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 And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive loss and multiple comorbidities developed an avoidable stage 3 sacral pressure ulcer due to the facility's failure to provide timely and consistent skin assessments, accurate documentation, and continuous wound care. Gaps in treatment orders, missed wound care interventions, and incomplete records contributed to the delayed identification and management of the pressure ulcer.
Facility staff failed to maintain accurate and complete clinical records for a resident with complex medical needs, including missing and delayed skin assessments, inconsistent Braden scale documentation, and incomplete wound care records. The presence of a pressure ulcer was not consistently documented in nursing and physician notes, and there were gaps in both treatment orders and administration, contrary to facility policy.
Facility staff did not post required daily nurse staffing information on the unit or in common areas over multiple days. Observations and interviews with a visitor, the Scheduling Coordinator, and the Regional Nurse Consultant confirmed that the staffing data was not publicly displayed, and the Scheduling Coordinator was unaware of the posting requirement.
A resident with multiple chronic conditions was documented as having a DNR order in the care plan, despite being Full Code. Interviews with the DON and MDS Coordinator confirmed the care plan was not updated to reflect the resident's actual code status, contrary to facility policy requiring timely care plan revisions.
A nurse failed to document the initiation of CPR for a resident with multiple complex diagnoses, as required by facility policy. The event was not recorded in the Code Blue Progress Note or in the electronic medical record system, despite confirmation from the Regional Nurse Consultant and DON that documentation should have occurred.
A resident with impaired mobility and a history of falls, who required two staff for bed mobility and incontinence care, was left unattended by an agency CNA during morning care. The CNA left the resident on his side with the bed in a high position and stepped away, resulting in the resident rolling off the bed and sustaining pain to multiple areas. An LPN confirmed the CNA was not at the bedside at the time of the fall, and the care plan requiring two staff was not followed.
The facility did not ensure that an RN was on duty for at least 8 consecutive hours each day, as required. Review of nursing schedules showed that on at least three days, there was no verification of the required RN coverage, a fact confirmed by the Scheduling Coordinator and acknowledged by the Administrator.
Failure to Prevent and Manage Pressure Ulcer Due to Inadequate Assessment and Documentation
Penalty
Summary
A resident with multiple complex medical conditions, including acute stroke with craniotomy, paralysis, diabetes, chronic kidney disease, and severe cognitive loss, was admitted to the facility and identified as being at high risk for pressure ulcer development. The resident was dependent on staff for all activities of daily living and required two-person assistance for bed mobility, toileting, and transfers. Despite these risk factors, the facility failed to provide consistent and accurate skin care assessments, as no skin assessments were documented until several days after the initial identification of a wound. The first Braden skin assessment was completed late, and only two were performed during the resident's stay, both indicating high risk. Upon review, it was found that wound care orders and documentation were inconsistent and incomplete. Initial treatment orders lacked clear documentation of who ordered them and did not include wound descriptions or measurements. There was a significant delay in wound evaluation and assessment, with no physician documentation of the wound until eight days after its identification. Additionally, there were gaps in wound care treatment, with no ordered treatment for the sacral wound for a 12-day period, and multiple documented omissions of wound care treatments on several days. The facility's policy required weekly skin assessments, but these were not completed as required. Staff interviews revealed confusion and errors in documentation, with discrepancies between nursing notes regarding the presence of the wound. The LPN interviewed acknowledged that the pressure ulcer was not present on admission and occurred after the resident was admitted. The lack of timely and accurate assessments, incomplete documentation, and missed treatments contributed to the development and delayed management of an avoidable stage 3 sacral pressure ulcer for this resident.
Failure to Maintain Accurate Clinical Records and Wound Care Documentation
Penalty
Summary
Facility staff failed to maintain a complete and accurate clinical record for one resident, resulting in multiple documentation and assessment deficiencies. The staff did not complete accurate weekly skin assessments before and after the identification of a pressure sore, and failed to document accurate Braden scale assessments upon admission and after the discovery of an unstageable pressure sore. Additionally, the presence of the pressure ulcer was not consistently or accurately documented in skilled nursing and physician progress notes, with some notes indicating no wound after the ulcer had been identified. The resident involved had a complex medical history, including acute stroke with craniotomy, paralysis, dysphagia with PEG tube, diabetes, chronic kidney disease, cardiomyopathy, and other significant conditions. The resident was dependent on staff for all activities of daily living and was at high risk for pressure ulcer development. Despite this, Braden risk assessments were only completed twice and both were done late. The initial wound treatment orders lacked proper documentation regarding who ordered the treatment and did not include wound evaluations, assessments, or measurements until eight days after the wound was first identified. There were also significant gaps in wound care documentation and treatment administration. No skin assessments were documented until the wound care nurse evaluated the resident, and there were periods where no treatment orders were in place for the sacral wound. Treatment administration records showed multiple missed treatments, and the facility's policy requiring weekly skin assessments was not followed. The lack of consistent and accurate documentation, assessment, and treatment monitoring contributed to the deficiency identified by surveyors.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
Facility staff failed to ensure the daily posting of nurse staffing information on the nursing unit, as required. Over a three-day survey period, surveyors repeatedly observed that nurse staffing data was not posted in the lobby, main hall, or on the nursing unit at various times of day. Interviews with a regular visitor confirmed that he had never seen nurse staffing information posted during his visits. The Scheduling Coordinator, responsible for maintaining staffing records, stated she kept the information at her desk and was unaware of the requirement to post it publicly. She also indicated that she assumed unit managers or charge nurses would post the information when she was not present, but this was not occurring. The Regional Nurse Consultant confirmed during an interview and walk-through that nurse staffing data was not posted anywhere in the facility and stated that it should be posted daily at the beginning of each shift. During the end-of-day debriefing, facility leadership, including the Administrator and DON, were informed of the ongoing lack of posted nurse staffing information throughout the survey period. No further information was provided regarding the presence of nurse staffing postings during the survey.
Failure to Update Care Plan to Reflect Accurate Code Status
Penalty
Summary
Facility staff failed to ensure that the care plan for a resident accurately reflected the resident's current code status. The resident, who had multiple diagnoses including discitis, type 2 diabetes with neuropathy, difficulty walking, muscle weakness, morbid obesity, and major depressive disorder, was admitted on 12/9/24 and had not been discharged since. The admission Minimum Data Set (MDS) assessment indicated the resident had moderately impaired cognitive abilities. Despite the resident's code status being Full Code, the care plan documented an advance directive of Do Not Resuscitate (DNR). Interviews with the Director of Nursing (DON) and the MDS Coordinator confirmed the discrepancy between the resident's actual code status and what was documented in the care plan. The MDS Coordinator acknowledged entering the incorrect care plan, and the DON confirmed the inconsistency. The facility's care planning policy requires care plans to be updated as changes occur and reviewed quarterly, but this was not followed in this instance, resulting in the care plan not being revised to reflect the resident's correct code status.
Failure to Document CPR Event per Facility Policy
Penalty
Summary
Facility staff failed to follow professional standards of quality regarding documentation for one resident. Specifically, when CPR was initiated for the resident, the responsible nurse did not document the event using the required Code Blue Progress Note or enter any information in the electronic medical record system, Point Click Care (PCC). This was confirmed through staff interviews, clinical record review, and examination of facility documents. The facility's own CPR policy required licensed nurses to document such events using the Code Blue Progress Note, but this was not done in this instance. The resident involved had multiple significant diagnoses, including discitis of the lumbar region, type 2 diabetes mellitus with diabetic neuropathy, difficulty walking, muscle weakness, morbid obesity, and major depressive disorder. The resident's cognitive abilities were moderately impaired, as indicated by a BIMS score of 12 out of 15 on the admission MDS assessment. Despite these complexities, the required documentation of the CPR event was not completed, as confirmed by both the Regional Nurse Consultant and the Director of Nursing during interviews.
Failure to Provide Adequate Supervision During Bed Mobility Results in Resident Fall
Penalty
Summary
Facility staff failed to provide adequate supervision and accident hazard prevention for a dependent resident with a history of falls and impaired mobility. The resident, who was cognitively intact but required substantial assistance for bed mobility and incontinence care, was care planned to always have two staff assist with bed mobility and ADLs. Despite this, an agency CNA provided care alone, left the resident on his side with the bed in a high position, and stepped away to the sink. During this time, the resident rolled off the bed, falling onto his right side and experiencing pain in his chest, elbow, chin, and knees. The incident was unwitnessed by the CNA but observed by an LPN standing outside the room, who confirmed the CNA was not at the bedside when the fall occurred. The resident was assessed, neurological checks were initiated, and x-rays were taken, revealing no acute fractures. The care plan and staff interviews confirmed that the resident should not have been left unattended or cared for by a single staff member during bed mobility, indicating a failure to follow established safety protocols and provide adequate supervision.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. A review of the as-worked nursing schedules for specific dates revealed that there was no verification of 8 consecutive hours of RN coverage on at least three days. This finding was confirmed by the Scheduling Coordinator, and the Administrator acknowledged that there should be 8-hour RN coverage daily. The deficiency potentially affects all residents in the facility, as the required RN coverage was not consistently provided.
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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 Yorktown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| York Post Acute | 2.7 mi | ★★★★★ | 0 | 0 |
| Old Dominion Rehabilitation And Nursing | 2.9 mi | ★★★★★ | 22 | 1 |
| Bayside Of Poquoson Health And Rehab | 3.8 mi | ★★★★★ | 0 | 0 |
| Riverside Lifelong H & R Warwick Forest | 4.1 mi | ★★★★★ | 7 | 0 |
| Newport News Nursing & Rehab | 4.7 mi | ★★★★★ | 2 | 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.