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 Focused Care At Webster during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, and hypertension had ordered doses of memantine and metoprolol prepared by a medication aide, who initially observed the resident taking some medications but then turned away to prepare medications for another resident and left the room without confirming all pills were swallowed. The surveyor later observed two pills left in a cup on the bedside table, and the resident stated she was not taking them and did not know what they were for. The MA, DON, NP, and Administrator all stated that residents are not allowed to self-administer medications, that staff must observe ingestion and not leave medications in rooms, and that medications must be administered exactly as ordered, yet the facility also failed to provide all requested medication administration policy documents.
A resident with severe dementia, hypertension, and other conditions was care planned as being at risk for side effects from missed medications. A medication aide prepared oral medications, placed them in a cup on the bedside table, and, after initially observing the resident take some pills, turned away to prepare medications for another resident and left the room without confirming all medications were swallowed. The surveyor later observed two pills remaining in the cup, and the resident stated she was not taking them and did not know what they were for. The DON and administrator stated that residents were not permitted to self-administer, that staff were required to observe ingestion and not leave medications in rooms, and the NP stated staff were expected to follow physician orders exactly as prescribed.
A resident with multiple comorbidities and continuous O2 via nasal cannula, who required extensive assistance and was care planned as at risk for pressure injuries, developed moisture-associated skin damage behind both ears. Despite weekly skin assessments documenting no such issues and staff reporting awareness only of hand wounds, family photographs and a hospice RN’s observations showed raw, broken, and reddened skin behind both ears days before the assessment. The ear breakdown was not identified or treated by facility staff during this period, and was only recognized later upon direct observation, at which point treatment orders were obtained.
A resident with respiratory failure and continuous O2 at 4 L/min via nasal cannula was observed with an oxygen concentrator whose humidifier bottle was completely empty, despite care plan orders for oxygen therapy and monitoring. The resident had significant cognitive impairment and required substantial assistance with care. An LVN confirmed the bottle should contain water for humidification and acknowledged it was out of water, while another LVN reported having filled the bottle two days earlier and that it was half full when she left her shift the previous night. The DON stated there should be water in the concentrator bottle to humidify nasal passages and that nurses should refill it when low, and facility policy required safe oxygen administration using distilled water for humidification.
Two residents' rooms were found with dirty floors, food debris, and pest control devices, while one room also had unrepaired maintenance issues including a splintered bed footboard, a broken closet door, and a cracked overhead light. Housekeeping staff reported inconsistent cleaning due to lack of assigned personnel and high turnover, and maintenance concerns were not documented or addressed in a timely manner. Staff and residents noted the presence of pests, and the facility's pest control program was described as ineffective.
The facility did not maintain an effective pest control program, resulting in live roaches, flies, and ants being observed in resident rooms and hallways. Staff and residents reported ongoing pest sightings, and pest control logs documented significant infestations. Inconsistent housekeeping practices and recent staff turnover contributed to lapses in cleaning and pest management, leading to the deficiency.
A cognitively impaired, nonverbal resident with a history of wandering and trauma was not adequately protected from sexual abuse by another resident with behavioral issues. Despite known risks and care plans addressing wandering and inappropriate behaviors, staff relied only on redirection and frequent rounds, without implementing one-on-one supervision or more restrictive interventions. The incident occurred when the resident wandered into another's room and was found by staff during a sexual assault, highlighting the facility's failure to prevent abuse.
Two cognitively impaired residents, one with a history of wandering and the other with behavioral issues including inappropriate sexual comments, were not adequately supervised. Despite care plans noting their risks, the facility relied on redirection and frequent rounds, which failed to prevent a sexual assault when one resident wandered into the other's room. Staff and care plans documented prior incidents and risks, but enhanced supervision or one-on-one monitoring was not implemented before the event.
The facility failed to transmit timely MDS assessments for two residents. One resident's Admission MDS was completed 20 days after admission, and another resident's Significant Change MDS was completed 53 days after the change. The MDS coordinator acknowledged the delays, and the DON mentioned a lack of training in signing the MDS.
A resident in an LTC facility lost her dentures, and the facility failed to refer her for dental services within the required three days. Despite the family member's offer to share the cost of new dentures, the facility declined, and the resident's dental appointment was scheduled nearly three months later. The social worker did not document the referral process or communicate effectively with the family, and the facility staff were unaware of the delay in services.
A resident with moderate cognitive impairment experienced misappropriation of property when a CNA allegedly used the resident's debit card for personal purchases. The resident recalled the CNA being present in her room, and the facility identified the staff member based on the resident's description. The police were involved, and the facility initiated an investigation. The CNA denied involvement, citing personal reasons for not working on the days in question.
A resident was unable to make private phone calls due to the facility's failure to provide a designated area for phone use, resulting in conversations being overheard at the nursing station. The resident expressed concerns about privacy and limited call time, while the DON and Administrator acknowledged the lack of a private area and policy for phone use.
A facility failed to change a resident's midline IV dressing as ordered, risking infection. The resident, with multiple diagnoses, had a dressing dated beyond the required change period. Staff interviews confirmed the oversight, and the facility lacked a specific policy, relying on a competency assessment for guidance.
A resident with a history of stroke and diabetes was prescribed Mucinex DM, but was instead given guaifenesin 400 mg due to a documentation error. The CMA notified the charge nurse about the unavailability of Mucinex DM and was instructed to administer guaifenesin, yet the MAR inaccurately documented the administration of Mucinex DM. Interviews revealed a lack of awareness among staff about the error, and the facility's medication administration policy was not followed.
A resident with a history of stroke and respiratory issues was not provided with the prescribed Mucinex DM due to a breakdown in the facility's medication ordering and stocking process. Instead, the resident received only guaifenesin, one of the active ingredients, as the complete medication was not in stock. The delay in procuring the medication was attributed to a winter storm and a lack of immediate action to obtain it from a local pharmacy.
A resident with a history of depression and anxiety was verbally abused by a medication aide during a bed bath. The aide used foul language and was rough, despite the resident's requests to leave. The incident was corroborated by CNAs and reported to the DON and LVN.
A facility failed to inform a resident's representative about significant changes in the resident's treatment and condition, including moisture-associated skin damage and new zinc oxide orders. The resident, with moderately impaired cognition, was receiving treatment without the representative's knowledge, contrary to facility policy requiring notification within 24 hours of significant changes.
A resident with a stage 3 pressure ulcer on the right buttock was found without a dressing, contrary to the care plan requiring daily monitoring and maintenance of the dressing. The CNA noticed the dressing was soiled but did not inform the wound care nurse or floor nurse, leading to the wound being exposed. Staff interviews confirmed the expectation for CNAs to report such issues immediately to ensure proper wound care.
A resident with cognitive and physical impairments did not have their treatment administration records accurately documented, despite physician orders for zinc oxide application to maintain skin integrity. Interviews revealed that treatments were performed but not recorded, violating the facility's documentation policy.
Medications Left Unattended and Not Administered as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensure accurate dispensing and administering of medications for one resident. A resident with severe cognitive impairment (BIMS score 3/15), dementia, anxiety disorder, psychotic disturbance, hypertension, and a need for assistance with personal care had active orders for memantine 10 mg twice daily for dementia and metoprolol tartrate 25 mg twice daily for high blood pressure. The resident’s care plan identified a risk for potential side effects due to missed medication. During an observation, the surveyor found two pills in a cup left on the resident’s bedside table. When questioned, the resident stated she was not taking the pills, did not know what they were for, and offered them to the surveyor, reiterating that she did not believe in continuing tests or medications. Medication Aide B reported that residents in the facility are not permitted to self-administer medications and described the protocol as requiring staff to observe residents taking medications, ensure adequate fluid intake, and confirm that medications are swallowed before leaving the room. MA B stated she prepared the resident’s medications in a cup, used the resident’s personal water cup, and initially observed the resident taking medications, but then turned her back to prepare for the next resident and left the room assuming all medications had been taken, without confirming ingestion. The DON, NP, and Administrator each stated that staff are responsible for administering medications as ordered, confirming they are taken, and that medications must not be left in a resident’s room, while also noting that no residents are permitted to self-administer medications. When the surveyor requested the facility’s medication administration policy, the facility did not provide all of the requested documents.
Unsecured and Unverified Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications were stored securely and administered in accordance with facility policy and professional standards. A medication aide (MA B) prepared oral medications for Resident #1, including memantine for dementia and metoprolol for hypertension, and placed them in a cup on the resident’s bedside table. The facility’s practice, as described by MA B and the DON, required staff to observe residents taking medications, ensure adequate fluid intake, and confirm that each medication was swallowed before leaving the room. The administrator stated that medications must not be left in a resident’s room and that no residents in the facility were permitted to self-administer medications. Resident #1 was an elderly female with diagnoses including unspecified dementia with severely impaired cognition (BIMS score of 03/15), anxiety disorder, cognitive communication deficit, essential primary hypertension, and a need for assistance with personal care. Her care plan identified her as being at risk for potential side effects due to missed medication. On observation, the surveyor found two pills in a cup left on Resident #1’s bedside table. When questioned, Resident #1 stated she was not taking the pills, did not know what the medication was for, and told the surveyor they could have the pills because she was not taking them, reiterating that she did not believe in continuing tests or medications. MA B reported that Resident #1 typically took medications one or two at a time and that she initially observed the resident taking some medications but then turned her back to prepare for the next resident. MA B assumed the remaining medications had been taken, exited the room, and did not confirm that all medications were consumed, leaving two pills unattended on the bedside table. The DON confirmed that medication aides were responsible for administering medications and confirming ingestion, and that no residents were allowed to self-administer. The NP stated that his expectation was that staff follow physician orders exactly as prescribed. When the surveyor requested the facility’s medication administration policy, the facility did not provide all of the requested policy documents.
Failure to Identify and Treat Moisture-Associated Skin Damage Behind Ears
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards, the resident’s care plan, and the resident’s assessed needs, specifically related to skin integrity. The resident was an older adult with hypertension, hyperlipidemia, shortness of breath, pneumonia, and respiratory failure, and had an order for continuous oxygen at 4 L/min via nasal cannula. The annual MDS showed the resident was rarely/never understood, had short- and long-term memory problems, and required substantial/maximal assistance for personal hygiene and transfers. The care plan identified the resident as being at risk for pressure injuries related to immobility, with interventions to follow facility policies for prevention and treatment of skin breakdown and to inform the resident/family of any new skin breakdown. On a weekly skin assessment dated 2/25/26, the Treatment Nurse documented that the resident had no bruises, skin tears, abrasions, lacerations, or moisture-associated skin damage, and under “other skin issues” only noted two wounds on the resident’s right hand. No other skin conditions were identified at that time. However, photographs taken by the resident’s family member on 2/20/26 showed both ears to be raw, with broken, red skin where the ears met the scalp at the top, indicating moisture-associated skin damage behind both ears that predated the weekly skin assessment. The Hospice RN reported that during a visit on 2/24/26, she observed skin breakdown behind both ears and notified the hospice physician about obtaining orders for ear protectors, and later called the facility on 2/26/26 to ask if any orders for the ears had been received. On 2/27/26, staff interviews revealed that the Treatment Nurse and RN B were only aware of wounds on the resident’s hand and denied knowledge of any other skin breakdown, and a CNA also reported not seeing any skin breakdown or rashes. Direct observation of the resident’s ears that same day showed scabbed areas, redness, raw skin, and peeling where both ears met the scalp. A progress note later on 2/27/26 documented blanchable redness behind both ears and new orders from a nurse practitioner for zinc oxide and ear protectors. A subsequent order dated 3/9/26 for Nystatin powder to the bilateral backs of the ears for moisture-associated skin damage was also noted. The DON and Treatment Nurse both stated they did not believe anything was missed during the 2/25/26 skin assessment, despite the earlier family photographs and hospice nurse report showing ear breakdown prior to that assessment, and the lack of treatment for the ear skin damage between 2/20/26 and 2/27/26.
Failure to Maintain Oxygen Humidifier Water Level for Resident on Continuous O2
Penalty
Summary
Surveyors found that a resident with diagnoses including hypertension, hyperlipidemia, shortness of breath, pneumonia, and respiratory failure, and an order for continuous oxygen at 4 L/min via nasal cannula, was not provided oxygen therapy consistent with professional standards of practice. Record review showed the resident used oxygen therapy and had care plan interventions to monitor for signs and symptoms of respiratory distress and to provide oxygen at 4 L via nasal cannula. The resident’s MDS indicated significant cognitive impairment, including short- and long-term memory problems and that he was rarely/never understood, and he required substantial/maximal assistance for personal hygiene and transfers. On observation, the resident was wearing a nasal cannula and the oxygen concentrator was set at 4 L/min, but the humidifier bottle attached to the concentrator was completely empty. An LVN confirmed during interview that the bottle should contain water for humidification to prevent nasal irritation and acknowledged that the bottle for this resident was out of water. The LVN stated that humidifier bottles are typically full for two days and that he had been off for a few days. Another LVN reported she had worked with the resident the previous two nights, that she checked the humidifier bottle and had filled it two days prior, and that it was about half full when she left the previous night. The DON stated there should be water in the oxygen concentrator bottle to humidify the nasal passages and that nurses should notice when the water is low and refill it. The facility’s oxygen therapy policy stated that all oxygen administration is to be conducted in a safe manner and that distilled water is to be used for humidification.
Failure to Maintain Cleanliness and Timely Repairs in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in two rooms on the 200 hallway, affecting two residents. Observations revealed that the floors in both rooms were dirty, with food crumbs, stains resembling dried coffee, and plastic wrappers present. One resident reported that her room was rarely swept or mopped, and both she and her family member stated that cleaning was inconsistent and only occurred when specifically requested. Pest control devices were observed throughout the room, and the resident mentioned the presence of bugs, with pest control personnel placing traps in the area. The second resident's room was also found to be unclean, with sticky floors and food debris, and he noted that cleaning times were inconsistent due to the lack of a designated housekeeper for the hallway. In addition to cleanliness issues, the facility failed to address several maintenance concerns in one resident's room. The footboard of the bed was splintered and had exposed wooden particle board, the closet door was off its hinges and could not be properly opened or closed, and the overhead light fixture above the bed was cracked with jagged edges. The resident stated that he had reported the closet door issue but could not recall to whom or when. Interviews with staff and administration revealed that there was no record of these maintenance issues in the facility's repair log, and the maintenance director was not notified about the needed repairs. The maintenance director also indicated that his focus had been on painting and preparing rooms for new admissions, with repairs being addressed only as time allowed. Housekeeping staff interviews confirmed that the 200 hallway did not have a regularly assigned housekeeper, and cleaning responsibilities were split among the available staff. Staff turnover in the housekeeping and maintenance departments contributed to the lack of consistent cleaning and timely repairs. Housekeepers and nursing staff reported seeing pests such as flies, gnats, and roaches in the facility, and the pest control program was described as ineffective by both staff and the maintenance director. Facility policy required daily cleaning of resident rooms, but this was not consistently implemented, and documentation of cleaning assignments and maintenance requests was lacking.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live pests such as roaches, flies, and ants in resident rooms and hallways. Observations included a live roach and flies in a resident's room, as well as a mound of ants or crawling insects in an empty room. Staff interviews confirmed that pests were seen throughout the facility, and pest control measures were not effective in eliminating the problem. The pest control logs documented significant roach activity and infestations in multiple rooms, with recommendations for clean-out services. A resident with multiple medical conditions, including encephalopathy, dysphagia, and moderate cognitive impairment, reported seeing pests in her room from time to time and stated that she would notify staff when this occurred. Housekeeping staff acknowledged seeing flies, gnats, and roaches in various areas and reported these sightings to administration and maintenance. However, there was no permanently assigned housekeeper for certain hallways, and cleaning assignments were inconsistently completed, with some areas not cleaned until later in the day. The facility experienced recent turnover in housekeeping and laundry staff, including the loss of the housekeeping supervisor, which contributed to lapses in daily cleaning and pest control oversight. The maintenance director and other staff indicated that the pest control program was ineffective, with ongoing complaints from residents and staff about pests. Facility policies required regular cleaning and an ongoing pest control program, but these were not consistently implemented, leading to the observed deficiencies.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment and a history of wandering from sexual abuse by another resident. The resident, who was nonverbal, unable to make her needs known, and had diagnoses including anoxic brain damage, epilepsy, and dementia, was care-planned for high elopement risk and wandering into male residents' rooms. Despite these known risks, the primary intervention was redirection and frequent staff rounds, with no one-on-one supervision or more restrictive measures implemented. The resident's care plan also identified her as a trauma survivor with a history of sexual abuse, further emphasizing her vulnerability. On the date of the incident, the cognitively impaired resident wandered into another resident's room, where staff discovered her and a male resident engaged in sexual activity. Eyewitness accounts from CNAs described the male resident standing behind the female resident with both of their clothes pulled down and semen present. The male resident, who had a history of making inappropriate sexual comments and was care-planned for behavioral issues related to dementia, admitted to assisting the female resident in the bathroom but denied sexual intercourse. However, staff and medical professionals determined that the female resident was not capable of consenting to sexual activity due to her cognitive status. Following the incident, the female resident was sent to the hospital for a forensic examination and received prophylactic treatment for potential sexually transmitted infections and pregnancy. Interviews with staff and administration revealed that the facility did not have policies or education in place regarding resident-to-resident sexual interactions or safe consensual sex. The male resident was placed on one-on-one supervision only after the incident, and it was noted that staff were aware of the female resident's frequent wandering into his room prior to the event. The facility's failure to implement effective interventions to prevent the resident's wandering and protect her from abuse led to the identified deficiency.
Failure to Prevent Sexual Assault Due to Inadequate Supervision of Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents with cognitive impairments. One resident, who was severely cognitively impaired, nonverbal, and at high risk for wandering, was care-planned for elopement risk and had a history of entering male residents' rooms. Despite interventions such as structured activities, a wander guard, and redirection, the resident continued to wander into other residents' rooms. The care plan also identified the resident as a trauma survivor with a history of abuse, and she required substantial assistance with activities of daily living and was always incontinent. Another resident, who was moderately cognitively impaired and had a documented history of making inappropriate sexual comments to staff, was care-planned for behavior problems and potential physical aggression. This resident had a BIMS score indicating moderate cognitive impairment and was receiving psychotropic medication. The care plan included interventions such as redirection and psychiatric consultation, but there was no evidence of increased supervision or restriction of access to other residents' rooms despite the behavioral concerns. On the date of the incident, the severely cognitively impaired resident wandered into the room of the resident with behavioral issues, where staff discovered a sexual assault in progress. Staff interviews confirmed that the resident with behavioral issues had previously assisted female residents in the bathroom and that the cognitively impaired resident frequently entered his room. The facility's interventions, such as making frequent rounds and redirecting the wandering resident, were ineffective in preventing the incident. The facility did not implement one-on-one supervision or other enhanced monitoring measures prior to the event, despite the known risks and previous behaviors.
Failure to Transmit Timely MDS Assessments
Penalty
Summary
The facility failed to transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS System for two residents. For one resident, the facility did not transmit a completed Admission MDS assessment within the required timeframe, as it was completed 20 days after admission. This delay in completing the MDS assessment could potentially impact the resident's care plan and the timely delivery of necessary services. For another resident, the facility did not ensure that a Significant Change MDS Assessment was completed within 14 days of a significant change in the resident's condition. The assessment was completed 53 days after the significant change, which could result in a delay in care and services. The MDS coordinator acknowledged the late MDS assessments and mentioned that a plan of correction was in place. The Director of Nursing (DON) stated that she was not trained to sign the MDS, and a corporate staff member was responsible for signing off on the MDS.
Delayed Dental Care for Resident with Lost Dentures
Penalty
Summary
The facility failed to ensure timely dental care for a resident who lost her dentures. The resident, a [AGE] year-old female, was admitted with several diagnoses, including protein calorie malnutrition and abnormal weight loss. Despite having intact cognitive function and requiring set-up assistance with eating, the resident's dentures were reported missing on 11/26/24. However, the facility did not refer her for dental services within the required three days, and there was no documentation of extenuating circumstances for the delay. The resident's family member reported the loss of dentures and requested a pureed diet due to the resident's inability to eat her regular diet. The family member also offered to share the cost of new dentures with the facility, but this offer was declined. The facility's social worker, responsible for scheduling dental services, failed to document the referral process or communicate effectively with the family about the dental appointment scheduled for 2/14/25, nearly three months after the dentures were lost. Interviews with facility staff, including the Administrator and Director of Nursing, revealed a lack of awareness and communication regarding the resident's dental needs and the delay in services. The resident did not experience significant weight loss, but the delay in dental care could have impacted her quality of life. The facility did not provide a policy or procedure for dental services to the survey team, highlighting a deficiency in their dental care program.
Misappropriation of Resident's Property by Facility Staff
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when an employee used the resident's credit card for personal benefit. The incident involved a resident with moderate cognitive impairment, who was independent with activities of daily living for toileting and personal hygiene. The resident's responsible party reported fraudulent charges on the resident's debit card, which was discovered missing. The facility's communication with the responsible party revealed that the debit card was stolen at the facility, and unauthorized charges were made at a gas station and a restaurant. During an interview, the resident recalled the incident, stating that a CNA, identified as CNA T, was present in her room and might have taken the debit card when the resident gave her money to buy coffee. The resident described the CNA, which helped the facility identify the staff member involved. The Director of Nursing (DON) confirmed that the police were called by the resident's responsible party, and an investigation was initiated by the facility. The police arrived at the facility during the investigation, and it was discovered that CNA T had left the facility through the back door. The facility's records showed that CNA T was hired and worked at the facility until the day the police arrived. However, during a phone interview, CNA T denied working with the resident and claimed she did not work on the days in question due to personal reasons. The facility's policy on abuse, neglect, and exploitation was reviewed, which emphasized the residents' right to be free from misappropriation of property.
Lack of Privacy for Resident Phone Calls
Penalty
Summary
The facility failed to ensure that residents had reasonable access to and privacy in their use of communication methods, specifically telephones. This deficiency was observed in the case of a resident who was required to use the phone at the nursing station, where conversations could be overheard by nurses and other residents. The resident expressed concerns about the lack of privacy and the limited time allowed for phone calls due to the nursing staff's need to use the phone. The facility did not provide a cordless phone or any alternative means for the resident to make private calls. Interviews with the Director of Nursing (DON) and the facility Administrator confirmed that the nursing station was the only area available for residents to use the phone, and there was no designated private area for phone use. The Administrator mentioned that a phone near his office could be used, but acknowledged the absence of a specific policy on resident phone use and privacy. The lack of a designated private area for phone calls and the absence of a policy contributed to the deficiency in ensuring residents' rights to privacy in communication.
Failure to Change IV Dressing as Ordered
Penalty
Summary
The facility failed to ensure the proper administration of intravenous (IV) fluids for a resident, specifically in maintaining the dressing on a mid-line IV line according to the physician's order and facility's standard of care. The resident, a female with diagnoses including unspecified dementia, urinary tract infection, type 2 diabetes, and unspecified systolic heart failure, was observed with a midline dressing dated 1/18/25, which had not been changed by the required date of 1/26/25. The facility's records indicated that there were no documented midline dressing and cap changes from 1/20/25 to 1/26/25, despite the resident receiving IV antibiotics during this period. Interviews with facility staff, including a Licensed Vocational Nurse (LVA) and the Director of Nursing (DON), confirmed the oversight. The LVA acknowledged that the dressing should have been changed by 1/26/25, and the DON admitted that the facility lacked a specific policy for midline dressing changes, relying instead on a competency assessment that required changes every five to seven days. The failure to adhere to these standards could place residents at risk of infections, as the facility did not follow the established protocol for IV dressing changes.
Medication Administration Error Due to Inaccurate Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, leading to the administration of incorrect medication. The resident, a male with a history of cerebral infarction, dysphagia, type 2 diabetes mellitus, and hypertensive disease with heart failure, was prescribed Mucinex DM for cough and congestion. However, the Medication Administration Record (MAR) inaccurately documented the administration of Mucinex DM when, in fact, guaifenesin 400 mg was given instead. This discrepancy was observed during medication administration and confirmed through interviews with facility staff. The Certified Medication Aide (CMA) responsible for administering the medication reported notifying the charge nurse about the unavailability of Mucinex DM and was instructed to administer guaifenesin 400 mg. Despite this, the MAR continued to reflect the administration of Mucinex DM. Interviews with other staff members revealed a lack of awareness regarding the medication error, and the facility's policy on medication administration was not followed, as the administration of the incorrect medication was not documented in the electronic medical record. This failure in documentation and communication could potentially place residents at risk for not receiving the correct therapeutic benefits of their prescribed medications.
Failure to Provide Prescribed Medication
Penalty
Summary
The facility failed to provide the medication Mucinex DM as ordered for a resident, leading to a deficiency in pharmaceutical services. The resident, who had a history of cerebral infarction, dysphagia, type 2 diabetes mellitus, hypertensive disease with heart failure, and a recent upper respiratory infection, was prescribed Mucinex DM for cough and congestion. However, instead of receiving the prescribed medication, the resident was administered only guaifenesin, one of the two active ingredients in Mucinex DM, due to the unavailability of the complete medication. The issue arose from a breakdown in the facility's medication ordering and stocking process. The Certified Medication Aide (CMA) responsible for administering the medication was unaware that Mucinex DM was not in stock and continued to administer guaifenesin. The Licensed Vocational Nurse (LVN) and Central Supply/Transportation staff were also unaware of the medication's unavailability until it was observed during a survey. The Central Supply/Transportation staff mentioned that the medication was ordered but delayed due to a winter storm, and there was a lack of immediate action to procure the medication from a local pharmacy. The facility's policy on maintaining a supply of over-the-counter medications was not effectively implemented, as evidenced by the absence of Mucinex DM in the medication room and on the medication cart. The Director of Nursing (DON) and other staff members were not promptly informed about the missing medication, leading to a delay in addressing the issue. This deficiency highlights a failure in the facility's medication distribution system, which is supposed to ensure the safe administration of medications without unnecessary interruptions.
Verbal Abuse Incident Involving Medication Aide
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, as evidenced by an incident involving a resident and a medication aide. The resident, who had a history of major depressive disorder, osteoarthritis, and anxiety disorder, was subjected to verbal abuse by a medication aide during a bed bath. The resident reported that the medication aide used foul language and was rough while assisting with the bed bath, despite the resident's requests for the aide to leave the room. The incident occurred when two CNAs were providing care to the resident and requested assistance from the medication aide, who had previously worked with the resident. The resident attempted to guide the CNAs on how to properly position him, but the medication aide was reportedly rough and used inappropriate language. The resident, along with the CNAs, reported that the medication aide refused to leave the room when asked and used profanity towards the resident. Interviews with the CNAs and the resident corroborated the resident's account of the incident. The Director of Nursing and an LVN were informed of the situation, and the resident was assessed for any physical injuries. The facility's policy on abuse and neglect emphasizes the residents' right to be free from any type of abuse, including verbal abuse, which was not adhered to in this case.
Failure to Notify Resident's Representative of Treatment Changes
Penalty
Summary
The facility failed to immediately inform the representative of a resident about significant changes in the resident's treatment and condition. Specifically, the facility did not notify the representative about the resident's moisture-associated skin damage (MASD) on the sacrum and buttock, which required new orders for zinc oxide treatment. Additionally, the facility did not inform the representative about the blanching redness observed on the resident's left lateral forefoot and left heel. The resident, an elderly female with moderately impaired cognition, was admitted to the facility with diagnoses including cognitive communication deficit, dysphagia, and cellulitis. Her care plan, initiated and revised in late September and early October, included interventions for skin integrity due to incontinence and immobility. Despite these measures, the facility's records showed that the resident was receiving zinc oxide treatment, but there was no documentation that the family representative was informed of these changes. Interviews with the resident's representative and facility staff revealed that the representative was unaware of the resident's condition changes until visiting the resident in the hospital. The Wound Care Nurse admitted to forgetting to notify the family, and the Director of Nursing confirmed that the facility's policy required family notification within 24 hours of a significant change in the resident's condition. The facility's policy emphasized the importance of notifying the resident's representative to ensure they are informed and can consent to care changes.
Failure to Maintain Dressing on Resident's Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident with a stage 3 pressure ulcer on the right buttock had a dressing covering the wound, as observed on 10/25/24. The resident, a male with a history of pressure ulcers, type 2 diabetes mellitus, and bed confinement, was found without a dressing on the wound during a wound care session. The resident's care plan required daily monitoring of the dressing to ensure it was intact and adhering, with instructions to report any loose dressings to the treatment nurse. However, the dressing was not in place, and the wound was exposed, which could lead to infection and delayed healing. Interviews with staff revealed that the CNA who provided care to the resident earlier in the day noticed the dressing was soiled but did not notify the wound care nurse or floor nurse due to the resident's scheduled appointment. The wound care nurse confirmed the absence of the dressing and emphasized the importance of keeping the wound covered to prevent infection. The DON and LVN also stated that CNAs are expected to report any issues with dressings immediately so that nurses can address them according to physician's orders. The facility's skin management policy outlines the procedure for wound care, including the importance of maintaining dressings to prevent skin breakdown.
Failure to Document Treatment Administration
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for a resident reviewed for clinical records. The treatment administration records (TAR) for the resident did not accurately document the administration of treatment orders. This lack of documentation could result in further error and a decline in health. The resident, an elderly female with cognitive communication deficit, dysphagia, and cellulitis, was admitted to the facility with a care plan focusing on maintaining skin integrity due to incontinence and immobility. Physician orders required the application of zinc oxide to the sacrum and buttock area every shift and as needed until healed. However, the TAR for October showed multiple blanks, indicating that the treatments were not documented as administered. Interviews with the wound care nurse (WCN) and the Director of Nursing (DON) revealed that the treatments were performed, but the TAR did not reflect this. The WCN was responsible for weekday treatments, while charge nurses handled weekends and night shifts. The DON confirmed the lack of documentation and emphasized the importance of following wound care orders to prevent infection and monitor healing. The facility's policy required documentation of all services provided, including treatments, but this was not adhered to in this case.
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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 Webster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ignite Medical Resort Webster, Llc | 1.1 mi | ★★★★★ | 1 | 0 |
| Regency Village | 1.2 mi | ★★★★★ | 4 | 0 |
| Baywind Village Skilled Nursing & Rehab | 3 mi | ★★★★★ | 2 | 0 |
| Mrc The Crossings | 3 mi | ★★★★★ | 0 | 0 |
| The Heights Of League City | 4.9 mi | ★★★★★ | 10 | 2 |
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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.