Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Webco Manor during CMS and state inspections, most recent first.
A resident with cardiac and pulmonary conditions, initially defaulted to full code status, later completed a physician-signed DNR order that was placed in an admission folder but not communicated to nursing or entered into the EMR. The Admissions Director did not forward the DNR paperwork to the SSD or DON, and the SSD created the resident’s profile as full code, leaving the hard chart, EMR, and door sticker system all reflecting full code. When the resident was found unresponsive, staff and EMS initiated and continued CPR based on the incorrect full code information, and only afterward did the SSD discover the signed DNR form in the admission packet.
A resident with multiple sclerosis and minimal cognitive impairment reported to a CNA that a CNA staff member was rough during incontinence care, turned on a bright light while the resident was sleeping, and then punched the wall above the resident’s head after being told to stop, causing the resident to feel fearful and request that the CNA not return. The CNA immediately informed an RN, wrote a statement, and attempted to contact the DON and Administrator by phone and text, but neither responded during the night. The RN reassigned the resident’s care and told the accused CNA not to re-enter the room but did not interview the resident and did not treat the report as an abuse allegation, so it was not escalated to leadership until later that morning, during which time the accused CNA continued working independently with other residents.
A resident with MS and minimal cognitive impairment reported that a CNA was rough during incontinence care, turned on a bright light while the resident was sleeping, and punched the wall above the resident’s head, causing the resident to feel fearful and request that the CNA not return. A CNA promptly informed the RN, documented the incident, and attempted to contact the DON and Administrator by phone and text, but the RN did not escalate the report, believing rough care was not abuse, and leadership did not respond during the night. The allegation was not documented in the resident’s progress notes, and the Administrator did not submit the required report to the State until more than seven hours after staff first became aware of the allegation, exceeding the facility’s two-hour reporting requirement for abuse allegations.
A resident with severe cognitive impairment was subjected to alleged abuse by a CNA, who placed a hand over the resident's mouth and used inappropriate language. The incident was witnessed by another CNA, who did not report it immediately but waited until the next day to inform another staff member, resulting in a delayed report to the DON, Administrator, and state agency. This delay exceeded the required two-hour reporting timeframe for abuse allegations.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with neurogenic bladder continued to have an indwelling urinary catheter in place and performed their own catheter care, but there was no current physician order specifying the catheter's use, size, or change frequency, despite staff awareness of this omission.
The facility failed to keep care plans current for two residents with a documented relationship and room restrictions, even though the SSD, DON, ADON, and Administrator all acknowledged the residents should not be in each other’s rooms. The facility also failed to update a resident’s care plan after multiple falls and new interventions, despite progress notes, event reports, and staff interviews showing the falls were reviewed and interventions such as closer toileting and low bed use were discussed.
Incomplete and Untimely Staff TB Screening: The facility failed to ensure timely two-step TB screening for multiple staff members. Several personnel files showed first-step TSTs that were not read or not fully documented, and second-step tests that were completed well beyond the expected timeframe. HR, the DON, the Administrator, and the ADON stated they were unaware of the missed readings, incomplete documentation, and delayed second tests, and HR reported the facility ran out of serum during part of the testing process.
Failure to implement an approved antipsychotic dose reduction for a resident with dementia and severe cognitive impairment. The resident was receiving Zyprexa for dementia with agitation, and pharmacy reviews identified the medication as due for GDR and recommended reducing the dose. The provider signed the recommendation, but staff did not document the reduction in a timely manner, and interviews with the ADON, DON, physician, LPN, CMT/medical records staff, and Administrator confirmed the reduction had been overlooked.
A resident with cerebral infarction, right-sided hemiplegia, muscle weakness, aphasia, and severe cognitive impairment had a right-hand brace observed in use and on the dresser at different times, but the chart had no order, TAR entry, progress note documentation, or care plan for the brace. Staff interviews showed mixed understanding of who was responsible for the brace, while multiple staff members stated a brace should have an order, skin checks, and care plan inclusion.
Failure to order, assess, and care plan colostomy care for a resident with a colostomy. The resident performed own ostomy care, but staff did not have physician orders for colostomy monitoring, did not assess ability for self-care, and did not include self-care in the care plan. The resident reported the pouch sometimes overfilled and the stoma area was red and sore; surveyors observed reddened, excoriated skin around the stoma, and staff acknowledged the resident sometimes needed assistance and should have been monitored.
Failure to Document and Authorize Side Rail Use: A resident with severe cognitive impairment and fall risk had two side rails in place on the bed, but the record lacked documentation of alternatives, a risk-versus-benefit review, informed consent, and a physician order. Staff interviews showed inconsistent understanding of the side rail process, while the care plan listed assist rails as needed for bed mobility and the resident was observed using the rails in the up position.
A resident with dementia, aphasia, severe cognitive impairment, and swallowing problems was ordered a puree diet with nectar-thick liquids, but staff served drinks with thickener settled in the cup and did not stir them before serving. Observations showed the resident coughing after drinking water and a chocolate drink, while staff interviews revealed inconsistent preparation practices and differing understanding of the thickener instructions, including how much thickener to use and the need to stir settled liquids.
Failure to offer and administer pneumococcal vaccines: A resident with Parkinson's disease, Alzheimer's disease, and CKD consented to PSV20, but the vaccine was not documented as given. Another resident with severe cognitive impairment had no documented pneumococcal consent or declination, and no vaccine was documented. The DON was unsure about administration, while the ADON stated staff did not offer or administer pneumococcal vaccines and could not locate consents after the former DON resigned.
A resident with cerebral infarction, right-sided hemiplegia, muscle weakness, aphasia, and severe cognitive impairment did not consistently have the call light within reach. Observations showed the call light clipped to a curtain, placed behind the resident, on top of a chair, and draped over the head of the bed while the resident was in bed or seated. Multiple staff members, including a CNA, CMT, LPN, ADON, DON, and the Administrator, stated the call light should be within easy reach and not clipped to a curtain.
The facility failed to notify the families of two residents after a significant change in condition and an allegation of abuse. A resident with dementia was involved in inappropriate touching, but their family was not informed. The facility's investigation revealed a lack of communication and documentation, and staff interviews confirmed that families should have been notified.
A facility failed to report allegations of sexual abuse involving inappropriate touching between residents to management and DHSS within the required timeframe. Despite staff awareness of the reporting protocol, incidents were not documented or reported promptly, leading to a deficiency in the facility's abuse prevention and reporting procedures.
A facility failed to investigate an alleged abuse incident when a resident was seen touching another resident inappropriately. Despite facility policies requiring immediate investigation and reporting, no documentation or investigation was conducted. Staff, including the DON and Administrator, were unaware of the incident, highlighting a deficiency in handling the situation.
A resident with dementia and psychotic disturbances exhibited inappropriate touching behavior towards other residents, but the facility failed to update the care plan to reflect these incidents. Despite staff awareness and documentation of the behavior, the MDS Coordinator did not amend the care plan, indicating a deficiency in the care planning process.
A resident with chronic pain syndrome and arthritis experienced inadequate pain management due to the facility's failure to document pain levels, follow up on medication effectiveness, and communicate with the physician about increased pain and unavailable medications. The resident's condition worsened, leading to a hospital transfer where a patella fracture was diagnosed.
A resident with rheumatoid arthritis experienced a decline in mobility and increased knee pain, which was not promptly communicated to the provider. Despite staff observations of the resident's swollen, red, and warm knee, and the resident's requests for medical attention, there was a delay in notifying the physician. The resident was eventually transferred to the hospital, where a patellar fracture was diagnosed.
A resident with severe cognitive impairment and a history of wandering eloped from the facility due to inadequate supervision and failure to implement necessary interventions. Despite triggering alarms and exhibiting exit-seeking behavior, the resident was not placed on 15-minute checks or given increased supervision. The resident was later found in a nearby cornfield after a search involving law enforcement.
Failure to Communicate and Update Resident DNR Status Resulting in CPR Contrary to Wishes
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s code status preference was clearly and accurately reflected in the medical record and available to staff, resulting in CPR being initiated contrary to the resident’s documented wishes. The resident was admitted with diagnoses including atrial fibrillation, cardiac disease, stroke, and lung disease, and was initially listed as a full code in the facility’s electronic medical record and on the face sheet. The facility’s practice was to default all new admissions to full code status until staff could confirm the resident’s preferences. The resident had normal cognition on the admission MDS and later completed an Outside Hospital Do-Not-Resuscitate (OHDNR) order, which was signed and dated by both the resident and the physician. The sequence of events leading to the deficiency began when the Admissions Director completed the admission paperwork with the resident, including code status and DNR documentation, and then placed all forms in a folder on their desk before leaving for the weekend. The Admissions Director did not notify nursing staff that the resident’s code status had changed from full code to DNR, did not make copies for the nursing charts, and did not provide the DNR paperwork to the Social Services Director (SSD) or the Director of Nursing (DON). As a result, the SSD created the resident’s electronic profile as a full code and did not receive or review the signed DNR form until after the resident’s death. The DON reported not receiving any DNR paperwork prior to the resident’s cardiopulmonary arrest, and the resident’s orders were not updated in the hard chart, EMR, or on the red/green door sticker system used to indicate code status. When the resident was later found unresponsive, staff followed the information available to them, which indicated the resident was a full code. Staff immediately called the nurse, initiated CPR, and called 911. EMS arrived and continued CPR for over an hour. During this time, the DON was called to the facility and contacted the family while the code was in progress. The resident’s progress notes documented the discovery of the resident unresponsive, the initiation of CPR, EMS involvement, and subsequent notifications to the family and physician. Only after these events did the SSD, while scanning the admission packet into the EMR, discover the signed DNR order that had not been communicated or entered into the resident’s record, confirming that staff had provided CPR despite the resident’s documented DNR preference.
Failure to Immediately Investigate and Protect Resident After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to immediately and thoroughly investigate an allegation of staff-to-resident abuse and to ensure resident protection during the investigation. The facility’s Abuse and Neglect Policy requires the Administrator, DON, or designee to begin an internal investigation immediately and report to DHSS when an allegation arises. A resident with multiple sclerosis and minimal cognitive impairment, admitted in early February, reported to a CNA that a CNA staff member had been rough during incontinence care, turned on a bright light while the resident was sleeping, and then punched the wall three times above the resident’s head after being told to stop. The resident stated fear of this CNA and requested that the CNA not return to the room. CNA A documented the allegation in a written statement and immediately reported it to RN C during the night shift. CNA A then attempted to contact the DON and the Administrator by phone and text, sending a picture of the written statement to both, but received no response at that time because both leaders were asleep and did not hear their phones. RN C reassigned the resident’s care to CNA A and instructed CNA B not to return to the resident’s room, but did not enter the resident’s room or interview the resident about the allegation. RN C stated that being rough with cares was not considered an allegation of abuse and therefore did not report the incident to the DON or Administrator during the night. The Administrator and DON later acknowledged that rough care and punching a wall constituted abuse and that an investigation should have been started immediately. Other nursing staff interviewed indicated that any report of rough care where a resident does not feel safe should be treated as an abuse allegation, with immediate steps to ensure safety and report to leadership. Despite this, there was a delay from the time of the initial report during the night until the Administrator became aware and began an investigation later that morning, during which time the staff member implicated in the allegation continued to work independently with residents.
Failure to Timely Report Allegation of Rough Care and Threatening Behavior
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident abuse to the State Survey Agency (DHSS) within the required two hours after staff became aware of the allegation. The facility’s abuse policy required that any suspicion or knowledge of abuse, neglect, or misappropriation be reported immediately to the Administrator and charge nurse, and that the Administrator, DON, or designee begin an internal investigation immediately and report to DHSS within two hours if the allegation involved serious injury, or within 24 hours if it did not. A resident with multiple sclerosis and minimal cognitive impairment, admitted on 02/02/24, reported that a CNA had been rough during incontinence care and had punched the wall above the resident’s head, causing the resident to feel fearful and not want that CNA to return. In the early morning hours, between approximately 2:00 A.M. and 2:25 A.M., a CNA entered the resident’s room to provide care and was informed by the resident that another CNA had turned on a bright light while the resident was sleeping, was rough while attempting to change the resident, and, after being told to stop, punched the wall three times above the resident’s head before leaving. The CNA immediately reported the incident to the charge RN, wrote a statement, and attempted to notify the DON and Administrator by phone and text, including sending photos of the written statement. The charge RN acknowledged being informed between 2:00 A.M. and 3:00 A.M. that the resident complained of rough care and that the CNA had punched a wall, reassigned staff so the alleged CNA would not return to the room, but did not report the allegation to the DON or Administrator, believing that “rough with cares” was not an allegation of abuse. Despite the CNA’s attempts to contact leadership during the night, the DON and Administrator did not respond at that time, later stating they had been sleeping and did not hear their phones. The Administrator did not confirm the incident with staff until later that morning and did not submit the online report to DHSS until 9:58 A.M., more than seven hours after staff first became aware of the allegation. Facility records showed no progress note documentation of the allegation in the resident’s chart. Interviews with other nursing and CNA staff indicated they understood that rough care and a resident not feeling safe should be treated as an abuse allegation and reported immediately, and both the DON and Administrator acknowledged that rough care and punching a wall constituted abuse that should be reported to the State within two hours. The delay in reporting and lack of timely notification to DHSS constituted the deficiency.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported immediately to facility management and within two hours to the State Survey Agency, as required by both facility policy and regulation. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including dementia and Alzheimer's disease, who required total assistance with activities of daily living. On the evening of the incident, a Certified Nurse Aide (CNA) was observed by another CNA placing a hand over the resident's mouth and telling the resident to "shut the fuck up" while the resident was crying. The witnessing CNA did not report the incident immediately but instead informed another CNA the following day, who then reported it to the Director of Nursing (DON) and the Administrator. Documentation and interviews confirmed that the facility did not report the allegation to the Department of Health and Senior Services (DHSS) until the day after the incident, exceeding the required two-hour reporting window for abuse allegations. Staff interviews revealed that employees were aware of the policy to report abuse immediately and to notify the state within two hours, but the initial witness failed to follow this protocol. There was no documentation of immediate reporting to DHSS in the resident's records, and the delay in reporting constituted a failure to comply with both facility policy and regulatory requirements.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Lack of Current Physician Order for Indwelling Catheter
Penalty
Summary
A resident with a diagnosis of neurogenic bladder had an indwelling urinary catheter in place. The physician initially ordered the discontinuation of the Foley catheter, but the resident refused, stating that the physician had not discussed the change and requested to speak with the physician first. The physician later agreed to allow the resident to keep the catheter and instructed that it be changed monthly. However, a review of the resident's medical record revealed there was no current physician's order for the catheter, including details such as catheter size or the frequency of changes, despite the resident continuing to have the catheter in place and performing their own catheter care. Observations confirmed the presence of the indwelling catheter and drainage bag, and staff interviews indicated awareness of the lack of a current physician's order for the catheter or its care. The absence of an updated physician's order for the ongoing use and maintenance of the urinary catheter constituted a deficiency in providing appropriate catheter care and ensuring proper documentation as required for residents with indwelling catheters.
Incomplete and Outdated Care Plans for Resident Restrictions and Repeated Falls
Penalty
Summary
The facility failed to keep resident care plans complete and current for identified changes in care. For two residents, the record showed an ongoing relationship and restrictions related to being in each other’s rooms, but the care plans were not updated to reflect those restrictions. One resident had diagnoses including HTN, bipolar disorder, and major depressive disorder, and a quarterly MDS showed moderately impaired cognitive skills with no behaviors. A progress note documented a care conference with the resident’s legal guardian and the interdisciplinary team, during which the guardian discussed the relationship with the other resident and supported the interventions staff had put in place. The other resident had diagnoses including PTSD, major depressive disorder, cognitive communication deficit, muscle weakness, and anxiety disorder, and progress notes documented staff discussions about appropriate boundaries and avoiding entering the other resident’s room, but the care plan still did not include the current relationship or room restrictions. The facility also failed to update the care plan for a resident who experienced multiple falls and new interventions after those falls. The resident had diagnoses including heart failure, hypotension, respiratory failure, kidney failure, use of coagulants, and conversion disorder with seizures or convulsions. The entry MDS showed severe cognitive impairment and dependence for several activities of daily living, with wheelchair use. Progress notes documented an unwitnessed fall in the room with the resident found sitting on the floor, another fall with the resident lying on the floor next to the bed and reporting right elbow pain with redness and bruising, and a third fall after the resident stripped clothes off, attempted to stand, urinated on the floor, and slipped in the urine. Facility event reports documented these falls and neurological assessments, but the care plan was not updated to include the falls or the new interventions put in place after each event. Interviews confirmed that multiple staff members expected the care plans to reflect the residents’ room restrictions and the resident’s falls and interventions. The SSD, MDS Coordinator/ADON, DON, Administrator, CNA, CMT, RN, and other staff stated that the residents should not be in each other’s rooms and that the restrictions should be on both care plans. Staff also stated that falls should be listed in the care plan and updated as falls occur with new interventions, but the resident’s care plan did not reflect the three June falls or the interventions discussed in meetings and documented in notes.
Incomplete and Untimely Staff TB Screening
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program when it did not ensure timely two-step TB screening for six of ten sampled staff members. The report identified that CNA E, CMT F, LPN G, CMT K, LPN H, and DA I had personnel records showing TB testing that was either not read, not documented completely, or not completed within the required timeframe. The facility policy required a two-step TST or BAMT and symptom screening before beginning employment, and state regulation required staff TB screening with documentation of completed test results. CNA E’s file showed a first TST administered before hire with no documented result, and a second TST given 79 days later and read with a result of 0 mm. CMT F’s file showed a first TST with no documented result and a second TST 67 days later with no induration size documented. LPN G’s file showed the first TST was read but the size was not documented, and the second TST was given 38 days later with no size documented. CMT K’s file showed the first TST was read after the start date but without documentation of induration, redness, or size, and the second TST was given 66 days later with incomplete documentation. LPN H’s file showed the first TST was not documented as read and the second TST was given 67 days later with no induration size documented. DA I’s file showed the first TST was read and documented with no redness, no induration, and 0 mm, and the second TST was given 67 days later with complete documentation. During interviews, HR, the DON, the Administrator, and the ADON stated they were not aware that several staff members’ first TSTs were not read or not fully documented, and that the second TSTs were not completed timely. HR stated that the facility ran out of serum during the time the second TB test was to be administered for some staff and that staff probably continued working the floor. Staff interviews also showed inconsistent understanding of who was responsible for administering, reading, and tracking TB tests, although HR said a spreadsheet and calendar reminders were used. The interviews further showed that the facility expected the first TB test to be administered before staff worked the floor and read within 48 to 72 hours, with the second step completed within 14 to 21 days, but this did not occur for the sampled staff.
Failure to Implement Approved Antipsychotic Dose Reduction
Penalty
Summary
The facility failed to ensure a resident was free from possible chemical restraint when staff did not implement a physician-approved pharmacy recommendation to decrease Zyprexa in a timely manner. The resident had diagnoses of cognitive communication deficit, unspecified dementia, and major depressive disorder, and the quarterly MDS showed severe cognitive impairment, no behaviors, and use of an antipsychotic medication. The care plan identified the resident as at risk for adverse reactions to psychotropic medications and included monthly pharmacy consultant review, use of the lowest dose possible unless contraindicated, and gradual dose reduction per pharmacy recommendation and/or as clinically needed per provider. The resident’s POS showed Zyprexa 5 mg daily without a diagnosis listed for the medication. A pharmacy recommendation created in December 2024 identified Zyprexa 5 mg daily for dementia with agitation as due for gradual dose reduction and recommended reducing it to 2.5 mg in the evening; the provider signed it on 12/26/24. The record showed staff did not document the reduction at that time. A later pharmacy recommendation in May 2025 again identified the medication as due for gradual dose reduction, recommended Zyprexa 2.5 mg in the evening, and was signed by the provider on 05/16/25. The POS was then updated to Zyprexa 2.5 mg daily on 05/19/25. During interviews, the ADON, DON, physician, LPN, CMT/medical records staff, and Administrator described the process for reviewing pharmacy recommendations and acknowledged that the December 2024 reduction should have been carried out and had been overlooked.
Failure to Order, Document, and Care Plan Right-Hand Brace Use
Penalty
Summary
The facility failed to ensure appropriate care for a resident with limited ROM and a right-hand contracture. The resident had diagnoses including cerebral infarction, right-sided hemiplegia, muscle weakness, and aphasia, and the quarterly MDS showed severe cognitive impairment, dependence on staff for transfers, mobility, dressing, and showering, and no restorative services. The resident’s care plan addressed impaired function and need for staff assistance with self-care and mobility, but it did not include the use of a right-hand brace. During observations, the resident was seen with a blue splint or brace on the dresser next to the bed, wearing the brace on the right hand and wrist, and later sitting with the brace on the right hand and a gauze roll in the palm. At other times, the brace was observed on the dresser and the resident was resting without it on. The July 2025 POS, nursing progress notes, and TAR contained no order to apply or monitor a right-hand brace, and there was no documentation of brace use or monitoring. Staff interviews showed inconsistent understanding of the brace. A CMT stated the brace should be applied during the day and removed at night and that there should be an order and care plan entry. An LPN, CNA, ADON, DON, and Administrator all stated a brace should have an order, times of use, skin checks, and care plan inclusion. The COTA stated occupational therapy is responsible for hand braces and was not aware of the resident having a wrist brace, while other staff said the resident had been admitted with a blue arm brace from another facility. Despite staff awareness that the resident used a brace, the record lacked an order, documentation, monitoring, and care plan inclusion for the right-hand brace.
Failure to Order, Assess, and Care Plan Colostomy Self-Care
Penalty
Summary
The facility failed to ensure appropriate colostomy care and monitoring for a resident with a documented colostomy. The resident’s record showed diagnoses including acute cholecystitis, generalized anxiety disorder, and colostomy, and the quarterly MDS indicated intact cognitive skills, no behaviors, and independence with toileting and hygiene. However, the medical record did not contain physician orders for the colostomy, colostomy care, or colostomy monitoring, and there was no documented assessment of the resident’s ability to provide self-care for the colostomy. The resident told surveyors that nurses did not look at the colostomy and that it was red and sore. The resident reported emptying the pouch two to three times daily and stated the bag was supposed to last a week but sometimes became too full and had to be changed. During observation, the resident was seen performing self-care of the ostomy, and upon removal of the wafer and bag, the skin around the stoma was reddened and excoriated in an approximately one-inch surrounding area, with an additional 1 1/2 area of excoriation below and lateral to the stoma. The resident also stated that stoma powder and paste had not helped because the adhesive would not stick. Staff interviews showed they knew the resident performed his or her own colostomy care and that the resident sometimes needed assistance, but the self-care was not care planned. Multiple staff members stated the resident should have an order, daily monitoring, weekly skin assessment, and care plan documentation for self-care of the colostomy. The ADON and DON both acknowledged they did not find documentation of an assessment for self-care or physician orders for the colostomy, and the DON stated staff should have documented education and care planned the resident’s self-management. The RN later observed the site as red and excoriated, and the provider was contacted after the condition was noted.
Failure to Document and Authorize Side Rail Use
Penalty
Summary
The facility failed to document identification and use of possible alternatives before using side rails, failed to document an assessment of the risks versus benefits of side rail use, failed to obtain informed consent before installation, and failed to obtain a physician order for side rail use for one resident. The resident had a quarterly fall risk assessment showing moderate fall risk with diminished safety awareness and poor recall and judgment, and an MDS showing severe cognitive impairment and partial assistance needs for toileting, bathing, dressing, hygiene, and transfers. The resident's care plan identified the resident as at risk for falling, directed staff to keep the bed in the lowest position and personal items within reach, and included assist rails as needed to enable bed mobility. Observations showed two quarter-size side rails in the up position on the resident's bed on multiple occasions. Review of the medical record showed no documentation of alternatives, risk-versus-benefit assessment, informed consent, routine ongoing assessments, or a physician order for the side rails. During interviews, staff gave differing descriptions of how side rails were used and what documentation was required. The Maintenance Director said the side rails were ordered by the doctor and that monthly checks had just begun in July. Other staff stated side rails were used to assist with turning, rolling, and pulling up, and several staff members said they believed consent and an assessment should exist, but they could not locate documentation for this resident.
Improper Preparation of Nectar-Thick Liquids
Penalty
Summary
The facility failed to prepare thickened liquids in the form ordered for a resident with dementia, aphasia, severe cognitive impairment, and swallowing problems. The resident’s record showed a puree diet with nectar-thick liquids, and staff documented that the resident was an aspiration risk, ate large bites, and often choked on them. The resident also had an order for nectar-thickened liquids and was noted to require set-up with eating and to have swallowing loss of liquids and solids from the mouth. During observations, the resident was served water and a chocolate drink that were not properly thickened. One cup of water had thickener settled partway down the cup, with no thickener in the upper portion, and the resident coughed after drinking the water and chocolate drink. On another observation, the resident’s cup of water again showed separation, with the top half clear and thickener settled at the bottom, and the resident coughed after drinking it. The ADON observed the resident but did not stir the water in the cup. Staff interviews showed inconsistent understanding and preparation of nectar-thick liquids. Dietary staff stated they prepared the resident’s water the same way they prepared another resident’s tea, using one tablespoon of thickener in a six-ounce glass, even though the container instructions called for one tablespoon per four ounces of liquid and allowed four minutes to reach desired thickness. The DM said staff should use two tablespoons for eight ounces and should shake thickened liquids before serving because they can settle. Other staff, including the ST, ADON, CMT, CNA, DON, and Administrator, stated that thickened liquids should be stirred if the thickener settles and that staff should follow the package directions, but the observed drinks were still served with settled thickener and without being stirred.
Failure to Offer and Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure residents were offered pneumococcal vaccination and, when requested, received the vaccine. The facility policy titled, Pneumococcal Vaccine, stated that all residents would be offered pneumococcal vaccines, that residents would be assessed prior to or upon admission for eligibility, and that eligible residents would be offered the vaccine series within 30 days of admission unless medically contraindicated or already vaccinated. The policy also required education about the benefits and potential side effects before vaccination and documentation of refusal if the vaccine was declined. Resident #55 had diagnoses including Parkinson's disease, Alzheimer's disease, and chronic kidney disease, and was documented as cognitively intact on the quarterly MDS. The resident's vaccination consent form showed consent for the pneumonia vaccine (PSV20), but the vaccination list did not document administration of the vaccine. Resident #17 had diagnoses including Alzheimer's disease, urinary tract infection, urinary incontinence, and congestive heart failure, and had severe cognitive impairment on the quarterly MDS. The resident's responsible party consented to influenza vaccination, but did not complete the pneumococcal consent or declination portion, and the vaccination list did not document administration of a pneumonia vaccine. During interviews, the DON was unsure whether pneumococcal vaccines had been administered, the ADON stated staff did not offer or administer pneumococcal vaccines in 2024 and could not locate consents after the former DON resigned, and the Administrator stated he/she had recently learned that residents had not been offered pneumonia vaccines on admission in the past.
Call Light Not Kept Within Resident Reach
Penalty
Summary
The facility failed to maintain a complete call light system accessible to all residents when staff did not consistently place Resident #8's call light within reach. Resident #8 was admitted on 06/06/25 and had diagnoses including cerebral infarction, right-sided hemiplegia, muscle weakness, and aphasia. The resident's care plan, revised on 06/19/25, identified impaired function, a fall risk, and the need for staff assistance with ambulation, bathing, bed mobility, dressing, grooming, hygiene, locomotion, toileting, and transfers, and directed staff to keep the call light within reach. The quarterly MDS dated 06/06/25 showed severe cognitive impairment and dependence on staff for transfers, mobility, dressing, and showering. Observations showed the resident with the call light clipped to a curtain and out of reach while resting in bed, placed behind the resident on a bedside table while seated in a chair, resting on top of the chair out of reach, and draped over the head of the bed out of reach. Staff interviews confirmed that call lights should be within easy reach and not clipped to a curtain. A CNA, CMT, LPN, CNA, ADON, DON, and the Administrator all stated that the resident's call light should be within reach, and several noted that the resident could use one because he/she was able to use a television remote.
Failure to Notify Families of Significant Changes and Allegations of Abuse
Penalty
Summary
The facility failed to notify the families or representatives of two residents following a significant change in condition and an allegation of abuse. Resident #1, who has a diagnosis of dementia and other mental health conditions, was involved in an incident where inappropriate touching of another resident occurred. The incident was documented by RN G, but there was no record of the resident's family or representative being informed about this change in condition or the abuse allegation. The facility's investigation revealed that the incident was discussed during a manager's meeting, but neither the interim administrator nor the Director of Nursing (DON) were initially informed. Additionally, the investigation showed that the families of both Resident #1 and Resident #2 were not notified of the incident. Resident #2, who has a durable power of attorney invoked, was also involved in the incident, but their representative was not informed of the potential abuse. Interviews with various staff members, including LPNs, the Social Services Director, and the interim administrator, confirmed that the families should have been notified of the incident. However, there was a lack of communication and documentation regarding the notification process. The facility did not have a policy in place for notifying resident representatives, which contributed to the oversight in communication.
Failure to Timely Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to report allegations of possible sexual abuse involving three residents to management and the state licensing agency, DHSS, within the required timeframe. The incidents involved inappropriate touching by one resident towards two other residents. The first incident occurred when a resident was observed putting their hands in the crotch of another resident, but the staff did not notify facility administration or DHSS immediately. The second incident involved the same resident touching another resident's groin area, which was also not reported to management or DHSS. The facility's policy requires that any allegations of abuse be reported immediately to management and within two hours to the state. However, the staff, including RN G, failed to notify the Director of Nursing (DON), Administrator, or DHSS about the incidents. The incidents were only brought to the attention of management during a meeting three days later, and the state was notified after this delay. Interviews with various staff members revealed that they were aware of the requirement to report such incidents within two hours, yet the protocol was not followed. The residents involved had various diagnoses, including dementia, depression, and cognitive communication deficits, which may have affected their ability to consent or understand the situation. Despite this, the facility did not document the incidents in the residents' medical records or take immediate action to report the allegations. The failure to report these incidents in a timely manner constitutes a deficiency in the facility's abuse prevention and reporting procedures.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility staff failed to immediately investigate a possible abuse incident when a staff member witnessed one resident touching another resident inappropriately in the groin area. The incident was observed by an Activities Assistant who heard a resident yell that the person being touched was not the spouse of the resident doing the touching. The Activities Assistant then moved the resident who was touching to the nurses' station and informed the MDS Coordinator about the incident. However, there was no documentation of an investigation being initiated or completed regarding this allegation of possible abuse. The facility's policies on abuse and neglect, as well as the abuse prevention program, require that all allegations of abuse be investigated and reported within the required timeframes. Despite these policies, the staff did not document any investigation into the incident involving the two residents. Interviews with various staff members, including nurse aides, LPNs, the DON, and the Administrator, revealed that they were not aware of the incident and that no investigation had been conducted. The residents involved in the incident had diagnoses that included dementia, depression, and cognitive impairments, which could affect their understanding and behavior. The failure to investigate the incident was a violation of the facility's policies and federal requirements, as it did not ensure the protection of residents during the investigation of alleged abuse. The lack of awareness and action by the facility's staff and administration contributed to the deficiency in handling the situation appropriately.
Failure to Update Care Plan for Resident's Inappropriate Behavior
Penalty
Summary
The facility failed to maintain a comprehensive person-centered care plan for a resident who exhibited inappropriate touching behavior towards other residents. The resident, diagnosed with unspecified dementia, psychotic disturbances, and depression, had incidents of inappropriate touching documented on two occasions. Despite these incidents, the resident's care plan was not updated to reflect the changes in behavior, which is a requirement for comprehensive care planning. The first incident involved the resident touching another resident inappropriately, which was observed by staff and documented by a Registered Nurse. However, the care plan was not updated following this incident. The second incident was witnessed by an Activities Assistant, who reported it to the MDS Coordinator and RN Consultant, yet the care plan still remained unchanged. Interviews with various staff members, including CNAs, LPNs, and the Social Services Director, revealed that inappropriate behaviors should be documented in the care plan, but this was not done. The MDS Coordinator, responsible for updating care plans, acknowledged awareness of the incidents but did not update the care plan to include the resident's inappropriate behavior. The Director of Nursing and Interim Administrator were also unaware of the incidents until days later, indicating a breakdown in communication and documentation processes. The failure to update the care plan after these incidents highlights a deficiency in the facility's care planning process.
Inadequate Pain Management and Communication in LTC Facility
Penalty
Summary
The facility failed to provide comprehensive pain management for a resident with chronic pain syndrome, rheumatoid arthritis, and osteoarthritis. The resident experienced increased pain in the right knee, which was swollen, red, and warm to the touch. Despite the resident's complaints and visible symptoms, staff did not consistently document the resident's pain levels or follow up on the effectiveness of administered pain medications. The resident's pain was not adequately addressed, and there was a lack of communication with the physician regarding the resident's increased pain and the ineffectiveness of the current pain management regimen. The facility's staff did not document the administration of prescribed medications, such as Lyrica, due to the medication being unavailable. The staff failed to notify the physician or nurse practitioner about the unavailability of Lyrica, which was intended to manage the resident's chronic pain. The resident's pain levels fluctuated, reaching as high as 10 on a scale of 0 to 10, yet there was no documented follow-up or additional interventions to address the continued pain. The resident's condition worsened, leading to increased dependency on staff for activities of daily living and a request for a second medical opinion. Interviews with staff revealed that there was a lack of communication and coordination in managing the resident's pain. Staff members were aware of the resident's pain and the unavailability of Lyrica but did not take appropriate steps to resolve the issue or communicate effectively with the physician. The resident was eventually transferred to the hospital, where a fracture of the right patella was diagnosed, indicating that the pain and symptoms were not adequately addressed in the facility.
Failure to Notify Provider of Change in Resident's Condition
Penalty
Summary
The facility failed to provide care per standards of practice by not addressing and notifying the provider of a change in condition for a resident whose knees became swollen, red, warm, and painful. The resident, who had a history of rheumatoid arthritis and chronic pain syndrome, experienced a significant decline in mobility and an increase in pain, which was not promptly communicated to the physician or nurse practitioner. Despite multiple staff observations and the resident's requests for medical attention, the necessary notifications and interventions were delayed. The resident's condition deteriorated over several days, with staff documenting the resident's inability to bear weight, increased pain, and changes in activities of daily living (ADLs). Various staff members, including CNAs and RNs, noted the resident's knee was swollen, red, and warm to touch, yet there was a lack of timely communication with the resident's healthcare provider. The resident expressed a desire for a second opinion and was eventually transferred to the hospital, where a fracture of the right patella was diagnosed. Interviews with facility staff revealed a breakdown in communication and documentation regarding the resident's condition. Several staff members assumed the resident was on the physician's list for evaluation, but there was no clear documentation of when or if the physician was notified of the resident's worsening condition. The facility's failure to have a policy related to change of condition contributed to the delay in appropriate medical intervention, resulting in the resident's transfer to the hospital for surgical repair.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and protective oversight for a resident with a history of wandering and elopement attempts. The resident, who had severe cognitive impairment and was assessed as a high risk for elopement, was not adequately monitored despite having an electronic monitoring device. On the day of the incident, the resident attempted to leave the facility multiple times, triggering alarms, but was not placed on 15-minute checks or given increased supervision as per the facility's policy. The resident was last seen in the common area by staff at 8:00 P.M. and was later found missing during rounds. Despite the resident's known history of exit-seeking behavior and verbalizing intent to leave, staff did not implement new interventions or ensure all working staff were aware of the resident's elopement risk. The facility's investigation revealed that the resident was able to leave the premises and was found in a nearby cornfield, approximately 100 yards from the facility, after a search involving law enforcement. Interviews with staff indicated a lack of consistent communication and adherence to the facility's elopement policy. Staff were aware of the resident's behaviors but did not consistently apply the necessary checks or communicate effectively about the resident's risk. The facility's systems for monitoring and responding to elopement risks were not effectively utilized, leading to the resident's unsupervised departure from the facility.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 137 citations issued within 25 miles in the last 12 months — including the 2 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Marshfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marshfield Care Center For Rehab And Healthcare | 1.4 mi | ★★★★★ | 8 | 0 |
| Strafford Care Center | 11.2 mi | ★★★★★ | 19 | 0 |
| Glenwood Healthcare | 15.3 mi | ★★★★★ | 0 | 0 |
| Copper Rock Healthcare | 18.2 mi | ★★★★★ | 1 | 0 |
| Woodland Care & Rehab Center | 18.9 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.