Focused Care at Webster

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who are unable to carry out activities of daily living receive the necessary treatment and services, consistent with professional standards of practice, to maintain personal hygiene. Video footage of in room surveillance revealed the facility failed to provide Resident #1, who was totally dependent on staff for ADL care, with timely incontinent care. Resident #1 did not receive incontinent care for more than 15 hours on 5/24/26 and 5/25/26, and on 05/25/26, was subsequently diagnosed with a Stage 3 pressure ulcer to his sacrum. This failure could place residents at risk for skin breakdowns, diminished quality of life, and a decline in personal hygiene. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable. Video footage of in room surveillance revealed the facility failed to provide Resident #1, who was totally dependent on staff for ADL care, with timely incontinent care. Resident #1 did not receive incontinent care for more than 15 hours on 5/24/26 and 5/25/26, and on 05/25/26, was subsequently diagnosed with a Stage 3 pressure ulcer to his sacrum. The failure could place residents at risk for worsening skin breakdowns, progression of the ulcer to move to more severe stages, and overall decline in quality of life. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs for 1 out of 4 (Resident #1) residents reviewed for pharmacy service in that: The facility failed to ensure MA B did not leave Resident #1 medications on top of the bedside table. This failure could place residents at risk of not receiving their medications, choking and respiratory distress.

Inspectors wroteBased on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys to meet the needs for 1 out of 4 (Resident #1) residents reviewed for pharmacy service in that: The facility failed to ensure MA B did not leave Resident #1 medications on top of the bedside table. MA B failed to ensure that the medication was secure when she walked away and left two pills in the cup unsupervised. This failure could place residents at risk of not getting their medications as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, based on the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for quality of care in that: Resident #1's skin was not thoroughly assessed on 2/25/26 when he had moisture-associated skin damage behind both ears that was not identified. Resident #1 had moisture-associated skin damage behind both ears that was not being treated between 2/20/26 and 2/27/26. This deficient practice placed residents at risk of delayed treatment and developing avoidable pressure injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration, was provided such care, consistent with professional standards of practice for 1 of 5 residents (Resident #1) reviewed for quality of care in that:Resident #1's oxygen humidifier bottle was empty. This failure could place residents at risk of discomfort, anxiety, and decline in quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 2 of 17 rooms from hallway 200 affecting 2 of 14 residents (Resident #1 and Resident #2) reviewed for environment. The facility failed to clean food crumbs, and stains from the floor in Resident #1 and Resident #2's rooms that looked like dried coffee. The facility failed to repair the footboard of Resident #2 's bed that had exposed wooden particle board and splintered edges. The facility failed to repair the closet door of Resident #2's closet that was off of the hinges and could not be closed or opened properly. The facility failed to repair the overhead light above Resident #2's bed, which was cracked with jagged edges. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 4 hallways, (Hall 100) and Resident #4's room. The facility had a live roach and live flies in Resident #4's room. This failure could place residents at risk for decreased residents' health, safety, and quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for resident abuse.-The facility failed to ensure that Resident #1 was free from sexual abuse when Resident #1 wandered into Resident #2's room in the facility on 9/23/25, and Resident #2 sexually assaulted Resident #1. An Immediate Jeopardy (IJ) was identified on 10/02/2025 at 4:41 p.m. The IJ template was provided to the Administrator and DON on 10/02/25 at 4:41 p.m. While the IJ was removed on 10/06/25 at 1:28 p.m. the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 out of 5 residents (Resident #1 and Resident #2) reviewed for adequate supervision.- The facility failed to ensure Resident #1 who was severely cognitively impaired and nonverbal and Resident #2 who was moderately cognitively impaired and had behaviors of inappropriate sexual comments to staff received adequate supervision to prevent abuse after she wandered into Resident #2's room in facility on 9/23/25. Resident #1 was sexually assaulted by Resident #2. An Immediate Jeopardy (IJ) was identified on 10/02/2025 at 4:41 p.m. The IJ template was provided to the Administrator and DON on 10/02/25 at 4:41 p.m. While the IJ was removed on 10/06/25 at 1:28 p.m. [...]

Inspectors wroteBased on Record review and interview, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for 2 (Resident #15, Resident #56) of 18 residents reviewed for MDS transmission, in that: -The facility failed to transmit a completed admission MDS assessment for Resident #15 - The facility failed to ensure Resident #56's Significant change MDS Assessment was completed within 14 days significant change. This failure could place residents at-risk of not having their assessments completed timely, which could result in denial of services and or payment for services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that §483.55(a)(5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay for 1 of 10 residents (Residents #70) reviewed for dental services. -The facility failed to assist in providing emergency or routine dental services in a timely manner. -The facility failed to promptly within 3 days, refer Resident #70 for dental services related to lost dentures. -The facility failed to provide documentation of the extenuating circumstances that led to the delay in Resident #70 being seen by a dentist. [...]

Inspectors wroteBased on observation , interview, and record review the facility failed to ensure the resident's had the right to have reasonable access to the use of telephone and a place in the facility where calls can be made without being without being overheard for 1 of 3 (Resident #1) residents reviewed for communication. The facility failed to provide a place for Resident #1 to make telephone calls without being overheard. Observation of Resident #1 using the phone at nursing station while (3) nurses were at the nurse station and (2) other resident's at the nurse station receiving medication. This failure could place residents at risk of conversation being overheard and privacy right's not being respected and could result in a decline in resident's psychosocial well-being and quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders and consistent with professional standards for 1 (Resident #286) of 2 residents reviewed for intravenous fluids. The facility failed to ensure that the dressing on Resident #286's mid-line intravenous line (a short flexible tube inserted into a vein to administer fluids and medications) was changed according to the doctor's order and facility's standard of care. The failure could place residents at risk of infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement described in §483.70(f) for 1 (Resident #3) of 5 residents reviewed for pharmacy services. The facility failed to provide Mucinex DM as ordered for Resident #3. The failure could place residents at risk of receiving less than therapeutic benefits from medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records on each resident that are accurately documented for 1 (Resident #3) of 5 residents reviewed for resident records. Resident #3's Medication Administration Record showed that Mucinex DM oral tablet extended release 12 Hour 30-600 mg was documented as being given when guaifenesin 400 mg tablet was administered. The failure could place residents who receive medications from facility staff at risk for less than therapeutic benefits, and/or not receiving ordered medications due to inaccurate documentation of administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from Misappropriation of property for one (Resident #15) of 18 residents reviewed for misappropriation of property. The facility failed to ensure Resident #15 was free from misappropriation of property when an employee used her credit card for personal benefit. The non-compliance was identified as past non-compliance. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of Exploitation/Misappropriation of Property and financial distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from verbal abuse for 1 of 5 residents (Resident # 1) reviewed for abuse. The facility failed to prevent Med Aide A, on 11/18/2024, from verbally abusing Resident # 1 when he used foul language. These failures could place residents at risk of emotional distress, fear, decreased quality of life and further abuse.

Inspectors wroteBased on record review and interview, the facility failed to immediately inform the resident representative(s) of the need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for one (Resident #1) of five residents reviewed for notification of changes. -The facility failed to ensure they reported, to Resident #1's Representative on 09/30/2024, Resident #1's change of condition with moisture associated skin damage (MASD) on the sacrum and buttock to include new orders for zinc oxide (used to treat and prevent diaper rash and other minor skin irritations). - The facility failed to ensure they reported, to Resident #1's Representative on 09/30/2024, when noted blanching redness to the left lateral forefoot and the left heel on Resident#1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received the necessary treatment and services, to promote healing, prevent infection for 1 of 5 residents (Resident #2) reviewed for pressure ulcers in that: -The facility failed to ensure Resident #2's right buttock stage 3 wound had a dressing covering the wound on 10/25/24. This failure could affect residents with wounds placing them at risk of infection, a decline in health, pain, and hospitalization.

Inspectors wroteBased on interview, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for clinical records. -The facility failed to ensure the treatment administration records (TAR) for Resident #1 reflected that the administration of the treatment orders was accurately documented . This failure could result in further error and a decline in heath.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services to include procedures that assure the accurate administering of all drugs and biologicals to meet the needs of each resident for 1 of 6 (CR#1) residents reviewed for pharmacy services to meet the needs of each resident in that: 1. The facility failed to ensure physician ordered, Tramadol (an FDA controlled medication for pain) was provided the scheduled or PRN as resident requested for her pain; 2. The facility failed to ensure Nifedipine hypertension medication was provided to CR#1 causing a high systolic pressure and hospital admission. This failure caused CR#1 to have unresolved pain and an increase in her BP and placed all residents in the facility at risk for missed medications. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the comprehensive resident-centered care plan was reviewed and revised by the Interdisciplinary team after each assessment for 1 of 18 residents reviewed for care plan accuracy (Resident # 80) in that: ---Resident # 80 was care planned for Restorative Care Program, but facility does not have a Restorative program This failure could place residents at risk of receiving inaccurate care and services.

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide pharmaceutical services, including procedures that ensure the accurate acquisition and administration of all drugs to meet the needs of 1 of 8 residents (Resident #67) reviewed for pharmaceutical services. - The facility failed to acquire and dispense Clonazepam 1 MG, an anticonvulsant (antiseizure) used to treat anxiety to Resident #67 as ordered from 11/5/23 through 11/9/23 and again on 11/24/23 and 11/25/23. This failure could place residents receiving medication at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 6 of 15 residents (Resident #31, #47, 44, #54, #66, #67, #77) reviewed for transmission base precautions and infection control. The facility failed to ensure LVN A implemented appropriate use of PPE and transmission-based precautions prior to enter and exiting residents' rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) The facility failed to ensure LVN A washed or sanitized their hands after providing care to Resident # 44 who was on contact isolation. Corporate Nurse A failed to implement appropriate use of PPE and transmission-based precautions prior to entering and exiting Resident #42's room (room [ROOM NUMBER]) who was on contact isolation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASARR) program to the maximum extent practicable for 1 of 7 residents (Resident #53) reviewed for PASARR. -The facility failed to update the PASARR Level 1 forms for Resident #53 after a diagnosis of intellectual disability. This failure could place residents requiring PASARR services at risk of not having their special needs assessed and met by the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 11%, based on four errors out of 34 opportunities, which involved 3 of 8 residents (Resident #31, #51, and #12 and two of four staff (MA T and MA C) observed during medication administration reviewed for medication error, in that: -MA C attempted to administer Resident #51's two blood pressure medications outside of prescribed parameters until surveyor intervened. -MA T failed to ensure Resident #31's medication preparation order was clarified and then left Resident #31's medication at the bedside. -MA C administered the wrong dose of Cranberry supplement tablet to Resident #12 as ordered by the physician. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program and procedure designated to provide a safe, sanitary, and comfortable environment and to help prevent the development, transmission of disease and infection for 3 out of 3 staff reviewed for CDC guidelines for COVID-19 infection control and prevention, in that: Food service attendant A and Housekeeper C were observed donning masks inappropriately. Housekeeper C had an unlabeled, undated, unnamed bottle of liquid on her housekeeping cart used for cleaning. This failure could effect residents and place them at risk of being exposed to COVID-19 or any infection, possibly resulting in serious illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility with a census of 84. -The facility failed to post notice of the availability of survey results in areas of the facility that are prominent and accessible to where individuals wishing to examine do not have to ask to see them. This failure could place residents at risk of being uninformed of the facility's inspection history and any plans of correction the facility should have in place.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours after the allegation were made, to other officials, including the State Survey Agency(SSA), for 2 of 2 residents (#7 and #12); reviewed for reporting in that: -The facility failed to report an incident to the SSA, Health and Human Service Commission (HHSC) immediately but not later than 24 hours of an incident of a missing jewelry on 06/20/2022 involving Resident #7 and $180 missing on 07/14/2022 involving Resident#12. This failure could place residents at risk for incidents involving misappropriation of resident property by the facility not reporting such incidents to the State Survey Agency.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate the allegation of misappropriation of property for 1 of 2 residents (Resident #12) reviewed for abuse, neglect, and exploitation in that: -The facility failed to investigate an allegation of misappropriation when Resident #12 alleged CNA A took $180 from his room. This failure could place residents at risk for incidents involving misappropriation of resident property by the facility not investigating such incidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a significant change MDS assessment within 14 days after a significant change in the resident's mental and physical condition for 1 of 35 residents (Resident #62) reviewed for assessments in that: -- Resident #62 was not re-assessed for her hospice (specific care for the sick or terminally ill) status. This failure affected 1 resident and placed residents at risk for not having their individual needs met due to inaccurate assessment/s. Findings Include: Resident #62 Record review of Resident #62's admission record revealed she was an 89- year -old female who was admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to review and revise the person-centered care plan to reflect current condition for 1 of 35 residents reviewed for care plan accuracy. (Resident #62) in that- --Resident # 62's care plan was not individualized or updated to reflect her discharge from Hospice services. This failure affected 1 Resident and could affect residents and place them at risk of not having a comprehensive plan of care that addresses their specific needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure waste were properly contained in dumpster and covered in that -On 9-20-22 at 9:42 a.m. the facility's dumpster lid was open. This failure has the potential to affect residents and place them at risk for infection and a decreased quality of life due to having an exterior environment which could attract pests, rodents, and other animals.