Webster Manor Rehabilitation & Health Care Center

In the surveyor’s words

From the most serious findings on record at Webster Manor Rehabilitation & Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 4, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure that he/she was provided with adequate preventative care measures during an application of and treatment with a hot compress, in an effort to maintain his/her safety to prevent an incident resulting in an injury, when nursing staff did not follow facility policy on how to heat the compress, but instead heated the moist compress in the microwave, applied it to his/her back, and as a result Resident #1 sustained a second-degree burn (burn that affects both the epidermis and second layer of skin (dermis), may cause swelling, red and white blotchy skin, blisters may develop, and pain can be severe) to the area. […]

• No harm, potential for more than minimal, widespreadF761Mar 1, 2024

  Based on observation, interview and policy review, the facility failed to store medications and biologicals under the proper temperature controls as required on two units (Lake Unit and Tapestry Unit) of three units in the facility. Specifically, the facility staff failed to ensure that medications and biologicals requiring refrigeration were stored within the required temperature range of 36 F (Fahrenheit) to 46 F. Findings include: Review of the facility's policy titled Storage of medications, dated 2017, indicated but was not limited to: -Medications and biologicals are stored at their appropriate temperatures and humidity according to the United States Pharmacopeia guidelines for temperature ranges. […]

• No harm, potential for more than minimal, widespreadF886Oct 5, 2022

  Based on interview, and record review the facility failed to ensure its staff performed COVID-19 outbreak testing for residents and staff as required, to stop the spread of infection. Findings include: Review of the COVID-19 Outbreak Checklist found in Appendix B of the Massachusetts Department of Public Health guidance titled Update to Caring for Long-Term Care Residents During the COVID-19 Pandemic Response, including, Visitation Conditions, Communal Dining and Congregate Activities, dated 6/10/22, indicated the following: If the facility identifies one new resident or staff case then the facility should take the following steps to mitigate any further transmission: -Testing all staff and all residents on affected units must take place as soon as possible. […]

• No harm, potential for more than minimal, widespreadF812Jan 13, 2022

  Based on observation, document review and interview, the facility failed to store, consistently monitor food temperature at meal, and serve food in accordance with professional standard for food safety to minimize the risk of food borne illnesses. Findings include: Review of the facility's Controlling Time and Temperature During Preparation policy, dated January 2014, indicated the following: -Take at least two internal temperatures from each pan of food at various stages of preparation. -The food service manager will verify that food service employees are taking the required temperatures. Review of the facility's Meal Temperature Tracking Sheet, dated 7/19/21, indicated temperatures are to be monitored for all meals for the beginning temperatures and ending temperatures. […]

• No harm, potential for more than minimal, patternF550May 20, 2026

  Based on observations, interviews, and record reviews, the facility failed to ensure dignity was maintained for two Residents (#11 and #30), out of a total sample of 29 residents, and during the dining experience on one unit (Tapestry Unit), out of three units observed.Specifically, the facility failed to ensure that:Resident #11 was dressed in clothing, not a hospital gown, when his/her preference was to be dressed daily in personal clothing.Resident #30 was provided with dignity/privacy when he/she was uncovered in bed with under briefs viewable to others, and signage indicating specific level of assistance with feeding were posted above the Resident's bed and in view of others. […]