Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ignite Medical Resort Webster, Llc during CMS and state inspections, most recent first.
A resident with urinary retention, an indwelling Foley catheter, and bowel incontinence received incontinent and catheter care during which a CNA failed to follow the facility’s infection control policy. The CNA did not clean the bedside table before placing supplies, repeatedly handled a peri cleanser bottle with contaminated gloves during peri care after a large bowel movement, and changed gloves without performing hand hygiene between glove changes. The CNA also continued care and handled the trash can and wash basin with the same contaminated gloves after the resident passed additional stool, only performing hand hygiene after leaving the room, contrary to the facility’s written hand hygiene and standard precautions requirements.
A resident with multiple complex medical conditions and several wounds was admitted, but the facility's baseline care plan failed to include specific, person-centered interventions within 48 hours. The care plan only listed general skin care measures and did not address the resident's individual wounds or other immediate needs, despite physician orders and treatment records indicating more detailed care requirements. Staff interviews confirmed the care plan lacked necessary detail and did not accurately reflect the resident's condition upon admission.
A resident's care plan was incomplete, lacking specific details about the types of care the resident resisted and omitting the names of medications used for pain, anticoagulation, and diuresis. The resident had a history of refusing medications and being weighed, but the care plan did not provide measurable objectives or time frames to address these issues. Staff interviews confirmed that care plans were not consistently updated with specific information, which could impact staff knowledge and care delivery.
Failure to Follow Hand Hygiene and Infection Control During Incontinent and Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain infection control protocols and proper hand hygiene during incontinent and Foley catheter care for one resident. The resident was an adult female recently admitted with a diagnosis of urinary retention and had an indwelling urinary catheter initiated on admission, as well as bowel incontinence. Her care plan included monitoring and reporting signs and symptoms of UTI and noted the presence of a urinary catheter and bowel incontinence. On the date of observation, the resident was in bed and could not be laid flat due to dizziness while incontinent care was being provided. During the observed care, CNA A donned a gown and double gloves but did not clean the bedside table before placing care supplies on it, including a peri wash cleanser bottle, loose gloves, wipes, and a basin with water and a washcloth. A clear trash bag was placed in a trash can on the floor beside the bed. When the brief was opened, a large bowel movement was present. CNA A rolled the brief to cover the feces, wiped the resident’s pubic area, discarded wipes in the brief, then rolled and removed the brief. Using the same gloved hand, CNA A grabbed the cleanser bottle, sprayed a wipe, and continued wiping the pubic area. After discarding the first layer of gloves, CNA A took another wipe from CNA B, again grabbed the cleanser bottle with gloved hands, and continued peri care, repeating contact with the cleanser bottle multiple times during care. CNA A did not perform hand hygiene before donning clean gloves and did not sanitize hands each time gloves were changed during incontinent care. After completing incontinence and Foley catheter care, the resident was placed on her side and a new brief was tucked under her; the resident then expelled flatulence combined with feces. CNA A continued to apply the brief and left the resident on her side to finish moving her bowels, without removing gloves. With the same gloved hands, CNA A placed a new clear bag in the trash can, picked up the wash basin from the bedside table, went to the bathroom, discarded the basin contents into the toilet, then removed her gown and gloves and performed hand hygiene. The facility’s infection control policy required that equipment or items in the resident’s environment likely contaminated with body fluids be handled to prevent transmission of infectious agents and that hand hygiene be performed before and after resident contact, immediately after touching body fluids or contaminated items (even when gloves are worn), immediately after removing gloves, when moving from contaminated to clean body sites, and after touching objects and medical equipment in the immediate care area.
Failure to Develop and Implement Person-Centered Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan that accurately reflected a resident's condition and provided person-centered care within 48 hours of admission. Upon review, the baseline care plan for a newly admitted male resident with multiple complex diagnoses, including hemiplegia, quadriplegia, morbid obesity, respiratory failure, and several wounds, was found to be incomplete and lacking specific instructions for effective care. The care plan only included general interventions for skin integrity, such as applying barrier cream and assisting with repositioning, without addressing the resident's specific wounds and other immediate needs. Record reviews revealed that the resident was admitted with several skin issues, including an abrasion to the abdomen and elbow, unstageable pressure ulcers on the foot and heel, and a fungal infection. Physician orders and treatment administration records indicated multiple wound care interventions and the use of pressure-reducing devices, but these were not fully incorporated into the baseline care plan. Interviews with staff confirmed that the care plan did not detail all necessary interventions, with the MDS nurse stating that a general statement to provide skin/wound care as ordered was considered sufficient, despite the presence of multiple wounds and specific physician orders. Further interviews with facility staff, including the DON and MDS nurse, revealed that the process for developing baseline care plans relied on minimal information and ongoing updates, rather than ensuring a comprehensive and individualized plan within the required 48-hour window. Facility policy required that baseline care plans be individualized and based on interdisciplinary assessments, but this was not followed in the resident's case, resulting in a care plan that did not accurately depict the resident's condition or provide clear guidance for staff.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, as required. Specifically, the care plan did not include measurable objectives or time frames to address the resident's medical, nursing, mental, and psychosocial needs. The care plan noted that the resident was resistive to care but did not specify what types of care the resident resisted. Additionally, the care plan referenced the use of certain medication classes, such as opioids, diuretics, and anticoagulants, but did not list the specific medications being administered. Record reviews showed that the resident had a history of refusing medications and being weighed, as documented in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for two consecutive months. The resident had intact cognition and required varying levels of assistance with activities of daily living. The Minimum Data Set (MDS) indicated that the resident had refused evaluation or care, including bloodwork, medication, and ADL assistance, on multiple occasions. Interviews with MDS Coordinators revealed that care plans were often not updated with specific medication names due to frequent changes in prescriptions and the short-term nature of many residents' stays. The coordinators acknowledged that the care plan should have specified what the resident was resistant to and that incomplete care plans could affect staff knowledge and the delivery of appropriate care. The Director of Nursing confirmed that MDS Coordinators were responsible for ensuring the accuracy of comprehensive care plans and that updates were supposed to be made based on input from all departments.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 375 citations issued within 25 miles in the last 12 months — including the 32 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Webster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Focused Care At Webster | 1.1 mi | ★★★★★ | 8 | 2 |
| Regency Village | 1.2 mi | ★★★★★ | 4 | 0 |
| Baywind Village Skilled Nursing & Rehab | 4.1 mi | ★★★★★ | 2 | 0 |
| Mrc The Crossings | 4.1 mi | ★★★★★ | 0 | 0 |
| Park Manor Of South Belt | 4.7 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Ignite Medical Resort Webster, Llc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.