A list of the most recent deficiencies for Webster House. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-07-20 | 2023-08-15 | Y |
| Assess the resident when there is a significant change in condition | Health | 2023-02-27 | 2023-03-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-27 | 2023-03-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-27 | 2023-03-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-27 | 2023-03-29 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-02-27 | 2023-03-29 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-02-27 | 2023-03-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-27 | 2023-03-29 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-02-27 | 2023-03-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-27 | 2023-03-29 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-27 | 2023-03-29 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-02-27 | 2023-03-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-02-27 | 2023-03-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-27 | 2023-03-29 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-02-27 | 2023-03-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-27 | 2023-03-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-06 | 2023-03-23 | N |
| Use approved construction type or materials. | Fire Safety | 2023-03-06 | 2023-03-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-06 | 2023-03-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-03-06 | 2023-03-23 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-03-06 | 2023-03-23 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-03-06 | 2023-03-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-06 | 2023-03-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-06 | 2023-03-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-03-06 | 2023-03-23 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-03-06 | 2023-03-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-06 | 2023-03-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-06 | 2023-03-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-06 | 2023-03-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-17 | 2021-11-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-20 | 2021-11-02 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-19 | 2021-07-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-22 | 2021-06-07 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-01-09 | 2020-01-21 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-01-09 | 2020-01-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-09 | 2020-01-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-09 | 2020-01-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-09 | 2020-01-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-09 | 2020-01-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-11-15 | 2019-12-03 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-11-15 | 2019-12-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-11-15 | 2019-12-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-15 | 2019-12-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-15 | 2019-12-03 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-01-17 | 2019-03-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-01-17 | 2019-03-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-17 | 2019-03-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-01-17 | 2019-03-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-17 | 2019-03-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-01-17 | 2019-03-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-17 | 2019-03-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-01-17 | 2019-03-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-11-02 | 2018-12-04 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-11-02 | 2018-12-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-02 | 2018-12-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-11-02 | 2018-12-04 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-11-02 | 2018-12-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-11-02 | 2018-12-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-11-02 | 2018-12-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-11-02 | 2018-12-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-11-02 | 2018-12-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-11-02 | 2018-12-04 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-11-02 | 2018-12-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-02 | 2018-12-04 | N |
