Webster Manor Rehabilitation & Health Care Center

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who required medication to treat hypotension (low blood pressure) and had a Physician's order to hold (not administer) the medication for a systolic blood pressure (SBP-top number, represents the pressure in arteries when the heart contracts) greater than 120, the Facility failed to ensure the resident was free from significant medication errors when he/she was administered the medication outside of the prescribed parameter, placing him/her at risk for high blood pressure.

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents, (Resident #1 and Resident #2), the Facility failed to ensure they maintained complete and accurate medical records, when their Certified Nurse Aide (CNA) Activities of Daily Living (ADL) Flow Sheets were incomplete.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) who was found to have an injury (new bruise), the Facility failed to ensure he/she was provided with quality of care and services in accordance with his/her comprehensive person-centered plan of care, when although the facility was unable to determine exactly when or how the injury occurred, as a result of their investigation it was determined that gait belts were not consistently being used by staff during transfers, in accordance with facility policy, therefore placing Resident #1 and other residents at risk for potential injury.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide sufficient nursing staff on two resident Units (Lake Unit and Tapestry Unit) out of three resident units, to attain/maintain the highest physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to: -Provide sufficient nursing staff to ensure all residents on the Lake Unit, including Resident #119, were provided with timely morning activity of daily living (ADL) care. -Provide sufficient nursing staff to ensure all residents on the Lake and Tapestry Units were provided timely medication administration.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to serve food that was palatable, and at a safe and appetizing temperature on one Unit ([NAME] Unit) out of three units observed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to: -Maintain meal carts and coffee carts in a sanitary manner for meal service for residents. -Maintain the plate warmer in a clean and sanitary manner prior to housing plates in the plate warmer for meal service to residents. -Prepare coffee for residents in a sanitary manner. -Maintain the stand-up refrigerator and stand-up freezer in a clean and sanitary manner for food storage.

Inspectors wroteBased on record reviews, and interviews, the facility failed to ensure that Pneumococcal immunizations were offered and administered for two Residents (#12 and #20) of five applicable residents, out of a total sample of 26 residents. Specifically, the facility failed to: 1. Offer Pneumococcal immunization for Resident #12 when the Resident had been previously immunized and was not up-to-date with Pneumococcal immunization, which increased the Resident's risk for Pneumococcal disease. 2. Administer Pneumococcal immunization for Resident #20 when the Resident had been previously immunized, was not up-to-date with the Pneumococcal immunization, and consented to Pneumococcal immunization, which increased the Resident's risk for Pneumococcal disease. 3. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide dignified experiences on two occasions during the survey period for one Resident (#119) out of a total sample of 26 residents. Specifically, the facility failed to: -ensure that Resident #119 was clothed so that his/her arm, chest, and back were not exposed while the Resident was sitting in a common area, on two separate occasions, when the Resident was dependent upon staff for dressing. -provide Resident #119 with a dignified dining experience during one noon time meal, relative to drink preferences and assistance for eating when the Resident was dependent on staff for assistance with eating.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain a clean and homelike environment for two Residents (#38 and #86), out of a total sample size of 26 residents, and for one Unit ([NAME] Unit), out of three units observed. Specifically, 1. For Resident #38, the facility staff failed to maintain the Resident's wheelchair in a clean and sanitary manner when the Resident was dependent on the wheelchair use for mobility and the wheelchair was visibly soiled. 2. For Resident #86, the facility staff failed to maintain the Resident's wheelchair in a clean and sanitary manner when the Resident was dependent on the wheelchair for mobility and the wheelchair was visibly soiled. 3. For the [NAME] Unit, the facility failed to ensure resident care equipment and the building were maintained in clean condition and good repair.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement a person-centered care plan relative to feeding strategies for one Resident (#98), out of a total sample size of 26 residents. Specifically, for Resident #98, the facility staff failed to provide appropriate supervision during meals placing Resident #98 at risk for aspiration (entrance of food, liquid or other substance into a person's airway and lungs instead of being swallowed into the esophagus).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide treatment in accordance with professional standards of practice relative to an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body) for one Resident (#3) out of a total sample of 26 residents. Specifically, the facility failed to: -obtain a Physician order that included the accurate size indwelling urinary catheter required for the Resident, when the ordered and inserted catheter sized were different. -ensure the Resident had a leg bag to promote mobility and dignity/privacy when the Resident was out of bed. -provide Enhanced Barrier Precaution (EBP) during ADL (activities of daily living - washing, bathing, grooming) care of the Resident.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide respiratory care and services consistent with professional standards of practice for three Residents (#123, #69, and #35) out of a total sample of 26 residents. Specifically, 1. For Resident #123, the facility failed to: -ensure that the oxygen concentrator was set at two (2) liters per minute (LPM) as ordered by the Physician. -ensure there was an indication for the use of oxygen. -ensure the staff provided a new nasal cannula to the Resident after his/her previous nasal cannula was contaminated after laying on the Resident's bedroom floor. 2. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide appropriate treatment and services for one Resident (#79), out of a total sample of 26 residents, who was diagnosed with Dementia, to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to provide diversional interventions for Resident #79, according to the Resident's interests, when the Resident repeatedly paced the hallways of the Lake Unit and repeatedly vocalized, he/she did not know what to do.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide preferred food items for one Resident (#60) out of a total sample of 26 residents. Specifically, the facility failed to provide the Resident's preferred food items for two consecutive meals when the preferred food items were to be provided, as indicated on the Resident's meal tray card.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to have an effective policy which addressed the reheating of residents' food brought into the facility in accordance with professional standards to ensure food safety. Specifically, the facility failed to provide a working thermometer and adequate reheating instructions to reheat residents' food brought into the facility by family to an internal temperature of 165 degrees Fahrenheit (F) to prevent potential foodborne illnesses.

Inspectors wroteBased on record reviews, and interview, the facility failed to ensure an updated COVID-19 immunization was administered for one Resident (#20) of five applicable residents, out of a total sample of 26 residents. Specifically, the facility failed to administer an updated 2024-2025 COVID-19 immunization for Resident #20 when the Resident had been previously immunized, was not up-to-date with the COVID-19 immunization, and consented to receive the updated 2024-2025 COVID-19 immunization, increasing the Resident's risk for COVID-19 infection.

Inspectors wroteBased on observation, interview and policy review, the facility failed to store medications and biologicals under the proper temperature controls as required on two units (Lake Unit and Tapestry Unit) of three units in the facility. Specifically, the facility staff failed to ensure that medications and biologicals requiring refrigeration were stored within the required temperature range of 36° F (Fahrenheit) to 46°F.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure a homelike environment relative to the resident dining experience on three of out three Units ([NAME] Unit, Tapestry Unit, and Lakeside Unit) dining rooms. Specifically, the facility staff failed to ensure that: -Residents seated together at the same table were served timely in the [NAME] Unit Dining Room, Tapestry Unit Dining Room and Lakeside Unit Dining Room. -Staff were seated while assisting residents with their meals in the [NAME] Unit Dining Room, Tapestry Unit Dining Room and Lakeside Unit Dining Room.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure that resident meals were palatable, attractive, and provided to residents within appetizing and acceptable temperatures for one Resident (#74) and on two of three units observed. Specifically, the facility staff failed to: 1) For Resident #74, provide food that was palatable and at an appetizing temperature. 2) Respond to and address Resident Council concerns pertaining to food service. 3) Serve Resident meals timely, to preserve meal temperatures as indicated by test tray results.

Inspectors wroteBased on interview, record and policy review, the facility failed to ensure that the Pneumococcal Vaccine was reviewed, offered and/or administered to three Residents (#6, #33 and # 67) out of five applicable residents, out of a total sample of 25 residents. Specifically, the facility staff failed to: 1. For Resident #6 and #33, offer the Pneumococcal Vaccine (PCV) after a consent had been obtained, placing the Residents at risk for contracting facility acquired Pneumonia. 2. For Resident #67, assess, review and/or offer the Pneumococcal Vaccination to the Resident and/or his/her Representative.

Inspectors wroteBased on observation, record review and interview, the facility failed to monitor and assess the use of equipment being used as restraint for one Resident (#69) out of a total sample of 25 residents. Specifically, the facility staff failed to: -For Resident #69, conduct individualized monitoring and ongoing assessments for the use of a seat harness/ pelvic belt (used to secure the body in a wheelchair to prevent slumping or falling out of the chair) and a positioning wedge cushion (mobility accessory that is designed to improve posture and relieve pressure on certain body areas) after identifying the equipment were being used as restraints.

Inspectors wroteBased on interview and record review, the facility failed to re-submit a Level I Preadmission Screening and Resident Review (PASRR- is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that: 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder (SMI) and/or intellectual disability (ID), 2) be offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting], and 3) receive the services they need in those settings) when it was identified that one Resident (#104) out of a total sample of 25 residents, had a SMI.

Inspectors wroteBased on record review and interview, the facility failed to failed to review and revise the care plan with the interdisciplinary team (IDT) and include the participation of the Resident and/or Resident Representative (RR) in care planning for one Resident (#93), out of a total sample of 25 residents. Specifically, the facility failed to schedule a quarterly care plan meeting as required for Resident #93, and facilitate the Resident and/or RR's participation to review and revise the plan of care.

Inspectors wroteBased on record and policy review, and interview, the facility failed to provide the necessary Behavioral Health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for one Resident (#52) out of a total sample of 25 residents. Specifically, the facility staff failed to provide Behavioral Health Services for Resident #52 when he/she displayed behavioral symptoms.

Inspectors wroteBased on observation, record and policy review, and interview, the facility failed to maintain a medication pass error rate of less than five percent (%) for two Residents (#224 and #4), out of three applicable residents, out of 36 opportunities of medication administration observation. Specifically, the medication error rate was observed to be 5.56% when: 1) For Resident #224, the facility staff prepared the incorrect dosage of a medication requiring the surveyor to intervene to prevent the wrong dose from being administered. 2) For Resident #4, the facility staff administered medications beyond the required timeframe of one hour after the scheduled dosing time and close to the next scheduled administration time.

Inspectors wroteBased on record review and interview, the facility failed to ensure the accuracy of the Advanced Directive (an individual's wishes regarding medical treatment), in the medical record of one Resident (#93) out of a total sample of 25 residents. Specifically, the Advanced Directive documented in the electronic health record (EHR) conflicted with Resident #93's health care proxy (HCP) wishes as indicated on the Massachusetts Medical Orders for Life Sustaining Treatment (MOLST - a medical order form that converts an individual's wishes regarding life-sustaining treatment into medical orders).

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to adhere to infection control standards in order to prevent or control the transmission of infections for one Resident (#41) in a total sample of 25 residents. Specifically, the facility staff failed to ensure that Isolation Precautions (actions implemented in addition to standard precautions based upon means of transmission) remained in effect for the required duration for Resident #41, after the Resident tested positive for COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately completed to reflect the status for two Residents (#64 and #69), in a total sample of 25 residents. Specifically, the facility staff failed to accurately reflect on the MDS assessment: 1. For Resident #64, to document that the Resident had a visual impairment of Diabetic retinopathy (damage to the delicate blood vessels in the retina caused by poorly controlled blood glucose (sugar) levels in patients with Diabetes). 2. For Resident #69, to document that the Resident had a facility identified restraint during the seven-day lookback period.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all required members of the QAPI (Quality Assurance and Performance Improvement) Committee participated in quarterly QAPI meetings. Specifically, the facility failed to ensure that the facility Infection Preventionist (IP) attended and participated in four out of five quarterly QAPI meetings reviewed.

Inspectors wroteBased on interview, and record review the facility failed to ensure its staff performed COVID-19 outbreak testing for residents and staff as required, to stop the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its staff implemented infection control measures according to State guidelines when the facility was in a COVID-19 outbreak period. Specifically, the facility failed to ensure staff implemented isolation precautions, when there was a positive staff case of COVID-19 identified within the previous 14 days, on nursing units where residents resided, with some residents not up to date (UTD) with their COVID-19 vaccines.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its staff provided dignified experiences for two Residents (#88 and #13) out of a sample of 27 total residents. Specifically, the facility failed to ensure that its staff provided: 1) A dignified verbal interaction with Resident #88 when the Resident was yelling, and 2) A privacy cover for Resident #13's urinary catheter (tube inserted into the bladder to drain urine) drainage bag, when the bag was exposed, containing urine, and visible for others to see.

Inspectors wroteBased on interview, and record review, the facility failed to ensure its staff informed the Health Care Proxy (HCP- designated person to make medical decisions on behalf of the resident if determined by the Physician to be incapacitated) of one Resident (#108) out of a total of 27 residents, of the risks and benefits of proposed care. Facility staff also failed to obtain consent prior to the administration of a psychotropic medication (one that alters mood/behavior).

Inspectors wroteBased on interview, and record review, the facility failed to ensure its staff promoted one Resident's (#84) choice to consume a beverage of preference, out of a total sample of 27 residents. Specifically, the facility failed to ensure its staff contacted Resident #84's activated healthcare proxy (HCP) and Physician to determine whether the Resident could consume wine after the Resident verbally expressed his/her preference for wine.

Inspectors wroteBased on record reviews, and interviews, the facility failed to ensure that its staff completely and accurately executed, updated, and documented the wishes of three Residents (#44, #108 and #36) out of a total sample of 27 residents, and their designated Health Care Proxy (HCP- an appointed individual to legally make medical decisions on a person's behalf if he/she became unable to do so) regarding advanced directives (a written statement of a person's wishes regarding medical treatment). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its staff provided notification of a change in condition for two Residents (#84 and #53) to the Physician/Non-Physician Practitioner (NPP). Specifically, the facility failed to ensure that its staff notified the Physician/NPP of a change in condition when: [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure that its staff implemented their abuse prohibition policy for two Residents (#88 and #179) out of 27 total sampled residents. Specifically, the facility failed to ensure that its staff implemented: 1) the facility's established immediate action plan when Nurse #6 failed to ensure Resident #88's safety and remove Certified Nurse Aide (CNA) #5 from the resident's room and care during an incident of alleged verbal abuse, and 2) the facility's established process for reporting when Resident #179 reported alleged sexual abuse between a staff member and a resident.

Inspectors wroteBased on record review, and interview, the facility failed to ensure that its staff included one Resident (#120) and/or the Resident Representative out of a total sample of 27 residents, in the care planning process as required. Specifically, the facility staff failed to include Resident #120 and/or their Resident Representative in the last two quarterly multidisciplinary Care Conference meetings, neglecting to communicate care planning information to the appropriate party.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its staff obtained necessary Podiatry (foot care) services for one Resident (#9) out of a total sample of 27 residents, resulting in neglected foot care.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure its staff followed professional standards of practice related to the proper care of a Peripherally Inserted Central Catheter (PICC- thin flexible tube that is inserted into a vein in the upper arm and is guided into a large vein above the right side of the heart) and Midline Catheter (a tube inserted into the the peripheral vein in the upper arm with the internal tip located near the armpit/axilla) used for intravenous (IV- into the vein) antibiotic therapy for one Resident (#53), out of a total sample of 27 residents. Specifically, the facility staff failed to A) ensure a change in the external catheter length of a PICC was documented accurately and changes reported to the Physician per standards of practice, and B) to ensure monitoring and flush orders were in place for the care of a Midline catheter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its staff provided two Residents (#46 and #84) out of 27 total sampled residents, with needed behavioral health care, in accordance with their comprehensive assessments, plans of care, and standards of practice. Specifically, the facility failed to ensure that its staff: 1) provided a qualified Practitioner to assess Resident #46 and develop/implement a plan of care for the Resident's safety when he/she expressed feelings of self-harm and wanting to die, and 2) obtained a Physician order for consultant Psychiatric services to evaluate Resident #84 prior to these services being provided to the Resident while at the facility.

Inspectors wroteBased on document review, and interview, the facility failed to ensure its staff notified Resident Representatives and families of positive COVID-19 staff cases in the facility by 5:00 P.M. the next calendar day during the month of September 2022, as required.