Inspection Reports for Regency Park Nursing and Rehabilitation Center of Carroll
500 East Valley Drive, Carroll, IA, 514010821
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 20, 2025 found the facility in substantial compliance with no deficiencies cited. Earlier inspections showed a mixed record with deficiencies related primarily to resident care, including failure to provide dignity and timely medical interventions, as well as infection prevention and control issues. Complaint investigations substantiated concerns about resident rights and clinical care, including one case where delayed care contributed to a resident’s death due to septic shock. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s recent compliance suggests some improvement following prior citations, though issues with care quality and infection control have recurred over time.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
3.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
33 residents
Based on a August 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
An annual recertification survey and investigation of a facility reported incident were conducted from November 17, 2025 to November 20, 2025.
Findings
The facility was found to be in substantial compliance with regulatory requirements.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 18, 2025
Visit Reason
This document is a statement of deficiencies and plan of correction related to the facility's compliance following a credible allegation of substantial compliance and Plan of Correction.
Findings
The facility will be certified in compliance effective August 7, 2025, based on acceptance of the credible allegation of substantial compliance and Plan of Correction.
Deficiencies (1)
Initial comments regarding acceptance of credible allegation of substantial compliance and Plan of Correction.
Report Facts
Certification effective date: Aug 7, 2025
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Date: Aug 4, 2025
Visit Reason
The inspection was conducted as a result of a facility reported incident #129208-I on August 4, 2025, related to resident rights and dignity concerns.
Complaint Details
The complaint investigation found the facility did not meet resident rights requirements, with substantiated findings based on clinical record review, staff interviews, and resident statements.
Findings
The facility failed to provide dignity to 2 of 4 residents reviewed, as evidenced by residents stating their care was rushed and rough. Staff interviews and record reviews confirmed the facility did not meet the requirement for resident rights to be free from interference, coercion, discrimination, or reprisal.
Deficiencies (1)
Failure to provide dignity to residents as evidenced by rushed care and rough handling.
Report Facts
Census: 33
Residents reviewed: 4
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Assistant (CNA) | Named in findings related to rushing care and resident complaints |
| Staff C | Licensed Practical Nurse (LPN) | Reported Staff A rushing when completing work |
| Staff D | Certified Nurse Assistant (CNA) | Reported Staff A rushing and resident complaints |
| Staff B | Certified Nurse Assistant (CNA) | Reported hearing staff swearing and described Staff A's hurried care |
| Staff E | Certified Nurse Assistant (CNA) | Observed Staff A hurrying to complete tasks |
| ADON | Assistant Director of Nursing | Confirmed Staff A's history of rushing and commented on care quality |
| DON | Director of Nursing | Reviewed employee record and provided training details |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 15, 2024
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective November 15, 2024.
Inspection Report
Annual Inspection
Census: 29
Deficiencies: 2
Date: Oct 31, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey from October 28, 2024 to October 31, 2024.
Findings
The facility was found deficient in infection prevention and control, specifically failing to maintain transmission-based precautions for a resident with rhinovirus and failing to follow an antibiotic stewardship program by not appropriately following up on a urine culture for another resident.
Deficiencies (2)
Failure to follow transmission-based precautions for Resident #34 with rhinovirus infection.
Failure to follow an antibiotic stewardship program including antibiotic use protocols and monitoring for Resident #3, specifically failure to follow up on a urine culture showing resistance to prescribed antibiotic.
Report Facts
Census: 29
Deficiencies cited: 2
Antibiotic dosage: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Reported on 10/30/24 about lab result communication and follow-up failure |
| Infection Preventionist | IP | Stated expectation to follow up on culture and sensitivity report |
| Director of Nursing | DON | Observed removing transmission-based precautions from Resident #34's room and interviewed about infection control practices |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 16, 2024
Visit Reason
An onsite revisit was conducted for the survey ending August 27, 2024 to verify compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The facility was found to be in compliance following the revisit survey conducted on September 16, 2024.
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 1
Date: Aug 27, 2024
Visit Reason
The inspection was conducted as a result of investigation of complaints #122832-C and #122949-C from August 21, 2024 to August 27, 2024. Complaint #122832-C was substantiated while complaint #122949-C was not substantiated.
Complaint Details
Complaint #122832-C was substantiated. Complaint #122949-C was not substantiated.
Findings
The facility failed to provide care and services according to accepted clinical standards for 1 of 4 residents reviewed, specifically failing to obtain a timely urinalysis per physician order which resulted in Resident #1 being transferred to the hospital and dying due to septic shock. The facility also failed to notify the physician timely and did not obtain orders for catheterization promptly.
Deficiencies (1)
Facility failed to provide care and services according to accepted standards, including failure to obtain a urinalysis per physician order in a timely manner, resulting in Resident #1's transfer to hospital and death due to septic shock.
Report Facts
Census: 30
Deficiencies cited: 1
Fine Amount: 8750
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse (RN) | Reported on Resident #1's condition and UA documentation issues |
| Staff A | Licensed Practical Nurse (LPN) | Reported attempts to obtain UA and communication with ADON |
| ADON | Assistant Director of Nursing | Involved in attempts to obtain UA and communication with staff |
| DON | Director of Nursing | Reported reason UA was ordered and Resident #1 behavior |
| Facility Administrator | Signed citation documents |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 11, 2023
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance, leading to certification in compliance effective September 8, 2023.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction submitted, resulting in certification of compliance.
Inspection Report
Annual Inspection
Census: 28
Deficiencies: 3
Date: Aug 24, 2023
Visit Reason
The inspection was conducted as an annual recertification survey from August 21, 2023 to August 24, 2023 to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The facility was found not in compliance with professional standards of quality related to comprehensive care plans, nurse staffing information posting and retention, and medical record documentation. Deficiencies were identified in following physician orders for insulin administration and posting accurate nurse staffing data.
Deficiencies (3)
Facility failed to follow a physician's order for insulin administration for one resident.
Facility failed to post daily nurse staffing information including resident census and hours worked in a clear and accessible manner.
Facility failed to maintain medical records that are complete, accurate, accessible, and systematically organized.
Report Facts
Facility Census: 28
Date Survey Completed: Aug 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Administered insulin doses and explained medication administration |
| Staff B | Licensed Practical Nurse | Administered insulin doses and reported on medication administration practices |
| Director of Nursing | Reported expectations for staff to follow physician's orders and medication administration policies |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 4, 2023
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 August 4, 2023, based on acceptance of the plan of correction. No specific deficiencies or findings are detailed in this document.
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 2
Date: Jul 10, 2023
Visit Reason
The inspection was conducted as a result of substantiated complaints #108763-C and facility reported incident #112397-I between July 5, 2023 and July 10, 2023.
Complaint Details
Complaint #108763-C and Facility Reported Incident #112397-I were substantiated.
Findings
The facility failed to assess and intervene appropriately for residents with changes in condition, including failure to notify the doctor about abnormal blood glucose levels and failure to properly manage skin integrity issues. Additionally, the facility failed to provide adequate nursing staff for the overnight shift, with multiple staff found sleeping on duty.
Deficiencies (2)
Failure to assess and intervene for residents with changes in condition, including failure to notify doctor of abnormal blood glucose levels and failure to manage skin integrity.
Insufficient nursing staff with appropriate competencies and skills, including nurse aides sleeping on duty during overnight shifts.
Report Facts
Blood Glucose Levels: 431
Blood Glucose Levels: 411
Census: 27
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 15, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
Based on acceptance of the credible allegation of compliance and plan of correction, the facility will be certified in compliance effective August 12, 2022.
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 6
Date: Jun 29, 2022
Visit Reason
The inspection was conducted as the facility's annual recertification survey from June 26, 2022 to June 29, 2022.
Findings
The facility was found deficient in multiple areas including failure to notify the resident's primary care provider and family of a significant change in condition, incomplete assessments and interventions for residents with constipation and seat belt use, and inadequate documentation in medical records. The facility also failed to maintain an effective infection prevention and control program.
Deficiencies (6)
Failure to notify resident's primary care provider and family of significant change in condition for Resident #10.
Failure to complete assessment and implement interventions for Resident #19 with constipation.
Failure to evaluate, document, and monitor use of seat belt for Resident #18.
Failure to maintain complete and accurate medical records for Residents #19 and #33.
Failure to establish and maintain an infection prevention and control program.
Failure to safeguard resident-identifiable information.
Report Facts
Census: 30
Residents reviewed: 12
Residents with deficiencies: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Reported on notification failure regarding Resident #10's unresponsive episode. |
| Staff B | Certified Nurse's Aide (CNA) | Observed Resident #18's seat belt use and assisted with care. |
| Staff D | Certified Nurse's Aide (CNA) | Observed Resident #18's seat belt use and assisted with care. |
| Director of Nursing (DON) | Director of Nursing | Provided explanations and reviewed care plans and documentation for Residents #10, #19, and #33. |
| MDS Coordinator | MDS Coordinator | Provided information on care plans and documentation for Residents #10, #18, #19, and #33. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 13, 2021
Visit Reason
A re-certification survey was conducted from 2021-05-10 to 2021-05-13 to assess compliance with federal regulations.
Findings
The survey resulted in no deficiencies being cited during the inspection period.
Inspection Report
Abbreviated Survey
Census: 24
Deficiencies: 0
Date: Dec 31, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals.
Findings
The facility was found in compliance with CMS and CDC recommended practices for COVID-19.
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 3
Date: Oct 27, 2020
Visit Reason
A focused COVID-19 infection control survey and investigation of multiple complaints and facility reported incidents ending on 10/27/20.
Complaint Details
Complaint #84445-C, #85212-C, Facility Reported Incidents #88568-I and #90160-I were substantiated.
Findings
The facility was found in compliance with CDC recommended COVID-19 practices. Deficiencies were found related to failure to meet professional standards in medication administration, quality of care including improper resident transfers resulting in injury, and inadequate supervision during mechanical lift use.
Deficiencies (3)
Failure to meet professional standards of quality when administering eye drops for 1 of 5 residents (Resident #5).
Failure to ensure all residents received assessment and intervention in accordance with professional standards for 1 of 3 residents reviewed (Resident #2), resulting in a fall with fracture and improper handling post-fall.
Failure to provide adequate supervision to ensure resident safety with the use of mechanical lift for transferring for 1 of 3 residents reviewed (Resident #1), resulting in a fall and compression fractures.
Report Facts
Total residents: 30
BIMS score: 6
BIMS score: 8
BIMS score: 8
Deficiency severity: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Licensed Practical Nurse (LPN) | Named in medication administration deficiency for improper eye drop administration |
| Staff J | Certified Nursing Assistant (CNA) | Involved in fall incident with Resident #2 and received disciplinary action |
| Staff I | Certified Nursing Assistant (CNA) | Involved in fall incident with Resident #2 and received disciplinary action |
| Staff C | Licensed Practical Nurse (LPN) | Responded to fall incident with Resident #2 and prepared disciplinary reports |
| Staff F | Certified Nursing Assistant (CNA) | Involved in mechanical lift incident with Resident #1 and received disciplinary action |
| Staff B | Assistant Director of Nursing (ADON) | Provided statements regarding incidents and disciplinary actions |
Inspection Report
Routine
Census: 34
Deficiencies: 0
Date: Jun 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals 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.
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