REGENCY VILLAGE (WEBSTER, TX) Detailed Nursing Home Profile

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

This Nursing Home:	23.5%
State:	20.4%

Percent of long-stay residents who self-report moderate to severe pain

Here:	11.4%
State:	11.4%

Percent of long-stay high-risk residents with pressure ulcers

This Nursing Home:	6.9%
Texas:	7.2%

Percent of long-stay residents who lose too much weight

Here:	18.1%
State:	6.7%

Percent of long-stay low-risk residents who lose control of their bowels or bladder

Here:	29.4%
Texas:	46.0%

Percent of long-stay residents who have had a catheter inserted and left in their bladder

This Nursing Home:	3.5%
Texas:	3.9%

Percent of long-stay residents with a urinary tract infection

This Nursing Home:	8.4%
Texas:	8.3%

Percent of long-stay residents who were physically restrained

Here:	5.9%
Texas:	1.6%

Percent of long-stay residents experiencing one or more falls with major injury

This Nursing Home:	3.5%
State:	3.5%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

This Nursing Home:	95.3%
Texas:	91.6%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

Here:	94.1%
Texas:	91.1%

Percent of short-stay residents who self-report moderate to severe pain

Here:	27.0%
Texas:	20.2%

Percent of short-stay residents with Pressure ulcers that are new or worsened

This Nursing Home:	1.6%
Texas:	1.4%

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	87.4%
State:	76.2%

Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	77.6%
Texas:	74.3%

Percent of short-stay residents who newly received an antipsychotic medication

Here:	6.8%
Texas:	3.6%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	25.0%
Texas:	28.5%

Complaint Deficiency

Conduct initial and periodic assessments of each resident's functional capacity
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Dispose of garbage and refuse properly
- Harm: Potential for minimal harm
- Scope: Some
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Fire-resistant interior walls
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Corridors or aisles that are unobstructed and are at least 8 feet in width
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly located and lighted Exit signs
- Harm: Minimal harm or potential for actual harm
- Scope: Some
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly maintained smoke detectors
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly protected cooking facilities
- Harm: Potential for minimal harm
- Scope: Many
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly sized and located linen or trash receptacles
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper medical gas storage and administration areas
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Weekly inspections and monthly testing of generators
- Harm: Minimal harm or potential for actual harm
- Scope: Many
The appropriate emergency electrical equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Emergency lighting that can last at least 1 1/2 hours
- Harm: Potential for minimal harm
- Scope: Many
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Potential for minimal harm
- Scope: Many
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Portable fire extinguishers
- Harm: Potential for minimal harm
- Scope: Many
Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly protected cooking facilities
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly installed hallway dispensers for alcohol-based hand rub
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Train all employees on what to do in an emergency, and carry out announced staff drills
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Few
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Weekly inspections and monthly testing of generators
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide activities to meet the interests and needs of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Maintain comfortable and safe temperature levels
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.510
Texas:	0.469

Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day

This Nursing Home:	0.890
Texas:	0.894

Total Number of Licensed Staff Hours Per Resident Per Day

Here:	1.400
Texas:	1.350

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

This Nursing Home:	0.140
Texas:	0.067

Number Therapy Hours Per Resident Per Day

This Nursing Home:	0.140
Texas:	0.074

REGENCY VILLAGE - WEBSTER, TX

Quality Measures

Complaint Deficiency

Staff Information

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