Inspection Reports for
Regency Park Nursing and Rehabilitation Center of Carroll

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.

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.

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.

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.

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.

The complaint investigation found substantiated issues with infection control and antibiotic stewardship, affecting a few residents.

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.

Complaint #122832-C was substantiated. Complaint #122949-C was not substantiated.

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.

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.

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.

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.

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.

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.

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.

Complaint #108763-C and Facility Reported Incident #112397-I were substantiated.

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.

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.

Complaint #84445-C, #85212-C, Facility Reported Incidents #88568-I and #90160-I were substantiated.

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.