Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0600
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure residents were free from sexual abuse for 1 of 6
(R5), reviewed for abuse in the sample of 6. This failure resulted in R5 experiencing two episodes of being
sexually abused by R1 on 9/8/24, in which R5 was verbally heard yelling for help, stating that it hurt. The
reasonable person concept can also be utilized, a reasonable person would experience fear, trauma,
humiliation, should sexual abuse occur to them.
The Immediate Jeopardy began on 9/8/2024 when R5 was sexually abused by R1. The abuse was
witnessed by V5 (Certified Nurse Assistant, CNA). After removing R1 from the room, leaving R1
unsupervised, R1 again re-entered the room and sexually abused R5 for a second time. V1 (Administrator)
was notified of the immediate jeopardy on 9/23/2024 at 2:27 PM. The surveyors confirmed by observations,
interview, and record review that the Immediate Jeopardy was removed on 9/24/24 but noncompliance
remains at Level Two due to additional time needed to evaluate the implementation and effectiveness of
in-service training.
Findings include:
On 9/20/2024 at 10:22 AM, V6 (Licensed Practical Nurse, LPN) stated she was the manager on duty and
was physically in the facility on 9/8/2024 when the incident between R1 and R5 occurred. V6 stated a
Certified Nursing Assistant (CNA) reported the incident to her. V6 stated it was witnessed by the CNA and
reported to her that R1 was holding R5's penis. V6 stated she reported the incident to the administrator
immediately. V6 stated she had not observed R1 have any inappropriate behavior recently. V6 stated there
was an incident with R1 involving sexual abuse in February 2024, which was founded. V6 stated R1 was
started on Provera at that time. V6 stated R1's Provera had been discontinued, but agreed R1 was started
back on Provera after the recent incident with R5.
On 9/20/2024 at 10:50 AM, V1 stated that based on her investigation she did substantiate the allegation of
abuse involving R1 and R5 based on witnessing of actual incident and witness statements. V1 did agree
that R1 did have a previous incident of abuse.
On 9/20/2024 at 11:00 AM, V5 stated she was on break on 9/8/2024 and upon return she heard R5 yelling
help, it hurts. V5 stated R1 had his hand under R5's sheet. V5 stated when she pulled the sheet back R1
had his hands around R5's penis. V5 stated R1 dropped R5's penis at that time. V5 stated she removed R1
from the room into the hall. V5 stated she left R1, going to report the incident to V6, who was the manager
on duty. V5 stated when she returned from reporting the incident R1 was back in the room holding R5's
penis a second time.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 5
Event ID:
146139
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146139
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Regency Care
2120 West Washington
Springfield, IL 62702
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
R1's care plan dated 2/26/2024 documents R1 has a hyper-sexual and flirtatious behavior. R1's care plan
documents the following interventions: 2/26/2024 anticipate and meet R1's needs, caregivers to provide
opportunity for positive interaction, attention, stop and talk with him as passing by, if reasonable discuss
behavior, explain/reinforce why behavior is inappropriate and/or unacceptable, intervene as necessary to
protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from
situation and take to alternative location as needed, md to review chart, medications, recent changes in
status, diagnosis, recent labs.
R5's electronic medical record documents R5 has diagnosis in part of encounter for closed fracture, with
routine healing, unspecified fall, and urinary tract infection. R5's Minimum Data Set (MDS) dated [DATE]
documents that R5 has severe cognitive impairment. R5's care plan dated 9/12/2024 documents R5 has
impaired physical mobility. R5's care plan documents R5 is at risk for Activities of Daily Living (ADL)
self-care deficit related to disease process. R5's care plan documents R5 requires mechanical lift with 2
staff for transfers.
On 9/20/2024 at 10:31AM V2 Director of Nursing (DON) stated if incident involving sexual abuse would
separate residents and have a visual on them.
On 9/19/24 at 11:22 AM, R1 was noted to be cognitively impaired, expressing no concerns regarding abuse
or memories of events that had occurred.
R5 was unable to be interviewed, as he did not reside in the facility during the time of this survey. R5's
Clinical Record documented his discharge from the facility on 9/12/24.
The facility policy abuse prohibition dated 3/15/2018 documents all residents have the right to be free from
sexual abuse. The policy documents sexual abuse is non-consensual sexual contact of any type which
includes, but is not limited to sexual coercion, or sexual assault. The policy documents sexual coercion shall
include any intentional or knowingly touching or fondling a non-consenting resident's sex organs, anus, or
breast either directly or through clothing for the purpose of sexual gratification or arousal of the accused.
The policy documents if the incident involves suspected abuse, the charge nurse shall assure that the
suspected abuser has no further contact with the resident involved or with any other resident.
The immediate jeopardy that began on 9/8/2024 was removed on 9/24/24, when the facility took the
following actions to remove the immediacy:
Nurse managers and Administrator interviewed all residents for abuse on 09/23/24 and 09/24/2024. No
abuse was determined or reported at this time.
Facility completed head to toe assessment on all residents by Nurse managers on 09/24/2024. No signs or
symptoms of abuse were noted at this time.
All resident charts have been reviewed on 09/24/2024 by the facility Administrator, DON, Nurse Managers
and Social Service Director, including progress notes and tasks, to identify any additional resident
behaviors and incidents if applicable; no residents were identified.
The resident identified for exhibiting inappropriate behaviors related to the citation is in a private room
directly across from the nurse's station for supervision and 1:1 when choosing to exit his private room interventions will remain in place as long as resident is residing in facility.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146139
If continuation sheet
Page 2 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146139
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Regency Care
2120 West Washington
Springfield, IL 62702
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
Assignments of 1-1 will alternate between staff directly assigned per Administrator.
Level of Harm - Immediate
jeopardy to resident health or
safety
Primary Care Physician reviewed chart and medications, ordered 5mg tablet of Provera daily and was
initiated. Primary Care Physician requested a psychiatry consult. V16, Psychiatrist, contacted and
recommended in-patient psychiatry evaluation. Facility has made several attempts to place for psychiatry
evaluation without acceptance. V16 will continue to follow the resident in the facility. Facility Pharmacy
consultant completed Medication Regimen Review and Chart Review.
Residents Affected - Few
Facility sent referrals with resident's approval to multiple facilities for the resident to reside, all referrals have
been declined.
The facility Social Service Director reassessed the resident's PTSD Screen for DSM-5/Trauma Informed
Care, PHQ-2 to 9 Evaluation, Brief Interview for Mental Status (BIMS) Evaluation; no significant changes
were identified.
Residents Identified:
There was 1 male resident identified to have been directly affected by the inappropriate behavior of the
male resident. The identification was reported to Administrator on 09/08/2024; full investigation was initiated
including staff and resident interviews conducted by the facility Administrator. Administrator completed full
body assessment of both male residents on 09/08/2024, no harm identified. All residents are at risk for
being affected by this male resident's behavior; he will reside in a private room directly across from the
nurse's station for supervision and 1:1 when choosing to exit his private room; resident will remain in the
private room across from the nurse's station while residing in the facility.
The male resident identified to have been directly affected by the inappropriate behavior on 09/08/2024 was
immediately provided a room reassignment. Resident was interviewed and assessed on 09/08/2024
immediately following occurrence by the Administrator, resident was unable to recall occurrence, he denied
pain. The resident did not display any s/s of negative effects. Administrator reviewed resident's chart on
09/08/2024 and implemented monitoring resident every shift to ensure any changes in mood, activities, or
ADL status would be identified and reviewed every shift by the Administrator. No changes in psychosocial
well-being were identified. Resident's care plan was updated on 09/08/2024 by Administrator. Resident was
reassessed on 09/11/2024 by the Social Service Director, PHQ-2 to 9 Evaluation, Brief Interview for Mental
Status (BIMS) Evaluation completed; no significant changes were identified. Upon admission from hospital,
resident had a discharge plan to return to previous facility he resided, once facility was able to accept
based on bed availability, discharged from facility on 09/11/2024.
Immediate Education:
Regency Care - [NAME] has policy, procedures, and protocols based on current standards of practice.
*
V1,Administrator provided education to each department manager on 09/23/24 and 09/24/2024 regarding
the facility Abuse and Neglect Policy; disciplinary action that will result if failure to follow facility policy.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146139
If continuation sheet
Page 3 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146139
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Regency Care
2120 West Washington
Springfield, IL 62702
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
*
Level of Harm - Immediate
jeopardy to resident health or
safety
Department managers V2 (Director of Nursing), V7 (Assistant Director of Nursing), V9 (Infection
Preventionist), V6 (MDS Coordinator), V10 (Restorative), V11 (Social Services), V12/V13 (Environmental
Services), V14 (Dietary Manager), V8 (Business Office Manager) provided education to all staff regarding
the facility Abuse and Neglect Policy; disciplinary action that will result if failure to follow facility policy on
09/23/2024 and 09/24/2024.
Residents Affected - Few
*
The Director of Nursing or designee will review behavior notes and progress notes (on the clinical
dashboard and 24-hour summary) of all residents to identify inappropriate behaviors and notify
Administrator and reviewed at daily IDT meetings.
*
The Administrator updated care plan on 09/08/2024 of the resident identified for exhibiting inappropriate
behaviors and staff were educated on 09/08/2024 - 09/13/2024. Care plan was reviewed and updated again
on 09/23/2024.
*
Administrator provided education regarding the 09/23/2024 updated care plan for resident identified for
exhibiting inappropriate behaviors to each department manager on 09/23/24 and 09/24/2024.
*
Administrator and department managers provided education to all staff of the 09/23/2024 Care Plan
revisions and updates on 09/23/2024 and 09/24/2024.
*
Administrator provided education to all department managers on 09/09/2024 regarding resident's care plan:
resident will reside in a private room directly across from the nurse's station for supervision and 1:1 when
choosing to exit his private room; resident will remain in the private room across from the nurse's station
while residing in the facility. Administrator educated department managers again on 09/23/24 and 09/24/24.
*
09/24/2024 The Interdisciplinary Team (IDT) has reviewed, discussed and approved the Immediate
Jeopardy Removal Plan. The IDT included staff members: V1 Administrator, V2 Director of Nursing, V7
Assistant Director of Nursing, V9 Infection Preventionist, V6 MDS Coordinator, V10 Restorative, V11 Social
Services, V12/V13 Environmental Services, V14 Dietary Manager, V8 Business Office Manager, V15
Medicaid Specialist/Admissions coordinator.
*
Administrator will monitor to ensure compliance of interventions put in place by auditing 3 X week
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146139
If continuation sheet
Page 4 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146139
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Regency Care
2120 West Washington
Springfield, IL 62702
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
for 4 weeks. Audits will be reviewed at nest QA meeting in October 2024.
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146139
If continuation sheet
Page 5 of 5
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
FAQ · About this visit
Common questions about this visit
What happened during the September 25, 2024 survey of REGENCY CARE?
This was a inspection survey of REGENCY CARE on September 25, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at REGENCY CARE on September 25, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.