Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Webco Manor during CMS and state inspections, most recent first.
A resident with cardiac and pulmonary conditions, initially defaulted to full code status, later completed a physician-signed DNR order that was placed in an admission folder but not communicated to nursing or entered into the EMR. The Admissions Director did not forward the DNR paperwork to the SSD or DON, and the SSD created the resident’s profile as full code, leaving the hard chart, EMR, and door sticker system all reflecting full code. When the resident was found unresponsive, staff and EMS initiated and continued CPR based on the incorrect full code information, and only afterward did the SSD discover the signed DNR form in the admission packet.
A resident with multiple sclerosis and minimal cognitive impairment reported to a CNA that a CNA staff member was rough during incontinence care, turned on a bright light while the resident was sleeping, and then punched the wall above the resident’s head after being told to stop, causing the resident to feel fearful and request that the CNA not return. The CNA immediately informed an RN, wrote a statement, and attempted to contact the DON and Administrator by phone and text, but neither responded during the night. The RN reassigned the resident’s care and told the accused CNA not to re-enter the room but did not interview the resident and did not treat the report as an abuse allegation, so it was not escalated to leadership until later that morning, during which time the accused CNA continued working independently with other residents.
A resident with MS and minimal cognitive impairment reported that a CNA was rough during incontinence care, turned on a bright light while the resident was sleeping, and punched the wall above the resident’s head, causing the resident to feel fearful and request that the CNA not return. A CNA promptly informed the RN, documented the incident, and attempted to contact the DON and Administrator by phone and text, but the RN did not escalate the report, believing rough care was not abuse, and leadership did not respond during the night. The allegation was not documented in the resident’s progress notes, and the Administrator did not submit the required report to the State until more than seven hours after staff first became aware of the allegation, exceeding the facility’s two-hour reporting requirement for abuse allegations.
A resident with severe cognitive impairment was subjected to alleged abuse by a CNA, who placed a hand over the resident's mouth and used inappropriate language. The incident was witnessed by another CNA, who did not report it immediately but waited until the next day to inform another staff member, resulting in a delayed report to the DON, Administrator, and state agency. This delay exceeded the required two-hour reporting timeframe for abuse allegations.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with neurogenic bladder continued to have an indwelling urinary catheter in place and performed their own catheter care, but there was no current physician order specifying the catheter's use, size, or change frequency, despite staff awareness of this omission.
The facility failed to notify the families of two residents after a significant change in condition and an allegation of abuse. A resident with dementia was involved in inappropriate touching, but their family was not informed. The facility's investigation revealed a lack of communication and documentation, and staff interviews confirmed that families should have been notified.
A facility failed to report allegations of sexual abuse involving inappropriate touching between residents to management and DHSS within the required timeframe. Despite staff awareness of the reporting protocol, incidents were not documented or reported promptly, leading to a deficiency in the facility's abuse prevention and reporting procedures.
A facility failed to investigate an alleged abuse incident when a resident was seen touching another resident inappropriately. Despite facility policies requiring immediate investigation and reporting, no documentation or investigation was conducted. Staff, including the DON and Administrator, were unaware of the incident, highlighting a deficiency in handling the situation.
A resident with dementia and psychotic disturbances exhibited inappropriate touching behavior towards other residents, but the facility failed to update the care plan to reflect these incidents. Despite staff awareness and documentation of the behavior, the MDS Coordinator did not amend the care plan, indicating a deficiency in the care planning process.
A resident with chronic pain syndrome and arthritis experienced inadequate pain management due to the facility's failure to document pain levels, follow up on medication effectiveness, and communicate with the physician about increased pain and unavailable medications. The resident's condition worsened, leading to a hospital transfer where a patella fracture was diagnosed.
A resident with rheumatoid arthritis experienced a decline in mobility and increased knee pain, which was not promptly communicated to the provider. Despite staff observations of the resident's swollen, red, and warm knee, and the resident's requests for medical attention, there was a delay in notifying the physician. The resident was eventually transferred to the hospital, where a patellar fracture was diagnosed.
A resident with severe cognitive impairment and a history of wandering eloped from the facility due to inadequate supervision and failure to implement necessary interventions. Despite triggering alarms and exhibiting exit-seeking behavior, the resident was not placed on 15-minute checks or given increased supervision. The resident was later found in a nearby cornfield after a search involving law enforcement.
Failure to Communicate and Update Resident DNR Status Resulting in CPR Contrary to Wishes
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s code status preference was clearly and accurately reflected in the medical record and available to staff, resulting in CPR being initiated contrary to the resident’s documented wishes. The resident was admitted with diagnoses including atrial fibrillation, cardiac disease, stroke, and lung disease, and was initially listed as a full code in the facility’s electronic medical record and on the face sheet. The facility’s practice was to default all new admissions to full code status until staff could confirm the resident’s preferences. The resident had normal cognition on the admission MDS and later completed an Outside Hospital Do-Not-Resuscitate (OHDNR) order, which was signed and dated by both the resident and the physician. The sequence of events leading to the deficiency began when the Admissions Director completed the admission paperwork with the resident, including code status and DNR documentation, and then placed all forms in a folder on their desk before leaving for the weekend. The Admissions Director did not notify nursing staff that the resident’s code status had changed from full code to DNR, did not make copies for the nursing charts, and did not provide the DNR paperwork to the Social Services Director (SSD) or the Director of Nursing (DON). As a result, the SSD created the resident’s electronic profile as a full code and did not receive or review the signed DNR form until after the resident’s death. The DON reported not receiving any DNR paperwork prior to the resident’s cardiopulmonary arrest, and the resident’s orders were not updated in the hard chart, EMR, or on the red/green door sticker system used to indicate code status. When the resident was later found unresponsive, staff followed the information available to them, which indicated the resident was a full code. Staff immediately called the nurse, initiated CPR, and called 911. EMS arrived and continued CPR for over an hour. During this time, the DON was called to the facility and contacted the family while the code was in progress. The resident’s progress notes documented the discovery of the resident unresponsive, the initiation of CPR, EMS involvement, and subsequent notifications to the family and physician. Only after these events did the SSD, while scanning the admission packet into the EMR, discover the signed DNR order that had not been communicated or entered into the resident’s record, confirming that staff had provided CPR despite the resident’s documented DNR preference.
Failure to Immediately Investigate and Protect Resident After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to immediately and thoroughly investigate an allegation of staff-to-resident abuse and to ensure resident protection during the investigation. The facility’s Abuse and Neglect Policy requires the Administrator, DON, or designee to begin an internal investigation immediately and report to DHSS when an allegation arises. A resident with multiple sclerosis and minimal cognitive impairment, admitted in early February, reported to a CNA that a CNA staff member had been rough during incontinence care, turned on a bright light while the resident was sleeping, and then punched the wall three times above the resident’s head after being told to stop. The resident stated fear of this CNA and requested that the CNA not return to the room. CNA A documented the allegation in a written statement and immediately reported it to RN C during the night shift. CNA A then attempted to contact the DON and the Administrator by phone and text, sending a picture of the written statement to both, but received no response at that time because both leaders were asleep and did not hear their phones. RN C reassigned the resident’s care to CNA A and instructed CNA B not to return to the resident’s room, but did not enter the resident’s room or interview the resident about the allegation. RN C stated that being rough with cares was not considered an allegation of abuse and therefore did not report the incident to the DON or Administrator during the night. The Administrator and DON later acknowledged that rough care and punching a wall constituted abuse and that an investigation should have been started immediately. Other nursing staff interviewed indicated that any report of rough care where a resident does not feel safe should be treated as an abuse allegation, with immediate steps to ensure safety and report to leadership. Despite this, there was a delay from the time of the initial report during the night until the Administrator became aware and began an investigation later that morning, during which time the staff member implicated in the allegation continued to work independently with residents.
Failure to Timely Report Allegation of Rough Care and Threatening Behavior
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident abuse to the State Survey Agency (DHSS) within the required two hours after staff became aware of the allegation. The facility’s abuse policy required that any suspicion or knowledge of abuse, neglect, or misappropriation be reported immediately to the Administrator and charge nurse, and that the Administrator, DON, or designee begin an internal investigation immediately and report to DHSS within two hours if the allegation involved serious injury, or within 24 hours if it did not. A resident with multiple sclerosis and minimal cognitive impairment, admitted on 02/02/24, reported that a CNA had been rough during incontinence care and had punched the wall above the resident’s head, causing the resident to feel fearful and not want that CNA to return. In the early morning hours, between approximately 2:00 A.M. and 2:25 A.M., a CNA entered the resident’s room to provide care and was informed by the resident that another CNA had turned on a bright light while the resident was sleeping, was rough while attempting to change the resident, and, after being told to stop, punched the wall three times above the resident’s head before leaving. The CNA immediately reported the incident to the charge RN, wrote a statement, and attempted to notify the DON and Administrator by phone and text, including sending photos of the written statement. The charge RN acknowledged being informed between 2:00 A.M. and 3:00 A.M. that the resident complained of rough care and that the CNA had punched a wall, reassigned staff so the alleged CNA would not return to the room, but did not report the allegation to the DON or Administrator, believing that “rough with cares” was not an allegation of abuse. Despite the CNA’s attempts to contact leadership during the night, the DON and Administrator did not respond at that time, later stating they had been sleeping and did not hear their phones. The Administrator did not confirm the incident with staff until later that morning and did not submit the online report to DHSS until 9:58 A.M., more than seven hours after staff first became aware of the allegation. Facility records showed no progress note documentation of the allegation in the resident’s chart. Interviews with other nursing and CNA staff indicated they understood that rough care and a resident not feeling safe should be treated as an abuse allegation and reported immediately, and both the DON and Administrator acknowledged that rough care and punching a wall constituted abuse that should be reported to the State within two hours. The delay in reporting and lack of timely notification to DHSS constituted the deficiency.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported immediately to facility management and within two hours to the State Survey Agency, as required by both facility policy and regulation. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including dementia and Alzheimer's disease, who required total assistance with activities of daily living. On the evening of the incident, a Certified Nurse Aide (CNA) was observed by another CNA placing a hand over the resident's mouth and telling the resident to "shut the fuck up" while the resident was crying. The witnessing CNA did not report the incident immediately but instead informed another CNA the following day, who then reported it to the Director of Nursing (DON) and the Administrator. Documentation and interviews confirmed that the facility did not report the allegation to the Department of Health and Senior Services (DHSS) until the day after the incident, exceeding the required two-hour reporting window for abuse allegations. Staff interviews revealed that employees were aware of the policy to report abuse immediately and to notify the state within two hours, but the initial witness failed to follow this protocol. There was no documentation of immediate reporting to DHSS in the resident's records, and the delay in reporting constituted a failure to comply with both facility policy and regulatory requirements.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Lack of Current Physician Order for Indwelling Catheter
Penalty
Summary
A resident with a diagnosis of neurogenic bladder had an indwelling urinary catheter in place. The physician initially ordered the discontinuation of the Foley catheter, but the resident refused, stating that the physician had not discussed the change and requested to speak with the physician first. The physician later agreed to allow the resident to keep the catheter and instructed that it be changed monthly. However, a review of the resident's medical record revealed there was no current physician's order for the catheter, including details such as catheter size or the frequency of changes, despite the resident continuing to have the catheter in place and performing their own catheter care. Observations confirmed the presence of the indwelling catheter and drainage bag, and staff interviews indicated awareness of the lack of a current physician's order for the catheter or its care. The absence of an updated physician's order for the ongoing use and maintenance of the urinary catheter constituted a deficiency in providing appropriate catheter care and ensuring proper documentation as required for residents with indwelling catheters.
Failure to Notify Families of Significant Changes and Allegations of Abuse
Penalty
Summary
The facility failed to notify the families or representatives of two residents following a significant change in condition and an allegation of abuse. Resident #1, who has a diagnosis of dementia and other mental health conditions, was involved in an incident where inappropriate touching of another resident occurred. The incident was documented by RN G, but there was no record of the resident's family or representative being informed about this change in condition or the abuse allegation. The facility's investigation revealed that the incident was discussed during a manager's meeting, but neither the interim administrator nor the Director of Nursing (DON) were initially informed. Additionally, the investigation showed that the families of both Resident #1 and Resident #2 were not notified of the incident. Resident #2, who has a durable power of attorney invoked, was also involved in the incident, but their representative was not informed of the potential abuse. Interviews with various staff members, including LPNs, the Social Services Director, and the interim administrator, confirmed that the families should have been notified of the incident. However, there was a lack of communication and documentation regarding the notification process. The facility did not have a policy in place for notifying resident representatives, which contributed to the oversight in communication.
Failure to Timely Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to report allegations of possible sexual abuse involving three residents to management and the state licensing agency, DHSS, within the required timeframe. The incidents involved inappropriate touching by one resident towards two other residents. The first incident occurred when a resident was observed putting their hands in the crotch of another resident, but the staff did not notify facility administration or DHSS immediately. The second incident involved the same resident touching another resident's groin area, which was also not reported to management or DHSS. The facility's policy requires that any allegations of abuse be reported immediately to management and within two hours to the state. However, the staff, including RN G, failed to notify the Director of Nursing (DON), Administrator, or DHSS about the incidents. The incidents were only brought to the attention of management during a meeting three days later, and the state was notified after this delay. Interviews with various staff members revealed that they were aware of the requirement to report such incidents within two hours, yet the protocol was not followed. The residents involved had various diagnoses, including dementia, depression, and cognitive communication deficits, which may have affected their ability to consent or understand the situation. Despite this, the facility did not document the incidents in the residents' medical records or take immediate action to report the allegations. The failure to report these incidents in a timely manner constitutes a deficiency in the facility's abuse prevention and reporting procedures.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility staff failed to immediately investigate a possible abuse incident when a staff member witnessed one resident touching another resident inappropriately in the groin area. The incident was observed by an Activities Assistant who heard a resident yell that the person being touched was not the spouse of the resident doing the touching. The Activities Assistant then moved the resident who was touching to the nurses' station and informed the MDS Coordinator about the incident. However, there was no documentation of an investigation being initiated or completed regarding this allegation of possible abuse. The facility's policies on abuse and neglect, as well as the abuse prevention program, require that all allegations of abuse be investigated and reported within the required timeframes. Despite these policies, the staff did not document any investigation into the incident involving the two residents. Interviews with various staff members, including nurse aides, LPNs, the DON, and the Administrator, revealed that they were not aware of the incident and that no investigation had been conducted. The residents involved in the incident had diagnoses that included dementia, depression, and cognitive impairments, which could affect their understanding and behavior. The failure to investigate the incident was a violation of the facility's policies and federal requirements, as it did not ensure the protection of residents during the investigation of alleged abuse. The lack of awareness and action by the facility's staff and administration contributed to the deficiency in handling the situation appropriately.
Failure to Update Care Plan for Resident's Inappropriate Behavior
Penalty
Summary
The facility failed to maintain a comprehensive person-centered care plan for a resident who exhibited inappropriate touching behavior towards other residents. The resident, diagnosed with unspecified dementia, psychotic disturbances, and depression, had incidents of inappropriate touching documented on two occasions. Despite these incidents, the resident's care plan was not updated to reflect the changes in behavior, which is a requirement for comprehensive care planning. The first incident involved the resident touching another resident inappropriately, which was observed by staff and documented by a Registered Nurse. However, the care plan was not updated following this incident. The second incident was witnessed by an Activities Assistant, who reported it to the MDS Coordinator and RN Consultant, yet the care plan still remained unchanged. Interviews with various staff members, including CNAs, LPNs, and the Social Services Director, revealed that inappropriate behaviors should be documented in the care plan, but this was not done. The MDS Coordinator, responsible for updating care plans, acknowledged awareness of the incidents but did not update the care plan to include the resident's inappropriate behavior. The Director of Nursing and Interim Administrator were also unaware of the incidents until days later, indicating a breakdown in communication and documentation processes. The failure to update the care plan after these incidents highlights a deficiency in the facility's care planning process.
Inadequate Pain Management and Communication in LTC Facility
Penalty
Summary
The facility failed to provide comprehensive pain management for a resident with chronic pain syndrome, rheumatoid arthritis, and osteoarthritis. The resident experienced increased pain in the right knee, which was swollen, red, and warm to the touch. Despite the resident's complaints and visible symptoms, staff did not consistently document the resident's pain levels or follow up on the effectiveness of administered pain medications. The resident's pain was not adequately addressed, and there was a lack of communication with the physician regarding the resident's increased pain and the ineffectiveness of the current pain management regimen. The facility's staff did not document the administration of prescribed medications, such as Lyrica, due to the medication being unavailable. The staff failed to notify the physician or nurse practitioner about the unavailability of Lyrica, which was intended to manage the resident's chronic pain. The resident's pain levels fluctuated, reaching as high as 10 on a scale of 0 to 10, yet there was no documented follow-up or additional interventions to address the continued pain. The resident's condition worsened, leading to increased dependency on staff for activities of daily living and a request for a second medical opinion. Interviews with staff revealed that there was a lack of communication and coordination in managing the resident's pain. Staff members were aware of the resident's pain and the unavailability of Lyrica but did not take appropriate steps to resolve the issue or communicate effectively with the physician. The resident was eventually transferred to the hospital, where a fracture of the right patella was diagnosed, indicating that the pain and symptoms were not adequately addressed in the facility.
Failure to Notify Provider of Change in Resident's Condition
Penalty
Summary
The facility failed to provide care per standards of practice by not addressing and notifying the provider of a change in condition for a resident whose knees became swollen, red, warm, and painful. The resident, who had a history of rheumatoid arthritis and chronic pain syndrome, experienced a significant decline in mobility and an increase in pain, which was not promptly communicated to the physician or nurse practitioner. Despite multiple staff observations and the resident's requests for medical attention, the necessary notifications and interventions were delayed. The resident's condition deteriorated over several days, with staff documenting the resident's inability to bear weight, increased pain, and changes in activities of daily living (ADLs). Various staff members, including CNAs and RNs, noted the resident's knee was swollen, red, and warm to touch, yet there was a lack of timely communication with the resident's healthcare provider. The resident expressed a desire for a second opinion and was eventually transferred to the hospital, where a fracture of the right patella was diagnosed. Interviews with facility staff revealed a breakdown in communication and documentation regarding the resident's condition. Several staff members assumed the resident was on the physician's list for evaluation, but there was no clear documentation of when or if the physician was notified of the resident's worsening condition. The facility's failure to have a policy related to change of condition contributed to the delay in appropriate medical intervention, resulting in the resident's transfer to the hospital for surgical repair.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and protective oversight for a resident with a history of wandering and elopement attempts. The resident, who had severe cognitive impairment and was assessed as a high risk for elopement, was not adequately monitored despite having an electronic monitoring device. On the day of the incident, the resident attempted to leave the facility multiple times, triggering alarms, but was not placed on 15-minute checks or given increased supervision as per the facility's policy. The resident was last seen in the common area by staff at 8:00 P.M. and was later found missing during rounds. Despite the resident's known history of exit-seeking behavior and verbalizing intent to leave, staff did not implement new interventions or ensure all working staff were aware of the resident's elopement risk. The facility's investigation revealed that the resident was able to leave the premises and was found in a nearby cornfield, approximately 100 yards from the facility, after a search involving law enforcement. Interviews with staff indicated a lack of consistent communication and adherence to the facility's elopement policy. Staff were aware of the resident's behaviors but did not consistently apply the necessary checks or communicate effectively about the resident's risk. The facility's systems for monitoring and responding to elopement risks were not effectively utilized, leading to the resident's unsupervised departure from the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Marshfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marshfield Care Center For Rehab And Healthcare | 1.4 mi | — | 7 | 0 |
| Strafford Care Center | 11.2 mi | — | 19 | 0 |
| Glenwood Healthcare | 15.3 mi | — | 0 | 0 |
| Copper Rock Healthcare | 18.2 mi | — | 1 | 0 |
| Woodland Manor | 18.9 mi | — | 6 | 0 |
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