Wharton Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, the facility failed to complete side (bed) rail assessments for the risk of entrapment and failed to obtain consents for side rails for 6 residents (Residents #1, #34 #5, #23, #25 and #45) of 6 residents reviewed for side rails. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses including Cognitive Communication Deficit, Quadriplegia and Bed Confinement Status. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 had moderate cognitive impairment and required extensive assistance of 2 staff for bed mobility, hygiene and dressing and total dependence on staff for toileting. Review of Resident #1's medical record showed no entrapment risk safety assessments or consent for siderails. During an observation on 2/12/2024 at 12:40 PM, Resident #1 was listening to the radio while lying in bed and 1/4 bilateral upper side rails were in place on the bed. No visible gaps between the matress…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, review of prior survey results, medical record review, facility documentation review, observation and interview, the facility's Quality Assurance Performance Improvement (QAPI) program failed to take effective actions plans to ensure appropriate interventions were put into place, and to monitor the effectiveness for falls for 1 resident (Resident #45) of 5 residents reviewed for falls. The findings include: Review of the facility's policy titled, Quality Assurance & Performance Improvement (QAPI) Plan, dated 9/21/2023, showed, .The QAPI plan .is designed to establish and maintain an organized facility-wide program that is data-driven and utilizes a proactive approach .Objectives of the QAPI plan include .establish a facility-wide process to identify opportunities of improvement through continuous attention to quality of care, quality of life and resident safety . Review of prior survey findings, the facility was previously cited a deficiency of F689 on a complaint survey on 6/6/2023 at a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, document review, medical record review, observation, and interview, the facility failed to ensure medical information was not visible for 5 residents (Residents #1, #3, #4, #22, and #46) of 55 residents observed. The findings include: Review of the facility's policy titled, Promoting-Maintaining Resident Dignity, dated 8/21/2023, showed .All staff members are involved in providing care to residents to promote and maintain resident dignity .Maintain resident privacy . Review of a facility document titled, Uplands Village Skilled and Long-Term Care admission Handbook, dated 10/1/2018, showed .Residents .To be treated with consideration, respect and full recognition of his/her dignity . Resident #1 was admitted to the facility on [DATE] with diagnoses including Cognitive Communication Deficit, Quadriplegia and Bed Confinement Status. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 had moderate cognitive impairment and required extensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observation, and interview, the facility failed to offer hand hygiene assistance to residents prior to meals for 3 residents (Resident #44, #156, and #157) of 3 residents observed on 1 of 3 hallways observed for meal tray distribution. The findings include: Review of the facility's policy titled, Hand Hygiene, updated on 8/21/2023, showed .POLICY .will perform proper hand hygiene procedures to prevent the spread of infection .Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .Hand Hygiene Table .Residents are offered hand hygiene prior to meals .Either Soap and Water or Alcohol Based Hand Rub . Resident #44 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Alzheimer's Disease, and Cognitive Communication Deficit. Review of Resident #44's admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) performed care within the scope of practice when she handed 1 resident (Resident #32) a cup of medications for the resident to take of 50 residents observed during the initial tour of the facility. The findings include: Review of the facility policy titled, Medication Administration, dated 1/13/2020, showed .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state .and In accordance with professional standards of practice . Resident #32 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, and Muscle Weakness. Observation and interview on 6/28/2021 at 9:54 AM, in Resident #32's room revealed a medication cup with approximately 5 medications in the cup sitting on the resident's overbed table. The resident stated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to maintain proper infection control procedures during a dressing change for 1 resident (Resident #32) of 2 residents reviewed for dressing change. The findings include: Review of the facility policy titled, Infection Control, dated 1/13/2020, showed .It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections .All staff shall wash their hand .after handling contaminated objects . Medical record review showed Resident #27 was admitted to the facility on [DATE] with diagnoses including Fracture of shaft Left tibia, Heart Failure, Chronic Obstructive Pulmonary Disease, Muscle Weakness, Reduced Mobility, and Abnormalities of Gait. Medical record review of a skin evaluation dated 6/22/2021 showed Resident #27 had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review, observation and interview, the facility failed to store a medication at the proper temperature in 1 of 3 medication carts and failed to dispose of expired medications and supplies available for resident use in 1 of 2 medication storage rooms. The findings include: Review of the facility policy, Storage and Expiration Dating of Medications, Biologicals Syringes and Needles, updated 10/28/2019, revealed .Facility should ensure that medications and biologicals are at their appropriate temperatures .should destroy or return all discontinued, outdated/expired or deteriorated .in accordance with .guidelines .laws . Observation with Licensed Practical Nurse (LPN) #3, on 6/29/2021 at 8:12 AM, on the 200 hallway revealed 1 opened bottle of acidophilus (probiotic) stored on the medication cart, with medication bottle labeled to refrigerate after opening. During an interview on 6/29/2021 at 8:12 AM, LPN #3 confirmed the medication had not been refrigerated and was available for resident use. Observation with LPN #1 on 6/30/2021 at 10:20 AM, in the Oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the Minimum Data Set (MDS), and interview, the facility failed to complete a quarterly assessment for 1 resident (#2) of 16 residents reviewed for MDS of 16 sampled residents. The findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Cerebrovascular disease, Essential Hypertension, Dysphagia, Muscle Weakness, Gastro-Esophageal Reflux Disease, Hyperlipidemia, Generalized Anxiety Disorder, Dementia with Behavioral Disturbance, Vascular Dementia with Behavioral Disturbance, Major Depressive Disorder, Insomnia, Hemiplegia and Hemiparesis, Insomnia, Post Traumatic Seizures, and Delusional Disorders. Medical record review revealed the annual MDS was dated 10/11/18. Continued review revealed a quarterly MDS had not been completed for 1/2019. Interview with the MDS coordinator, Licensed Practical Nurse #1 confirmed the MDS for 1/2019 had not been completed as scheduled .the system didn't pull it forward .it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview the facility failed to implement a baseline care plan for 1 resident (#148) related to vision impairment of 16 residents sampled. The findings include: Medical record review revealed Resident #148 was admitted to the facility on [DATE] with diagnoses of Legal Blindness, Other Reduced Mobility, and Acquired Absence of Right Leg Below the Knee. Interview with Resident #148's family on 2/10/19 at 12:12 PM, in the resident's room, revealed she required assistance with meal set up and food preparation due to her vision impairment. Medical record review of Resident #148's interim care plan revealed no identified risk, goal, or interventions in place for vision impairment. Interview with the Director of Nursing (DON) on 2/10/19 at 2:44 PM, in the training room, confirmed no interim care plan was initiated for Resident #148's vision impairment.

Based on facility policy, observation, and interview the facility failed to complete and post the direct care daily staffing roster for 1 of 3 staffing rosters posted for 2-10-19. The findings include: Review of the facility policy Posting Direct Care Daily Staffing Numbers, revised 7/2016, revealed .1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses .and the number of unlicensed nursing personnel .directly responsible for resident care will be posted in a prominent location .and in a clear and readable format . Observation on 2/10/19 at 10:28 AM, in the Wellness Center Nurse's station, revealed the direct care staffing roster posted was dated 2/9/19. Interview with Licensed Practical Nurse (LPN) #3 on 2/10/19 at 10:28 AM, in the Wellness Center Nurse's station, confirmed the direct care roster had not been updated and posted for 2/10/19. Interview with the Director of Nursing (DON) on 2/10/19 at 2:20 PM, in the admission nurse's office, confirmed the staffing roster should be posted and updated daily. Further interview confirmed the staffing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observation and interview, the facility failed to ensure expired over the counter medications were not available for resident use in 1 medication storage room of 2 medication storage rooms observed. The findings include: Facility policy review of the Storage of Medications policy revised 4/2017 revealed . The facility shall not use .outdated .drugs .All such drugs shall be .destroyed . Facility policy review of the Administering Oral Medications policy revised 10/2010 revealed .Check the expiration date on the medication . Observation with Licensed Practical Nurse (LPN) #2 on [DATE] at 10:00 AM, in the Wellness Medication Storage room [ROOM NUMBER], revealed 1 bottle of Citracal Calcium Supplement 500 International Units with Calcium 400 milligram had expired on 11/2018 and was available for resident use. Interview with LPN #2 on [DATE] at 10:00 AM, in the Wellness Medication Storage room [ROOM NUMBER], confirmed the Citracal Calcium Supplement was expired and available for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to act on a pharmacy recommendation with a rationale for declining the recommendation for 1 resident (#20) of 5 residents reviewed for unnecessary medications, of 16 residents reviewed. The findings include: Review of a facility policy Medication Regimen Review with an effective date of 12/1/17, revealed . 7.1 The attending Physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any action had been taken to address it . 7.2.1 If the attending Physician has decided to make no change in the medication, the attending Physician should document the rationale in the resident's health record . Medical record review revealed Resident #20 was admitted on [DATE] with diagnoses including Diabetes Mellitus Type 2, Abnormalities of Gait and Mobility, Weakness, Recurrent Depressive Disorder, Delusional Disorder, and Anxiety Disorder. Medical record review of a Pharmacy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and interview, the facility failed to provide an evaluation and rationale for the continued use of an as needed (PRN) antianxiety medication beyond 14 days for 1 Resident (#44) of 5 residents reviewed for unnecessary medications of 16 residents sampled. The findings include: Medical record review revealed Resident #44 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses including Pneumonia, Chronic Obstructive Pulmonary Disease, Unspecified Symptoms Involving Cognitive Function and Awareness, and Cognitive Communication Deficit. Medical record review of the Pharmacist Consultation Report dated 1/20/19 revealed a recommendation to discontinue the PRN Xanax (an anti-anxiety medication) or provide rationale for the continued use beyond 14 days. Continued review revealed an evaluation or rationale was not provided for the continued use of the Xanax. Medical record review of the 5 day minimum data set (MDS) dated [DATE] revealed Resident #44 scored a 10 on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observation and interview, the facility failed to properly store laboratory specimens and medications separately in 1 medication refrigerator in 1 medication storage room of 2 medication storage rooms and refrigerators observed. The findings include: Facility policy review of the Storage of Medication Requiring Refrigeration reviewed and revised 1/2019 revealed .Refrigerators used for the storage of medications and biologicals .Used solely for the purpose of storing medications and biological that require refrigeration .Not used for food, blood or blood products or specimen storage . Observation with Licensed Practical Nurse #2 on 2/12/18 at 10:00 AM, in the Wellness Medication Storage room [ROOM NUMBER], revealed 1 undated, unlabeled urinalysis specimen cup with urine in a clear unsealed plastic bag stored in the medication refrigerator. Interview with LPN #2 on 2/12/18 at 10:00 AM, in the Wellness Medication Storage room [ROOM NUMBER], confirmed the urine was not properly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.