Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Regency Care during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and high fall risk were not adequately protected from accidents. One resident, dependent for mobility and transfers, was found on the floor and was forcefully lifted by a CNA from the floor to the bed without a nurse assessment, gait belt, mechanical lift, or assistance from other staff, while audibly expressing pain. The CNA did not report the fall to nursing staff, despite facility policy requiring nurse assessment and use of a full mechanical lift for floor transfers. Another resident, known to be very confused and a frequent wanderer, had documented fall-risk interventions such as a cushion and nonskid footwear but was able to leave bed and was later found on the floor in another resident’s bathroom shower area, complaining of pain and subsequently diagnosed with fractures. Staff interviews confirmed the resident’s ongoing wandering behavior and frequent reminders to sit, indicating that supervision and fall-prevention measures were not effectively implemented.
Multiple residents reported that call lights were not answered promptly, with some waiting up to 30 minutes for assistance. One resident, who required significant help with toileting and hygiene due to fractures and urinary retention, became incontinent after waiting too long for staff response, leading to feelings of humiliation. Resident council meetings and facility records confirmed ongoing concerns about delayed call light responses and unresolved issues.
The facility did not ensure that food served to residents was palatable or maintained at safe and appetizing temperatures. Food was observed to be cold, bland, and overcooked by the time it reached residents, with staff and residents reporting frequent complaints and the need to reheat meals due to delayed tray delivery and insufficient staffing.
Dishware, including trays and covers, were observed to be wet during meal service, causing napkins to become wet and water droplets to potentially fall onto food. Staff confirmed the issue, and the administrator noted insufficient supplies and time for proper drying, as well as the absence of a relevant policy. This affected all residents in the facility.
Staff failed to provide complete and appropriate incontinent and catheter care for several residents, including not cleansing the labia, urethral opening, or catheter tubing, not drying after cleaning, improper glove use, and lack of hand hygiene. These actions were inconsistent with facility policy and were observed in residents with catheters, cognitive impairments, and mobility issues.
Surveyors found that medications were not consistently labeled or securely stored, with several residents observed having medication cups left at their bedside and an unlabeled insulin pen found in a medication cart. Staff confirmed that leaving medications at the bedside was a common practice, and a bottle of Pepto-Bismol was found in a resident's room without a physician's order, all in violation of facility policy.
A resident with a history of falls, moderate cognitive impairment, and urinary retention requiring a catheter was admitted without a baseline care plan being developed and implemented within 48 hours, as required by facility policy. The omission occurred because the nurse completing the admission assessment did not answer the care plan questions in the electronic system, resulting in no interim care plan being generated to address the resident's immediate medical and safety needs.
Two residents did not have updated care plans reflecting their current clinical needs. One resident's care plan lacked documentation of a dialysis fistula site and necessary precautions for the left arm, while another's care plan did not accurately reflect the use of bed rails as observed and documented elsewhere. The facility did not revise care plans as required by policy.
A resident with multiple chronic conditions and moderate cognitive impairment did not receive scheduled showers or adequate grooming assistance, as evidenced by repeated observations of poor hygiene and the resident's own reports. Staff interviews and record reviews revealed missing documentation for showers, inconsistent staff responses, and a lack of facility policy regarding ADL care, resulting in the resident not receiving necessary hygiene support.
A resident with multiple medical conditions was administered oxygen therapy without a physician order or care plan, and staff failed to notify the medical director of the change in condition or the initiation of oxygen. The resident was later sent to the ER for acute hypoxia, but the required physician notification and documentation were not completed as per facility policy.
A resident with a stage 2 pressure injury on the coccyx did not receive the physician-ordered dressing during incontinence care. A CNA changed the resident's adult brief and returned the resident to a wheelchair without applying the required dressing, despite facility policy and wound care orders specifying the need for topical treatment on scheduled days.
Staff failed to follow safe transfer procedures with mechanical lifts, did not provide required supervision during meals for a resident with a recent choking incident, and left an oxygen cylinder unsecured on the floor. Additionally, another resident was transferred without staff maintaining physical contact, increasing the risk of accidents.
A resident requiring hemodialysis did not have consistent assessments of their dialysis access site documented, as required by facility policy. Staff interviews confirmed that assessments should occur every shift and after each dialysis session, but the necessary documentation was missing from the resident's records.
The facility did not complete required assessments, obtain physician orders, or secure informed consent before using bed rails for three residents with varying medical conditions, including hemiplegia, CHF, and cognitive impairment. Bed rail evaluations lacked documentation of alternatives, medical justification, and risk assessment, and staff confirmed that proper diagnoses and documentation were missing.
A resident admitted with pneumonia did not receive a prescribed course of oral Augmentin after hospital discharge because the medication order was not transcribed into the facility's physician orders. The DON confirmed the omission, and the physician indicated that all discharge medications were expected to be continued as written.
Staff failed to follow Enhanced Barrier Precautions and hand hygiene protocols during care for three residents requiring infection control measures. In separate incidents, an LPN did not wear a gown during nephrostomy care, and CNAs provided incontinent care and dressing assistance while only wearing gloves, failing to change gloves or perform hand hygiene between tasks. These actions did not comply with the facility's infection prevention policies.
A facility failed to follow physician orders for timely changing an indwelling urinary catheter for a resident with hydronephrosis. The catheter was changed 10 days late due to an oversight in scheduling, despite the resident being cognitively intact and aware of her care routine. The facility's policy required catheter changes every 30 days, but the lapse in adherence led to a deficiency.
A facility failed to follow a resident's care plan by not providing appropriate footwear during a transfer, resulting in a deficiency. The resident, with severe cognitive impairment and a history of falls, was transferred by a CNA wearing regular socks instead of the required non-skid footwear. The administrator confirmed this was against the care plan.
A resident with moderately impaired cognition reported that a CNA, who was on her phone while in the resident's room, later threw a bowl of soup at her. The resident was not injured, and the soup was not hot. The incident was reported to the BOM, who informed the DON. The CNA was advised to use her phone only during breaks but later left the facility upset and returned to throw the soup. The facility's policy to protect residents from abuse was not upheld, resulting in a deficiency.
A resident with a history of hyper-sexual behavior sexually abused another resident twice in one day, despite being removed from the room after the first incident. The facility failed to adequately supervise the abuser, leading to repeated abuse. The victim, who had severe cognitive impairment, was unable to recall the incident.
Failure to Follow Transfer Policy and Provide Adequate Supervision for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow its own transfer and fall-prevention policies and to provide adequate supervision, resulting in improper handling of one resident found on the floor and a fall with fracture for another resident. One resident (R2), with diagnoses including sepsis, cerebral infarction, type 2 diabetes, dementia, and cellulitis of the buttock, was severely cognitively impaired, dependent for mobility and transfers, and had documented upper and lower one-sided impairment. R2’s care plan identified a high risk for falls related to stroke history, traumatic brain injury, dementia, prior falls, incontinence, and medication use, with interventions such as a low bed, fall mat, bed/chair alarm, non-skid footwear, and keeping the resident within staff vision when up. R2’s fall assessment documented a high fall risk. Video evidence reviewed by the surveyor showed that on the evening of the incident, a CNA (V5) entered R2’s room where R2’s arm reached toward the CNA, and V5 then picked R2 up from the floor by the shoulders and forcefully placed the resident on the bed. The CNA then pulled on R2’s right leg and shirt to straighten the resident in bed and raised the bed, placing a pillow behind R2. During this transfer, R2 could be heard calling out “Ouch” and moaning. No gait belt, mechanical lift, staff assistance, or nursing assessment was used during this transfer, despite the facility’s transfer policy requiring that a nurse first assess any resident who has fallen and that, if medically appropriate, a full-size mechanical lift be used to transfer a resident from the floor. R2’s progress note later documented that it was reported the resident had rolled out of bed onto the floor and was observed lying on the fall mat, with an assessment noting range of motion and neurological status within normal limits and no visible injuries. The facility’s abuse and fall investigations for R2 documented that the nurse on duty (V4, LPN) was not informed by the CNA that R2 had been on the floor, and other CNAs (V6 and V7) reported they were not aware of a fall and had not been asked to assist with a transfer. The Administrator (V1) stated that the incident was not reported by V5, that V5 did not tell the nurse that R2 had fallen or was on the floor, and that the transfer was not done in accordance with policy. R2’s family member reported having a video recorder in the room, observing V5 “very forcefully” handling R2 from the floor to the bed, hearing R2 yell “Ouch,” and submitting the video as a complaint. A second resident (R6) experienced a fall resulting in fractures. R6 had diagnoses including senile degeneration of the brain, hypertensive heart disease with heart failure, CHF, atrial fibrillation, and metabolic encephalopathy, and had a BIMS score of 4, indicating significant cognitive impairment. R6 required partial/moderate assistance with mobility, transfers, and walking, and was care planned as high risk for falls with interventions such as a cushion, nonskid footwear, and a clear pathway. R6’s progress notes documented that a CNA alerted the nurse that R6 was found on the floor in another resident’s bathroom, in the shower area, with the resident’s head and back against the shower wall, legs positioned toward the door, and the resident holding the left shoulder while tearful and complaining of pain in the head, left shoulder, buttocks, and right lower extremity, and verbalizing inability to move. The initial fall investigation for R6 documented that approximately 20 minutes before being found on the bathroom floor, R6 had been assisted to the bathroom and then to bed, with the call light placed within reach. After the fall, R6 complained of pain to the left shoulder, right lower extremity, and buttocks, and would not allow staff to assist off the floor due to pain. Vital signs and neurological checks were within normal limits, and the resident was sent to the emergency room at the request of the power of attorney. A CT scan showed a nondisplaced avulsion fracture of the right ilium and a minimally displaced right distal clavicle fracture. Staff interviews described R6 as very confused and a wanderer who frequently got up on her own despite use of a bucket seat and cushion, and that multiple staff, including kitchen staff, would remind her to sit down. Despite R6’s known wandering behavior and high fall risk, she was able to leave her bed area and be found on the floor in another resident’s bathroom, indicating that supervision and fall-prevention measures were not sufficient to prevent this fall and resulting injury. The facility’s written transfer policy required that when a resident falls to the floor, a nurse must first assess the resident and, if medically appropriate, a full-size mechanical lift must be used to transfer the resident from the floor, or EMS must be called if not medically appropriate. The fall policy required assessment of each resident’s fall risk on admission, quarterly, and with each fall, to guide care planning and monitoring to reduce injury risk. In R2’s case, the CNA did not follow the transfer policy, moved the resident from the floor without a nursing assessment or mechanical lift, and did not report the fall to nursing staff. In R6’s case, despite documented high fall risk and known wandering, the resident was able to ambulate unsupervised to another resident’s bathroom where the fall occurred, resulting in fractures, demonstrating that the facility did not provide adequate supervision or effective implementation of fall-prevention interventions for this resident.
Delayed Call Light Response Compromises Resident Dignity
Penalty
Summary
The facility failed to answer call lights in a timely manner for six residents, resulting in unmet needs and compromised dignity. One resident, who required substantial to maximal assistance for toileting and personal hygiene due to multiple fractures and urinary retention, reported waiting at least 30 minutes or more for staff to respond to her call light. As a result of the delay, she was unable to wait any longer and became incontinent, which she described as humiliating. The facility's policy requires prompt response to call lights and instructs staff to seek assistance if unable to meet a resident's needs immediately. During a resident council meeting, five additional residents reported that call lights were not answered promptly, sometimes taking up to 30 minutes. These residents, most of whom were cognitively intact, expressed ongoing concerns over delayed responses, with some stating that CNAs would check the reason for the call light but leave without resolving the issue. Resident council minutes from previous months documented similar unresolved complaints about delayed call light responses, particularly at night.
Failure to Serve Palatable and Appropriately Tempered Food
Penalty
Summary
The facility failed to serve palatable food to its residents, as evidenced by multiple observations, interviews, and record reviews. During a meal service observation, food temperatures were initially within safe ranges on the steam table, but by the time trays were delivered to residents, the food had cooled significantly, with sampled items measuring between 106 and 124 degrees Fahrenheit and described as cold, lukewarm, dry, tough, and bland. Staff interviews revealed that food is often reheated for residents due to delays in tray delivery, attributed to insufficient staffing. There was no facility policy on ensuring food palatability. Resident council meeting minutes over several months documented ongoing complaints about food being overcooked, cold, and inconsistently served at appropriate temperatures. Residents and staff confirmed these issues, with one resident explicitly stating the food is usually cold and unpalatable, and a CNA acknowledging frequent complaints about cold food and the need to reheat trays. Observations included instances where residents received cold food after returning from therapy, requiring staff to warm up their meals. The deficiency affected all 87 residents in the facility, as documented in the facility's application for Medicare and Medicaid.
Failure to Properly Dry Dishware Before Use
Penalty
Summary
The facility failed to ensure that dishware, including trays and dish covers, were properly dried before use during meal service. During kitchen service, trays and dish covers were observed to be wet, resulting in napkins becoming wet and water droplets from the dish covers potentially dropping onto the food. A dietary aide confirmed the trays were wet, and the cook indicated that the dishware likely was not shaken out enough to dry. The administrator acknowledged a lack of sufficient supplies and time between meals to allow for proper drying and also stated that there was no policy in place regarding palatable food or drying dishes. This deficiency had the potential to affect all 87 residents residing in the facility, as documented in the facility's application for Medicare and Medicaid.
Failure to Provide Complete Incontinent and Catheter Care
Penalty
Summary
The facility failed to provide complete and appropriate incontinent and catheter care for five residents, resulting in deficiencies related to the prevention of urinary tract infections (UTIs). Direct observations revealed that staff did not follow established protocols for perineal and catheter care, such as cleansing the labia, urethral opening, and catheter tubing, or ensuring proper drying after cleaning. In one instance, a resident with an indwelling urinary catheter and a history of urinary retention was not properly cleaned around the catheter site, and the drainage bag was positioned above the bladder, contrary to policy. The resident was subsequently treated for a UTI. Other residents with significant medical histories, including morbid obesity, Parkinson's disease, and cognitive impairments, were also observed receiving incomplete care. Staff failed to clean all necessary areas, did not change gloves between soiled and clean tasks, and neglected hand hygiene after providing care. In some cases, staff did not use appropriate personal protective equipment (PPE) while on enhanced barrier precautions, and did not follow proper procedures for cleaning and drying the perineal and anal areas. Supplies and techniques used, such as reusing washcloths and not rinsing or drying the skin, were inconsistent with facility policy. Facility policies required thorough cleaning of the perineal area, including the external genitalia and anal area, with separate strokes and clean sections of washcloths, as well as rinsing and drying. However, staff actions deviated from these protocols, as evidenced by multiple instances where residents were not properly cleaned, dried, or protected from cross-contamination. These failures were confirmed by interviews with staff and review of facility policies, which outlined the correct procedures that were not followed during care.
Improper Medication Storage and Administration Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication storage and administration practices. An opened Basaglar insulin pen was found in the medication cart without a resident label, name, or date of opening, and the responsible RN stated the label must have fallen off. Several residents were observed with cups of medications left on their bedside tables, including one resident who had seven pills left in a cup after the scheduled administration time, and another who reported that the nurse routinely leaves morning medications at the bedside for later consumption. Staff interviews confirmed that it is common practice to leave medications at the bedside for residents to take on their own. Additionally, a bottle of Pepto-Bismol was found in a resident's room without a physician's order for its use. Facility policies require that medications be stored securely in properly labeled containers and that medications are not left at the bedside except in rare, care-planned circumstances. The observed practices did not align with these policies, as medications were not consistently labeled, stored securely, or administered directly to residents as required.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident with a history of falling and moderate cognitive impairment. The resident was admitted with diagnoses including a history of falls, chronic confusion, moderate memory loss, and urinary retention requiring a urinary catheter. Despite the facility's policy requiring a baseline care plan to be completed and implemented within 48 hours of admission, the electronic medical record did not contain a care plan addressing the resident's medical and safety needs. The administrator confirmed that the interim care plan was not created because the nurse responsible for the admission assessment did not complete the necessary care plan questions in the computer program.
Failure to Maintain Updated, Resident-Centered Care Plans
Penalty
Summary
The facility failed to maintain updated, resident-centered care plans that addressed the current needs of two residents. For one resident with end-stage renal disease and dependence on hemodialysis, the care plan did not include documentation of the left upper arm fistula site or instructions to avoid using the left arm for blood pressure measurements or blood draws, despite this information being present in other clinical records. The care plan only referenced general interventions such as fluid restriction, oral hygiene, medication administration, and monitoring for changes in mental status, but omitted critical details specific to the resident's dialysis access site. For another resident with hemiplegia, hemiparesis following a stroke, and epilepsy, the care plan documented the use of 1/4 side rails bilaterally to promote bed maneuverability. However, the resident's bed rail evaluation and direct observation indicated the use of bilateral 1/2 bed rails, and staff confirmed the resident attempted to use them during repositioning. The facility's policy required care plans to be evaluated and modified at least quarterly or with significant changes in condition, but the care plans for both residents were not updated to reflect their current needs and interventions.
Failure to Provide Scheduled Showers and Grooming Assistance
Penalty
Summary
A resident with diagnoses of congestive heart failure, chronic kidney disease, and osteoarthritis, and who was assessed as having moderate cognitive impairment, was not provided with adequate assistance for activities of daily living, specifically bathing and grooming. The resident required partial to moderate staff assistance for bathing and dressing, as documented in her care plan and Minimum Data Set. Over several days of observation, the resident was repeatedly noted to have greasy, matted hair and reported not having received a shower or bath for an extended period. The resident expressed discomfort and a desire for her hair to be washed, indicating that she only received limited hygiene care focused on her groin area. Interviews with staff revealed inconsistencies and a lack of documentation regarding the resident's showers. The CNA assigned to the resident stated that showers were scheduled on specific evenings but denied responsibility for the resident's care on those days. The LPN responsible for auditing shower records found no documentation of showers for the resident for the months reviewed and acknowledged that it appeared the resident had not received a shower since admission. When questioned, staff retroactively completed shower sheets, some indicating refusals, but these were not contemporaneous records. The facility administrator confirmed the absence of a policy for showers or ADL care and acknowledged that the lack of documentation and the resident's appearance suggested showers were not provided as scheduled.
Failure to Notify Physician and Document Oxygen Therapy Initiation
Penalty
Summary
The facility failed to clarify pre-operative instructions, document, and notify the physician of a change in condition while providing medical treatment without an order for one resident. The resident, who had diagnoses including atrial fibrillation, hypertension, and malignant neoplasm of the colon, was cognitively intact and did not have any care plan or physician order for oxygen therapy. Despite this, the resident was observed receiving oxygen via concentrator in her room, and staff reported she had been using oxygen at night for some time, though no order was found in her chart. On multiple occasions, the resident was seen with an oxygen concentrator in use, and at one point was noted to have blue-tinged lips and low oxygen saturation, prompting staff to administer oxygen and send her to the emergency room, where she was diagnosed with acute hypoxia. Documentation revealed that the medical director was not notified of the resident's change in condition or the initiation of oxygen therapy, as required by facility policy. The medical director confirmed there were no orders for oxygen and that she was not informed of the resident's condition changes or hospital transfer. Facility policy required prompt physician notification of significant changes in resident condition, including the commencement of new treatments such as oxygen therapy. However, staff failed to notify the physician in a timely manner, and the administrator acknowledged that the expected protocol was not followed. The lack of documentation, failure to obtain physician orders, and inadequate communication regarding the resident's condition and treatment changes led to the identified deficiency.
Failure to Apply Ordered Dressing to Pressure Ulcer
Penalty
Summary
A certified nursing assistant (CNA) was observed removing an incontinent resident's adult diaper and failing to apply a dressing to a pressure ulcer located on the resident's coccyx, despite physician orders specifying that a control gel formula dressing should be applied topically to the area on designated days. The CNA acknowledged that a bandage is normally placed on the sore but did not do so at the time, instead placing a new adult diaper and returning the resident to a wheelchair without the required dressing. The wound nurse confirmed that dressings are to be in place as ordered for pressure sores and referenced having performed the treatment the previous day. Facility policy requires adherence to nursing standards for wound management and the initiation of appropriate treatment protocols for pressure ulcers.
Failure to Prevent Accidents and Ensure Safe Supervision
Penalty
Summary
The facility failed to ensure safe transfer practices, adequate supervision during meals, and proper storage of oxygen cylinders for three residents. In one instance, a resident with hemiplegia and moderate cognitive impairment, who was dependent on staff for transfers, fell during a full mechanical lift transfer when the sling strap became unhooked. Observations revealed that staff did not double-check or pull down on the sling loops during subsequent transfers, and the administrator confirmed that aides should have been double-checking the straps and steadying the sling, which was not done. Another resident, who had a history of pneumonia and congestive heart failure and was cognitively intact, was observed eating unsupervised in his room despite a physician's order requiring supervision at all meals in the dining room. This resident had recently experienced a choking incident that required intervention. Additionally, an unsecured oxygen cylinder was found on the floor in the resident's room on multiple occasions, contrary to facility policy requiring cylinders to be kept in a cart, rack, or chained to the wall. A third resident, who was at risk for falls and required substantial assistance for transfers, was transferred using a full body mechanical lift without staff holding onto her while she was suspended in the air. The resident was moved across the room while swinging freely, and staff acknowledged that they did not maintain physical contact with the resident during the transfer, which was inconsistent with expected safety practices.
Failure to Consistently Assess and Document Dialysis Access Site
Penalty
Summary
The facility failed to consistently assess the dialysis access site for a resident with a diagnosis of dependence on renal dialysis. Documentation in the resident's electronic medical record showed that assessments of the left upper arm fistula were only recorded on two specific dates, with no documentation of assessments between those dates or after the most recent dialysis session. The facility's policy requires monitoring of the dialysis site every shift and upon return from dialysis for signs of bleeding and redness, but this was not reflected in the resident's records. Interviews with facility staff confirmed that assessments of the fistula site should be performed and documented at least every shift and after each dialysis session. However, the responsible LPN was unable to locate any such documentation for the resident in the medication or treatment records. The administrator also acknowledged that the required assessments and documentation were not present, indicating a failure to follow established protocols for monitoring dialysis access sites.
Failure to Assess, Obtain Orders, and Consent for Bed Rail Use
Penalty
Summary
The facility failed to conduct complete assessments, obtain physician orders, and secure informed consent for the use of bed rails for three residents. For one resident with hemiplegia and hemiparesis following a stroke, the bed rail evaluation did not document any alternatives considered, the medical reason for bed rail use, or the associated risks. The care plan indicated the resident required assistance with bed mobility using side rails, and observation confirmed the resident was in bed with half bed rails raised. A certified nurse aide stated the resident used the rails when being turned. Another resident with pneumonia and congestive heart failure had a bed rail evaluation that also failed to document alternatives, medical reasons, or risks, and there was no physician order for bed rail use in the medical record. This resident was observed in bed with side rails raised. A third resident with a history of falling and moderate cognitive impairment had a bed rail evaluation listing confusion as the reason for bed rails, which staff later stated was not an appropriate diagnosis for their use. There was no consent or physician order documented for this resident, who was also observed with side rails raised. Facility policy requires assessment, physician order, and consent prior to bed rail use, but these steps were not followed for the residents reviewed.
Failure to Administer Prescribed Antibiotic Following Hospital Discharge
Penalty
Summary
A deficiency occurred when a resident admitted with a diagnosis of pneumonia did not receive a physician-prescribed antibiotic following hospital discharge. The hospital discharge plan and medication report specified that the resident was to receive amoxicillin-clavulanate (Augmentin) orally every twelve hours for three days. However, the facility's physician orders for March did not include this medication, resulting in the resident not receiving the prescribed antibiotic. The Director of Nursing confirmed that the hospital discharge orders for Augmentin were not transferred to the admitting orders, which led to the omission. The attending physician stated that the expectation was for the facility to transcribe and continue all hospital discharge medications as written.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for three residents who required Enhanced Barrier Precautions (EBP) and personal protective equipment (PPE) during care. In one instance, a resident with a history of sepsis, hydronephrosis, and a methicillin-susceptible staphylococcus aureus infection received nephrostomy care from an LPN who did not wear a gown, despite EBP signage and supplies being present outside the room. The LPN acknowledged that a gown should have been worn during the procedure. In another case, two CNAs provided incontinent care to a resident with morbid obesity, urinary tract infections, and an indwelling catheter due to hydronephrosis, while only wearing gloves and not utilizing other required PPE under EBP. The CNAs used soiled gloves to perform multiple care tasks, including dressing the resident and handling clean items, and did not perform hand hygiene after glove removal or upon leaving the room. The care provided was also incomplete, as certain areas were not cleaned or dried as required. A third resident, dependent on staff for toileting and with a history of Parkinson's disease and falls, was assisted by a CNA who donned gloves but failed to change them between soiled and clean tasks. The CNA used the same gloves to clean the resident after a bowel movement and then to dress the resident, without performing hand hygiene after glove removal or before leaving the room. The facility's own hand hygiene protocol requires hand cleaning before and after resident contact, after glove removal, and after contact with body fluids, which was not followed in these instances.
Failure to Timely Change Indwelling Urinary Catheter
Penalty
Summary
The facility failed to adhere to physician orders regarding the timely change of an indwelling urinary catheter for a resident. The resident, who is cognitively intact and has a diagnosis of hydronephrosis with renal and ureteral calculous obstruction, reported that her catheter bag is regularly emptied, but she was unsure about the frequency of catheter changes. The facility's policy and physician orders required the catheter to be changed every 30 days or as needed. However, there was a lapse in following this schedule, as the catheter was changed 10 days late. The Director of Nurses confirmed that the catheter was due for a change on November 18, but the order was discontinued and subsequently changed on November 21. The next scheduled change was incorrectly set for December 31, resulting in a delay. The facility's catheter protocol mandates that catheter changes be recorded on treatment sheets and nurse's notes, but the oversight led to a deviation from the prescribed schedule, highlighting a failure in maintaining consistent catheter care as per the physician's directive.
Failure to Provide Appropriate Footwear During Resident Transfer
Penalty
Summary
The facility failed to adhere to a resident's care plan by not providing appropriate footwear during a transfer, leading to a deficiency in accident prevention. The resident, identified as R4, was admitted with diagnoses including heart failure, Alzheimer's disease, and dementia, and was documented as severely cognitively impaired, requiring moderate staff assistance with transfers. According to R4's care plan, she was at risk for falls and required specific footwear, such as properly fitting shoes or non-skid socks, during ambulation or mobilization. However, on December 23, 2024, a Certified Nursing Assistant transferred R4 from her bed to a wheelchair using a gait belt while she was wearing regular socks that were not non-skid. R4 was then left in her recliner without the proper footwear. The facility administrator acknowledged that the fluffy socks worn by R4 were not in accordance with her care plan.
Failure to Prevent Physical Abuse by CNA
Penalty
Summary
The facility failed to prevent physical abuse for a resident, identified as R2, who was involved in an incident with a Certified Nurse Assistant (CNA), V3. R2, who has moderately impaired cognition and requires assistance for mobility and dressing, reported that V3 was on her phone while in her room and later threw a bowl of soup at her. R2 did not sustain any injuries from the incident, and the soup was not hot. R2 had previously been in an abusive relationship but declined services and intervention at the time of the incident. The Business Office Manager (BOM), V5, was informed by R2 about V3's behavior, including being on the phone while in R2's room. V5 reported this to the Director of Nurses (DON), V2, who found V3 on her phone in the sunroom and advised her to use her phone only during breaks. Despite this, V3 was later reported by therapy staff for being on her phone during incontinent care. V3 left the facility upset after being spoken to about her phone use and returned later to throw soup at R2. The facility's Administrator, V1, and other staff were informed of the incident and assessed R2, finding no injuries. V3 was placed on a do-not-return list with the staffing agency. The facility's policy states that all residents have the right to be free from abuse, but the incident with V3 indicates a failure to uphold this policy, resulting in a deficiency in protecting residents from abuse.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R5, from sexual abuse by another resident, R1. On September 8, 2024, R5 was sexually abused twice by R1, an incident that was witnessed by a Certified Nurse Assistant (CNA), V5. Despite removing R1 from the room after the first incident, R1 was left unsupervised and re-entered the room to abuse R5 a second time. The abuse was reported to the Licensed Practical Nurse (LPN), V6, who was the manager on duty, and subsequently to the facility administrator, V1. R1 had a history of hyper-sexual and flirtatious behavior, with a previous incident of sexual abuse in February 2024. At that time, R1 was prescribed Provera, which was later discontinued but restarted after the incident with R5. R1's care plan included interventions to anticipate and meet his needs, provide positive interaction, and remove him from situations as necessary to protect others. However, these interventions were not effectively implemented, leading to the repeated abuse of R5. R5, who had severe cognitive impairment and impaired physical mobility, was unable to defend himself or recall the incident. The facility's policy on abuse prohibition clearly states that all residents have the right to be free from sexual abuse, and any suspected abuser should have no further contact with the resident involved or any other resident. The failure to adequately supervise R1 and protect R5 from further abuse constituted a significant deficiency in the facility's duty to ensure resident safety.
Removal Plan
- Nurse managers and Administrator interviewed all residents for abuse.
- Facility completed head to toe assessment on all residents by Nurse managers.
- All resident charts have been reviewed by the facility Administrator, DON, Nurse Managers and Social Service Director.
- The resident identified for exhibiting inappropriate behaviors is in a private room directly across from the nurse's station for supervision and 1:1 when choosing to exit his private room.
- Primary Care Physician reviewed chart and medications, ordered 5mg tablet of Provera daily and was initiated.
- Primary Care Physician requested a psychiatry consult.
- Facility Pharmacy consultant completed Medication Regimen Review and Chart Review.
- Facility sent referrals with resident's approval to multiple facilities for the resident to reside.
- 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.
- Administrator provided education to each department manager regarding the facility Abuse and Neglect Policy.
- Department managers provided education to all staff regarding the facility Abuse and Neglect Policy.
- The Director of Nursing or designee will review behavior notes and progress notes of all residents to identify inappropriate behaviors and notify Administrator.
- The Administrator updated care plan of the resident identified for exhibiting inappropriate behaviors and staff were educated.
- Administrator provided education regarding the updated care plan for resident identified for exhibiting inappropriate behaviors to each department manager.
- Administrator and department managers provided education to all staff of the Care Plan revisions and updates.
- Administrator provided education to all department managers regarding resident's care plan.
- The Interdisciplinary Team (IDT) has reviewed, discussed and approved the Immediate Jeopardy Removal Plan.
- Administrator will monitor to ensure compliance of interventions put in place by auditing.
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 70 citations issued within 25 miles in the last 12 months — including the 3 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 Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arc At Sangamon Valley | 1.4 mi | — | 4 | 0 |
| Arcadia Care On The Hill | 1.5 mi | — | 30 | 2 |
| Springfield Suites Rehab And Nursing | 1.6 mi | — | 15 | 0 |
| Concordia Village Care Center | 3.1 mi | — | 3 | 0 |
| Avenues At Springfield | 3.7 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.