Webster House

Inspectors wroteBased on interview and record review, the facility failed to provide services according to professional standards for one of three residents (Resident 1) when there was no documentation of medication administration for Resident 1's scheduled medications and nutritional supplements, five to six days on day shifts and one to two days on evening shifts in November 2025. These failures had the potential to affect Resident 1's health, safety and well-being.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure medications were properly stored for 1 (Resident #31) of 6 residents observed for medication administration.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff performed hand hygiene and wore gloves during eye drop administration for 1 (Resident #35) of 6 residents observed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review the risks and benefits of bed rails (adjustable metal or rigid plastic bars that attach to the bed) with the resident or resident representative and obtain informed consent prior to the use of bed rails for seven of 27 residents (Residents 18, 23, 27, 37, 45, 55, and 363). This failure had the potential to put the residents at risk for entrapment and serious injury due to not being aware of the risks and benefits of bed rails.

Inspectors wroteBased on observation, interview and record review, the facility had a medication error rate of 17.86%, when five medication errors out of 28 opportunities occurred during medication administrations for three of six residents (Residents 11, 24, and 49). These deficient practices resulted in medications not being given in accordance with the prescriber's orders and/or manufacturer's specifications, which could have resulted in the residents not receiving the full therapeutic effects of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were removed, and medications were labeled and stored according to manufacturer's instructions for one out of one medication room and two out of two medication carts. These deficient practices had the potential for residents to receive medications with reduced potency and had the potential to result in medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dietary staff followed their recipe when the senior lead cook (SLC) prepared yellow squash and red pepper vegetables for lunch. This failure had the potential to compromise the nutritional value and palatability of the food for 58 residents who received food services from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared under sanitary conditions when: 1. There was expired food in the kitchen; 2. Prepared food trays in the walk-in refrigerator were uncovered and undated; 3. Wet and dry containers were stored together; 4. The Dish washer (DW) used expired sanitizer test strips to test sanitizer solution; and 5. [NAME] K (CK) failed to perform hand hygiene between tasks. These failures had the potential to result in food borne illness for 58 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a significant change in status Minimum Data Set (MDS, a comprehensive assessment tool) when one of 15 sampled residents (Resident 35) experienced declines in multiple areas of health status. Failure to comprehensively assess the resident had the potential to compromise the facility's ability to develop and implement resident-centered care plan interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 60) had hearing aids on while awake for optimal hearing abilities. This failure had the potential to result in ineffective and insufficient communication between Resident 60 and caregivers, and could have negatively affected the resident's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary services were provided to promote healing of a pressure ulcer (damage to the skin and underlying tissues due to prolonged pressure) for one of two sampled residents (Resident 35) when: 1. There were 8 days for which there was no documentation that Resident 35's pressure ulcer was treated; and 2. Resident 35's pressure ulcer assessment was incomplete. These failures had the potential to result in worsening of Resident 35's pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their fall management program for two of four residents (Residents 56 and 4) when: 1. Fall interventions were not implemented for Resident 56; and 2. No new interventions were developed and implemented after Resident 4 fell. These failures had the potential to result in further falls and/or injury to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive policy for enteral feeding (the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum) services, when there was no policy that indicated a consistent method that a licensed nurse should use for bolus feeding (the administration of a limited volume of enteral formula over brief periods of time). This failure had the potential to result in inconsistency of care and complications related to the G-tube and cause harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the controlled substance (drugs with high potential for abuse or addiction) medications were fully accounted for when: 1. A random controlled medication use audit for two out of three residents (Residents 20 and 39) showed that medications were signed out of the Control Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications), but were not documented as given to the residents on the medication administration record (MAR); and 2. Expired and discontinued controlled drugs were not removed from the medication cart. These failures had the potential to result in loss, misuse, and/or diversion of controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 15 sampled residents (Residents 27) was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors). Resident 27 received Abilify (an antipsychotic medication) when there were no specific target behaviors (behaviors intended to be reduced or eliminated by the medication) monitored. There was also no indication that Resident 27's behaviors presented a danger to herself or others, or caused significant distress to the resident. This failure put the resident at risk for experiencing adverse effects from unnecessary psychotropic medications such as dry mouth, blurred vision, urinary retention, constipation, heat intolerance, and tachycardia (abnormally rapid heart rate).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of ten sampled residents (Resident 24) was free from significant medication errors when she received six doses of expired Insulin Lispro (fast-acting insulin, medication to lower blood sugar level). This deficient practice had the potential for the resident to receive ineffective use of the insulin, resulting in uncontrolled high blood sugar for the resident.

Inspectors wroteBased on interview and record review, the facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare & Medicaid Services (CMS) for August of 2022. This deficient practice prevented the provision of complete and accurate direct care staffing information to the public.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection prevention and control practices when: 1. Certified nurse assistant G (CNA G) did not wear a facemask while providing care to Resident 32; 2. Registered nurse H (RN H) did not perform hand hygiene (hand washing or use of alcohol-based hand rub [ABHR]) when changing gloves; and 3. Licensed vocational nurse B (LVN B) did not disinfect medical equipment before and after using it on Resident 24 These failures had the potential to result in transmission and spread of infection in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a cook utilized standardized recipes for puree (smooth texture) food preparation to ensure nutritive value. This failure resulted in the residents prescribed puree diet being placed at an increased risk for nutritional impairment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared and served under sanitary conditions when: 1. Bin used to store flour was unlabeled; 2. Scoop utensil was lying on top of the thickener bin; 3. Ice machine spout was dirty; 4. Staff crossed yellow line (division between kitchen and dining area) during trayline without hairnets; 5. Beef meat loaf was held for service at 140 F (F, fahrenheit, unit of temperature). This failure had the potential for occurrence of food-borne illnesses.

Inspectors wroteBased on observation, interivew and record review, the facility failed to properly store and label drug and biological's in accordance with facility policy and current standards when: 1. A bottle of Milk of Magnesia (used for constipation) was with altered pharmacy label. 2. An eye antibiotic passed its length of therapy was found in the medication cart. 3. A vial of Humalog (used to regulate insulin in the blood) was expired. 4. Licensed vocational nurse I (LVN I) left Brimonidine 0.2% (used to relieve redness in the eyes caused by minor eye irritations.) on top of the cart unattended. These failures can potentially compromise Residents' health and safety.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a follow up was made in a timely manner for a missing denture for one of two sampled residents (6). Resident 6' s upper denture was missing and Resident 6's insurance denied to replace. These failures caused a delay in Resident 6 receiving the necessary dental services and could negatively affect Resident 6's physical comfort and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff implemented the infection control practices when: 1. Treatment nurse C (TXN C) did not perform hand hygeine while providing wound treatment; 2. Certified nursing assistant D (CNA D) disposed dining ware of a resident in the isolation room; 3. Licensed vocational nurse E (LVN E) failed to perform hand hygeine between different medication routes. These failures had the potential to put vulnerable residents at risk for infection.