TCU AT WEBSTER

Nursing Home Inspector

340 THOMPSON ROAD - 1ST FLOOR
WEBSTER, MA 01570
Worcester County
Phone: 508-949-8420
Provider Number: 225735
Last Inspection: 06/09/2017

About the Nursing Home

Number of Beds: 21
Number of Residents: 14
Beds Available: 7
Percent Occupancy: 67%
Insurance Accepted: Medicare & Medicaid
Types of Councils: None
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

18

Facility
16

County
16

MA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

18

2017
22

2016
12

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

6/9/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Widespread : Potential 4 7/7/2017
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Minimal 4 7/7/2017
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 7/7/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 7/7/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Isolated : Minimal 3 7/7/2017
 

5/18/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Widespread : Potential 4 7/2/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 7/2/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 7/2/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 7/2/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 7/2/2016
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 7/2/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 7/2/2016
 

2/12/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 3/29/2015
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 3/29/2015
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 3/29/2015
 
Failed To: Provide food in a way that meets a resident's needs. Isolated : Minimal 3 3/29/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

No Complaint Deficiencies Reported

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MA State Avg
Number of Residents 14 99.96 96.79
Registered Nurses 2.66 0.88 0.89
Licensed Practical / Vocational Nurses 1.10 1.00 0.84
Certified Nursing Assistants 3.56 2.37 2.30
Total Staff Hours 7.32 4.25 4.03

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MA State Avg%
of short-stay residents assessed and appropriately given the pneumococcal vaccine 86 4 4
of short-stay residents who had an outpatient emergency department visit 13 93 92
of short-stay residents who made improvements in function 61 96 95
of short-stay residents who newly received an antipsychotic medication 2 3 3
of short-stay residents who self-report moderate to severe pain 20 3 2
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 91 5 5
of short-stay residents who were rehospitalized after a nursing home admission 22 22 20
of short-stay residents who were successfully discharged to the community 62 18 18
of short-stay residents with pressure ulcers that are new or worsened 1 5 4