Inspection Reports for Regency Park Nursing and Rehabilitation Center
100 Ram Drive, Jefferson, IA, 501292728
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 31, 2025, identified deficiencies related to the environment, quality of care, respiratory and tracheostomy care, food sanitation, and infection prevention. Earlier inspections showed a pattern of similar issues including medication management, food safety, documentation, and infection control, with some complaint investigations substantiated for narcotic medication discrepancies and infection control lapses. Inspectors frequently cited problems with clinical documentation, food handling, respiratory care, and medication administration. Several complaint investigations were substantiated, particularly concerning narcotic medication management and infection control, while others were found unsubstantiated. The facility’s deficiencies have persisted over time without a clear pattern of sustained improvement.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
43 residents
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 5
Date: Dec 31, 2025
Visit Reason
The inspection was conducted as an annual recertification survey from December 29, 2025 to December 31, 2025.
Findings
The facility was found deficient in providing a safe, clean, comfortable, and homelike environment, quality of care, respiratory/tracheostomy care and suctioning, food procurement and sanitation, and infection prevention and control. Specific issues included worn recliners, incomplete clinical documentation, inadequate respiratory care, improper food handling, and failure to follow infection control protocols.
Deficiencies (5)
Safe/Clean/Comfortable/Homelike Environment - Facility failed to ensure residents had a safe, clean, comfortable and homelike environment with recliners showing extensive wear.
Quality of Care - Facility failed to complete and document appropriate assessments and interventions for residents, including bowel and skin care issues.
Respiratory/Tracheostomy Care and Suctioning - Facility failed to change oxygen tubing and water humidifier for one resident as required.
Food Procurement, Store, Prepare, Serve - Facility failed to prepare and serve food under sanitary conditions, including improper glove use by Dietary Manager.
Infection Prevention & Control - Facility failed to follow infection control practices including handling of linens and use of personal protective equipment.
Report Facts
Census: 43
Deficiencies cited: 5
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 15, 2025
Visit Reason
The document reflects acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, resulting in certification of compliance effective February 15, 2025.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction; no specific deficiencies or severity levels are detailed in the report.
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 4
Date: Jan 15, 2025
Visit Reason
The inspection was conducted as an annual recertification survey including investigation of complaints #125829-C, #125830-I, and #125924-I from January 12 to January 15, 2025.
Complaint Details
The inspection included investigation of complaints #125829-C, #125830-I, and #125924-I. The facility alleges substantial compliance as of February 15, 2025.
Findings
The facility was found deficient in verifying residents' advanced directive choices, following physician orders for medication administration, food safety and handling practices, and training of feeding assistants. Multiple residents' records and observations revealed failures in compliance with federal regulations.
Deficiencies (4)
Failure to verify the resident's advanced directive choice for 1 of 12 residents reviewed.
Failure to follow a physician's order for medication administration for 1 of 12 residents reviewed.
Failure to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Failure to ensure a person assisting a resident to eat was a certified paid feeding assistant for 1 of 15 residents reviewed.
Report Facts
Residents reviewed: 12
Residents reviewed: 15
Census: 42
Dates medication patch unavailable: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Medication Aide | Interviewed regarding resident's code status and DNR order |
| Director of Nursing | Director of Nursing (DON) | Confirmed resident's chart status and acknowledged food handling deficiencies |
| Staff C | Licensed Practical Nurse | Interviewed about medication patch availability and ordering procedures |
| Staff A | Cook | Observed violating food safety protocols during meal preparation |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Observed making direct ungloved contact with food |
| Registered Dietician | Registered Dietician | Acknowledged food service issues observed by surveyor |
| Dietary Manager | Dietary Manager | Interviewed about food handling and observed ungloved contact with food |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 19, 2024
Visit Reason
A complaint investigation for complaints #124589-C, #124658-C, and #124789-C was conducted from November 14, 2024 to November 19, 2024.
Complaint Details
Investigation involved three complaints (#124589-C, #124658-C, #124789-C) and resulted in a finding of substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 16, 2024
Visit Reason
The document is a Plan of Correction submitted following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility effective September 16, 2024.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, resulting in certification effective September 16, 2024. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Date: Sep 11, 2024
Visit Reason
The inspection was conducted as an investigation of a facility reported incident #122890-I from September 10-11, 2024, which was substantiated.
Complaint Details
The visit was complaint-related, investigating incident #122890-I which was substantiated.
Findings
The facility failed to maintain accurate records and counts of narcotic medications for residents, with discrepancies found in morphine quantities and documentation. Multiple staff admissions and observations revealed inconsistent medication administration and record-keeping practices.
Deficiencies (2)
Failure to keep accurate account of narcotic medications for residents, including discrepancies in morphine quantities and inconsistent documentation.
Failure to safely store liquid narcotic medications under double lock as required by policy and regulations.
Report Facts
Census: 39
Medication discrepancies: 12
Medication discrepancies: 8
Medication doses: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jana Cater | Administrator | Signed the initial comments and plan of correction |
| Staff F | Licensed Practical Nurse (LPN) | Involved in medication administration and acknowledged discrepancies |
| Staff F | Assistant Director of Nursing (ADON) | Signed note about medication bottle and involved in narcotic count investigation |
| Staff A | Registered Nurse (RN) | Witnessed medication administration and involved in narcotic count |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Date: Jan 11, 2024
Visit Reason
The inspection was conducted as an onsite revisit of the survey ending November 13, 2023, with a new investigation of complaint intakes #117183-C and #117077-I from January 8 to January 11, 2024.
Complaint Details
Complaint #117183-C substantiated. Facility reported incident #117077-I substantiated.
Findings
The facility was found not in compliance with 42 CFR Part 483 due to failure to consistently count resident narcotics between shifts and failure to ensure proper disposal of resident narcotics for one of three residents reviewed (Resident #7). The investigation revealed narcotic discrepancies, improper narcotic disposal, and failure to follow narcotic count policies.
Deficiencies (2)
Failed to consistently count resident narcotics between shifts for Resident #7.
Failed to ensure resident narcotics were disposed of properly for Resident #7.
Report Facts
Total census: 40
Missing hydrocodone tablets: 4
Medication order dosage: 5.325
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Failed to count narcotics between shifts and improperly disposed hydrocodone tablets in sharps container. |
| Staff A | Licensed Practical Nurse (LPN) | Witnessed Staff B disposing hydrocodone tablets and reported narcotic count discrepancies. |
| Staff C | Registered Nurse (RN) | Did not count narcotics with Staff B at shift change as required. |
| Director of Nursing (DON) | Director of Nursing | Interviewed staff, found narcotics in sharps container, and explained facility expectations for narcotic counts and disposal. |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 9
Date: Nov 13, 2023
Visit Reason
The inspection was conducted due to a complaint investigation (#115908) from November 6 to November 13, 2023, to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Complaint Details
Complaint #115908-C was substantiated based on findings from staff interviews, resident interviews, and clinical record reviews.
Findings
The facility was found not in compliance with resident rights, notification of changes, comprehensive assessments, professional standards of care, accident prevention, medication administration, and other regulatory requirements. Several residents had deficiencies in care related to dignity, medication management, fall prevention, and supervision.
Deficiencies (9)
Failure to provide care in a manner to promote dignity and respect for Resident #37.
Failure to notify physician of significant changes and blood sugar levels for Resident #37.
Failure to complete significant change comprehensive assessment in a timely manner for Resident #18.
Failure to provide care and services according to accepted standards for Residents #29, #18, #30, and #37.
Failure to provide adequate nursing supervision to prevent accidents and injuries for Residents #18 and #10.
Failure to provide oxygen as ordered and proper medication administration for Resident #3.
Failure to provide sufficient nursing staff to meet resident needs.
Failure to label and store drugs and biologicals properly, including insulin pens.
Failure to prepare and serve food under sanitary conditions.
Report Facts
Total Census: 38
Medication refusal dates: 15
Fall dates: 2
Insulin units: 100
Oxygen liters: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Regional Nurse Consultant (RNC) | Verified physician notification and medication administration issues. |
| Staff J | Licensed Practical Nurse (LPN) | Reported medication administration and insulin pen issues. |
| Staff C | Certified Medication Aide (CMA) | Reported medication administration and dressing change issues. |
| Staff L | Certified Medication Aide (CMA) | Reported medication administration and documentation issues. |
| Director of Nursing | DON | Reported expectations for staff notification and follow-up on lab results and medication administration. |
| Administrator | Administrator | Signed the initial comments and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 7, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address previously identified deficiencies and certify compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective August 7, 2023.
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 1
Date: Jul 10, 2023
Visit Reason
The inspection was conducted as an investigation of complaints #110617-C and #112324-C from July 5, 2023 to July 10, 2023.
Complaint Details
Complaints #110617-C and #112324-C were investigated and found not substantiated.
Findings
The facility failed to review and revise care planned interventions and document reasons for revision in the medical record for one resident. The resident exhibited multiple inappropriate and wandering behaviors, and the care plan lacked complete documentation of interventions. The complaints were not substantiated.
Deficiencies (1)
Facility failed to review and revise care planned interventions and document the reason for revision in the resident's medical record for 1 of 1 resident reviewed.
Report Facts
Resident census: 45
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurses Aide (CNA) | Reported resident wandering and inappropriate behaviors |
| Staff B | Certified Medication Aide (CMA) | Reported resident behaviors and incidents |
| Staff C | Certified Nurses Aide (CNA) | Reported incidents involving Resident #1 |
| Administrator | Administrator | Interviewed regarding care plan expectations |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan expectations |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding care plan expectations |
| Advanced Registered Nurse Practitioner | ARNP | Interviewed regarding resident behavior and diagnosis |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 13, 2022
Visit Reason
The document is a plan of correction submitted following a prior inspection, indicating acceptance of the facility's credible allegation of compliance.
Findings
The facility will be certified in compliance effective November 30, 2022, based on acceptance of the plan of correction and credible allegation of compliance. No specific deficiencies are detailed in this document.
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 1
Date: Oct 27, 2022
Visit Reason
The inspection was conducted as the facility's annual recertification survey combined with an investigation of complaint #107530-C.
Complaint Details
Complaint #107530-C was investigated and found to be unsubstantiated.
Findings
The facility was found to have deficiencies related to incontinent care for residents, specifically failing to provide complete incontinence care for one of two residents reviewed. The complaint was unsubstantiated.
Deficiencies (1)
Failure to provide complete incontinence care for a resident, including inadequate cleaning of the scrotum, thighs, and above the penis during male perineal care.
Report Facts
Census: 42
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse's Aide | Named in deficiency related to inadequate perineal care |
| Staff B | Certified Medication Aide | Named in deficiency related to inadequate perineal care |
| Assistant Director of Nursing | Interviewed regarding staff expectations for cleansing during perineal care |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 13, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and demonstrate compliance for continued certification.
Findings
The facility submitted a credible allegation of compliance and plan of correction, resulting in certification in compliance effective August 20, 2022. No specific deficiencies are detailed in this document.
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Date: Jul 14, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey and an investigation of Complaints #102275-C and #105406-C were conducted by the Department of Inspections and Appeals from 7/14/22 to 7/20/22.
Complaint Details
Complaint #102275 and Complaint #105406 were substantiated.
Findings
The facility was found to be out of compliance with CMS and CDC recommended practices for COVID-19 infection control during the period from 4/28/22 to 7/20/22, including failure to maintain infection control practices such as proper PPE usage by staff. Complaints #102275 and #105406 were substantiated.
Deficiencies (1)
Failure to maintain infection control practices during outbreak status, including staff not wearing masks and protective eyewear as required.
Report Facts
Total Residents: 43
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 13, 2021
Visit Reason
An investigation of Complaint #99907-C was conducted from 12/8/2021 to 12/15/2021.
Complaint Details
Complaint #99907-C was not substantiated.
Findings
The complaint investigation resulted in no deficiencies and the complaint was not substantiated.
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 3
Date: May 26, 2021
Visit Reason
The inspection was conducted as part of the facility's annual health survey and investigation of two complaints (97296-C and 97226-C), both of which were not substantiated.
Complaint Details
Complaints 97296-C and 97226-C were investigated and found not substantiated.
Findings
The facility was found deficient in providing a safe, clean, and homelike environment for residents, food safety practices, and infection prevention and control procedures. Specific issues included environmental concerns, improper food labeling and storage, and failure to follow infection control protocols for multiple residents.
Deficiencies (3)
Failed to provide a homelike environment for 3 of 40 residents, including issues with sink maintenance, housekeeping, and chipped paint.
Failed to ensure staff cover drink items in the beverage cooler, label and date food and drink items to prevent food borne illness.
Failed to assure staff utilized appropriate infection control procedures for 3 of 4 residents reviewed, including improper hand hygiene and catheter care.
Report Facts
Residents present: 40
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nurses Aide (CNA) | Named in infection control deficiency related to improper hand hygiene with Resident #33 |
| Staff A | Certified Nurses Aide (CNA) | Named in infection control deficiency related to failure to assist Resident #25 with hand washing after care |
| Staff B | Certified Nurses Aide (CNA) | Named in infection control deficiency related to failure to assist Resident #25 with hand washing after care |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding food labeling and storage deficiencies |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding infection control expectations and catheter care |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 2
Date: Jan 12, 2021
Visit Reason
Investigation of Complaint #87062-C, Facility Reported Incident #92936-M and Complaint #94773-C completed on 01/12/2021.
Complaint Details
Complaint #87062-C and Complaint #94773-C were substantiated. Facility Reported Incident #92936-M was investigated; results to be provided later.
Findings
The facility failed to immediately notify resident representatives of significant changes in residents' physical, mental, or psychosocial status for 3 of 4 residents reviewed. Additionally, the facility failed to follow physician orders and properly document treatments for 1 of 4 residents reviewed.
Deficiencies (2)
Failure to immediately notify resident representatives of significant changes in residents' condition and treatment orders.
Failure to follow physician orders and document treatments as ordered for wound care.
Report Facts
Resident count: 35
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed lack of family notification and documentation issues |
Inspection Report
Abbreviated Survey
Census: 34
Deficiencies: 0
Date: Dec 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 34
Inspection Report
Abbreviated Survey
Census: 40
Deficiencies: 0
Date: Nov 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals ending 11/23/20.
Findings
The facility was found in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19.
Inspection Report
Abbreviated Survey
Census: 41
Deficiencies: 0
Date: Jun 18, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/18/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 41
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