Webco Manor

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a system in place to ensure each resident's code status preference was clear and accurate when staff failed to update a full code (every possible measure, including cardiopulmonary resuscitation (CPR - an emergency procedure that is done when a person stops breathing or heart stops, to save a person's life)) to a do not resuscitate (DNR - an order that instructs providers not to start CPR if a person stops breathing or heart stops) for one resident (Resident #1). The facility census was 61. On [DATE], Social Services Director (SSD) notified the Administrator that staff provided CPR to Resident #1, who wished to be a DNR. On [DATE], the facility completed an audit of all residents' code status. On [DATE] the facility implemented a new process and in-serviced all staff. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all allegations of possible abuse were thoroughly and timely investigated, and steps were taken to protect all residents during the investigation, when staff did not begin an immediate investigation into an allegation staff to resident (Resident #1) abuse and the staff member continued to work independently with residents. The facility census was 64. Review of the facility's Abuse and Neglect Policy, undated, showed the following information:-Types of abuse include physical, verbal, sexual, mental, and financial exploitation;-The Administrator or Director of Nursing (DON) or designee must begin an internal investigation immediately and report to DHSS. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of possible abuse were reported timely to State Survey Agency (SSA - Department of Health and Senior Services (DHSS)) when staff failed to report an allegation of staff to resident abuse within the required two hours of the facility staff becoming aware of the allegation involving one resident (Resident #1). The facility census was 64. Review of the facility's Abuse and Neglect Policy, undated, showed the following information:-Types of abuse include physical, verbal, sexual, mental, and financial exploitation;-All employees are mandated reporters;-Any suspicion or knowledge of abuse, neglect, or misappropriation must be reported immediately to the Administrator and charge nurse;-The Administrator or Director of Nursing (DON) or designee must begin an internal investigation immediately and report to DHSS; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to facility management and within two hours to the State Survey Agency (Department of Health and Senior Service (DHSS) when the facility failed to report one resident's (Resident #1) allegation of abuse by a staff member in a timely fashion. The facility census was 56. Review of the facility's policy titled. Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised April 2021 showed the following:-All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident when staff did not ensure physicians' orders and pharmacy dosage directions matched resulting in staff administering incorrect dosages of Paxlovid (oral antiviral medication used to treat coronavirus disease 2019 (COVID-19) disease (an infectious disease caused by the SARS-CoV-2 virus)) to four residents (Resident #1, Resident #2, Resident #3 and Resident #4) out of 9 sampled residents. The facility census was 55. Review of the facility's policy titled Medication Orders, revised 11/2014, showed the following:-The purpose of the procedure was to establish uniform guidelines in the receiving and recording of medication orders;-When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure all resident care plans were completed and current when staff failed to care plan related to a relationship and restrictions involving two residents (Resident #20 and #2) and when the staff failed to care plan new falls and new interventions for one resident (Resident #50). A sample of 20 residents was reviewed in a facility with a census of 57. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent and treat urinary tract infections when staff failed to notify the physician of and provide treatment for suspected urinary tract infections (UTI) two residents (Resident #17 and #51). The facility also failed to ensure proper catheter (a thin, flexible tube inserted into the body to drain fluid) use for residents when staff failed to obtain appropriate physician orders to place a catheter, to provide catheter care, and to change the catheter for one resident (Resident #43) with an indwelling urinary catheter. The facility census was 57. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program when the facility failed to ensure the required two step tuberculosis (TB - a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) screening test was administered timely for six staff members (Certified Nursing Assistant (CNA) E, Certified Medication Technician (CMT) F, Licensed Practical Nurse (LPN) G, CMT K, LPN G, and Dietary Aide (DA) I) of ten sampled staff members. The facility census was 57. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were free from possible chemical restraints when staff failed to implement a physician approved pharmacy recommendation to decrease an antipsychotic in a timely fashion for one resident (Resident #4) out of a sample of five residents. The facility census was 57. Review showed the facility did not provide a policy regarding pharmacy consultations or pharmacy recommendations. 1. Review of Resident #4's face sheet (resident's information at a quick glance) showed the following:-admission date of 12/08/22;-Diagnoses included cognitive communication deficit, unspecified dementia, and major depressive disorder. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion when facility staff failed to obtain an order for the use of a brace, failed to document use of a brace, failed to monitor the use of a brace, and failed to care plan the use of brace to the right-hand brace for one resident (Resident #8) with a contracture. The facility census was 57. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents who required colostomy (a surgical procedure that creates an opening, or stoma, in the abdominal wall to allow the colon to pass waste through the body) services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences when staff failed to obtain an order for a colostomy, colostomy care, and colostomy monitoring, failed to assess resident for ability to provide self-care for the colostomy, and failed to care plan self-care of the colostomy for one resident (Resident #49). The facility census was 57. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed document identification and use of possible alternatives prior to use of side rails; failed to document assessing risk versus benefits of side rail use; failed to obtain informed consent for the use of side rails prior to installation,; and failed to obtain physician orders for side rail usage, for one resident (Resident #50). The facility's census was 57. Review of the resident's quarterly fall risk assessment, dated 11/27/17, showed the resident to was a moderate risk with diminished safety awareness and poor recall and judgment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare all food in a form designed to meet each resident's needs when staff failed to appropriately prepare thickened liquids to nectar consistency for one resident (Resident #27) in a selected sample of 20 residents. The facility census was 57. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were offered, and received if requested, the pneumococcal vaccine when one resident (Resident #55) requested the vaccine, but staff failed to administer the vaccine and when facility staff failed to offer one resident (Resident #17), or his/her responsible party, the vaccine. The facility census was 57. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain a complete call light system accessible to all residents when staff failed to consistently place the call light within the reach of one resident (Resident #8). The facility census was 57. Review of the facility policy titled Answering the Call Light, dated October 2010, showed the following:-The purpose of the procedure was to respond to the resident requests and needs;-Be sure the call light is plugged in at all times;-When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident;-Answer the resident's call as soon as possible. 1. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure all residents' families or representatives were notified of all significant changes and potential changes in care when staff did not notify two residents' (Resident #1 and #2) family/representative after a change in condition/allegation of abuse. The facility census was 54. Review showed the facility did not provide a policy regarding notification of resident representatives. 1. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 09/07/24; -Diagnoses included unspecified dementia (loss of memory), psychotic disturbances (mental health condition that causes people to lose touch with reality, and depression (feelings of sadness). Review of the resident's care plan, last revised on 12/11/24, showed the following: [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the state licensing agency (Department of Health and Senior Services - DHSS) when staff failed to report two allegation of sexual abuse involving three residents (Resident #1, #2, and #3) to management and DHSS in a timely fashion. The facility census was 54. Review of the facility's policy titled, Abuse and Neglect-Clinical Protocol, revised July 2017, showed the following: -Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse; -Sexual abuse is the non-consensual contact of any type with a resident. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to immediately begin an investigation of possible abuse when staff witnessed one resident (Resident #1) touch another resident (Resident #3) in the groin area. The facility census was 54. Review of the facility's policy titled, Abuse and Neglect-Clinical Protocol, revised July 2017, showed the following: -Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse; -Sexual abuse is defined as non-consensual contact of any type with a resident; -Staff, with the physician's input as needed, will investigate alleged occurrences of abuse and neglect to clarify what happened and identify possible causes. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a comprehensive person-centered care plan for all residents when staff failed to update the care plan for one resident (Resident #1) to include two incidents of the resident touching other residents inappropriately. The facility's census was 54 Review showed the facility did not provide a policy on updating care plans. 1. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 09/07/24; -Diagnoses included unspecified dementia (loss of memory), psychotic disturbances (mental health condition that causes people to lose touch with reality), and depression (feelings of sadness). Review of the resident's care plan, last revised on 12/11/24, showed the following: -The resident had communication problems as evidenced by his/her impaired hearing. He/she usually understands; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to comprehensively assess pain, follow-up on effectiveness of pain medication, failed to try additional steps when pain was not relieved, and failed to notify the physician of the pain, ineffectiveness of the current pain medication regimen, and when an order for a new pain medication was not received from the pharmacy for one resident (Resident #1) in a review of four sampled residents. The facility census was 52. Review of the facility's policy titled 'Pain Assessment and Management, revised March 2015, showed the following: -The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care per standards of practice when staff failed to address and notify the provider of a change in condition for one resident (Resident #1) whose knees became swollen, red, warm, and painful. The facility census was 52. Review showed the facility did not provide a policy related to change of condition. 1. Review of Resident #1''s face sheet (brief resident profile sheet) showed the following: -admission date of 03/08/23; -Diagnoses included cognitive communication deficit, rheumatoid arthritis (a chronic autoimmune disease that causes inflammation in the joints, resulting in pain, swelling, stiffness, and tenderness), osteoarthritis (a degenerative joint disease that causes the cartilage and bone in joints to break down over time), and chronic pain syndrome. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide protective oversight to all residents when staff did not put new interventions in place after, or make all working staff aware of, elopement attempts made by one resident (Resident #1) with a history of wandering and talking about leaving the facility. The resident eloped later the same day and was found in a nearby [NAME], located between the facility and the interstate. The facility census was 53. Review of the facility's policy titled, Elopement Policy & Procedure, undated, showed the following: -Elopement included when a resident left the premises or a safe area, without authorization and/or necessary supervision placing the resident at risk for harm or injury; -It is the intent of the facility to be aware of its residents usual habits and locations as reasonably practicable; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure each resident's choice of code status (the desire to be resuscitated or not if breathing stops) was clearly documented in each resident's chart when four residents' (Resident #8, #43, #150, and #5) charts had conflicting information regarding code status. A sample of 14 residents was selected for review out of a facility census of 47. Review showed the facility did not provide a policy regarding resident choice of code status. 1. Review of Resident #8's Face Sheet, dated reviewed [DATE], showed the following: -admission date of [DATE]; -Diagnoses included congestive heart failure (the heart loses the ability to pump enough blood), chronic kidney disease, history of pneumonia and bronchitis, pain, cognitive loss, and difficulty making decisions; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care for all residents on oxygen per professional standards of practice when staff failed to ensure oxygen equipment was cared for in a manner to prevent possible contamination or bacteria growth for three residents (Resident #20, #5, and #9) and when staff a failed to care plan regarding the care of oxygen equipment for two residents (Resident #20 and #9). The facility census was 47. Review of the facility's policy titled, Care of Oxygen Equipment, undated, showed the following: -Staff should remove the humidifier bottle weekly and wash it in warm soapy water, rinse thoroughly and air dry before refilling with distilled water; -Staff should remove and clean oxygen cannula's/masks as needed, and weekly by night nurse; [...]

Inspectors wroteBased observation, interview, and record review, the facility failed to complete and document risks vs benefits reviewed, assessment for entrapment, prior alternatives tried, or informed/signed consent for the bed rails before installing bed rails on five residents' (Resident #1, #4, #9, #11, and #13) beds. The facility census was 47. Review of the facility's policy titled, Bed Safety and Bed Rails, revised August 2022, showed the following: -The use of bed rails is prohibited unless the criteria for use of bed rails have been met; -The resident's sleeping environment is evaluated by the interdisciplinary team; -Bed frames, mattresses and bed rails are checked for compatibility and size prior to use; -Regardless of mattress type, width, length, and/or depth, the bed frame, bed rails and mattress will leave no gap wide enough to entrap a resident's head or body. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to maintain an effective infection control program when staff failed to perform proper hand hygiene while performing personal cares and perineal care on three sampled residents (Residents #20, #4, and #34). The facility census was 47. Review of the facility's policy Handwashing/Hand Hygiene, reviewed July 2019, showed the following: -Hand hygiene is the primary means to prevent the spread of infections; -Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies; -Wash hands with soap and water when hands are visibly soiled and after contact with a resident; -Use an alcohol-based hand rub containing at least 62% alcohol or alternatively, soap and water for the following: [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed ensure care was completed in accordance with standards of practice when staff failed to care plan the use of a neck brace, failed to address the neck brace not fitting correctly, and failed to arrange timely follow-up physician appointments for one resident (Resident #43) who was admitted after being diagnosed with a neck fracture. The facility census was 47. Review showed the facility did not provide a policy regarding regarding appointments, medical equipments, or follow-up on hospital directives. 1. Review of Resident #43's electronic Face Sheet showed the following: -admission date of 11/16/23; -Diagnoses included neck fracture, dementia, depression, and pain. Review of the resident's hospital notes, dated 11/12/23, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment to prevent possible urinary tract infections for all residents when staff failed to perform urinary catheter (tube placed into the bladder to drain urine) care for one resident (Resident #20), of two residents sampled, with an indwelling urinary catheter. The facility census was 47. Review of the facility's policy for Indwelling Catheter (Foley) Care, revised and reviewed August, 2018, showed the following: -Care for an indwelling urinary catheter can be delegated to certified nurse aides (CNAs); -Routine catheter care is a part of routine perineal hygiene; -Catheter care is performed every shift and as needed (PRN) for soiling. 1. Review of Resident #20's face sheet (admission information at a glance) showed the following: -admission date of 05/30/23; [...]

Inspectors wroteBased on interview and record review the facility failed to provide an effective, thorough program for the prevention of the growth of the Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella) when staff were unaware of the steps the facility needed to take to prevent Legionella; staff failed to complete a Legionella risk assessment for the facility; and staff failed to monitor water temperatures and the pH (a measure of how acidic/basic water is) levels routinely. The facility census was 54. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to position a specialized call light within reach for one resident (Resident #36) who was dependent on staff for cares and failed to provide to consistently provide a [NAME] Cup (a lightweight spill proof drinking cup with a straw and handles and will not spill when shaken or tipped over) for one resident (Resident #20) as care planned to assist the resident with drinking. A sample of 16 residents was selected for review. The facility's census was 54. Record review of the facility's policy titled, Quality of Life-Accommodation of Needs, revised August 2009, showed the following information: -The facility's environment and staff behaviors are directed toward assisting the residents in maintaining and/or achieving independent functioning, dignity, and well-being; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely identify, assess, document, implement interventions, and follow-up on recommendations, for one resident (Resident #5) who developed limited range of motion progressing to contractures of his/her right hand out of a selected sample of 16 residents. The facility's census was 54. Record review of the facility's Functional Impairment-Clinical Protocol policy revised 9/2012, included the following: -Upon admission to the facility, at any time a significant change of condition occurs, and periodically during a resident's stay, the physician and staff will assess the resident physical condition and functional status; The physician will help identify individuals who have had a recent history of functional decline and those who are at risk for additional functional decline; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure water was consistently accessible to one (Resident #21) with a history of urinary tract infections (UTI - an infection in any part of the urinary system, the kidneys, bladder or urethra) in a selected sample of 16 residents. The facility's census was 54. Record view of the facility's policy Serving Drinking Water, revised October 2010, showed the following: -The purposes of this procedure are to provide the resident with a fresh supply of drinking water and to provide adequate fluids for the resident; -Return the water pitcher to the resident's bedside stand; -Place the water pitcher and cup within easy reach of the resident. Place flexible straws next to the water pitcher. 1. Record review of Resident #21's face sheet (document that gives resident's information at a quick glance) showed the following: [...]