Webster Park Rehabilitation And Healthcare Center

Based on observation, interview, and record review, the facility failed to monitor range of motion (ROM) of left knee flexion contracture and implement the care plan to maintain ROM to reduce the risk of worsening the contracture for one Resident (#13), out of a sample of 13 residents. Findings include:Review of the facility's policy titled Resident Mobility and Range of Motion, revised July 2017, indicated but was not limited to the following:-Residents with limited range of motion will receive treatment services to increase and/or prevent a further decrease in range of motion.-Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.-As part of the resident's comprehensive assessment, the nurse will identify the resident's:Current range of motion of his or her joints;-Opportunities for improvement; and-Previous treatment and services for mobility.-The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure the physician signed therapeutic diet orders for total parenteral nutrition (TPN- a method of delivering complete nutrition intravenously to patients who cannot use their digestive system), written by a registered dietitian (RD) for one Resident, (#10), out of a total sample of 13 residents.Findings include:Review of 105 CMR 150 Standards for Long Term Care Facilities indicated the RD's role within long-term care facilities to be as follows: -150.009: Dietary Service (A) All facilities shall provide adequate dietary services to meet the daily dietary needs of residents in accordance with written dietary policies and procedures. (2) Dietary services shall be provided directly by the facility, or facilities may contract with an outside food company provided the facility and the food company comply with 105 CMR 150.000; provided the facility or the company has a qualified dietitian who serves, as required in 105 CMR 150.000; and provided the facility and the dietitian provide for continuing liaison with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to ensure for one Resident (#15), out of a total sample of 21 residents, that the Resident's legal guardian (a person who has been appointed by a court or otherwise has the legal authority to care for the personal and property interests of another person who is deemed incapacitated) was informed of a change in skin condition by the physician or other practitioner or professional, informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option he/she preferred. Specifically, the facility failed to inform the legal guardian when Resident #15 developed wounds on his/her left heel and the second and third toes of the right foot, failed to inform of the risks and benefits of treatment and obtain consent for surgical debridement (surgically cleaning a wound by removing non-viable tissue with a scalpel or other surgical tools) and skin substitute grafting of wounds to the Resident's left heel and/or second and third toes of the right foot on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and document review, the facility failed to ensure that residents were fully aware of the grievance process. Specifically, for 14 of 14 residents attending the resident group meeting during the facility survey, the facility failed to ensure residents were aware they could formulate grievances anonymously, should they choose not to alert a staff member of their concern(s). Findings include: Review of the facility's policy titled Grievance and Complaint Procedure, dated January 2022, indicated but was not limited to: -Upon admission, residents are provided with written information on how to file a grievance or complaint within the facility. Such information will also be posted on the resident bulletin board. -Grievances and complaints may be submitted orally or in writing without threat or fear of retaliation. They may also be filed anonymously. On 1/24/25 at 10:30 A.M., the surveyor held a resident group meeting with 14 residents, representing each of the facility's three units, in attendance. The residents said they don't always want to identify who…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide care and services consistent with professional standards of practice for three Residents (#85, #15, and #23), out of a total sample of 21 residents. Specifically, the facility failed to ensure: 1. For Resident #85, staff implemented a taper and discontinuation of a Nicotine patch (smoking cessation treatment) recommended by the consultant pharmacist and agreed upon by the Resident's physician; 2. For Resident #15, the consultant wound physician did not perform treatments including invasive surgical procedures, cauterization, ultrasound therapy and substitute skin grafts to the Resident's wounds without obtaining informed consent to do so from the Resident's legal guardian; and 3. For Resident #23, to ensure a left upper extremity (LUE) hand carrot (device designed to position fingers away from the palm protecting the skin from moisture, pressure and other injury) was donned/doffed (put on/ taken off) as prescribed in physician's orders. Findings include: 1. Resident #85 was admitted to the facility in January 2024…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure it was free from a medication error rate of greater than 5% when two of five nurses observed made two errors out of 28 opportunities, resulting in a medication error rate of 7.14%. Those errors impacted two Residents (#22 and #64). Findings include: Review of the facility's policy titled Administering Medications, revised April 2019, indicated but was not limited to the following: -Medications are administered in accordance with prescriber orders, including any required time frame. -Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and/or the need for additional staff training. -The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 1. Resident #22 was admitted to the facility in July 2022 and had diagnoses including atrial fibrillation, osteoarthritis, benign intracranial hypertension,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interviews, the facility failed to ensure the call light was accessible and within reach for one Resident (#37), out of a total of 21 sampled residents. Specifically, the facility failed to ensure the call light switch above Resident #37's bed had a string attached to it to enable the Resident to independently call for assistance. Findings include: Review of the facility's policy titled Answering the Call Light, dated April 2016, indicated but was not limited to: - Purpose: The purpose of this procedure is to respond to the resident's requests and needs. - General Guidelines: 4. Be sure that the call light is plugged in at all times. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Resident #37 was admitted to the facility in January 2018 with diagnoses including chronic obstructive pulmonary disease and need for assistance with personal care. Review of the Minimum Data Set (MDS) assessment, dated 12/10/24, indicated Resident #37 was cognitively intact as evidenced by a Brief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on document review, policy review, and interviews, the facility failed to maintain an infection prevention and control program with a complete and accurate system of surveillance to identify any trends of actual or potential infections within the facility using their predetermined infection definition criteria. Findings include: Review of the facility's policy titled Surveillance of Infections, dated as revised September 2017, indicated but was not limited to the following: - The purpose of surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections to guide appropriate interventions and prevent future infections. - Criteria for infections are based on current standard definitions of infections. - In addition to collecting data on incidents of infections the surveillance system is designated to capture certain epidemiologically important data that may influence how overall surveillance data is interpreted, for example: surveillance data gathered for residents with a recent hospital…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, policy review, grievance review, and review of Resident Council Minutes, the facility failed to ensure residents' grievances were brought forward and the grievance process was implemented, and concerns were resolved in a timely manner. Specifically, the facility failed: 1. For Resident #2, to implement the grievance process for lost laundry; and 2. To address and promptly resolve several grievances regarding lost laundry brought forward during the September 2023 Resident Council Meeting. Findings include: Review of the facility's policy titled Grievance and Compliant Procedure, dated January 2022, indicated but was not limited to the following: -Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the government agencies without threat or fear of retaliation. -The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or complainant. -Any resident, family member, or appointed resident representative may file a grievance or complaint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and policy review, the facility failed to ensure it was free from a medication error rate of greater than 5% when 1 out of 3 nurses observed made 2 errors out of 28 opportunities, resulting in a medication error rate of 7.14%. Those errors impacted one Resident (#56), out of three residents observed. Findings include: Review of the facility's policy titled Medication Administration-General Guidelines, dated November 2021, indicated but was not limited to: - FIVE RIGHTS-Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. - A triple check of the five rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication is put away. - Check #2: Prepare the dose- the dose is removed from the container and verified against the label and the medication administration record (MAR) by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, policy review, and interview, the facility failed to ensure all drugs and biologicals were secured in locked compartments with only authorized personnel having access. Findings include: Review of the facility's policy titled Storage of Medications, dated November 2021, indicated but was not limited to: -Medications and biologicals are stored safely and securely following manufacturers' recommendations or those of the supplier. -The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. On 10/27/23 at 8:34 A.M., the surveyor observed Nurse #1 prepare medications to administer to a resident, placing them into a medication cup. Nurse #1 put the medication cup containing the medications in the medication cart and locked the cart, and then walked away from the medication cart and entered the medication room and closed the door. Nurse #1 left the medication cart unattended and not within this eyesight, with the following medications left on top of the medication cart:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.