Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Park Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Failure to monitor and provide ROM for a resident with a left knee flexion contracture. The resident had dementia, hemiplegia, and a CVA history, and the care plan called for ROM exercises and passive ROM for limited limbs. The resident was observed with the left leg positioned in marked flexion and reported pain at one point, while records showed no nursing documentation of left leg ROM or positioning, no OT assessment of the lower extremity ROM, and a PT evaluation documenting a minus 86-degree left knee flexion contracture.
Physician Did Not Sign Complete TPN Orders: A resident with peritoneal abscess, enterocutaneous fistula, and short gut syndrome was receiving TPN, but the physician order in the chart did not list all ingredients and additives. The full TPN formula was on the pharmacy order form, yet the signature line was signed by an RD instead of a physician. Interviews confirmed the RD wrote the recommendations, the RD said TPN ordering was beyond her scope, and the CNO acknowledged the physician did not sign the complete TPN order.
Improper Disposal and Containment of Trash and Refuse: Surveyors observed an enclosed dumpster area with one trash dumpster left open because the lid was broken, along with leaves and scattered refuse including milk cartons, thickened liquid containers, juice containers, water bottles, plastic cups, plates, lemon pieces, and bread. On a later observation, the same debris remained in the area. The FSD and Maintenance Director stated the lid had been broken since a snowstorm and that the area often had debris after pickups, while the trash disposal company said the facility had not contacted them until shortly before the surveyor inquiry.
A resident with moderate cognitive impairment and a legal guardian underwent multiple wound treatments without the guardian's consent. The facility failed to inform the guardian of the resident's condition and treatment plans, leading to unauthorized procedures. The consultant wound physician and facility staff did not communicate with the guardian, assuming the resident could consent, despite being legally incapacitated.
The facility failed to inform residents about their right to file grievances anonymously. During a resident group meeting, 14 residents expressed unawareness of this option, confirmed by the Activity Director. The grievance policy allows anonymous submissions, but posted information lacked this detail, and no grievance information was found on the first floor. The Administrator was unaware of this issue.
A facility failed to implement a nicotine patch taper for a resident, perform wound treatments without legal guardian consent, and ensure consistent use of a prescribed hand carrot device. The nicotine patch taper was not initiated despite physician agreement, and the wound physician performed treatments without guardian consent due to unawareness of the resident's legal status. Additionally, the hand carrot device was inconsistently applied, with no documentation of refusal or intolerance.
The facility exceeded the acceptable medication error rate of 5%, reaching 7.14%, due to two nurses administering multivitamins with minerals instead of the prescribed multivitamins without minerals to two residents. Both residents had specific medical conditions, and the errors were acknowledged by the nurses and noted by the DON.
A resident in a LTC facility was unable to independently access a call light due to the absence of a pull string on the switch above their bed. The resident, who required assistance with personal care, relied on their roommate to request help. Staff interviews confirmed that each resident should have their own call light, but the deficiency persisted until it was addressed after a surveyor's visit.
Failure to Monitor and Provide ROM for Resident With Left Knee Contracture
Penalty
Summary
The facility failed to monitor range of motion and implement the care plan for a resident with a left knee flexion contracture. The resident had diagnoses including dementia, left-sided hemiplegia, paralysis following a CVA, and chronic pain, and the MDS showed functional limitation in lower-extremity ROM on both sides. The care plan included ROM exercises several times per day and passive ROM for limbs with limitations, and a prior rehab screen had noted the resident remained with a left lower extremity knee flexion contracture with staff performing passive ROM daily to reduce worsening. On observation, the resident was seen sitting in a specialized adjustable medical wheelchair with the left lower extremity externally rotated and the knee flexed to 90 degrees, with the leg positioned across the right lower extremity. The resident stated the left leg was painful and that pain medication had been given but the leg still hurt and could not be straightened. On a later observation, the resident was lying in bed with the left knee bent to approximately 90 degrees of flexion and stated there was no pain at that time. Record review showed the rehab screen and therapy documentation did not establish left lower extremity ROM goals or measurements, and the OT evaluation did not assess left lower extremity ROM or strength even though a contracture was present. A PT evaluation later documented a minus 86 degree left knee flexion contracture and stated skilled rehab was needed to prevent worsening with an orthotic device and ROM program. Nursing notes from 2/16/26 through 4/6/26 did not indicate ROM or positioning for the left lower extremity, and the DON stated there was no documentation that nursing staff or CNAs performed ROM for the resident's left leg.
Physician Did Not Sign Complete TPN Orders
Penalty
Summary
The facility failed to ensure the physician properly assigned and delegated therapeutic diet tasks to a qualified dietitian or other qualified nutrition professional for a resident receiving total parenteral nutrition (TPN). Resident #10 was admitted with diagnoses including peritoneal abscess, enterocutaneous fistula, and short gut syndrome, and the MDS indicated moderate cognitive impairment with a BIMS score of 10 and that the resident received parenteral/IV feeding. The resident stated he/she had been on TPN for over a year. Review of the medical record showed a physician's order for TPN that did not include the individual ingredients, nutrients, and additives. The Pharmacy TPN Order Form contained the full TPN formula, including amino acids, dextrose, lipids, electrolytes, zinc, multivitamins, and insulin, but the physician signature line on that form was signed by an RD and not by a physician. During interviews, the Medical Director stated the RD wrote the TPN recommendations on the pharmacy form and the physician co-signed them, while the RD stated writing TPN orders was beyond her scope of practice. The CNO stated the RD reviewed hospital orders and the attending physician was supposed to confirm them, and also acknowledged that the physician did not sign the TPN Pharmacy Order Form containing all ingredients and additives.
Improper Disposal and Containment of Trash and Refuse
Penalty
Summary
The facility failed to ensure trash, garbage, and refuse were disposed of and properly contained within a receptacle constructed with a tight-fitting lid. Surveyor observation of the enclosed dumpster area found two dumpsters, one containing cardboard and one containing bags of trash, with the trash dumpster open at the top. Between the dumpsters was a large amount of leaves mixed with empty milk containers, thickened liquid containers, juice containers, water bottles, plastic cups, and plates, with pieces of lemon and bread next to the dumpster. Behind the dumpsters were disassembled pieces of white piping with wheels on the bottom and a power wheelchair. On a later observation with the Food Service Director, the same dumpster area still contained the pile of leaves with trash debris, and the trash dumpster remained open on top. During interview, the Food Service Director stated the dumpster lid was broken and could not be closed, and said staff should be telling him if the area needed to be cleaned. The Maintenance Director stated the area usually had trash debris after pickups and said he was not sure why the same trash observed earlier was still on the ground. He also stated the lid had broken during a snowstorm and that he had contacted the dumpster company about the broken lid prior to the surveyor inquiry, but had no documentation showing notification for repair or replacement. The contracted trash disposal company representative stated the facility had contacted the company only one half hour before the call and had not contacted them prior to that day.
Failure to Inform Legal Guardian of Resident's Treatment
Penalty
Summary
The facility failed to ensure that the legal guardian of a resident with moderate cognitive impairment was informed of changes in the resident's skin condition and the associated treatment plans. The resident, who had been adjudicated incapacitated and had a legal guardian appointed, developed wounds on the left heel and toes. Despite the resident's inability to provide informed consent, the facility proceeded with multiple treatments, including surgical debridement and skin substitute grafting, without notifying the legal guardian or obtaining their consent. The medical records and interviews revealed that the consultant wound physician performed various procedures on the resident's wounds over several months. The physician documented obtaining consent from the resident, who was not legally capable of providing it, and was unaware of the need to involve the legal guardian. The facility's nursing progress notes also failed to indicate any communication with the legal guardian regarding the resident's condition and treatment options. Interviews with the legal guardian confirmed that she had not been informed of the resident's wounds or the treatments administered. The guardian had not been contacted by the facility since a care plan meeting months prior, and she assumed the resident's condition was stable. The Director of Nursing acknowledged the oversight and confirmed that the procedures should not have been performed without the guardian's consent. The Unit Manager also could not verify any communication with the guardian regarding the resident's treatment.
Residents Unaware of Anonymous Grievance Filing Option
Penalty
Summary
The facility failed to ensure that residents were fully informed about their right to file grievances anonymously. During a resident group meeting attended by 14 residents from various units, it was revealed that none of the residents were aware of their ability to submit grievances without identifying themselves. This lack of awareness was confirmed by the Activity Director, who acknowledged that residents often refrain from voicing complaints due to a reluctance to disclose their identities. The facility's grievance policy, dated January 2022, states that residents are provided with information on filing grievances upon admission and that grievances can be submitted anonymously. However, observations during the survey showed that the posted grievance information on the second and third floors did not mention the option for anonymous submissions. Additionally, no grievance process information was found on the first floor. The Administrator, who serves as the Grievance Officer, was unaware of the residents' lack of knowledge regarding anonymous grievance filing.
Deficiencies in Care and Consent Procedures
Penalty
Summary
The facility failed to implement a taper and discontinuation of a Nicotine patch for a resident, as recommended by the consultant pharmacist and agreed upon by the resident's physician. Despite the physician's agreement and signature on the recommendation, the taper was not initiated, and the Nicotine patch continued to be administered at the same dosage. The Unit Manager acknowledged that the signed recommendation should have been implemented, but it remained in the physician's binder without action. Another deficiency involved a resident with dementia who had a legal guardian. The consultant wound physician performed multiple treatments, including surgical debridement and skin grafts, without obtaining informed consent from the legal guardian. The legal guardian confirmed that they were not informed of the treatments and did not provide consent. The physician was unaware of the resident's legal status and obtained consent directly from the resident, who was unable to provide it due to cognitive impairment. The facility also failed to ensure that a resident with severe cognitive impairment consistently wore a prescribed hand carrot device. Observations revealed that the device was not applied as ordered, and there was no documentation of refusal or inability to tolerate the device. Staff interviews indicated a lack of awareness regarding the wearing schedule, and the resident's representative noted inconsistency in the device's application. The DON stated that any refusal or difficulty should have been documented, but this was not done.
Medication Error Rate Exceeds 5% Due to Incorrect Multivitamin Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.14% due to errors made by two nurses. Nurse #4 administered a multivitamin with minerals to Resident #22, despite the physician's order specifying a multivitamin without minerals. This resident, admitted in July 2022, had medical conditions including atrial fibrillation and lymphedema. The error was observed during a medication pass, where the nurse did not adhere to the physician's specific order, leading to the administration of the incorrect medication. Similarly, Nurse #5 made an error while administering medication to Resident #64, who was admitted in January 2021 with conditions such as thrombocytopenia and hypercholesterolemia. The nurse gave a multivitamin with minerals instead of the ordered multivitamin without minerals. Both nurses acknowledged the errors during interviews, confirming that the medications were not administered according to the physician's orders. The Director of Nurses was aware of these errors, emphasizing the importance of following physician's orders for medication administration.
Resident Lacked Independent Access to Call Light
Penalty
Summary
The facility failed to ensure that a call light was accessible and within reach for a resident, identified as Resident #37, who was part of a sample of 21 residents. Resident #37, who was cognitively intact and required assistance with personal care, did not have a call light string attached to the switch above their bed, making it impossible for them to independently call for assistance. Instead, Resident #37 relied on their roommate, Resident #91, to pull the call light string attached to their own bedrail when assistance was needed. This arrangement was confirmed through multiple observations and interviews with both residents and staff. Interviews with staff, including nurses and certified nursing assistants, revealed that all residents should have their own call light to request assistance. However, it was noted that the call light string for Resident #37 was missing, and the residents had been sharing a call light. The Unit Manager acknowledged that the strings attached to the call light switches were prone to breaking easily, but it was unclear how long the deficiency had persisted. The Director of Maintenance confirmed that the call light for Resident #37 was repaired after the surveyor's visit, but the duration of the deficiency was not known.
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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.
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Nursing homes near Rockland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southshore Health Care Center | 0.4 mi | ★★★★★ | 23 | 0 |
| Dwyer Home | 2.5 mi | ★★★★★ | 3 | 0 |
| Southwood At Norwell Nursing Ctr | 2.8 mi | ★★★★★ | 9 | 0 |
| Colony Center For Health And Rehabilitation | 2.9 mi | ★★★★★ | 1 | 0 |
| Queen Anne Nursing Home, Inc | 3.1 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.