Regency Village

Scope/severity J — IMMEDIATE JEOPARDY

Survey 2025-04-19 · Tag F0580 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2025-04-20 · Under dispute (IDR)

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

What this scope/severity letter means: CMS found the facility's failure caused, or was likely to cause, serious injury, harm, impairment, or death to a resident. This is the most serious finding a surveyor can make. Affected one resident or instance. How the A–L grid works

Scope/severity J — IMMEDIATE JEOPARDY

Survey 2025-04-19 · Tag F0684 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2025-04-20 · Under dispute (IDR)

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

What this scope/severity letter means: CMS found the facility's failure caused, or was likely to cause, serious injury, harm, impairment, or death to a resident. This is the most serious finding a surveyor can make. Affected one resident or instance. How the A–L grid works

Scope/severity J — IMMEDIATE JEOPARDY

Survey 2025-04-19 · Tag F0689 · Complaint investigation · Past Non-Compliance · Correction reported 2025-04-19 · Under dispute (IDR)

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

What this scope/severity letter means: CMS found the facility's failure caused, or was likely to cause, serious injury, harm, impairment, or death to a resident. This is the most serious finding a surveyor can make. Affected one resident or instance. How the A–L grid works

Scope/severity G — ACTUAL HARM

Survey 2024-03-02 · Tag F0600 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2024-03-03

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

What this scope/severity letter means: A resident was actually harmed. CMS found real harm occurred, affecting one resident. How the A–L grid works

Scope/severity G — ACTUAL HARM

Survey 2024-03-02 · Tag F0610 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2024-03-03

Respond appropriately to all alleged violations.

What this scope/severity letter means: A resident was actually harmed. CMS found real harm occurred, affecting one resident. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2025-12-01 · Tag F0550 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2025-12-29

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2025-12-01 · Tag F0690 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2025-12-29

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2025-11-20 · Tag F0600 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2025-12-15

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2025-05-14 · Tag F0636 · Routine survey · Deficient, Provider has date of correction · Correction reported 2025-06-13

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2025-05-14 · Tag F0641 · Routine survey · Deficient, Provider has date of correction · Correction reported 2025-06-13

Ensure each resident receives an accurate assessment.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2025-05-14 · Tag F0656 · Routine survey · Deficient, Provider has date of correction · Correction reported 2025-06-13

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2025-05-14 · Tag F0677 · Routine survey · Deficient, Provider has date of correction · Correction reported 2025-06-13

Provide care and assistance to perform activities of daily living for any resident who is unable.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2025-05-14 · Tag F0695 · Routine survey · Deficient, Provider has date of correction · Correction reported 2025-06-13

Provide safe and appropriate respiratory care for a resident when needed.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity F — Potential for harm

Survey 2025-05-14 · Tag F0812 · Routine survey · Deficient, Provider has date of correction · Correction reported 2025-06-13

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it affected the facility broadly. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2025-04-19 · Tag F0644 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2025-04-20 · Under dispute (IDR)

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2025-03-21 · Tag F0657 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2025-04-15

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2025-03-14 · Tag F0880 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2025-04-11

Provide and implement an infection prevention and control program.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2024-03-02 · Tag F0657 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2024-03-03

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2024-03-02 · Tag F0759 · Routine survey · Deficient, Provider has date of correction · Correction reported 2024-03-03

Ensure medication error rates are not 5 percent or greater.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2022-12-16 · Tag F0636 · Routine survey · Deficient, Provider has date of correction · Correction reported 2023-01-20

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2022-12-16 · Tag F0656 · Routine survey · Deficient, Provider has date of correction · Correction reported 2023-01-26

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2022-12-16 · Tag F0657 · Routine survey · Deficient, Provider has date of correction · Correction reported 2023-01-26

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2022-12-16 · Tag F0658 · Routine survey · Deficient, Provider has date of correction · Correction reported 2023-01-26

Ensure services provided by the nursing facility meet professional standards of quality.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2022-12-16 · Tag F0755 · Routine survey · Deficient, Provider has date of correction · Correction reported 2023-01-26

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2022-12-16 · Tag F0759 · Routine survey · Deficient, Provider has date of correction · Correction reported 2023-01-26

Ensure medication error rates are not 5 percent or greater.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works