Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Regency Village during CMS and state inspections, most recent first.
Failure to report and investigate alleged staff abuse involving a resident with ALS and extensive ADL needs. The resident said a CNA handled him roughly during care, wrenched his arm behind him, and left him with left shoulder pain rated 10/10; he later described being treated “like a rag doll.” The DON was unsure whether the allegation had been reported, the Administrator was not aware of a completed investigation, and no incident report was documented.
A resident with multiple medical conditions and an indwelling catheter was left in urine-soaked clothing and bedding after an LVN failed to flush or change the leaking catheter as ordered, despite the resident's requests. The resident called 911 for help and was transported to the hospital, where he was treated for a dislodged catheter and UTI. The incident was not reported to the DON until after the resident's return.
A resident with a neurogenic bladder and Foley catheter did not receive required catheter care when the device was leaking and not draining, despite physician orders to flush or change the catheter as needed. The assigned LVN did not take action, resulting in the resident being soaked in urine and requiring EMS transport to the ER, where a dislodged catheter and UTI were diagnosed. Facility policy and orders for catheter management were not followed.
A resident with behavioral and psychiatric diagnoses physically assaulted another resident in the dining room, resulting in a failure to protect the victim from abuse. The incident was witnessed by staff, and although the assaulted resident did not sustain injuries or emotional distress, the event highlighted a lapse in preventing resident-to-resident abuse despite existing care plans and staff training.
Surveyors found that the facility failed to maintain kitchen equipment cleanliness, properly label and date food items, and remove expired products from storage. Observations included dirty equipment, undated and unlabeled foods, and expired items in the walk-in cooler. Staff interviews confirmed that these practices did not meet expected standards for food safety and sanitation.
Three residents with documented falls had their incidents omitted or inaccurately recorded in their MDS assessments, despite falls being noted in care plans and facility logs. Staff interviews confirmed that these falls should have been included in the MDS, and the omission was acknowledged by facility leadership.
Three residents with complex medical needs did not have comprehensive care plans developed or implemented, as required. Their electronic medical records contained blank care plans, with no documented focus areas, goals, or interventions to guide direct care staff. Staff interviews revealed that the MDS coordinator did not enter the care plans into the EMR, and the process for care plan development was not completed, despite facility policy requiring timely and individualized care planning.
A resident's admission MDS assessment was not completed and transmitted within the required 14-day period due to staffing shortages and turnover in the MDS department. Interim coverage by the DON, Director of Reimbursement, and an MDS Consultant was in place, but the assessment was finalized late, exceeding regulatory requirements.
A resident with severe cognitive impairment and a need for extensive assistance did not receive adequate oral care, as evidenced by missed documentation, visible buildup in the mouth, and inconsistent staff understanding of oral hygiene responsibilities. This failure was confirmed through observations, interviews, and record review, and placed the resident at risk of diminished quality of life.
Two residents receiving oxygen therapy did not have their oxygen humidifier bottles properly maintained, with one resident's humidifier found empty on multiple occasions and another resident's humidifier low on water while her concentrator was beeping. Both residents had significant medical conditions requiring oxygen, and staff interviews confirmed that humidifier maintenance was not consistently performed as required by facility policy.
A resident with diabetes and peripheral vascular disease experienced a change in condition when pain and an open wound developed on his right foot. Nursing staff noted the issue but did not notify the physician or responsible party, nor did they obtain wound care orders or escalate the concern. The resident's condition deteriorated, leading to multiple toe amputations and loss of independent mobility. Documentation and interviews revealed a lack of timely physician notification, missed podiatry appointments, and absence of staff training or competency checks related to change in condition and wound care.
A resident with diabetes and peripheral vascular disease did not receive scheduled podiatry care, and staff failed to promptly notify a physician after a change in the resident's foot condition was observed. The delay in assessment and intervention led to the development of gangrene, resulting in multiple toe amputations and loss of independent mobility.
A resident with severe cognitive impairment and a history of wandering and exit-seeking behaviors repeatedly attempted to leave the facility without effective interventions being implemented. The resident ultimately eloped and was found walking outside by staff, despite prior documentation of multiple elopement attempts and the need for supervision.
A resident with intellectual disabilities and multiple medical conditions did not receive timely habilitative therapy services (PT, OT, ST) as agreed upon in an IDT meeting, due to the facility's failure to complete and submit required PASRR documentation and therapy evaluations within the mandated timeframe. Staff turnover and incomplete records contributed to the lack of service initiation, leaving the resident without the specialized therapies needed for optimal functioning.
A facility failed to develop a comprehensive care plan within the required timeframe for a resident with multiple health issues, including dementia and recurrent Enterocolitis. The resident's care plan was not completed due to communication and staffing issues, as revealed in interviews with the DON and MDS coordinator. This oversight could risk the resident not receiving necessary care.
A facility failed to maintain an effective infection control program when an Administrator entered a resident's room, who was on droplet precautions for COVID-19, without proper PPE and hand hygiene. The resident, an elderly female with COVID-19, was on strict isolation. The Administrator did not wear a gown, gloves, or N95 mask, and failed to sanitize his hands, potentially exposing others to the virus. Interviews with the DON and ADON confirmed non-compliance with infection control policies.
Failure to Report and Investigate Alleged Staff Abuse
Penalty
Summary
The facility failed to report and investigate an allegation of staff abuse involving one resident. The resident was a cognitively intact male with ALS, muscle wasting/atrophy, and significant assistance needs for bathing, toileting, dressing, transfers, and personal hygiene. His care plan reflected extensive to total assistance needs, including total assistance with transfers and extensive assistance with several ADLs. Record review showed no incident report documented for the resident between 11/1/25 and 1/14/26, despite a complaint stating that a CNA was changing the resident and, when unable to get his arm through a sleeve, wrenched the resident's left arm behind him “like the cops do to suspects,” after which the resident reported pain in his left shoulder. The resident later stated that he felt he was handled “like a rag doll,” that his arm hurt after the incident, and that he reported the matter to the facility and former Administrator B. A pain assessment documented left shoulder pain rated 10/10, and an x-ray of the left shoulder showed no fracture, dislocation, or separation. Statements from the CNA involved denied rough handling or injury, and an LVN stated she assessed the resident after he used the phrase “rag doll” to describe the care he received. The DON said she vaguely remembered an issue but was unsure whether the former Administrator had reported it, and when asked whether the allegation would be considered abuse, she said she would need more information. The Administrator stated he was not in the role at the time and would begin an investigation, while the former Administrator did not recall the allegation. The facility policy stated residents have the right to be free from abuse, neglect, misappropriation, and exploitation, including physical abuse.
Failure to Provide Timely Catheter Care and Maintain Resident Dignity
Penalty
Summary
A resident with neuromuscular dysfunction of the bladder, paraplegia, osteomyelitis, diabetes, and a right below-knee amputation, who was dependent on staff for toileting and had an indwelling catheter, experienced a failure in care when his foley catheter began leaking and was not draining properly. The resident had physician orders for the catheter to be flushed every shift and as needed, and to change the catheter if there was leakage, blockage, or sedimentation. On the day of the incident, the resident was found soaked in urine, with both his bed linen and t-shirt wet, and he requested assistance from an LVN to change his catheter. Despite the resident's request and the presence of standing orders, the LVN did not flush or change the catheter, instead telling the resident that she wanted to call the physician first. The resident, not wanting to wait and still sitting in urine, called 911 for assistance. EMS staff who arrived observed the resident covered in urine from his mid-chest down. The LVN did not provide any catheter care or hygiene assistance prior to the resident's transport to the hospital. Upon return from the hospital, the resident reported the incident to another LVN, who did not escalate the issue. The Director of Nursing confirmed that this was the first time she was made aware of the incident. The facility's policy requires staff to treat residents with kindness, respect, and dignity, and to support residents in exercising their rights. The failure to provide timely catheter care and hygiene resulted in the resident being left in a urine-soaked state and ultimately being transported to the hospital for a dislodged catheter and a urinary tract infection.
Failure to Provide Appropriate Catheter Care and Prevent UTI
Penalty
Summary
A deficiency occurred when a resident with a history of neuromuscular bladder dysfunction, paraplegia, diabetes, and a stage 4 pressure ulcer did not receive appropriate catheter care as ordered. The resident had physician orders for a Foley catheter, including instructions to flush the catheter every shift and as needed, and to change the catheter in cases of leakage, blockage, or sedimentation. On the day of the incident, the resident's catheter was leaking and not draining properly, resulting in the resident being soaked in urine and experiencing a full, tender bladder. Despite the resident's request for assistance, the assigned LVN did not flush or change the catheter as ordered, nor did she clean the resident or address the leakage. The LVN stated she intended to call the physician before taking action, even though standing orders were in place to change the catheter for leakage. She also reported not having previously changed a catheter at the facility and only working PRN. The resident, after not receiving help, called 911 and was transported to the emergency room, where it was found that the catheter was dislodged and a UTI was present. EMS personnel and another LVN confirmed the resident was covered in urine, the catheter was leaking, and the tip was improperly positioned in the urethra rather than the bladder. Facility policy required replacing the catheter and collecting system using aseptic technique in cases of leakage or system compromise, and to observe and report complications such as urinary retention or infection. The DON confirmed that the nurse should have flushed or changed the catheter per orders and policy. The incident was not documented accurately in the nursing notes, and the DON was not made aware of the situation until after the resident filed a grievance.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was not protected from abuse by another resident in the facility's dining room. One resident, with a history of dementia, schizoaffective disorder, bipolar disorder, and traumatic brain injury, physically assaulted another resident by punching him in the face. The incident was witnessed by dietary staff, and the aggressor was noted to have been upset because the other resident was looking at him while he ate. There was no verbal exchange prior to the assault, and the two residents were immediately separated by staff. The resident who was assaulted had a history of malnutrition, myocardial infarction, Type 2 diabetes, unspecified dementia, and depression, and was assessed after the incident. He did not exhibit any physical injuries or pain, and subsequent assessments showed no changes to his skin or signs of emotional distress. The facility's investigation included witness statements and post-incident monitoring, but the event itself demonstrated a failure to ensure the right of the resident to be free from abuse. Interviews with facility leadership revealed that staff were aware of the potential for resident-to-resident abuse, particularly among residents with behavioral issues. The facility had policies and care plans in place for managing behaviors, but the incident still occurred. Staff had been trained on abuse and neglect, and interventions such as monitoring and redirection were described, but these measures did not prevent the physical assault in the dining area.
Deficient Food Storage, Labeling, and Kitchen Cleanliness
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, preparation, and cleanliness. The commercial can opener had a dark substance around the cutting blades and holder, and the deep fryer contained dark grease with white floating substances, with uncertainty about when the grease was last changed. In the walk-in cooler, several food items were found either expired, undated, or unlabeled, including dairy drinks, sandwich meats, coleslaw, crushed pineapple, cottage cheese, margarine, and other products. Some items were partially exposed or had unknown substances, and all undated and unlabeled items were removed by the cook during the inspection. Interviews with dietary staff and facility leadership confirmed expectations that all food items should be labeled with identification and expiration dates, and that the kitchen should be kept clean. The Dietary Manager was noted to be new to the position and facing challenges, and the Registered Dietitian stated that prepared foods should be discarded after three days if unused. Facility policy requires food storage areas to be maintained in a clean, safe, and sanitary manner, with prepared foods dated and sealed, and daily checks of refrigerator and freezer temperatures.
Failure to Accurately Document Falls in MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the fall history of three residents. For one resident with diagnoses including congestive heart failure and muscle weakness, two unwitnessed falls that occurred on the same day were documented in the care plan and nurses' notes, but were not recorded in the annual MDS assessment. Interviews with the DON and Director of Reimbursement confirmed that these falls should have been included in the MDS, and that omission could impact care planning. Two additional residents with multiple falls documented in care plans and the facility's accident and incident logs also had MDS assessments that either left the fall history section blank or incorrectly coded no falls since admission or the prior assessment. These inaccuracies were confirmed through record review and staff interviews, with staff acknowledging that the MDS should have reflected the residents' fall history as documented elsewhere in their records.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans with measurable objectives and timetables for three residents, as required by regulation. For each of these residents, the electronic medical records contained blank care plans with no focus areas, goals, or interventions documented to guide direct care staff. The residents involved had complex medical histories, including conditions such as chronic obstructive pulmonary disease, hypertension, heart failure, Parkinson's disease, visual impairment, anxiety, depression, dementia, peripheral neuropathy, and osteoarthritis. Their Minimum Data Set (MDS) assessments indicated varying levels of cognitive function and assistance needs, but these assessments were not translated into individualized care plans. Interviews with facility staff, including the DON, ADON, and RDO, revealed that the MDS coordinator did not enter the care plans into the electronic medical record system, and that the process for developing care plans from MDS-triggered areas was not completed for the affected residents. Staff acknowledged that the responsibility for care plans lay with the DON and MDS nurse, and that there had been turnover in the MDS nurse position. The facility's policy required comprehensive, person-centered care plans to be developed within seven days of the required assessment and updated as resident conditions changed, but this was not followed for the residents in question.
Failure to Complete and Transmit Admission MDS Assessment Timely
Penalty
Summary
The facility failed to complete and transmit an accurate and complete Minimum Data Set (MDS) assessment for a resident within the required 14-day timeframe following admission. Record review showed that the resident's admission MDS assessment was signed as completed 18 days after admission, exceeding the regulatory requirement. The delay was confirmed through interviews with facility staff, including the DON, Director of Reimbursement, and MDS Consultant, who indicated that the MDS process was being managed remotely due to staffing shortages and that the facility was in the process of hiring a new MDS nurse. The previous MDS Coordinator had recently left, and interim coverage was being provided by the Director of Reimbursement and an MDS Consultant. The deficiency was identified for one resident whose admission MDS assessment was not completed and transmitted to the CMS system within the mandated period. The facility's policy was to follow the RAI manual for MDS completion, but due to turnover and gaps in MDS staffing, the assessment was not finalized on time. Staff interviews confirmed the late completion and acknowledged the staffing challenges that contributed to the delay.
Failure to Provide Adequate Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically oral care, for a resident with severe cognitive impairment who required extensive staff support for personal hygiene. Record review showed gaps in documentation of oral care over several days, and interviews with staff revealed uncertainty about the frequency and responsibility for providing oral care. Observations confirmed the resident had dried brown crustiness on her lips and a dry brown substance coating her teeth, indicating inadequate oral hygiene. The resident's family member also reported concerns about the state of the resident's mouth and had previously requested assistance with oral care. Staff interviews indicated inconsistent understanding and training regarding oral care procedures, with some staff unsure of the required frequency and others stating oral care should be performed daily or after meals. The facility's own policies required assistance for residents unable to perform activities of daily living, including oral hygiene, but these were not consistently followed. The lack of adequate oral care placed the resident at risk of diminished quality of life or decreased self-esteem, as directly stated in the report.
Failure to Maintain Oxygen Humidifiers and Equipment for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required oxygen therapy. For one resident with severe cognitive impairment and diagnoses including Alzheimer's Disease and heart failure, observations on two consecutive days revealed that the oxygen humidifier bottle attached to her concentrator was empty while she was receiving oxygen via nasal cannula. Facility records indicated that the oxygen tubing and water were to be changed weekly and as needed, and the care plan specified continuous oxygen therapy. The Director of Nursing confirmed that nurses were responsible for refilling humidifiers, which should occur on Sundays, but the humidifier was found empty during the survey. For another resident with moderate cognitive impairment and diagnoses including diabetes and heart failure, observations showed that her oxygen humidifier bottle was low on water and her oxygen concentrator was beeping on two occasions. The resident reported discomfort from a dry nose and recalled nearly running out of water in the humidifier. Staff interviews revealed that daily checks of humidifier bottles were performed, but the responsibility for refilling them was assigned to Sunday night staff. Facility policy required periodic re-checks of the water level in humidifying jars, but this was not consistently followed, resulting in inadequate respiratory care for the residents.
Failure to Notify Physician of Change in Condition Resulting in Amputation
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify a resident's physician of a significant change in the resident's physical condition. The resident, who had a history of intellectual disabilities, Down syndrome, Type II diabetes mellitus with circulatory complications, peripheral vascular disease, and acute osteomyelitis, reported pain in his right foot. Upon assessment by a nurse, a small opening and swelling were noted on the third toe of the right foot, but there was no documentation that the physician, nurse practitioner, or responsible party were notified of this change. The nurse applied topical antibiotic ointment and a bandage without obtaining an order or further escalating the issue. The resident was not seen by the scheduled podiatrist, and there was no documentation explaining the missed appointment. Over the following days, the resident's condition worsened, and it was only after the resident requested an evaluation from the nurse practitioner that a full assessment was conducted. At that time, the third toe was found to have black eschar, maceration, foul odor, and exposed bone, leading to the resident being sent to the hospital. The resident subsequently underwent amputation of the third toe, and later, the remaining toes on the right foot due to ongoing infection and complications. The resident, who had previously been independent in ambulation, became wheelchair-bound as a result. Record reviews and interviews revealed a lack of documentation regarding timely physician notification, absence of wound care orders prior to the incident, and no evidence of staff following up on the resident's change in condition. Staff interviews indicated poor recall of the incident, lack of use of change in condition forms, and no clear communication with the physician or responsible party. Additionally, there was no evidence of staff training or competency checks related to change in condition, wound care, or physician notification in personnel files. The facility's policies did not provide specific guidance on wounds, skin, or foot problems, and there was no documentation of appropriate notifications or interventions at the time of the resident's decline.
Failure to Provide Timely Podiatry Care and Physician Notification Resulting in Amputation
Penalty
Summary
A resident with a history of intellectual disabilities, Down syndrome, Type II diabetes mellitus with circulatory complications, peripheral vascular disease, and acute osteomyelitis was admitted and readmitted to the facility. The resident was care planned for risks related to fragile skin and peripheral vascular disease, with interventions including monitoring for injury, infection, and ulcers, and education on proper foot care. Despite being scheduled for podiatry services, the resident was not seen as planned, and there was no documentation or explanation for the missed appointment. Additionally, there were no wound care orders in place for the months leading up to the incident. On one occasion, the resident complained of pain in his right foot, and a nurse noted a small opening and swelling on the third toe. The nurse cleansed the area and applied a topical antibiotic and bandage but did not document notifying the physician, nurse practitioner, or responsible party, nor did they complete a change in condition form or incident report. There was no evidence of further assessment or physician notification until several days later, when the resident requested evaluation from a nurse practitioner due to ongoing pain. At that time, the toe was found to be ischemic, macerated, with foul odor and exposed bone, leading to the resident being sent to the hospital, where gangrene and diabetic foot infection were diagnosed, resulting in amputation of the third toe and, later, the remaining toes on the right foot. The resident, who had previously been independent with ambulation and activities of daily living, became wheelchair-dependent following the amputations. Interviews with staff revealed a lack of recall regarding proper notification and documentation procedures, and personnel files showed no evidence of completed training or competencies related to wound care, change in condition, or physician notification. Facility policies required timely notification of changes in resident condition, but there was no documentation that these procedures were followed in this case. The failure to provide timely podiatry care and to accurately and thoroughly report and address the resident's change in condition resulted in significant harm, including loss of all toes on the right foot and decreased mobility.
Failure to Prevent Elopement of Resident with Cognitive Impairment
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with a known history of exit-seeking behaviors and wandering. The resident, who had diagnoses including dementia with behavioral disturbance, depression, hypertension, psychosis, and schizoaffective disorder, was assessed as having severely impaired cognitive skills and was independent in ambulation but required supervision with activities of daily living. Despite multiple documented attempts to elope on a single day, the resident was only re-directed and re-educated each time, with no additional safety measures or interventions implemented to address the ongoing risk. The resident's baseline care plan identified him as a fall and safety risk, with instructions to re-direct him to use a walker and return to his room. However, the admission elopement assessment was not completed for safety measures, and the care plan was not updated to reflect the resident's elopement risk until after the incident. On the day of the elopement, the resident was last seen being escorted to his room, but was later found walking on the street outside the facility by a staff member, who then returned him to the facility. The resident was confused at the time and could not explain where he was going. Interviews with staff confirmed that the resident was known to wander and required frequent re-direction, but no staff reported that he had previously eloped. Observations revealed that some egress doors had added keypads and alarms, but not all doors had delayed egress hardware installed at the time of the incident. The facility's policies required staff to report and prevent resident departures, but these measures were not effectively implemented prior to the resident's elopement.
Failure to Coordinate and Initiate PASRR Habilitative Therapy Services
Penalty
Summary
The facility failed to coordinate with the Pre-Admission Screening and Resident Review (PASRR) program and did not initiate habilitative therapy services within the required timeframe for a resident with intellectual and developmental disabilities. Despite an interdisciplinary team (IDT) meeting where the need for specialized assessments and services in physical therapy (PT), occupational therapy (OT), and speech therapy (ST) was agreed upon, the facility did not complete or submit the necessary therapy evaluations and NFSS forms within 30 days as required. As a result, requests for these services were denied due to missing or late documentation, and the resident did not receive timely habilitative therapies as outlined in the PASRR service plan. The resident involved was an adult male with diagnoses including intellectual disabilities, Down syndrome, diabetes mellitus type II, peripheral vascular disease, and acute osteomyelitis of the right ankle and foot. At the time of the deficiency, he had moderate cognitive impairment and required assistance with all activities of daily living. He had undergone multiple surgeries resulting in the loss of all toes on his right foot, which left him unable to walk and reliant on a wheelchair for mobility. The resident expressed a desire to regain the ability to walk, but was not receiving the agreed-upon therapy services due to the facility's failure to complete the necessary PASRR processes. Interviews with facility staff revealed that there had been a change in facility ownership and staff turnover, resulting in incomplete records and a lack of continuity in care coordination. The current Director of Rehabilitation and MDS Coordinator were unable to account for the actions or documentation of previous staff, and there was no evidence that the required therapy assessments or service initiation had occurred within the mandated timeframe. Facility policy required that all specialized services identified by the Local Authority be added to the care plan and initiated within 25 days, but this was not followed in this case.
Incomplete Care Plan for Resident
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed within 7 days after the completion of the comprehensive assessment for a resident. The resident, an elderly male with multiple diagnoses including recurrent Enterocolitis due to Clostridium Difficile, schizoaffective disorders, and unspecified dementia, was admitted to the facility. His initial MDS assessment indicated severely impaired cognition with a BIMS score of 03, and he required partial/moderate assistance with daily activities such as eating and oral hygiene. However, a review of his electronic health record revealed that his care plan was not completed. Interviews with the Director of Nursing (DON) and the MDS coordinator highlighted a lack of communication and staffing issues as contributing factors to the incomplete care plan. The DON mentioned being on vacation and the responsibility falling on the MDS coordinator, who was unsure why the care plan was not completed. The facility's policy requires the interdisciplinary team to develop a comprehensive, person-centered care plan within seven days of the comprehensive assessment, but this was not adhered to, potentially placing the resident at risk of not receiving necessary care or services.
Inadequate Infection Control Practices by Administrator
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of the Administrator who did not adhere to proper infection control protocols. The Administrator entered the room of a resident who was on droplet precautions for COVID-19 without donning the appropriate personal protective equipment (PPE), which included a gown, gloves, and an N95 mask. Additionally, the Administrator did not sanitize his hands before entering or after exiting the resident's room, and he left the door open, which could potentially expose others to the virus. The resident involved was an elderly female with a history of lymphedema, anemia, and hypertension, who had tested positive for COVID-19 and was placed on strict isolation. The resident was cognitively intact, as indicated by a BIMS score of 15 out of 15. The Administrator assisted the resident with her meal without following the necessary infection control measures, which included not sanitizing his hands or wearing the required PPE. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed that the Administrator's actions were not in compliance with the facility's infection control policies. The DON stated that the Administrator's failure to wear the required PPE and sanitize his hands placed residents and staff at risk of spreading infection. The facility's infection control policy and CDC guidelines emphasize the importance of using PPE and hand hygiene to prevent the transmission of communicable diseases.
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 372 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) |
|---|---|---|---|---|
| Ignite Medical Resort Webster, Llc | 1.2 mi | ★★★★★ | 1 | 0 |
| Focused Care At Webster | 1.2 mi | ★★★★★ | 8 | 2 |
| Friendship Haven Healthcare And Rehabilitation Cen | 3.7 mi | ★★★★★ | 2 | 0 |
| Baywind Village Skilled Nursing & Rehab | 3.9 mi | ★★★★★ | 2 | 0 |
| Mrc The Crossings | 4 mi | ★★★★★ | 0 | 0 |
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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.