Webco Manor

Based on observation, record review, and interview, the facility failed to ensure residents who required colostomy (a surgical procedure that creates an opening, or stoma, in the abdominal wall to allow the colon to pass waste through the body) services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences when staff failed to obtain an order for a colostomy, colostomy care, and colostomy monitoring, failed to assess resident for ability to provide self-care for the colostomy, and failed to care plan self-care of the colostomy for one resident (Resident #49). The facility census was 57. Review of the facility's policy titled Colostomy/Ileostomy Care, revised October 2010, showed the following:-The purpose of the procedure was to provide guidelines that would aid in preventing exposure of the resident's skin to fecal matter;-Review the resident's care plan to assess for any special needs of the resident;-The following information should be recorded in the resident's medical record:…

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, interview, and record review, the facility failed document identification and use of possible alternatives prior to use of side rails; failed to document assessing risk versus benefits of side rail use; failed to obtain informed consent for the use of side rails prior to installation,; and failed to obtain physician orders for side rail usage, for one resident (Resident #50). The facility's census was 57. Review of the resident's quarterly fall risk assessment, dated 11/27/17, showed the resident to was a moderate risk with diminished safety awareness and poor recall and judgment.Review of the resident's entry Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 05/08/25, showed the following information:-Severe cognitive impairment;-Partial assistance with toileting, showers, upper and lower body dressing, personal hygiene, lying to sitting and chair to chair transfer.Review of the facility records showed on 05/12/25, staff completed a bed rail safety check. Review of the resident's care plan, last revised 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, interview, and record review, the facility failed to prepare all food in a form designed to meet each resident's needs when staff failed to appropriately prepare thickened liquids to nectar consistency for one resident (Resident #27) in a selected sample of 20 residents. The facility census was 57. Review of the facility's policy titled 'Thickened Liquids, dated 2022, showed the following:-Liquids are categorized as thin - Level 0 (regular), mildly thick - Level 2 (nectar-like), moderately thick-Level 3 (honey-like), and extremely thick - Level 4 (pudding-like) for the purposes of this manual;-If liquids are to be thickened by nursing or dining service staff, proper training on the use of the thickening product and specific product instructions should be conducted by the Dining Services Manager, Speech Language Pathologist, or Registered Dietitian;-Proper preparation of thickened liquids improves acceptance and safety for individuals requiring thickened liquids;-The type of thickener, temperature of the liquid being thickened, and amount of thickening product…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all residents were offered, and received if requested, the pneumococcal vaccine when one resident (Resident #55) requested the vaccine, but staff failed to administer the vaccine and when facility staff failed to offer one resident (Resident #17), or his/her responsible party, the vaccine. The facility census was 57.Review of the facility policy titled, Pneumococcal Vaccine, revised August 2016, showed the following:-All residents will be offered pneumococcal vaccines to aid in preventing pneumonia and pneumococcal infections;-Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated of the resident has already been vaccinated;-Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the…

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, observation, and record review, the facility failed to maintain a complete call light system accessible to all residents when staff failed to consistently place the call light within the reach of one resident (Resident #8). The facility census was 57.Review of the facility policy titled Answering the Call Light, dated October 2010, showed the following:-The purpose of the procedure was to respond to the resident requests and needs;-Be sure the call light is plugged in at all times;-When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident;-Answer the resident's call as soon as possible. 1. Review of Resident #8's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 06/06/25;-Diagnoses included cerebral infarction (sudden loss of brain function that occurs when blood flow to the brain is interrupted), hemiplegia (paralysis of one side of the body) of right side, muscle weakness, and aphasia (language disorder that affects a person's ability to…

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 interviews and record review, the facility failed to ensure all residents' families or representatives were notified of all significant changes and potential changes in care when staff did not notify two residents' (Resident #1 and #2) family/representative after a change in condition/allegation of abuse. The facility census was 54. Review showed the facility did not provide a policy regarding notification of resident representatives. 1. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 09/07/24; -Diagnoses included unspecified dementia (loss of memory), psychotic disturbances (mental health condition that causes people to lose touch with reality, and depression (feelings of sadness). Review of the resident's care plan, last revised on 12/11/24, showed the following: -The resident had communication problems as evidenced by his/her impaired hearing. He/she usually understands; -The resident had mood problems; -Staff to establish trusting relationship with resident and encourage resident to verbalize feelings, concerns, fears, and…

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 interviews and record review, the facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the state licensing agency (Department of Health and Senior Services - DHSS) when staff failed to report two allegation of sexual abuse involving three residents (Resident #1, #2, and #3) to management and DHSS in a timely fashion. The facility census was 54. Review of the facility's policy titled, Abuse and Neglect-Clinical Protocol, revised July 2017, showed the following: -Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse; -Sexual abuse is the non-consensual contact of any type with a resident. Review of the facility's policy titled, Abuse Prevention Program, revised December 2021, showed the following: -Purpose to protect residents from abuse by anyone, including but not necessarily limited to, facility staff, other residents; - Investigate and report any…

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 staff failed to immediately begin an investigation of possible abuse when staff witnessed one resident (Resident #1) touch another resident (Resident #3) in the groin area. The facility census was 54. Review of the facility's policy titled, Abuse and Neglect-Clinical Protocol, revised July 2017, showed the following: -Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse; -Sexual abuse is defined as non-consensual contact of any type with a resident; -Staff, with the physician's input as needed, will investigate alleged occurrences of abuse and neglect to clarify what happened and identify possible causes. Review of the facility's policy titled, Abuse Prevention Program, revised December 2021, showed the following: -Purpose to protect residents from abuse by anyone, including but not necessarily limited to, facility staff, other residents; -Identify and assess all…

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 interview, the facility failed to maintain a comprehensive person-centered care plan for all residents when staff failed to update the care plan for one resident (Resident #1) to include two incidents of the resident touching other residents inappropriately. The facility's census was 54 Review showed the facility did not provide a policy on updating care plans. 1. Review of Resident #1's face sheet (admission data) showed the following: -admission date of 09/07/24; -Diagnoses included unspecified dementia (loss of memory), psychotic disturbances (mental health condition that causes people to lose touch with reality), and depression (feelings of sadness). Review of the resident's care plan, last revised on 12/11/24, showed the following: -The resident had communication problems as evidenced by his/her impaired hearing. He/she usually understands; -The resident had activities of daily living (ADL) functional problems as evidenced by the need for staff assistance with ADLs due to my diagnosis of (nothing added). Balance wasn't always steady, but he/she was…

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, interview, and record review, the facility failed to provide care per standards of practice when staff failed to address and notify the provider of a change in condition for one resident (Resident #1) whose knees became swollen, red, warm, and painful. The facility census was 52. Review showed the facility did not provide a policy related to change of condition. 1. Review of Resident #1''s face sheet (brief resident profile sheet) showed the following: -admission date of 03/08/23; -Diagnoses included cognitive communication deficit, rheumatoid arthritis (a chronic autoimmune disease that causes inflammation in the joints, resulting in pain, swelling, stiffness, and tenderness), osteoarthritis (a degenerative joint disease that causes the cartilage and bone in joints to break down over time), and chronic pain syndrome. Review of the resident's care plan, dated 03/16/23, showed the following: -The resident had activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) functional problems as evidenced by the need for staff assistance…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide protective oversight to all residents when staff did not put new interventions in place after, or make all working staff aware of, elopement attempts made by one resident (Resident #1) with a history of wandering and talking about leaving the facility. The resident eloped later the same day and was found in a nearby [NAME], located between the facility and the interstate. The facility census was 53. Review of the facility's policy titled, Elopement Policy & Procedure, undated, showed the following: -Elopement included when a resident left the premises or a safe area, without authorization and/or necessary supervision placing the resident at risk for harm or injury; -It is the intent of the facility to be aware of its residents usual habits and locations as reasonably practicable; -If the resident used an electronic device that alarms, the supervisor or designee will determine location of device on resident and test any used…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure each resident's choice of code status (the desire to be resuscitated or not if breathing stops) was clearly documented in each resident's chart when four residents' (Resident #8, #43, #150, and #5) charts had conflicting information regarding code status. A sample of 14 residents was selected for review out of a facility census of 47. Review showed the facility did not provide a policy regarding resident choice of code status. 1. Review of Resident #8's Face Sheet, dated reviewed [DATE], showed the following: -admission date of [DATE]; -Diagnoses included congestive heart failure (the heart loses the ability to pump enough blood), chronic kidney disease, history of pneumonia and bronchitis, pain, cognitive loss, and difficulty making decisions; -Code status of do not resuscitate (DNR - a person has decided not to have cardiopulmonary resuscitation (CPR - an emergency lifesaving procedure performed when the heart stops beating)…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care for all residents on oxygen per professional standards of practice when staff failed to ensure oxygen equipment was cared for in a manner to prevent possible contamination or bacteria growth for three residents (Resident #20, #5, and #9) and when staff a failed to care plan regarding the care of oxygen equipment for two residents (Resident #20 and #9). The facility census was 47. Review of the facility's policy titled, Care of Oxygen Equipment, undated, showed the following: -Staff should remove the humidifier bottle weekly and wash it in warm soapy water, rinse thoroughly and air dry before refilling with distilled water; -Staff should remove and clean oxygen cannula's/masks as needed, and weekly by night nurse; -Staff should place oxygen cannula/mask and tubing in a plastic ziplock bag when not in use, and secure the bag to the tank carrier or oxygen concentrator with masking tape, and should be changed and dated weekly 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview, and record review, the facility failed to complete and document risks vs benefits reviewed, assessment for entrapment, prior alternatives tried, or informed/signed consent for the bed rails before installing bed rails on five residents' (Resident #1, #4, #9, #11, and #13) beds. The facility census was 47. Review of the facility's policy titled, Bed Safety and Bed Rails, revised August 2022, showed the following: -The use of bed rails is prohibited unless the criteria for use of bed rails have been met; -The resident's sleeping environment is evaluated by the interdisciplinary team; -Bed frames, mattresses and bed rails are checked for compatibility and size prior to use; -Regardless of mattress type, width, length, and/or depth, the bed frame, bed rails and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the Food and Drug Administration (FDA); -Maintenance staff routinely inspects…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to maintain an effective infection control program when staff failed to perform proper hand hygiene while performing personal cares and perineal care on three sampled residents (Residents #20, #4, and #34). The facility census was 47. Review of the facility's policy Handwashing/Hand Hygiene, reviewed July 2019, showed the following: -Hand hygiene is the primary means to prevent the spread of infections; -Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies; -Wash hands with soap and water when hands are visibly soiled and after contact with a resident; -Use an alcohol-based hand rub containing at least 62% alcohol or alternatively, soap and water for the following: before and after coming on duty, before and after direct contact with residents, before donning sterile gloves, before moving from a…

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 ensure care was completed in accordance with standards of practice when staff failed to care plan the use of a neck brace, failed to address the neck brace not fitting correctly, and failed to arrange timely follow-up physician appointments for one resident (Resident #43) who was admitted after being diagnosed with a neck fracture. The facility census was 47. Review showed the facility did not provide a policy regarding regarding appointments, medical equipments, or follow-up on hospital directives. 1. Review of Resident #43's electronic Face Sheet showed the following: -admission date of 11/16/23; -Diagnoses included neck fracture, dementia, depression, and pain. Review of the resident's hospital notes, dated 11/12/23, showed the following: -Recommendation to continue use of neck brace and discussing with orthotist (a medical professional who specializes in making braces and splints) need for better-fitting neck brace to avoid skin breakdown; -Recommended follow-up with the neurosurgeon in four to six weeks…

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, interview, and record review, the facility failed to provide treatment to prevent possible urinary tract infections for all residents when staff failed to perform urinary catheter (tube placed into the bladder to drain urine) care for one resident (Resident #20), of two residents sampled, with an indwelling urinary catheter. The facility census was 47. Review of the facility's policy for Indwelling Catheter (Foley) Care, revised and reviewed August, 2018, showed the following: -Care for an indwelling urinary catheter can be delegated to certified nurse aides (CNAs); -Routine catheter care is a part of routine perineal hygiene; -Catheter care is performed every shift and as needed (PRN) for soiling. 1. Review of Resident #20's face sheet (admission information at a glance) showed the following: -admission date of 05/30/23; -Diagnoses included urinary tract infection (infection in the bladder and urine) and neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord, or nerve problems. Review of the resident's physician's order, dated…

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 an effective, thorough program for the prevention of the growth of the Legionella bacteria (a bacteria which causes a respiratory disease when breathing in small droplets of water in the air that contain Legionella) when staff were unaware of the steps the facility needed to take to prevent Legionella; staff failed to complete a Legionella risk assessment for the facility; and staff failed to monitor water temperatures and the pH (a measure of how acidic/basic water is) levels routinely. The facility census was 54. The Centers for Disease Control (CDC) Toolkit for Legionella (which is officially titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings) showed that healthcare facilities need to actively identify and manage hazardous conditions that support growth and spread of Legionella by: -Identifying building water systems for which Legionella control measures are needed; -Assess how much risk the hazardous conditions in those water systems pose; -Apply control measures to…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to position a specialized call light within reach for one resident (Resident #36) who was dependent on staff for cares and failed to provide to consistently provide a [NAME] Cup (a lightweight spill proof drinking cup with a straw and handles and will not spill when shaken or tipped over) for one resident (Resident #20) as care planned to assist the resident with drinking. A sample of 16 residents was selected for review. The facility's census was 54. Record review of the facility's policy titled, Quality of Life-Accommodation of Needs, revised August 2009, showed the following information: -The facility's environment and staff behaviors are directed toward assisting the residents in maintaining and/or achieving independent functioning, dignity, and well-being; -The resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to timely identify, assess, document, implement interventions, and follow-up on recommendations, for one resident (Resident #5) who developed limited range of motion progressing to contractures of his/her right hand out of a selected sample of 16 residents. The facility's census was 54. Record review of the facility's Functional Impairment-Clinical Protocol policy revised 9/2012, included the following: -Upon admission to the facility, at any time a significant change of condition occurs, and periodically during a resident's stay, the physician and staff will assess the resident physical condition and functional status; The physician will help identify individuals who have had a recent history of functional decline and those who are at risk for additional functional decline; -The staff will identify individuals with significant decline in function, including ability to perform activities of daily living (ADLs - dressing, grooming, bathing,…

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, interview, and record review, the facility failed to ensure water was consistently accessible to one (Resident #21) with a history of urinary tract infections (UTI - an infection in any part of the urinary system, the kidneys, bladder or urethra) in a selected sample of 16 residents. The facility's census was 54. Record view of the facility's policy Serving Drinking Water, revised October 2010, showed the following: -The purposes of this procedure are to provide the resident with a fresh supply of drinking water and to provide adequate fluids for the resident; -Return the water pitcher to the resident's bedside stand; -Place the water pitcher and cup within easy reach of the resident. Place flexible straws next to the water pitcher. 1. Record review of Resident #21's face sheet (document that gives resident's information at a quick glance) showed the following: -Last admission date of 5/12/17; -Diagnoses included age-related physical debility, constipation, and UTI. Record review of the resident's May 2021 physician orders showed the following: -An order, dated…

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.