Inspection Reports for
Regency Park Nursing and Rehabilitation Center of Carroll
500 East Valley Drive, Carroll, IA, 514010821
Back to Facility Profile20 Reports
Inspection Report — Nov 20, 2025
Annual Inspection State
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 — Aug 18, 2025
Plan of Correction State
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.
Violations (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 — Aug 4, 2025
Complaint Investigation State
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.
Violations (1)
Failure to provide dignity to residents as evidenced by rushed care and rough handling.
Report Facts
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 — Aug 4, 2025
Annual Inspection CMS
Date: Aug 4, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and evaluate the quality of care provided at Regency Park Nursing & Rehab Center of Carroll.
Findings
The facility failed to honor residents' rights to dignity and self-determination, as evidenced by residents reporting rushed and rough care by Staff A. Multiple staff interviews and employee reviews confirmed that Staff A frequently hurried through care, which sometimes caused discomfort to residents.
Violations (1)
F 0550: The facility failed to provide dignity to residents, with two residents reporting that care was rushed and rough due to the speed of care delivery. Staff A was documented to have a history of rushing care despite repeated feedback to slow down.
Report Facts
Residents Affected: 2
Annual Employee Reviews: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Assistant | Named in findings related to rushing care and dignity issues |
| Staff C | Licensed Practical Nurse | Provided statements about Staff A's rushing behavior |
| Staff D | Certified Nurse Assistant | Reported observations of Staff A rushing care |
| Staff B | Certified Nurse Assistant | Reported resident statements about Staff A's hurried care |
| Staff E | Certified Nurse Assistant | Observed Staff A rushing care |
| Staff F | Certified Nurse Assistant | Reported Staff A's rushing could be construed as rough care |
| ADON | Assistant Director of Nursing | Confirmed Staff A's history of rushing care |
| DON | Director of Nursing | Reviewed Staff A's employee record and commented on care quality |
Inspection Report — Nov 15, 2024
Plan of Correction State
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 — Oct 31, 2024
Annual Inspection State
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.
Violations (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
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 — Oct 31, 2024
Complaint Investigation CMS
Date: Oct 31, 2024
Visit Reason
The inspection was conducted due to complaints regarding infection prevention and control practices and antibiotic stewardship at Regency Park Nursing & Rehab Center of Carroll.
Complaint Details
The complaint investigation found substantiated issues with infection control and antibiotic stewardship, affecting a few residents.
Findings
The facility failed to follow transmission-based precautions for a resident with rhinovirus and did not properly monitor antibiotic use for another resident, including failure to follow up on a urine culture showing antibiotic resistance.
Violations (2)
F 0880: The facility failed to provide and implement an infection prevention and control program, specifically failing to maintain transmission-based precautions for Resident #34 with rhinovirus infection.
F 0881: The facility failed to implement a program that monitors antibiotic use, including failure to follow up on a urine culture showing antibiotic resistance for Resident #3.
Report Facts
Antibiotic dosage: 100
Antibiotic treatment duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding removal of transmission-based precautions for Resident #34 | |
| Assistant Director of Nursing (ADON) | Interviewed regarding follow-up on culture and sensitivity report for Resident #3 | |
| Infection Preventionist (IP) | Interviewed regarding expectations for follow-up on culture and sensitivity report | |
| Physician | Interviewed regarding expectations for maintaining precautions for Resident #34 |
Inspection Report — Sep 16, 2024
Re-Inspection State
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 — Aug 27, 2024
Complaint Investigation CMS
Date: Aug 27, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide timely urinalysis per physician order for Resident #1, which resulted in the resident's transfer to the hospital and subsequent death from septic shock and urosepsis.
Complaint Details
The investigation was complaint-driven, focusing on the failure to timely obtain a urinalysis for Resident #1 despite physician orders. The complaint was substantiated as the facility delayed obtaining the UA from 8/12/24 to 8/16/24, did not notify the physician of inability to obtain the specimen, and failed to obtain an order for catheterization until 8/16/24. Resident #1 subsequently developed septic shock and died.
Findings
The facility failed to obtain a urinalysis for Resident #1 from 8/12/24 to 8/16/24 despite physician orders, failed to notify the physician about inability to obtain the specimen, and delayed catheterization. Resident #1 developed septic shock and died. Staff interviews and documentation revealed multiple unsuccessful attempts to obtain urine specimens and lack of timely communication with the provider.
Violations (1)
F 0658: The facility failed to obtain a urinalysis per physician order in a timely manner for Resident #1, resulting in delayed diagnosis and treatment of urosepsis and septic shock leading to death.
Report Facts
Urinalysis delay days: 4
UA abnormalities: 100
UA abnormalities: 5
UA abnormalities: 79
Vital signs: 102.6
Time of death: 4.52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Reported attempts to obtain UA, catheter insertion, and clinical observations related to Resident #1 |
| Staff B | Registered Nurse (RN) | Reported clinical observations, lab draws, and communication with provider regarding Resident #1 |
| Staff C | Registered Nurse (RN) | Reported attempts to obtain UA and communication with staff regarding Resident #1 |
| ADON | Assistant Director of Nursing | Reported investigation findings, facility policies, and communication with provider regarding Resident #1 |
| ARNP | Advanced Registered Nurse Practitioner | Provided orders for UA, medication, and hospital transfer for Resident #1 |
| DON | Director of Nursing | Reported facility expectations and policies related to UA and Resident #1 behavior |
Inspection Report — Oct 11, 2023
Plan of Correction State
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 — Aug 24, 2023
Annual Inspection State
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.
Violations (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
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 — Aug 24, 2023
Routine CMS
Date: Aug 24, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality, nurse staffing posting requirements, and accurate medication administration documentation at Regency Park Nursing & Rehab Center of Carroll.
Findings
The facility failed to follow a physician's order for insulin administration timing for one resident, did not post daily nurse staffing information including resident census and staff hours in an accessible location, and failed to accurately document medication administration for one resident.
Violations (3)
F 0658: The facility failed to follow a physician's order for insulin administration timing for one of twelve residents reviewed, administering insulin after meals instead of before as ordered.
F 0732: The facility failed to post daily nurse staffing information including resident census, total staff, and hours worked in a prominent place accessible to residents and visitors.
F 0842: The facility failed to accurately document medication administration for one of twelve residents reviewed, with a staff member signing off on medication not administered.
Report Facts
Residents reviewed: 12
Blood sugar reading: 273
Insulin units administered: 6
Insulin units administered: 5
Insulin units administered: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Administered insulin after lunch and explained medication administration |
| Staff B | Licensed Practical Nurse | Documented insulin administration but did not administer medication |
| Director of Nursing | Reported expectations for staff to follow physician's orders and proper medication documentation |
Inspection Report — Aug 4, 2023
Plan of Correction State
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 — Jul 10, 2023
Complaint Investigation CMS
Date: Jul 10, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to assess and intervene when residents had changes in condition, and concerns about staff sleeping while on duty during overnight shifts.
Complaint Details
The investigation was complaint-driven based on reports of inadequate resident care related to monitoring of blood glucose and skin conditions, and staff sleeping on duty during overnight shifts. The complaints were substantiated by observations, record reviews, and staff interviews.
Findings
The facility failed to properly monitor and intervene for residents with elevated blood glucose levels and skin integrity issues. Additionally, several overnight staff were found to be sleeping while on duty, compromising resident care.
Violations (2)
F 0684: The facility failed to assess and intervene for residents with changes in condition, including elevated blood glucose levels above 350 mg/dl without notifying the doctor and failure to apply cream or follow up on skin irritation under abdominal folds.
F 0726: The facility failed to provide adequate staffing on the overnight shift, with several staff found sleeping while on duty, impacting resident care.
Report Facts
Blood Glucose Levels: 390
Blood Glucose Levels: 380
Blood Glucose Levels: 367
Blood Glucose Levels: 350
Blood Glucose Levels: 391
Blood Glucose Levels: 377
Blood Glucose Levels: 431
Blood Glucose Levels: 411
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nurse Aide (CNA) | Named in findings related to sleeping on duty during overnight shifts and difficulty staying awake. |
| Staff H | Registered Nurse (RN) | Named in findings related to sleeping on duty during overnight shifts and disciplinary actions. |
| Staff I | Certified Nurse Aide (CNA) | Reported observations of Staff F sleeping and confusion on duty. |
| Staff A | Certified Nurse Aide (CNA) | Reported observations of Staff F sleeping and appearing high while on duty. |
| Staff K | Registered Nurse (RN) | Reported Staff F falling asleep during overnight shifts. |
| Staff L | Certified Nurse Aide (CNA) | Reported Staff F sleeping and Staff H also falling asleep on duty. |
| Director of Nursing (DON) | Director of Nursing | Provided statements about expectations for calling doctors and staff sleeping policies. |
Inspection Report — Aug 15, 2022
Plan of Correction State
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 — Jun 29, 2022
Annual Inspection State
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.
Violations (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
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 — May 13, 2021
Annual Inspection State
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 — Dec 31, 2020
Abbreviated Survey State
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 — Oct 27, 2020
Complaint Investigation State
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.
Violations (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 — Jun 10, 2020
Routine State
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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