Focused Care at Webster

In the surveyor’s words

From the most serious findings on record at Focused Care at Webster, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Oct 8, 2025

  Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for resident abuse.-The facility failed to ensure that Resident #1 was free from sexual abuse when Resident #1 wandered into Resident #2's room in the facility on 9/23/25, and Resident #2 sexually assaulted Resident #1.An Immediate Jeopardy (IJ) was identified on 10/02/2025 at 4:41 p.m. The IJ template was provided to the Administrator and DON on 10/02/25 at 4:41 p.m. While the IJ was removed on 10/06/25 at 1:28 p.m. […]

• Immediate jeopardy, isolatedF689Oct 8, 2025

  Based on observation, interviews and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 out of 5 residents (Resident #1 and Resident #2) reviewed for adequate supervision.- The facility failed to ensure Resident #1 who was severely cognitively impaired and nonverbal and Resident #2 who was moderately cognitively impaired and had behaviors of inappropriate sexual comments to staff received adequate supervision to prevent abuse after she wandered into Resident #2's room in facility on 9/23/25. Resident #1 was sexually assaulted by Resident #2. An Immediate Jeopardy (IJ) was identified on 10/02/2025 at 4:41 p.m. The IJ template was provided to the Administrator and DON on 10/02/25 at 4:41 p.m. […]

• Actual harm, patternF755Feb 1, 2024

  Based on interview and record review the facility failed to provide pharmaceutical services to include procedures that assure the accurate administering of all drugs and biologicals to meet the needs of each resident for 1 of 6 (CR#1) residents reviewed for pharmacy services to meet the needs of each resident in that: 1. The facility failed to ensure physician ordered, Tramadol (an FDA controlled medication for pain) was provided the scheduled or PRN as resident requested for her pain; 2. […]

• Actual harm, isolatedF677Jun 5, 2026

  Based on observation, interview and record review, the facility failed to ensure that residents who are unable to carry out activities of daily living receive the necessary treatment and services, consistent with professional standards of practice, to maintain personal hygiene. Video footage of in room surveillance revealed the facility failed to provide Resident #1, who was totally dependent on staff for ADL care, with timely incontinent care. Resident #1 did not receive incontinent care for more than 15 hours on 5/24/26 and 5/25/26, and on 05/25/26, was subsequently diagnosed with a Stage 3 pressure ulcer to his sacrum. This failure could place residents at risk for skin breakdowns, diminished quality of life, and a decline in personal hygiene. […]

• Actual harm, isolatedF686Jun 5, 2026

  Based on observation, interview and record review, the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable. Video footage of in room surveillance revealed the facility failed to provide Resident #1, who was totally dependent on staff for ADL care, with timely incontinent care. Resident #1 did not receive incontinent care for more than 15 hours on 5/24/26 and 5/25/26, and on 05/25/26, was subsequently diagnosed with a Stage 3 pressure ulcer to his sacrum. […]