Inspection Reports for
Regency Heritage Nursing And Rehabilitation Center

The facility was found deficient in completing required resident assessments, accurate medication inventory and documentation, ensuring required Quality Assurance and Performance Improvement (QAPI) committee attendance and antibiotic stewardship presentations, proper infection control practices including PPE use and hand hygiene, and implementation of an effective Antibiotic Stewardship Program.

Complaint investigation based on complaints NJ00185340, NJ00175616, and NJ00183791. The facility was found not in substantial compliance with federal requirements related to resident records and ADL documentation.

The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, specifically failing to accurately and consistently document Activities of Daily Living (ADLs) for residents. Deficiencies were observed in medical record documentation and staff adherence to documentation policies.

Complaint investigation based on complaints NJ00185340, NJ00175616, and NJ00183791. The facility was found to have deficient documentation practices for ADLs. The report does not explicitly state substantiation status.

The facility failed to accurately and consistently document ADLs for Residents #1, #2, and #3 in the COS according to facility policy. This deficient practice was observed in three out of five residents reviewed, with multiple blank boxes on ADL documentation sheets for dietary intake, toileting, bladder, bowel, and turning/positioning across various dates in April 2025. Interviews with staff confirmed omissions in documentation despite care being provided.

Complaint #NJ181913 was substantiated with findings that the facility did not meet mandatory CNA staffing ratios on all day shifts reviewed during the complaint period.

The facility was found not in compliance with New Jersey staffing requirements, failing to meet minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on all 21 day shifts reviewed. The facility was deficient in CNA staffing for 7 of 7 day shifts during 12/15/2024 to 12/21/2024 and 14 of 14 day shifts from 12/29/2024 to 01/11/2025, with fewer CNAs than required by state law.

The visit was triggered by multiple complaints (NJ163525, NJ179143, NJ162866, NJ171841, NJ161011, NJ168161). The facility was found not in substantial compliance based on these complaints.

The facility was found not in substantial compliance with federal and state regulations, including failure to notify resident representatives of significant changes, incomplete PASARR Level I assessments for residents, and failure to maintain required minimum direct care staff-to-resident ratios. Additionally, fire doors were not inspected annually as required.

The complaint investigation found that the facility did not notify the responsible party of resident R434's change in condition and medication, and notification attempts were not documented. The Director of Nursing confirmed no documentation existed showing family notification within 24 hours as required.

The facility failed to notify the responsible party of resident R434's pneumonia diagnosis and antibiotic change, and there was no documentation of notification attempts in the medical record. Interviews confirmed staff did not properly document notification efforts as required by facility policy.

The complaint investigation found that the facility failed to notify the responsible party of a resident's pneumonia diagnosis and antibiotic change, and failed to document notification attempts. It also found that the facility failed to complete accurate PASARR Level I assessments for three residents, missing mental illness diagnoses.

The facility failed to notify the responsible party of a resident's pneumonia diagnosis and antibiotic change, and failed to document notification attempts. Additionally, the facility did not ensure accurate completion of PASARR Level I assessments for three residents, omitting mental illness diagnoses.

The facility was found deficient in infection control related to respiratory/tracheostomy care and suctioning, and food safety practices including improper handling, storage, and dating of food items. Additionally, the facility failed to maintain required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey.

The facility was found to be in noncompliance with several Life Safety Code requirements including fire barrier door self-closing mechanisms, fire alarm notification in outdoor resident areas, sprinkler system coverage, smoke barrier maintenance, HVAC ventilation system maintenance, and electrical receptacle GFCI protection. Corrective actions and plans of correction were outlined for each deficiency.

The facility failed to implement proper infection control measures for respiratory equipment handling and storage for two residents, and failed to maintain safe food handling and sanitation practices, including improper storage, labeling, and disposal of food items.

Complaint numbers NJ 147495, NJ 148044, NJ 148226, NJ 148430 triggered the investigation. The facility failed to report verbal abuse allegations timely and failed to thoroughly investigate abuse allegations. Staffing shortages and care delays were documented. Infection control lapses were identified in glucometer cleaning practices.

The facility was found not in substantial compliance with requirements due to failure to report alleged verbal abuse timely, inadequate investigation of abuse allegations, failure to maintain required minimum direct care staff-to-resident ratios, delayed feeding of a resident, delayed call bell responses, and failure to follow manufacturer cleaning instructions for glucometers leading to infection control concerns.

The facility was found not in compliance with infection control regulations related to appropriate use of PPE during COVID-19 testing and care of newly admitted residents under investigation, sharing of gowns between residents, hand hygiene practices, proper doffing of single-use gowns, posting of transmission-based precaution signs, and access to hand hygiene stations in the COVID-19 positive cohort unit.