Inspection Reports for
Regency House Of Wallingford I

181 E Main Street, Wallingford, CT 06492, CT, 06492

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Deficiencies (last 7 years)

Deficiencies (over 7 years) 6.6 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

18% worse than Connecticut average
Connecticut average: 5.6 deficiencies/year

Deficiencies per year

12 9 6 3 0
2018
2019
2020
2021
2023
2024
2025

Census

Latest occupancy rate 94% occupied

Based on a September 2025 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Occupancy over time

80 100 120 140 Feb 2018 Apr 2020 Jul 2021 Apr 2023 Jan 2025 Sep 2025

Inspection Report

Plan of Correction
Census: 122 Capacity: 130 Deficiencies: 5 Date: Sep 24, 2025

Visit Reason
A desk audit was conducted to review the implementation of the Plan of Correction for a prior Violation letter dated August 14, 2025.

Findings
Violations #1 through #5 were identified as corrected as of August 39, 2025. The Director of Nursing was notified of the corrections on September 24, 2025.

Deficiencies (5)
Violation #1
Violation #2
Violation #3
Violation #4
Violation #5
Report Facts
Violations corrected: 5

Employees mentioned
NameTitleContext
Kathy LopezDirector of NursingNotified of correction of violations #1-#5 on September 24, 2025

Inspection Report

Complaint Investigation
Deficiencies: 2 Date: Aug 1, 2025

Visit Reason
The inspection was conducted due to a complaint investigation regarding an alleged resident-to-resident physical abuse incident involving Resident #92 and Resident #134.

Complaint Details
The complaint investigation involved an alleged physical abuse incident between Resident #92 and Resident #134 on 6/29/24. The allegation was substantiated as the incident was witnessed by a charge nurse. The facility delayed notifying the social work department until 7/8/24, seven days after the incident. The social worker was unable to recall details but confirmed Resident #92 is usually not aggressive. The facility took corrective actions including re-education and audits.
Findings
The facility failed to ensure Resident #92 was free from physical abuse and failed to notify the social work department timely about the resident-to-resident altercation. The incident was witnessed by a charge nurse, and although no injury was observed, the facility delayed notifying social work by 7 days. The facility re-educated staff and implemented corrective actions to prevent recurrence.

Deficiencies (2)
Failed to protect Resident #92 from physical abuse by another resident.
Failed to notify the social work department timely of a resident-to-resident altercation to ensure follow-up.
Report Facts
Residents reviewed for abuse: 3 Days delay in social work notification: 7 Date of incident: Jun 29, 2024 Date of report: Aug 1, 2025

Employees mentioned
NameTitleContext
Director of Nursing ServicesDirector of Nursing Services (DNS)Notified all parties of the abuse incident and involved in investigation
Social Worker #2Social WorkerFollowed up on resident altercation and provided interview information
Social Worker #1Social WorkerIdentified late notification of resident-to-resident altercation and oversaw timely reporting
Registered Nurse #1Registered NurseInterviewed regarding the incident and facility corrective actions
Licensed Practical Nurse charge nurseLicensed Practical NurseWitnessed the physical altercation between residents

Inspection Report

Complaint Investigation
Deficiencies: 5 Date: Aug 1, 2025

Visit Reason
The inspection was conducted following a complaint regarding resident-to-resident abuse and failure to properly notify social work and ensure timely follow-up, as well as concerns about medication administration and staffing reporting accuracy.

Complaint Details
The complaint involved allegations of resident-to-resident physical abuse and failure to notify social work timely for follow-up. The abuse incident was substantiated with witness statements and documentation. The social work department was notified 7 days late. The facility re-educated staff and implemented corrective actions.
Findings
The facility failed to protect a resident from physical abuse by another resident, delayed notification to social work for follow-up on the altercation, improperly administered medication by giving the wrong formulation, failed to document medication administration accurately, and inaccurately reported weekend staffing data to the Payroll Based Journal.

Deficiencies (5)
Failed to ensure Resident #92 was free from physical abuse by another resident.
Failed to notify social work department timely of a resident-to-resident altercation for follow-up.
Failed to ensure licensed staff used the correct medication formulation as per physician orders for Resident #85.
Failed to document administration of as-needed medications in the medical record for Residents #7 and #85.
Failed to accurately report weekend staffing data to the Payroll Based Journal for quarters 3 and 4 of 2024.
Report Facts
Medication administration dates: 3 Controlled substance removal dates: 9 PBJ quarters with inaccurate staffing data: 2

Employees mentioned
NameTitleContext
LPN #7Licensed Practical NurseAdministered lorazepam tablets after order changed to liquid and failed to document administration
DNSDirector of Nursing ServicesNotified parties of abuse incident, discussed resident altercation, and identified lack of social work notification
SW #2Social WorkerFollowed up on resident altercation late and unable to recall incident details
RN #1Regional NurseIndicated LPN #7 should have notified DNS about medication administration error and reviewed medication documentation policies
APRN #1Advanced Practice Registered NurseEvaluated Resident #85 for medication renewal and explained medication formulation change
LPN #4Licensed Practical NurseAdministered hydromorphone and admitted to inconsistent documentation in MAR
AdministratorFacility AdministratorDiscussed PBJ staffing reporting issues and corrective actions
Corporate Director #1Corporate DirectorReported that staff were misclassified in PBJ reporting causing inaccurate weekend staffing data

Inspection Report

Complaint Investigation
Census: 127 Capacity: 130 Deficiencies: 0 Date: Aug 1, 2025

Visit Reason
The inspection was conducted as a licensing inspection and to investigate complaints identified by complaint investigation numbers 124427 CT, 124416, and CT 2573687.

Complaint Details
Complaint investigation numbers 124427 CT, 124416, and CT 2573687 were referenced in relation to this inspection.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, with an attached violation letter referenced.

Report Facts
Licensed Bed Capacity: 130 Census: 127

Employees mentioned
NameTitleContext
David BondAdministratorPersonnel contacted during the inspection.
Katherine LopezDNSPersonnel contacted during the inspection.

Inspection Report

Complaint Investigation
Census: 129 Capacity: 130 Deficiencies: 0 Date: Jan 3, 2025

Visit Reason
The inspection was conducted as a complaint investigation related to complaint numbers #42277 and #42362.

Complaint Details
Complaint investigation related to complaint numbers #42277 and #42362; no violations were found.
Findings
No violations of the General Statutes of Connecticut and/or the regulations of Connecticut State Agencies were identified at the time of this inspection.

Employees mentioned
NameTitleContext
David BondAdministratorPersonnel contacted during the inspection.

Inspection Report

Complaint Investigation
Deficiencies: 3 Date: Jul 24, 2024

Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely notify a provider of a resident's change in condition and to conduct a full investigation related to an injury of unknown origin.

Complaint Details
The complaint investigation focused on Resident #1, who had a left tibial fracture of unknown origin. The facility was not aware of a recent fall and failed to timely notify the provider of the resident's change in condition. The investigation was incomplete with only 42% of staff statements obtained. The resident was found unattended on the toilet despite requiring assistance.
Findings
The facility failed to notify the provider timely of a change in condition for Resident #1, failed to obtain a STAT venous doppler ultrasound as ordered, and failed to supervise the resident while on the toilet. The resident was found to have a left tibial fracture of unknown origin, and the facility's investigation was incomplete with only partial staff statements obtained.

Deficiencies (3)
Failed to notify a provider timely of a change in condition for Resident #1.
Failed to ensure a full investigation was conducted related to an injury of unknown origin (left tibial fracture).
Failed to follow a physician's order related to a STAT venous doppler ultrasound and failed to supervise a resident while on the toilet.
Report Facts
Staff statements obtained: 5 Date of survey completion: Jul 24, 2024

Employees mentioned
NameTitleContext
LPN #1Identified unusual behavior of Resident #1 and left resident unattended on the toilet.
LPN #2Received report of Resident #1's unusual behavior and fed the resident lunch.
LPN #3Notified RN #8 about redness and swelling to Resident #1's left lower extremity.
RN #8Registered NurseObtained the order for venous doppler ultrasound and aware the order was STAT.
RN #1Unit ManagerCalled diagnostic company regarding venous doppler ultrasound scheduling.
DNSDirector of Nursing ServicesReported incident to state agency and conducted investigation.
APRN #1Advanced Practice Registered NurseAssessed Resident #1 and ordered STAT venous doppler ultrasound.
NA #1Nursing AssistantReported Resident #1's unusual behavior and assisted with feeding.
NA #5Nursing AssistantAssisted LPN #1 in getting Resident #1 off the toilet.
NA #7Nursing AssistantFound Resident #1 unattended on the toilet and unable to get resident off without assistance.
PTA #1Rehab DirectorReported Resident #1 should not have been left unattended on the toilet.

Inspection Report

Routine
Deficiencies: 3 Date: Oct 10, 2023

Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to residents' rights, care planning, and food safety in the nursing home.

Findings
The facility was found deficient in ensuring a physician's order for cardiopulmonary code status was in place, developing and implementing comprehensive care plans reflecting boundary restrictions between residents, and properly dating opened food items in the dietary department.

Deficiencies (3)
Failed to ensure there was a physician's order directing cardiopulmonary code status elected by the resident.
Failed to develop and implement a comprehensive care plan to ensure nursing staff were aware of boundary restrictions between residents.
Failed to ensure food items were appropriately dated to reflect the opening date and/or the use-by date.
Report Facts
Residents affected: 2 Residents affected: 1 Residents affected: 3

Employees mentioned
NameTitleContext
APRN #1Advanced Practice Registered NurseWrote the physician's order addressing Resident #50's code status and evaluated residents for psychiatric concerns.
LPN #4Licensed Practical NurseInterviewed regarding procedures for reviewing Resident #50's code status.
DNSDirector of Nursing ServicesInterviewed about the delay in entering the DNR order and awareness of resident relationship restrictions.
SW #1Social WorkerProvided education and guidance to Resident #45 and developed boundary restrictions between residents.
NA #3Nursing AssistantInterviewed about awareness of resident relationships and boundary restrictions.
LPN #3Licensed Practical NurseInterviewed about awareness of resident relationships and boundary restrictions.
NA #2Nursing AssistantInterviewed about awareness of resident relationships and boundary restrictions.
Food Service DirectorFood Service DirectorInterviewed regarding food dating practices and staff in-service.

Inspection Report

Renewal
Census: 123 Capacity: 130 Deficiencies: 0 Date: Oct 2, 2023

Visit Reason
The inspection was conducted as a renewal licensing inspection of the Regency House Nursing Center.

Findings
Violations of the General Statutes of Connecticut and/or regulations were identified at the time of this inspection. Additional narrative or violation details are referenced but not included in the provided pages.

Report Facts
Licensed Bed/Bassinet Capacity: 130 Census: 123

Employees mentioned
NameTitleContext
David BoylePersonnel contacted during inspection
Kathleen LopezPersonnel contacted during inspection

Inspection Report

Follow-Up
Census: 125 Capacity: 130 Deficiencies: 0 Date: Apr 5, 2023

Visit Reason
A desk audit was completed on 4/5/23 to review the implementation of the Plan of Correction for the Violation Letter dated 1/31/23.

Findings
Violation #1 was corrected as of 2/9/23 and the Administrator was notified via telephone on 4/5/23.

Employees mentioned
NameTitleContext
David BondAdministratorPersonnel contacted during the inspection
Judy BirtwistleSNCReport submitted by and signature on inspection report

Inspection Report

Annual Inspection
Deficiencies: 5 Date: Jul 27, 2021

Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to resident care, safety, medication management, and infection control at Regency House Nursing and Rehabilitation Center.

Findings
The facility was found deficient in multiple areas including failure to timely address physician recommendations for a resident with exit-seeking behavior, inadequate RN assessment after a resident fall before moving the resident, failure to date oxygen tubing and medication supplies properly, improper storage of cleaning and personal supplies in medication rooms, and failure to properly disinfect the glucometer according to facility policy.

Deficiencies (5)
Failed to ensure staff addressed a physician recommendation timely for a resident with exit seeking behavior.
Failed to ensure an RN assessment was completed timely after a resident fall before the resident was moved.
Failed to ensure oxygen tubing was dated to identify the date it was last changed.
Failed to ensure cleaning supplies and personal supplies were stored appropriately, failed to ensure multidose medications were dated when opened, and failed to ensure expired medications were removed from the medication cart.
Failed to disinfect the facility glucometer after resident use in accordance with facility policy.
Report Facts
Residents affected: 5 Date of survey completion: Jul 27, 2021 Expiration date of vinegar: 202102 Date tubing was due to be changed: Jul 18, 2021 Number of times glucometer wiped: 3

Employees mentioned
NameTitleContext
APRN #1Psychiatric Advanced Practice Registered NurseRecommended Wander Guard device for Resident #89 and involved in fall assessment for Resident #13
RN #1Nursing SupervisorFailed to follow through with APRN #1's recommendations for Resident #89
RN #2Corporate NurseIdentified RN #1 should have followed APRN #1's recommendations
RN #3Registered NurseCould not remember oxygen tubing change schedule; replaced undated tubing
RN #6Registered Nurse SupervisorAssessed Resident #13 after fall and expressed concern about premature resident transfer
LPN #2Licensed Practical NurseObserved medication cart storage issues and removed undated medications
LPN #3Licensed Practical NurseObserved personal items in medication room and removed expired medications
LPN #5Licensed Practical NurseNotified RN #6 of Resident #13 fall and involved in post-fall events
NA #5Nursing AssistantWitnessed Resident #13 fall and transferred resident before RN assessment
LPN #1Licensed Practical NurseFailed to properly disinfect glucometer using two wipes as per policy

Inspection Report

Renewal
Census: 121 Capacity: 130 Deficiencies: 0 Date: Jul 27, 2021

Visit Reason
The inspection was conducted as a renewal licensing inspection for Regency House Nursing Home.

Findings
The facility was found to be in compliance with visitation policies and no violations of the General Statutes or regulations were identified during this inspection. The facility did not apply for CMP funds but did apply for a CRF grant.

Employees mentioned
NameTitleContext
Cynthia HaydeRNReport submitted by
David BondAdminPersonnel contacted
Rosalyn MoranoAdminPersonnel contacted

Inspection Report

Annual Inspection
Deficiencies: 5 Date: Jul 27, 2021

Visit Reason
An unannounced visit was made to Regency House Nursing And Rehabilitation Center by the Department of Public Health for the purpose of conducting an annual survey.

Findings
The report details multiple violations of Connecticut State regulations identified during the visit, including issues with resident care, nursing assessments, medication storage, infection control, and oxygen therapy management. Plans of correction were submitted addressing each violation with measures to prevent recurrence and ensure compliance.

Deficiencies (5)
Failure to ensure timely RN assessment after a resident fall before transfer.
Failure to ensure oxygen tubing was dated to identify last change.
Failure to ensure cleaning supplies and personal supplies were stored appropriately and multidose medications were dated when opened; failure to remove expired medications from medication cart.
Failure to disinfect the facility glucometer after resident use in accordance with facility policy.
Failure to properly disinfect glucometers according to facility policy.
Report Facts
Plan of correction submission deadline: Aug 21, 2021 Dates of observations and incidents: Jul 7, 2021 Dates of observations and incidents: Jul 20, 2021 Dates of observations and incidents: Jul 26, 2021 Dates of observations and incidents: Jul 27, 2021

Employees mentioned
NameTitleContext
Maureen Golas MarkureSupervising Nurse ConsultantSigned the notice letter and responsible for overseeing the inspection
APRN #1Named in findings related to resident care and elopement risk assessment
RN #1Interviewed regarding resident care and elopement risk
RN #3Interviewed regarding oxygen tubing schedule
RN #6Supervisor involved in resident fall incident
LPN #2Interviewed regarding medication room observations
LPN #3Interviewed regarding medication room observations
LPN #5Witnessed resident fall and involved in incident
NA #5Witnessed resident fall and involved in incident

Inspection Report

Renewal
Census: 121 Capacity: 130 Deficiencies: 0 Date: Jul 20, 2021

Visit Reason
The inspection was conducted as a renewal licensing inspection for the facility.

Findings
The facility was found to be in compliance with visitation policies and did not apply for CMP funds. The report indicates no violations were identified at the time of inspection.

Employees mentioned
NameTitleContext
Tricia CalderonePersonnel contacted during the inspection

Inspection Report

Complaint Investigation
Deficiencies: 4 Date: May 11, 2020

Visit Reason
Unannounced visits were made to Regency House Nursing And Rehabilitation Center to conduct an investigation and a COVID-19 focused infection control survey.

Complaint Details
The visit was complaint-related, focusing on falls and infection control practices. The facility was found noncompliant in multiple areas related to resident care and infection control.
Findings
The facility was found to have multiple violations including failure to notify the physician when a resident continued to complain of pain after a fall, failure to address abnormal diagnostic X-ray findings timely, failure to ensure post-fall monitoring was completed per policy, failure to address complaints of pain adequately, and failure to implement appropriate infection control practices to prevent spread of infection.

Deficiencies (4)
Failed to contact the physician as directed when pain continued after a fall for Resident #1.
Failed to ensure appropriate care and treatment for Resident #1 who was non-ambulatory, including failure to address abnormal diagnostic X-ray findings timely and failure to ensure post-fall monitoring was completed according to policy.
Failed to ensure complaints of pain were addressed after a fall for Resident #1.
Failed to ensure appropriate infection control practices were implemented to prevent and control the spread of infection, including improper use of isolation gowns by staff.
Report Facts
Date of fall event: Apr 26, 2020 Date of X-ray: Apr 27, 2020 Plan of correction submission deadline: Jun 5, 2020 Audit frequency: 4

Employees mentioned
NameTitleContext
Susan NewtonSupervising Nurse ConsultantAuthor of the inspection report letter
David O. BondAdministratorFacility administrator addressed in the report
LPN #7Licensed Practical NurseDid not inform supervisor of resident's continued pain after fall
RN #4Registered NurseSupervisor who was to be notified of resident's continued pain
APRN #2Advanced Practice Registered NurseDirected staff to notify if resident continued to complain of pain
LPN #1Licensed Practical NurseObserved resident's bed elevated at time of fall
NA #1Nurse AideObserved bed elevated and resident's habit of playing with bed controls
RN #3Registered NurseHelped X-ray technician and reported X-rays taken
LPN #4Licensed Practical NurseCharge nurse on shift unaware of X-ray results and resident's pain complaints
RN #1Registered NurseNursing supervisor who did not receive X-ray results report
RN #2Unit ManagerCalled APRN and sent resident to emergency department after discovering X-ray results
LPN #6Licensed Practical NurseDid not medicate resident with as needed Tylenol after pain complaints
NA #3Nurse AideReported resident's pain complaints during repositioning
NA #4Nurse AideReported resident's pain complaints during repositioning
AdministratorInterviewed about PPE gown shortages and isolation gown usage

Inspection Report

Complaint Investigation
Deficiencies: 4 Date: May 11, 2020

Visit Reason
A Covid-19 focused survey was conducted to determine compliance with 42 CFR Part 483 requirements for LTC facilities including infection control and prevention, and an investigation for complaint CT #27447 was completed.

Complaint Details
Investigation related to complaint CT #27447 regarding failure to notify physician and inadequate care after resident fall with pain complaints.
Findings
The facility failed to notify the physician timely after a resident's fall with continued pain, failed to provide appropriate care and treatment including timely response to abnormal X-ray findings, failed to monitor post-fall resident properly, and failed to manage pain adequately. Infection control practices were also found deficient related to improper use of isolation gowns.

Deficiencies (4)
Failed to notify physician promptly when pain continued after a fall.
Failed to ensure appropriate care and treatment after fall including timely response to abnormal X-ray findings and post-fall monitoring.
Failed to ensure complaints of pain were addressed after a fall.
Failed to implement appropriate infection control practices to prevent spread of infection, including improper use of isolation gowns.
Report Facts
Deficiencies cited: 4 Fall date: Apr 26, 2020 X-ray order time: 1100 X-ray taken time: 2210 X-ray results received time: 2239 Pain monitoring shifts prior to fall: 75 Pain complaints shifts prior to fall: 2

Employees mentioned
NameTitleContext
LPN #7Licensed Practical NurseNamed in failure to notify physician of continued pain after fall
RN #4Registered NurseSupervised on day of fall, failed to ensure notification to APRN of continued pain
APRN #2Advanced Practice Registered NurseDirected to be notified if resident continued to complain of pain after fall
LPN #1Licensed Practical NurseWitnessed resident fall from elevated bed
NA #1Nurse AideReported resident habit of elevating bed and found resident on floor
NA #2Nurse AideReported resident needed assistance and found resident on floor
LPN #4Licensed Practical NurseCharge nurse on shift after fall, unaware of X-ray results and pain complaints
RN #1Registered NurseNursing supervisor on shift after fall, did not receive report of pending X-ray results
RN #2Unit ManagerDiscovered X-ray results and arranged transfer to hospital
LPN #6Licensed Practical NurseFailed to medicate resident with as needed pain medication after complaints
NA #3Nurse AideReported resident pain during repositioning not communicated to nurse
NA #4Nurse AideReported resident pain during repositioning not communicated to nurse

Inspection Report

Abbreviated Survey
Deficiencies: 1 Date: May 9, 2020

Visit Reason
An unannounced visit was made to Regency House Nursing and Rehabilitation Center on May 9, 2020 for the purpose of conducting a COVID-19 Focused survey.

Complaint Details
Complaint #27385 triggered the visit. No substantiation status was stated.
Findings
The facility failed to update policies and improperly reused disposable gowns contrary to CDC recommendations during the COVID-19 pandemic, risking staff and resident safety. Observations and interviews confirmed gowns were reused throughout shifts without proper guidelines on discarding or extended use.

Deficiencies (1)
Facility failed to update policies and failed to utilize personal protective equipment according to CDC recommendations by reusing disposable gowns instead of extending their use, risking infection control.
Report Facts
Disposable gowns available: 600 Facility units with COVID-19 residents: 4

Employees mentioned
NameTitleContext
Karen GworekSupervising Nurse ConsultantSigned the notice letter and directed questions regarding violations
David BondAdministratorNamed in relation to the facility and plan of correction
Director of NursingInterviewed regarding PPE policies and COVID-19 resident cohorting
Licensed Practical Nurse #1Charge NurseInterviewed about gown use practices during COVID-19 care
Licensed Practical Nurse #2Interviewed about gown use and safety concerns during COVID-19 care

Inspection Report

Abbreviated Survey
Deficiencies: 1 Date: May 9, 2020

Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.

Findings
The facility failed to update policies and failed to utilize personal protective equipment according to CDC recommendations during the COVID-19 pandemic by extending the use of disposable gowns instead of reusing them, putting staff and residents at risk of infection. Observations and interviews confirmed gowns were reused throughout shifts and hung outside resident rooms, contrary to proper infection control practices.

Deficiencies (1)
Failure to update policies and failure to utilize personal protective equipment according to CDC recommendations during the COVID-19 pandemic by extending the use of disposable gowns instead of reusing disposable gowns.
Report Facts
Disposable gowns available: 600 Units with COVID-19 positive residents: 4 Audit frequency: 3 Audit frequency: 1

Employees mentioned
NameTitleContext
Licensed Practical Nurse #1Charge NurseInterviewed regarding PPE gown use and reuse practices
Licensed Practical Nurse #2Interviewed regarding PPE gown use and reuse practices and safety concerns
Director of NursingDirector of NursingInterviewed regarding PPE policies and unable to provide CDC documentation

Inspection Report

Routine
Deficiencies: 1 Date: May 9, 2020

Visit Reason
An unannounced visit was made to Regency House Nursing and Rehabilitation Center on May 9, 2020 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a COVID-19 focused survey.

Findings
The facility had 600 disposable gowns available, but staff were reusing disposable gowns throughout shifts when caring for COVID-19 positive residents, contrary to CDC guidelines. The Director of Nursing was unable to provide documentation of CDC recommendations on extended use versus reuse of PPE. The facility's cohort guidelines lacked clarity on when gowns should be discarded. The policy allowed staff to reuse gowns for entire shifts, which was a concern for infection control.

Deficiencies (1)
Staff were not following proper procedure for PPE usage, specifically reusing disposable gowns throughout shifts when caring for COVID-19 positive residents.
Report Facts
Disposable gowns available: 600 Units with COVID-19 positive residents: 4 Audit frequency: 3 Audit frequency: 1

Employees mentioned
NameTitleContext
Karen GworekSupervising Nurse ConsultantSigned the notice letter
Director of Nursing (DON)Interviewed regarding PPE usage and facility policies
Licensed Practical Nurse (LPN) #1Interviewed about gown usage practices
Licensed Practical Nurse (LPN) #2Interviewed about gown usage practices and concerns

Inspection Report

Monitoring
Census: 94 Capacity: 130 Deficiencies: 1 Date: May 9, 2020

Visit Reason
The visit was conducted for monitoring COVID-19 infection control and included a complaint investigation (Complaint #27385).

Complaint Details
Complaint investigation #27385 was conducted as part of the visit. The complaint was related to infection control practices concerning COVID-19.
Findings
The inspection identified violations related to the extended use and reuse of disposable gowns for COVID-19 positive residents, with concerns about staff safety and adherence to CDC guidelines. A plan of correction was required to address these issues.

Deficiencies (1)
Improper reuse of disposable gowns for COVID-19 positive residents, contrary to CDC guidelines.
Report Facts
Licensed Bed Capacity: 130 Census: 94 Disposable Gowns: 600

Employees mentioned
NameTitleContext
Donna DwyerDirector of NursingInterviewed regarding COVID-19 cohorting and gown usage policies.
Karen GworekSupervising Nurse ConsultantSigned the complaint investigation letter.
LPN #1Licensed Practical NurseInterviewed about gown usage when caring for COVID-19 positive residents.
LPN #2Licensed Practical NurseInterviewed about gown usage and safety concerns during COVID-19 care.

Inspection Report

Routine
Census: 109 Capacity: 130 Deficiencies: 0 Date: Apr 28, 2020

Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.

Findings
No deficiencies were cited as a result of this COVID-19 focused survey.

Inspection Report

Complaint Investigation
Census: 120 Capacity: 130 Deficiencies: 1 Date: Apr 11, 2019

Visit Reason
The inspection was conducted as a complaint investigation related to multiple complaint numbers (CT00023992, CT0023782, CT00024018, CT00024140) and to assess violations of Connecticut State regulations.

Complaint Details
The visit was complaint-related, investigating complaints #23992, #23782, #24018, and #24140. Violations were substantiated as indicated by the issuance of citation #19-23.
Findings
Violations of Connecticut General Statutes and regulations were identified during the inspection, resulting in a citation (19-23). A desk audit conducted later found that violations 1-4 were corrected. The facility was required to submit a plan of correction by May 6, 2019.

Deficiencies (1)
Violations of the General Statutes of Connecticut and/or regulations were identified during the complaint investigation.
Report Facts
Licensed Bed Capacity: 130 Census: 120 Citation Number: 19 Citation Number: 23

Employees mentioned
NameTitleContext
David BondAdministratorNamed as personnel contacted during the inspection and in relation to findings.
Donna DwyerRNNamed as personnel contacted during the inspection.
Siobhan O'NeillNurse ConsultantConducted desk audit and provided findings on correction of violations.

Inspection Report

Plan of Correction
Deficiencies: 5 Date: Apr 11, 2019

Visit Reason
Unannounced visits were made to Regency House Nursing And Rehabilitation Center to conduct multiple investigations and a certification survey.

Findings
The report details violations related to resident care, including issues with advanced directives, medication administration, skin integrity, hospice notification, and documentation. Plans of correction were submitted addressing these deficiencies with education, audits, and monitoring.

Deficiencies (5)
Failure to ensure resident code status was correctly identified and honored.
Failure to notify responsible party of medication changes or changes in condition.
Failure to ensure skin integrity impairment was addressed and documented.
Failure to notify hospice service of changes in resident condition.
Medication error involving methotrexate administration and failure to follow physician orders.
Report Facts
Complaints referenced: 4 Dates of plan of correction completion: Completed 5/2/19, 5/21/19, and 8/8/18

Employees mentioned
NameTitleContext
Cher MichaelSupervising Nurse ConsultantSigned the amended violation letter
RN #1Registered NurseWitnessed consent form, involved in medication error and skin integrity findings
Person #2Responsible party for Resident #128, involved in notification findings
Physician (MD) #3PhysicianInterviewed regarding medication sensitivities
Director of NursesInterviewed regarding skin integrity audit and findings
Licensed Practical Nurse (LPN) #1Licensed Practical NursePerformed weekly skin integrity checks
RN #3Registered NurseInterviewed regarding hospice notification
Hospice nurseInterviewed regarding hospice assessments
Corporate nurseInterviewed regarding hospice service notification
RN #1Registered NurseInvolved in medication administration error and disciplinary action
Licensed Practical Nurse (LPN) #4Licensed Practical NurseInterviewed regarding medication order verification
Licensed Practical Nurse (LPN) #5Licensed Practical NurseInterviewed regarding medication pass and error notification
APRN #2Advanced Practice Registered NurseConsulted on medication error and treatment
Physician (MD) #1PhysicianInterviewed regarding methotrexate administration and toxicity
Pharmacist #1PharmacistInterviewed regarding methotrexate dosing and medication alerts

Inspection Report

Renewal
Census: 125 Capacity: 130 Deficiencies: 0 Date: Feb 26, 2018

Visit Reason
The inspection was conducted as a renewal licensing inspection and included review of complaint investigations CT# 21847 and CT# 22556.

Complaint Details
The inspection included review of complaint investigations CT# 21847 and CT# 22556.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as referenced in an attached violation letter dated 2018-03-19.

Employees mentioned
NameTitleContext
David BindAdministratorPersonnel contacted during the inspection
Donna DwyerDNSPersonnel contacted during the inspection

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