Inspection Report
Annual Inspection
Census: 132
Capacity: 153
Deficiencies: 6
Sep 5, 2025
Visit Reason
A recertification survey and state licensure survey were conducted at Kent Regency Center from 09/02/2025 through 09/05/2025 to determine compliance with 42 C.F.R. Part 483 for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified related to failure to post survey results accessibly, quality of care issues including failure to ensure follow-up appointments and treatments, pressure ulcer care deficiencies, improper storage of drugs and biologics, failure to conduct quarterly evaluations of medication technicians, and life safety code violations regarding gas equipment storage.
Severity Breakdown
C: 1
E: 3
F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to post the results of the most recent surveys in a readily accessible area for residents, families, and visitors. | C |
| Failure to ensure that a resident received necessary follow-up care and services including radiology services and appointments with Alzheimer's Disease and Memory Disorder Center. | E |
| Failure to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. | E |
| Failure to properly label and store drugs and biologics in accordance with accepted professional principles. | E |
| Failure to ensure quarterly evaluations of Certified Medication Technicians were conducted, documented, and placed in personnel records. | — |
| Failure to maintain oxygen cylinders in accordance with National Fire Protection Association (NFPA) 99, 2012 Edition, including failure to mark full and empty cylinders and improper storage. | F |
Report Facts
Census: 132
Total Capacity: 153
Deficiencies cited: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Medication Technician | Named in deficiency related to failure to conduct quarterly evaluations |
| Staff F | Certified Medication Technician | Named in deficiency related to failure to conduct quarterly evaluations |
Inspection Report
Plan of Correction
Census: 132
Capacity: 153
Deficiencies: 6
Sep 3, 2025
Visit Reason
A comprehensive survey and state licensure survey were conducted at Kent Regency Center from 08/02/2025 through 09/03/2025 to determine compliance with 42 CFR Part 483 and state licensure and emergency preparedness requirements.
Findings
Multiple deficiencies were identified related to emergency preparedness, quality of care, wound care, medication labeling and storage, quarterly evaluations of medication technicians, and life safety code compliance. Plans of correction were provided with specific actions and completion dates.
Severity Breakdown
SS = C: 2
SS = E: 2
SS = F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| The facility failed to make survey results readily available to residents, families, and visitors as required. | SS = C |
| Quality of care deficiencies including failure to ensure residents received appropriate treatment and follow-up for orthopedic and neurological conditions. | SS = C |
| Failure to ensure proper wound care and prevention of pressure ulcers for affected residents. | SS = E |
| Failure to properly label and store drugs and biologicals, including opened and undated medications. | SS = E |
| Failure to conduct and document quarterly evaluations for Certified Medication Technicians (CMTs). | — |
| Life Safety Code deficiency related to failure to mark and segregate full and empty oxygen cylinders in storage. | SS = F |
Report Facts
Capacity: 153
Census: 132
Deficiencies cited: 5
Completion dates: 2025
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 4, 2024
Visit Reason
An off-site desk audit was conducted on October 4, 2024, to review all previous deficiencies cited on August 21, 2024.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Census: 151
Capacity: 153
Deficiencies: 5
Aug 21, 2024
Visit Reason
A recertification and complaint surveys were conducted from 8/19/2024 through 8/21/2024 to determine compliance with federal regulations for Long Term Care Facilities, including state licensure and emergency preparedness. Additionally, an annual Federal Life Safety Code survey was conducted.
Findings
Deficiencies were identified related to failure to meet professional standards in care plans for residents with indwelling urinary catheters, failure to maintain acceptable nutritional parameters for residents, failure to complete annual performance reviews for nursing aides, and food safety violations including improper food storage and labeling. Life safety code deficiencies were also noted regarding emergency lighting and sprinkler system maintenance.
Deficiencies (5)
| Description |
|---|
| Facility failed to provide services meeting professional standards for residents with indwelling urinary catheters, including monitoring urine output and sediment. |
| Facility failed to maintain acceptable nutritional status parameters for residents, including monitoring significant weight changes. |
| Facility failed to complete annual performance reviews for nursing aides as required. |
| Facility failed to store food in accordance with food safety standards, including unlabeled and undated food items. |
| Facility failed to maintain emergency lighting systems and automatic sprinkler system in compliance with life safety code requirements. |
Report Facts
Residents with indwelling urinary catheters not properly monitored: 4
Residents with nutritional deficiencies: 2
Nursing aides missing annual performance reviews: 5
Facility capacity: 153
Facility census: 151
Weight loss percentage: 11.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kellen Moran | Executive Director | Signed plan of correction documents |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 29, 2023
Visit Reason
An off-site desk audit was conducted on September 29, 2023, to review all previous deficiencies cited on August 23, 2023.
Findings
Based on an acceptable plan of correction and supporting documentation, the previously cited deficiencies have been corrected. The facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Capacity: 143
Deficiencies: 7
Aug 23, 2023
Visit Reason
A Recertification Survey was conducted at Kent Regency Center from 08/21/2023 through 08/23/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were cited in multiple areas including prevention and treatment of pressure ulcers, accident hazards and supervision, dialysis care, nursing staff competencies, medication error rates, infection prevention and control, and life safety code compliance. The facility failed to meet several regulatory requirements as evidenced by observations, record reviews, and staff interviews.
Severity Breakdown
Level 3: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to provide necessary treatment and services to prevent pressure ulcers for residents at risk. | Level 3 |
| Failure to ensure residents receive adequate supervision to prevent accidents during meals. | Level 3 |
| Failure to ensure residents requiring dialysis receive appropriate services consistent with professional standards. | Level 3 |
| Failure to ensure nursing staff have completed required competencies related to CLIA, IV insertion, PPE, and safe resident handling. | Level 3 |
| Medication error rate exceeded 5%, with 3 errors resulting in a 12% error rate involving multiple residents. | Level 3 |
| Failure to establish and maintain an infection prevention and control program to prevent spread of infections. | Level 3 |
| Failure to maintain minimum 18 inch clearance between sprinkler head deflector and storage of combustible materials as required by Life Safety Code. | Level 3 |
Report Facts
Residents reviewed for pressure ulcer prevention: 7
Residents observed during supervision failure: 2
Residents reviewed for dialysis care: 1
Nursing staff reviewed for competencies: 6
Medication administration opportunities observed: 25
Medication errors observed: 3
Facility licensed capacity: 143
Inspection Report
Complaint Investigation
Deficiencies: 2
Jun 27, 2022
Visit Reason
A Recertification, COVID-19 Vaccination Compliance, and Complaint Survey was conducted at Kent Regency Center from 06/22/2022 through 06/27/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
The facility was found not in compliance with food safety requirements related to improper storage and labeling of food items, and infection prevention and control practices including improper use of personal protective equipment (PPE) and failure to disinfect face shields. Corrective actions and education were implemented to address these deficiencies.
Complaint Details
The survey included a complaint investigation related to COVID-19 infection control practices and food safety. The findings indicated noncompliance with infection control and food safety standards.
Deficiencies (2)
| Description |
|---|
| Failed to properly store, distribute, and serve food under sanitary conditions relative to the main kitchen and 2 of 2 unit kitchenettes, including improper thawing and labeling of food items. |
| Failed to establish and maintain an infection prevention and control program, including improper use of PPE and failure to disinfect face shields when exiting isolation rooms. |
Report Facts
Survey dates: 06/22/2022 through 06/27/2022
PPM sanitizer bucket reading: 200
Number of wings observed for PPE compliance: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nursing Assistant | Observed not disinfecting face shield and not wearing gloves while handling resident's meal tray in isolation room |
| Staff B | Nursing Assistant | Observed not disinfecting face shield and not performing hand hygiene when exiting isolation rooms |
| Staff C | Unit Manager | Acknowledged expectations for PPE use and hygiene in isolation rooms |
| Staff D | Licensed Practicable Nurse | Observed not disinfecting face shield when exiting resident rooms and preparing medications |
| Food Service Director | Acknowledged sanitizer bucket reading was not within acceptable range and unable to explain missing thaw dates on health shakes |
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