Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Webster Manor Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
A resident with orthostatic hypotension had an order for Midodrine 10 mg BID with instructions to hold if SBP was greater than 120. Nursing administered the medication twice despite documented SBP readings of 128/72 and 129/69, and the nurse, NP, and DON all confirmed the doses should have been held based on the order.
Incomplete CNA ADL Documentation: Two residents had incomplete CNA ADL Flow Sheets, with multiple shifts left blank for all ADL care areas. One resident had diagnoses including respiratory failure with hypoxia, UTI, pneumonia, and orthostatic hypotension, and the other had vascular dementia, HTN, and depression. The facility policy stated staff must chart every time care is given and complete all charting before leaving, but CNA documentation was missing across numerous shifts.
A resident with dementia, mobility impairment, and dependence on staff for ADLs sustained an acute distal femur fracture after staff failed to follow the care plan and facility policy requiring gait belt use during transfers. The resident’s records showed a need for assisted transfers and ambulation, yet multiple CNAs reported lifting and stand-pivot transferring the resident from bed and wheelchair without gait belts on several occasions, including the last transfer before a bruise and swelling were noted on the resident’s knee. An assessment and x-ray subsequently confirmed the fracture, and the ADON’s investigation concluded the injury most likely occurred during a chair-to-bed transfer performed without a gait belt.
Insufficient nursing staff on two units resulted in delayed ADL care and late medication administration. A resident with multiple medical conditions experienced significant delays in receiving assistance with eating and morning care due to a shortage of CNAs. Staff interviews confirmed that the reduced staffing led to incomplete and late care, and nurses reported being unable to administer medications on time because they had to assist with other resident needs. The facility's response to staff callouts was inadequate, and resident acuity was not considered in staffing decisions.
Multiple residents reported that hot food was consistently served cold, and a test tray confirmed that several breakfast items were below appetizing temperatures. Staff interviews acknowledged ongoing complaints, and documentation showed insufficient monitoring of food temperatures on the affected unit.
Surveyors found that meal carts, coffee carts, the plate warmer, and food storage units were not maintained in a clean and sanitary manner, with visible dried debris present on multiple surfaces. Staff were observed preparing and serving food and beverages using unclean equipment, and there was no established cleaning schedule or documentation of cleaning activities in the kitchen. The Food Service Director confirmed these practices did not meet professional standards for food service safety.
The facility did not ensure that pneumococcal vaccines were offered or administered to eligible residents, including two individuals who were not up-to-date with immunizations—one of whom had provided consent for the vaccine but did not receive it. An audit also found that 75 residents were eligible and not up-to-date, yet none had been offered the updated vaccine, and there was no tracking system in place for immunization status.
A resident dependent on staff for dressing and eating was repeatedly left exposed in a common area due to an untied hospital gown, and did not receive consistent assistance during meals. Staff failed to determine or honor the resident's drink preferences, and the resident's care plan and facility policies regarding dignity and individualized care were not followed.
Staff failed to keep two residents' wheelchairs clean and sanitary, with visible dried substances and food debris observed over several days. There was confusion among staff about who was responsible for cleaning, and no evidence of regular cleaning was provided. Additionally, one unit had significant wall damage, unpainted repairs, and uncleaned food spills on walls and furniture, with no formal process for reporting or addressing these issues.
A resident with a history of dysphagia and aspiration pneumonia was repeatedly left unsupervised while eating, despite physician orders and care plan directives requiring continual staff supervision during meals. Staff interviews confirmed knowledge of the resident's aspiration risk and the need for supervision, but the resident was observed eating alone in their room on multiple occasions, in violation of facility policy and individualized care plans.
A resident with an indwelling urinary catheter did not receive care in accordance with professional standards, including a mismatch between the physician's catheter order and the device used, lack of a leg bag for privacy and mobility, and failure to implement Enhanced Barrier Precautions (EBP) during ADL care. Staff were unaware of the resident's EBP status, and appropriate PPE was not used during care activities.
Three residents did not receive respiratory care in accordance with professional standards: one resident's oxygen was not set as ordered and a soiled nasal cannula was reused; another resident's oxygen concentrator filter was not cleaned as required; and a third resident's CPAP equipment was not maintained or cleaned per policy, with no physician orders for its care.
A resident with severe dementia repeatedly paced the hallways and expressed confusion, but staff failed to provide diversional activities or engage the resident according to their care plan and documented interests. Instead, staff only directed the resident to sit in a chair without offering meaningful engagement, leading to continued distress and unmet psychosocial needs.
A resident with diabetes and protein-calorie malnutrition did not receive their preferred food items for two consecutive meals, despite these preferences being documented on their meal tray card. The resident was served items they disliked or did not request, and key preferred items such as cottage cheese, fruit cup, and the correct flavor of Magic Cup were missing. The Food Service Director confirmed issues with food item availability and acknowledged that available items were not provided as required.
The facility did not ensure that staff followed proper procedures for reheating food and beverages brought in by families, as required by policy. An Activities Director reheated a resident's coffee without checking its temperature, using a non-functioning thermometer, and was unsure of the correct reheating temperature. There was no regular process to check thermometer functionality, and posted instructions were unclear. Staff interviews revealed a lack of training and documentation regarding safe reheating practices.
A resident with a history of respiratory conditions, who was over 65 and not up to date with COVID-19 immunizations, did not receive the updated 2024-2025 vaccine despite providing consent. Facility records and staff interview confirmed the vaccine was not administered as required by policy and CDC guidance.
Medication Given Despite Hold Parameter
Penalty
Summary
The Facility failed to ensure a resident was free from significant medication errors when Midodrine HCL 10 mg was administered outside of the physician-ordered parameter. Resident #1 was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, urinary tract infection, pneumonia, and orthostatic hypotension. The physician’s order for Midodrine directed staff to give the medication in the morning and afternoon but to hold it if the systolic blood pressure (SBP) was greater than 120. Review of the MAR showed that on 04/11/26 the resident received Midodrine in the morning and again in the afternoon even though blood pressure readings documented at those times were 128/72 and 129/69. During interview, the nurse who administered the medication stated she should not have given Midodrine because the SBP was greater than 120 both times. The NP stated she expected staff to check blood pressure before each dose and hold the medication if SBP was greater than 120, and the DON stated nurses were expected to read and follow physician orders on the MAR and that the doses should not have been administered.
Incomplete CNA ADL Documentation
Penalty
Summary
The Facility failed to ensure complete and accurate medical records were maintained for two sampled residents when CNA ADL Flow Sheets were incomplete. The facility policy titled, POC Documentation Skill Sheet, dated 10/27/23, stated that staff must chart every time care is given, complete all charting before leaving, and that if it is not documented, it means it was not done. Resident #1 was admitted in March 2026 with diagnoses including acute and chronic respiratory failure with hypoxia, UTI, pneumonia, and orthostatic hypotension. His/her MDS dated 04/06/26 showed the resident required varying levels of staff assistance with ADLs including bathing, dressing, grooming, transfer, toileting, and personal hygiene. Review of the ADL Flow Sheets from 04/01/26 through 04/13/26 showed multiple shifts with all ADL care areas left blank, including 9 of 13 day shifts, 3 of 13 evening shifts, and 2 of 13 night shifts. Resident #2, admitted in September 2023 with diagnoses including vascular dementia, hypertension, and depression, also required varying levels of staff assistance with ADLs per the MDS. Review of the April 2026 CNA Flow Sheet showed all ADL care areas left blank on 16 day shifts, 2 evening shifts, and 4 night shifts.
Failure to Use Gait Belts During Transfers Resulting in Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services in accordance with a resident’s comprehensive person-centered plan of care and facility policy regarding gait belt use during transfers. The facility had a written policy, dated April 2025, requiring that gait belts be used when physically transferring or ambulating residents. The resident involved had vascular dementia, hypertension, hypothyroidism, a history of repeated falls, difficulty walking, and documented short- and long-term memory problems. The resident’s MDS and CNA care card indicated dependence on staff for activities of daily living, including transfers, and the care plan for impaired functional mobility required staff assistance for transfers and ambulation. On the morning in question, nursing staff requested that the Assistant Director of Nurses assess a bruise on the resident’s right knee. The Assistant Director of Nurses found the knee bruised and swollen, notified the Nurse Practitioner, and obtained an order for an x-ray. A nurse progress note and a mobile x-ray report dated the following day documented an acute distal right femoral metaphysis fracture. The Assistant Director of Nurses conducted an investigation and determined that the injury most likely occurred during a transfer from chair to bed. During interviews, multiple CNAs reported transferring the resident without using a gait belt, contrary to facility policy and the resident’s care needs. One CNA stated he had previously transferred the resident by lifting from the bed with another CNA without a gait belt. Another CNA reported assisting with stand-pivot transfers of the resident on previous days without a gait belt. A third CNA stated that she and another CNA had transferred the resident from wheelchair to bed by lifting and pivoting the resident without using a gait belt on the afternoon prior to the bruise being noticed, and acknowledged that a gait belt should have been used. The Assistant Director of Nurses concluded that the last transfer before the bruise was observed was this wheelchair-to-bed transfer, during which staff reported that a gait belt had not been used, in violation of facility policy and the resident’s plan of care.
Insufficient Nursing Staff Leads to Delays in Resident Care and Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff on two resident units, resulting in delays in morning activities of daily living (ADL) care and medication administration. On the Lake Unit, there were only three CNAs assigned to care for 42 residents during the day shift, which was below the required staffing level. Observations showed that a resident with a history of traumatic brain injury, dementia, dysphagia, and weakness experienced significant delays in receiving assistance with eating and morning care. Staff interviews confirmed that the reduced number of CNAs led to late completion of ADL care, with some residents not out of bed before lunch and showers being postponed. The CNAs reported being unable to complete all required tasks in a timely manner due to the staffing shortage, and the late care was not due to resident preference but rather insufficient staff coverage. The facility's staffing schedule and interviews revealed that the required number of CNAs for the day shift was not met, and there was a lack of effective response to staff callouts. The scheduler acknowledged that resident acuity was not considered when determining staffing needs and that attempts to fill callout spots were limited. The Director of Nursing stated that the Lake Unit was typically staffed with three CNAs, and a fourth would be added if needed, but was unaware of any issues with timely completion of care when staffed with three CNAs. Additionally, a Resident Care Assistant was also absent, and this was not known to the DON until later in the day. The facility's process for redistributing staff and responding to callouts was insufficient to ensure adequate coverage. Medication administration was also delayed on both the Lake and Tapestry Units. Nurses reported being very late with medication passes due to having to stop and assist with other resident care tasks, such as delivering breakfast trays, feeding residents, answering call lights, and toileting. On the Tapestry Unit, nurses and CNAs had to frequently redirect wandering residents and assist with feeding, further delaying medication administration. The DON was aware that resident behaviors could cause delays but stated that staffing was based on ratios managed by the scheduler. The scheduler confirmed that she was unable to call additional staff to cover callouts due to being pulled to work as a CNA herself. These staffing shortages and lack of timely response to absences directly contributed to the deficiencies in resident care and medication administration.
Failure to Serve Palatable and Appropriately Heated Food
Penalty
Summary
The facility failed to serve food that was palatable and at a safe and appetizing temperature on one unit, as evidenced by multiple resident complaints and direct observations. Residents consistently reported that hot food was served cold, with some stating that staff either did not offer to reheat the food or that reheating in the microwave resulted in overcooked meals. During a Resident Council meeting, half of the attendees confirmed that hot food was often served cold, and previous meeting minutes also documented similar concerns. Despite these ongoing complaints, there was no evidence that the facility had conducted adequate or ongoing test trays on the affected unit to assess or address the issue. A test tray conducted by the surveyor, accompanied by the Regional Food Services Director (FSD), revealed that several hot breakfast items were served at temperatures below what is considered appetizing, with all items described as cold to taste. Interviews with staff, including the FSD and a nurse, confirmed awareness of the problem and acknowledged that residents frequently complained about cold food. Documentation provided by the FSD showed limited and outdated test tray assessments, none of which were conducted on the unit in question or after the most recent resident complaints, indicating a lack of ongoing monitoring and response to the deficiency.
Failure to Maintain Sanitary Conditions in Food Service Operations
Penalty
Summary
Surveyors observed multiple failures in the facility's food service operations, specifically regarding the cleanliness and sanitation of equipment and food storage areas. Meal carts used to deliver resident trays for breakfast and lunch were found with spattered, dried, white and brown debris on both the inside and outside surfaces, as well as on the floors of the carts. Coffee carts used to serve beverages to residents also had visible dried debris on the shelves and handles. Additionally, the plate warmer, which housed clean plates for resident use, had several areas of dried debris and food crumbs on its surface. During meal preparation, dietary staff were seen filling large, insulated beverage containers with coffee while the containers were placed on the floor, with the spout openings positioned just above the floor. Nearby, two stacked milk crates, also covered in dried debris, were used to elevate the beverage containers. A rolling cart containing a used surgical mask, a foam cup with liquid, and a partially eaten meal tray was observed next to the coffee station, rather than being taken directly to the dish room as required. The stand-up refrigerator and freezer, which stored food for resident consumption, had spattered debris on the floors, inside walls, and outside doors. Interviews with the Food Service Director (FSD) and Regional FSD revealed that there was no established cleaning schedule for items in the main kitchen, nor were there logs maintained to document when cleaning occurred. The FSD confirmed that meal carts, coffee carts, the plate warmer, and food storage units should be kept clean and that the observed conditions did not meet the facility's own guidelines for sanitary food storage, preparation, and distribution.
Failure to Offer and Administer Pneumococcal Immunizations to Eligible Residents
Penalty
Summary
The facility failed to ensure that pneumococcal immunizations were properly offered and administered to eligible residents, as evidenced by record reviews and staff interviews. Specifically, one resident was not offered an updated pneumococcal vaccine upon admission, and there was no documentation that the resident or their representative had been educated about or offered the vaccine, despite the resident not being up-to-date with current recommendations. Another resident, who had previously received PCV13 and had provided signed consent for the updated PCV20 vaccine, did not have any evidence in their clinical record that the vaccine was administered or that it was medically contraindicated. Additionally, an audit revealed that 75 residents in the facility were eligible for pneumococcal immunization and not up-to-date, yet none had been offered the updated vaccine. The Infection Preventionist in Training confirmed that there was no tracking system in place for pneumococcal immunizations when she began her role, and that although some vaccine supply was available, no eligible residents had been offered or administered the updated immunization at the time of the audit.
Failure to Maintain Resident Dignity and Provide Consistent Dining Assistance
Penalty
Summary
The facility failed to ensure a resident's right to a dignified existence and self-determination by not providing adequate clothing coverage and not ensuring a dignified dining experience. On two separate occasions, a resident who was dependent on staff for dressing was observed in a common area wearing a hospital gown that was not properly tied, resulting in exposure of the resident's back, upper arm, chest, and incontinence brief. The resident was left in this state in the dining room, visible to other residents, staff, and from the hallway, without timely intervention from staff to address the exposure. During a lunch meal, the same resident, who required assistance with eating, did not receive consistent support from staff. The resident was left partially exposed while being assisted with eating, and staff did not adjust the gown to maintain the resident's dignity. Additionally, the resident's drink preferences were not determined or honored, as staff were unsure how the resident preferred their coffee and did not seek clarification from the resident's health care proxy, despite the resident's communication limitations. The resident had a history of dementia, bilateral hearing and visual loss, and was at risk for nutritional decline, requiring staff to determine food and beverage preferences and provide consistent assistance. The facility's own policies and the resident's care plan called for maintaining normal living patterns, explaining procedures, and ensuring proper coverage and assistance, but these were not followed, resulting in repeated lapses in dignified care.
Failure to Maintain Clean and Homelike Environment for Residents and Unit
Penalty
Summary
Facility staff failed to maintain a clean and homelike environment for two residents who were dependent on wheelchairs for mobility. Both residents' wheelchairs were observed on multiple occasions to be visibly soiled with dried white and brown substances, food debris, and stains. Despite the facility's policy requiring regular cleaning of wheelchairs, there was no evidence that these wheelchairs had been cleaned as required. Interviews with staff revealed confusion regarding responsibility for cleaning, with housekeeping, nursing, and the director of nursing providing inconsistent statements about cleaning schedules and duties. The Housekeeping Manager confirmed that the wheelchairs were not sanitary or homelike and could not provide documentation of recent cleaning. In addition to the issues with wheelchair cleanliness, the facility failed to maintain resident care equipment and the building in a clean condition and good repair on one unit. Observations included significant wall damage, missing baseboard trim, exposed insulation, and unpainted drywall repairs in resident rooms. There were also instances of dried food substances on walls and bedside tables that remained uncleaned over several days. Residents and their representatives reported that these areas had not been cleaned or repaired in a timely manner, and staff interviews confirmed that there was no formal process for environmental rounds or systematic notification of maintenance needs. Facility policies and cleaning schedules indicated that wheelchairs should be cleaned bi-monthly and that daily cleaning tasks included wiping down bedside tables and walls. However, the lack of adherence to these policies and the absence of clear communication and accountability among staff led to persistent unsanitary conditions and unrepaired environmental damage. These deficiencies were directly observed by surveyors and confirmed through staff and resident interviews.
Failure to Provide Required Supervision During Meals for Resident with Aspiration Risk
Penalty
Summary
Facility staff failed to implement a person-centered care plan for a resident with significant aspiration risk, as evidenced by multiple observations of the resident eating meals unsupervised in their room. The resident, who had a history of dysphagia following a stroke and prior aspiration pneumonia, was on a physician-ordered puree diet with honey thick liquids and required continual supervision during oral intake, as documented in the care plan and physician's orders. Despite these clear directives, the resident was observed eating alone behind a closed privacy curtain, out of staff view, on more than one occasion. Interviews with staff confirmed that the resident should not have been left unattended with food due to the risk of aspiration. The nurse responsible for the resident acknowledged that staff were expected to supervise the resident during meals and that the meal tray should not have been left with the resident. The certified nurse aide who delivered the meal tray also stated that the resident required supervision and that the nurse should have been notified when the resident refused to relinquish the tray. The facility's own policy on aspiration precautions required individualized care plans and supervision for residents at risk of aspiration, with interventions based on speech therapy recommendations. Despite these policies and the resident's documented needs, staff failed to provide the required supervision during meals, resulting in noncompliance with the care plan and physician's orders.
Failure to Provide Proper Catheter Care and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to provide care in accordance with professional standards for a resident with an indwelling urinary catheter. Specifically, there was a discrepancy between the physician's order and the actual catheter inserted; the order specified a 16 French catheter with a 10 ml balloon, but the resident had a 16 French catheter with a 5 ml balloon. This mismatch was identified during a review of the resident's clinical record and confirmed by nursing staff. Additionally, the resident was not provided with a leg bag for urinary drainage when out of bed, despite facility policy and the resident's care plan indicating that a leg bag should be used to promote mobility, dignity, and privacy. Observations showed the resident in public areas with visible catheter tubing and drainage, and staff acknowledged that a leg bag should have been provided but was not. The facility also failed to implement Enhanced Barrier Precautions (EBP) during activities of daily living (ADL) care for the resident, who had a history of urinary tract infection and required a urinary catheter. There was no signage or personal protective equipment (PPE) available in the resident's care area, and staff performed care without donning appropriate PPE. Staff interviews revealed a lack of awareness regarding the resident's EBP status, and the infection preventionist confirmed that EBP had not been implemented as required.
Failure to Provide Safe and Appropriate Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for three residents. For one resident with severe cognitive impairment and a history of dementia, anxiety, and legal blindness, the oxygen concentrator was not set to the physician-ordered flow rate of 2 liters per minute, and there was no documented indication for oxygen use. Additionally, staff failed to replace a nasal cannula that had been contaminated after falling on the floor, instead placing the soiled cannula back on the resident. The resident's care plan also lacked documentation regarding oxygen use or a corresponding diagnosis. Another resident, who was cognitively intact and had diagnoses including COPD and respiratory failure, was observed using an oxygen concentrator with a gross particle air intake filter that was coated in thick dust over multiple days. The filter had not been cleaned in accordance with manufacturer guidelines, and nursing staff were unaware of the proper cleaning process. Facility policy and the device manual both require regular cleaning of the filter to prevent contamination and ensure proper function. A third resident, diagnosed with obstructive sleep apnea and using a CPAP machine nightly, did not have physician's orders in place for the care and maintenance of the CPAP equipment. The CPAP mask was found with dried debris and was not stored in a bag as required, while the humidifier chamber contained significant buildup and debris. Staff confirmed that regular cleaning and maintenance of the CPAP equipment had not been documented or performed, and the resident reported that staff did not clean the equipment regularly.
Failure to Provide Diversional Interventions for Resident with Dementia
Penalty
Summary
A deficiency was identified when a resident diagnosed with dementia did not receive appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. The resident, who was severely cognitively impaired and had a history of wandering, pacing, and vocalizing confusion, was observed repeatedly pacing the hallways and expressing uncertainty about what to do. Despite a care plan that included interventions such as encouraging participation in meaningful activities, establishing routines, and providing diversional activities based on the resident's interests, staff failed to implement these interventions during multiple observed instances. During several observations, staff members directed the resident to sit in a hallway chair but did not offer any diversional activities or engage the resident in activities aligned with their documented interests, such as games, arts and crafts, exercise, music, or conversation. Each time the resident was instructed to sit, staff walked away, and the resident resumed pacing and verbalizing confusion. The resident was also observed to become increasingly distressed, rubbing their face and expressing fear or frustration when interacting with other residents. Interviews with staff confirmed that the resident required redirection and engagement in diversional activities, and that simply instructing the resident to sit was not effective. Staff acknowledged that the resident had demonstrated interest in certain activities, such as folding towels and word searches, but these were not offered during the observed periods. The lack of implementation of the care plan interventions and failure to provide appropriate diversional activities contributed to the deficiency.
Failure to Provide Resident's Preferred Food Items
Penalty
Summary
The facility failed to provide a resident with their preferred food items as indicated on their meal tray card for two consecutive meals. The resident, who was cognitively intact and had diagnoses including diabetes and protein-calorie malnutrition, had documented preferences for certain breakfast and lunch items, including cottage cheese, fruit cup, cereal, and a specific flavor of Magic Cup. During observations, the resident's breakfast tray did not include the preferred fruit cup, cereal, or cottage cheese, and the lunch tray was missing the fruit cup, cottage cheese, and the preferred berry-flavored Magic Cup. Instead, the resident received items not listed as preferences, such as eggs, which the resident had previously expressed a dislike for, and a chocolate-flavored Magic Cup, which the resident stated they would not eat. Interviews with the Food Service Director (FSD) revealed that there were difficulties in obtaining specific food items, such as cottage cheese and berry-flavored Magic Cups. Although cottage cheese was eventually sourced from a neighboring facility, it was not provided to the resident as required. The FSD also acknowledged that fruit cups were available but were not included on the resident's trays as indicated. The FSD had not consulted with the dietician or the resident regarding suitable substitutes for unavailable items. These actions and omissions resulted in the resident not receiving their preferred and prescribed food items during the observed meals.
Failure to Ensure Safe Reheating of Food and Beverages Brought in by Families
Penalty
Summary
The facility failed to maintain an effective policy and procedure for the safe reheating of food and beverages brought in by family members for residents. The policy required staff to use a thermometer to ensure food was reheated to an internal temperature of 165°F and to follow a reheating chart and USDA guidelines. However, observations revealed that staff, including the Activities Director (AD), reheated a resident's coffee without checking its temperature and were unsure of the correct reheating temperature. The thermometer available in the kitchenette was not functioning, and there was no regular process to ensure thermometers were in working order. Additionally, the posted instructions in the kitchenette did not clearly address reheating beverages or specify the correct temperature. Interviews with staff indicated a lack of clarity and training regarding the proper procedures for reheating food and beverages brought in by families. The Food Service Director (FSD) and Regional FSD were unaware of the training provided to non-dietary staff, and the Staff Development Coordinator (SDC) could not provide documentation showing that the AD or Certified Nurses Aide (CNA) had received education on safe reheating practices. These lapses resulted in the facility not ensuring that food and beverages were reheated in accordance with professional standards to prevent potential foodborne illnesses.
Failure to Administer Updated COVID-19 Vaccine After Consent
Penalty
Summary
The facility failed to ensure that an updated 2024-2025 COVID-19 immunization was administered to one resident who was eligible and had provided consent. The resident, who had a history of acute respiratory failure with hypoxia, COPD, and asthma, was over the age of 65 and had last received a COVID-19 vaccine in November 2022. Documentation showed that the resident was not up to date with COVID-19 immunizations and had signed a consent form in October 2024 to receive the updated vaccine. Despite the facility's policy to follow CDC and state guidance for COVID-19 vaccination, and the CDC's recommendation for updated vaccination for individuals in long-term care, the resident did not receive the updated immunization after consent was obtained. The Infection Preventionist in Training confirmed during an interview that the resident had not been administered the updated vaccine, acknowledging that it should have been given once consent was secured.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 341 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Webster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lanessa Extended Care | 0 mi | ★★★★★ | 1 | 0 |
| Brookside Rehabilitation And Healthcare Center | 1.9 mi | ★★★★★ | 1 | 0 |
| Matulaitis Rehabilitation & Skilled Care | 7.7 mi | ★★★★★ | 3 | 0 |
| Southbridge Rehabilitation & Health Care Center | 8.3 mi | ★★★★★ | 8 | 0 |
| Overlook Masonic Health Center | 8.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.