, and D hall were found to have an A and B bed in each room, with a single ceiling-to-floor curtain dividing the center of the room but stopping approximately 18 inches from the wall. The side curtains for both beds also had gaps of approximately 18 inches and 30 inches, and the curtains did not allow the beds to have total visual privacy. During interview on 12/18/2025 at 2:54 PM, the Administrator was informed of the observation of resident rooms with curtains that did not provide full visual privacy and stated he understood that it was an issue and that they were in the process of fixing it. Record review of the facility policy titled Bedrooms, dated January 2025, stated that each room is designed to provide full visual privacy for each resident in the form of ceiling suspended curtains that extend around the bed and is equipped for adequate nursing care.
Failure to Notify Physician Before Using Wheelchair Head Strap
Penalty
Summary
The facility failed to consult with Resident #76’s physician when there was a need to alter treatment related to the use of a head strap for her wheelchair. Resident #76 was admitted with diagnoses including quadriplegia and a history of traumatic brain injury. Her admission MDS indicated she was sometimes able to make herself understood, had a BIMS score of 11, used a wheelchair and mechanical lift, had upper and lower extremity range of motion impairments on both sides, and was dependent on staff for all ADLs. Her care plan did not include a plan for her range of motion impairment, and her order summary contained no order for a head strap. Nurse’s notes documented that the resident’s family was in the facility and was working on the resident’s wheelchair, including getting new head gear to keep her head in place. Observation showed the resident up in her wheelchair with a u-shaped pillow supporting her head, and later with a head strap attached to the wheelchair head piece across her forehead; at one point the strap fell into her eyes and she moved her head trying to get it up. The physician stated he was not made aware of the family’s demand for a head strap and did not give an order for it, and he stated he would expect to be notified because the strap was a restraint. The DON stated she talked to the doctor before using the strap and did not enter the order until later because the facility was trying to come up with a plan for what to do with the strap.
Unassessed Head Strap Used Without Physician Order
Penalty
Summary
The facility failed to ensure the least restrictive alternative was used for the least amount of time and failed to document ongoing re-evaluation of the need for a restraint for one resident. Resident #76 was admitted with diagnoses including quadriplegia and a history of traumatic brain injury. Her admission MDS showed she used a wheelchair and mechanical lift, had upper and lower extremity range of motion impairments, was dependent on staff for all ADLs, and had no restraints identified. Her care plan did not include a plan for her range of motion impairment, and the order summary did not contain an order for the head strap. The record showed the resident’s family and therapy staff were involved with a temporary head positioning device attached to the wheelchair. Nursing notes documented the family working on the wheelchair and getting new head gear to keep the resident’s head in place. Therapy notes described the device as supportive positioning for swallowing and neck alignment, and speech therapy documented that the resident and family were told the positioning was important for swallowing safety and that the strap was not a restraint. The DON later stated the head strap was only as needed when the resident was at a 90-degree angle, that the facility had tried a u-pillow, and that the strap had not been used, while the physician stated he had not been informed of the head strap use, would have expected to be notified, and had not given an order for it. Observations showed the resident in her wheelchair with the head strap across her forehead on multiple occasions, including in the dining room and lobby, and at one point the strap fell into her eyes while she moved her head to get it up. The resident was also observed reclined with the strap on while not eating and without staff consistently present. The administrator stated the strap met the definition of a restraint. The facility policy stated that use of assistive devices and equipment should be based on comprehensive assessment and documented in the care plan, but no restraint policy was provided.
Catheter bag left above bladder level
Penalty
Summary
The facility failed to ensure appropriate care for a resident with an indwelling catheter to prevent urinary tract infections. Resident #30 was admitted with benign prostatic hyperplasia, had a BIMS score of 11 indicating moderate impairment, and his MDS identified an indwelling catheter. His care plan directed staff to position the catheter bag and tubing below the level of the bladder and away from the entrance room door, and to show no signs or symptoms of urinary infection through the review date. During an observation, Resident #30 was sitting in his wheelchair in the hallway outside the shower room with his urine collection bag hanging on the armrest of the wheelchair and positioned higher than his bladder. CNA A stated she had not assisted him out of bed that morning and believed someone else may have placed the bag on the armrest; she also stated that when she assisted him she placed the bag lower on the wheelchair frame to keep it below the bladder and prevent backflow. The bag remained on the armrest while the CNA continued other tasks and later took the resident into the shower room. The DON and Administrator were informed of the observation and acknowledged that the bag was supposed to be below the bladder, and the DON stated the resident sometimes placed it on the armrest when transferring himself out of bed.
Food Safety Violation Due to Uncovered Mustache
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not ensuring that the Food Supervisor (FS) wore a mustache guard while handling uncovered food in the kitchen. During an observation, the FS was seen with an uncovered mustache while leaning over pots containing food on the stove. When questioned, the FS admitted to not considering the need to cover his mustache and subsequently put on a face mask. The facility's policy on employee sanitation, dated 10/01/2018, requires the use of hair restraints to prevent hair from contaminating food and food contact surfaces. However, the policy did not specifically mention mustache coverings, which led to the FS's non-compliance. The Administrator acknowledged the oversight but noted that the policy only specified beard coverings, not mustache coverings.
Failure to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, specifically in the kitchen area. During an observation, it was noted that one of the six stove top burners did not ignite automatically, requiring the use of a lighter to turn it on. This issue had persisted for approximately two weeks, as reported by a staff member, [NAME] D. The failure to address this malfunction could potentially place residents at risk of foodborne illnesses and pose a safety hazard to both residents and staff. Interviews with the kitchen staff and the Maintenance Supervisor revealed a lack of communication regarding the malfunctioning burner. The Maintenance Supervisor was not informed of the issue until after the state surveyors had entered the facility. The Administrator acknowledged the absence of a specific policy for kitchen equipment maintenance, although it was expected that any malfunctioning equipment should be reported promptly for repair. The delay in addressing the issue highlights a gap in the facility's maintenance reporting process.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, leading to deficiencies in addressing their specific needs. Resident #17, who was admitted with diagnoses including dementia and muscle wasting, had a severely impaired cognition and a pressure ulcer. The care plan for this resident did not include interventions for Enhanced Barrier Protection, which was necessary for managing her pressure ulcer. The MDS Coordinator acknowledged the need for such an intervention but was not familiar with it, indicating a gap in the care planning process. Resident #65 exhibited behavioral problems, including emotional outbursts and yelling at staff, which were known to the facility's staff. However, the care plan addressing these behavioral issues was not in place, as it had been resolved when the resident was hospitalized and not reinstated upon return. The MDS Coordinator was aware of the need for a care plan to manage these behaviors but had not ensured its implementation. This oversight placed residents at risk of not receiving individualized care and services to meet their needs.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments for two of the eight medication carts reviewed. Specifically, Med Cart #1 and Med Cart #2 were observed to be unlocked and unattended. This was noted during an observation on September 17, 2024, at 9:06 am and 9:08 am, respectively. The failure to secure these medication carts could potentially allow unauthorized access to medications. An interview with a Certified Medication Aide (CMA) revealed that the cart was left unlocked while the aide administered medication to a resident, acknowledging that the policy was to lock the cart when not in use or when unattended. The Director of Nursing (DON) confirmed that medication carts should be locked when unattended and stated that staff had been educated on this policy following the initial observation. The facility's policy on medication administration, revised on December 1, 2021, mandates that medication carts be kept closed and locked when out of sight of the medication nurse or aide, ensuring they are inaccessible to residents or passersby.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of adherence to Enhanced Barrier Precautions (EBPs) by staff members. Specifically, two Certified Nursing Assistants (CNAs) did not wear personal protective equipment (PPE) while transferring a resident with a urinary catheter using a mechanical lift. This resident, who had been diagnosed with benign prostatic hyperplasia and diabetes, was at risk due to the improper handling of his catheter during the transfer. The CNAs were unaware of the EBP requirements and had not received training on the necessity of using PPE in such situations. Additionally, a treatment nurse failed to don PPE while providing wound care to another resident who was on EBP precautions. This resident, suffering from dementia and muscle wasting, had a pressure ulcer requiring specific wound care procedures. The nurse admitted to forgetting to wear PPE during the procedure, despite being aware of the requirement to prevent infection spread. This oversight further highlights the facility's failure to implement and enforce proper infection control measures. Interviews with the Director of Nursing (DON) and the Administrator revealed that staff had not been adequately trained on EBP procedures, and necessary precautions had not been communicated or implemented. The facility's policies on infection control, which were intended to prevent and manage infections, were not effectively followed, leading to potential risks of cross-contamination and infection among residents.
Improper Catheter Bag Positioning During Resident Transfer
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, which could lead to catheter-associated urinary tract infections (CAUTI). During a transfer from a wheelchair to a bed using a mechanical lift, a certified nursing assistant (CNA) improperly elevated the resident's urine collection bag above the level of the bladder. This action caused the urine in the drainage bag to flow back towards the resident's bladder, increasing the risk of infection. The resident, who was admitted with diagnoses including benign prostatic hyperplasia and diabetes, had a care plan that required the catheter to be secured and monitored to prevent catheter-related trauma. Interviews with the CNA and the Director of Nursing (DON) confirmed that the catheter bag should be kept below the bladder to prevent backflow and potential infections. The CNA acknowledged the mistake and the DON emphasized the importance of maintaining the catheter bag at the correct height. The facility's policy on catheter care also stated that the drainage bag must be positioned lower than the bladder to prevent backflow. Despite training and proficiency checks, the incident occurred, highlighting a lapse in adherence to established protocols.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for four residents were completed and transmitted to the CMS System within the required timeframe. Specifically, the quarterly MDS assessments for Residents #22 and #46, the significant change MDS assessment for Resident #63, and the annual MDS assessment for Resident #77 were not transmitted within 14 days after completion. The MDS Coordinator acknowledged that these assessments were ready for export but had not been transmitted for a month, citing her absence due to illness and being the sole person responsible for MDS assessments as contributing factors. The report details the medical conditions of the residents involved, including diagnoses such as vascular dementia, malnutrition, and heart disease. The MDS Coordinator explained that the assessments were sent to a regional boss for export, but this process was delayed. The failure to transmit these assessments on time could affect the facility's quality measures and star rating, as noted by the MDS Coordinator. The CMS RAI Version 3.0 Manual requires that comprehensive assessments be transmitted electronically within 14 days of the Care Plan Completion Date, which was not adhered to in these cases.
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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 San Angelo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Meadow Creek | 1.2 mi | ★★★★★ | 3 | 0 |
| Avir At San Angelo | 2.9 mi | ★★★★★ | 19 | 0 |
| St. Juanita Retirement And Rehab | 3.6 mi | — | 5 | 0 |
| Park Plaza Nursing And Rehabilitation Center | 3.9 mi | ★★★★★ | 3 | 0 |
| Cedar Manor Nursing And Rehabilitation Center | 4.4 mi | ★★★★★ | 8 | 0 |
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