Wharton Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to ensure dialysis residents received services consistent with standards of practice, comprehensive person-centered care plan, and the residents' goals and preferences for 1 out of 5 residents (Resident # 2) reviewed for quality of care. The facility failed to document Resident # 2 dialysis communication sheets of snack or food prior to dialysis treatment, list specific chair time of treatment and record all vitals once Resident #2 returned from treatment.The facility failed to document the monitoring of Resident # 2's daily nutrition intake for all meals, refusal of meals, as well as any meal substitutions or offers.This failure could place dialysis residents at risk of not receiving adequate care and services, lethargy, weakness, and dialysis residents with diabetes at risk for low blood sugar and or hypoglycemia resulting in decreased quality of life. Findings include: Resident # 2 Record review of Resident # 2;s admission record revealed a [AGE]…

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 observation, interviews, and record review, the facility failed to ensure a resident with limited range in motion receives the treatment and services to increase range of motion, a person-centered care plan including specific interventions, equipment, frequency, duration and measurable objectives addressing hand contracture for 1 out of 5 residents (Resident # 4) reviewed for quality of care.The facility failed to ensure Resident #4's hand roll/ splint/ foam tubing was scheduled, used and monitored for left hand contracture and prevention of palm injury. The facility also failed to ensure Resident # 4 person-centered care plan addressed specific interventions with the use of equipment to address left hand contracture.This failure could place residents at risk diminished skin integrity, decreased range in motion resulting in a decreased quality of life.Findings include: Resident # 4 Record review of Resident # 4's admission record revealed an [AGE] year-old male with original admission date of 11/25/2020…

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 observation, interview and record review the facility failed to ensure a resident had a right to a safe, clean, comfortable and homelike environment, including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 8 residents (Resident #2) reviewed for environmental concerns.1. The facility failed to ensure there were not dried, thick streaks of mucus covering Resident #2's dresser and the walls surrounding his dresser spanning an area of approximately 5 feet by 5 feet. 2. The facility failed to ensure there were no crayon and/or pen marks of multiple colors on the wall next to Resident #2's bed.These failures could place residents at risk of a diminished quality of life due to exposure to an environment that was unpleasant, unsanitary, and unsafe.The findings include:Record review of Resident #2's admission Record generated on 2/6/26 revealed he was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, heart failure,…

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 interview and record review, the facility failed to ensure they did not employ an individual who was found guilty of a criminal offense barring employment by a court of law for 1 of 1 (CNA A) employees reviewed for abuse and neglect.The facility did not follow their policy on abuse when they screened CNA A for hire. CNA A had worked in the facility from 2/25/2025 through 6/27/2025. This failure could place residents at risk for possible abuse, neglect or exploitation. Findings included: Record review of an undated personnel file for CNA A indicated a hire date of 2/24/2025.Further review revealed a national background check had been conducted on 2/24/2025. It revealed CNA A had an offense date of 11/29/2023 and disposition date of 1/8/2025 charged with assault causing bodily injury statute: 22.01 (A) (1) - misdemeanor sentenced to 12-month probation; a $200 fine and $297.00 court costs. Record review of CNA A's time sheets revealed she worked 14 out of 30 days in June 2025. An interview on 7/1/2025 at…

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 observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to store a mop in the proper position in the utility closet. 2. The facility failed to store bowls and cups properly. 3. The facility failed to ensure the food preparation area was free of personal food and beverage items. These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness. The findings were: 1. Observation on 03/25/2025 at 10:58 AM revealed a soiled mop was stored head-side down in the drain compartment of a mop bucket in the utility closet. There was dirty water in the bottom of the bucket. The mop was not in use at the time of the observation. During an interview on 03/25/2025 at 11:19 AM, the regional dietary manager stated the mop should have been stored in an upright position on one of the hooks inside the utility closet to ensure it dried 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #81) whose comprehensive person-centered care plans were reviewed. The facility failed to ensure that Resident #81's diagnosis of depression was a focus area in the resident's comprehensive care plan. This deficient practice could affect residents by failing to ensure residents received appropriate care for their health conditions. The findings included: Record review of Resident #81's face sheet dated 08/21/2024 revealed the resident was a [AGE] year old female admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease (a progressive brain disorder that causes…

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 observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment, as well as to help prevent the development of communicable diseases and infections, for 1 of 3 residents (Resident #47) reviewed for infection control. The facility did not ensure that LVN (A) followed proper infection control practices, including hand hygiene /glove changes, while checking Resident #47's blood sugar. This failure could place residents at risk of contracting disease and infection. The findings included: Record review of Resident # 47's Face sheet, dated 3/27/25, revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included Type 2 diabetes (a disorder when the body cannot use insulin correctly and sugar builds up in the blood), Hyperlipidemia (excess of lipids or fats in your blood) and Hypertension (a common condition that affects the body's arteries). Record review of…

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 observations, interviews and record reviews, the facility failed to immediately consult with the residents' Physician; and notify her authority, the resident' representative when there was need to alter treatment for 1 of 1 resident (Resident # 1)reviewed for notification . The facility failed to notify Resident #1's physician and Relative # 1 when Resident # 1 experienced a change of condition including low blood sugar on 6/23/2024. This failure placed residents experiencing a delay in medical treatment and worsening of condition symptoms. Findings include: Record review of Resident # 1's face sheet, dated 12/7/2021, revealed she was [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with End Stage Renal Disease (a medical condition in which kidneys cease functioning on a permanent basis), Essential (Primary) Hypertension (high blood pressure), Type 2 Diabetes Mellitus with Hyperglycemia (high blood sugar levels), Dependence on Renal Dialysis ( someone's kidneys are no…

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 observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the walk-in refrigerator in that: -The facility stored unlabeled and unsealed foods in the freezer. This failure had the potential to place residents at risk of serious complications from foodborne illness as a result of their compromised health status. Findings Included: Interview and observations on 01/17/2024 at 8:22 AM with the Dietary Manager. In freezer #1 there were unlabeled bags of what the Dietary Manager identified as diced ham, chicken fried steak, and taquitos. The Dietary Manager said the bags should be labeled. Interview on 01/18/2024 at 9:05 AM with the Dietary Manager. He said he was responsible for ensuring residents are served what they needed and what they were supposed to have. He said he was responsible for the day-to-day things like inventory, ordering, training, and interviewing patients on their preferences He said the food items must be dated with the pick sticker. The pick…

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 observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for one waste receptacle reviewed for garbage disposal. -The waste receptacle had its top left lid opened when no one was disposing of trash. These failures could place residents at risk for exposure to germs and diseases carried by vermin and rodents. Findings include: Observation 01/17/2024 at 8:42 AM. The left lid on the outside dumpster was observed to be open. Interview on 01/18/2024 at 9:05 AM with the Dietary Manager. He said the policy on the dumpster was the lids should have been closed. He said it was difficult to close the lids and he said he would talk to the Maintenance director for something to help close the lids. He said the wind may have helped close or open the lid to the dumpster. He said he did not know who was responsible for ensuring the dumpster lid was closed. He said the risk to residents if policy were not followed was it could draw in rodents and pests, and they could then get into the building. Interview on 01/18/2024 at 11:01 AM with 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 observation, interview and record review, the facility failed to maintain an infection control program designed to ensure catheter changing procedures were followed by staff in the direct care for 2 (Resident #1 and Resident #2) of 5 residents reviewed for catheter care. The facility failed to change Resident #1 and Resident #2's foley catheters when ordered. These failures could place residents at risk for infection and blocked urinary catheters. Findings: Resident #1 Record review of Resident #1's Face Sheet revealed an [AGE] year-old male who was admitted on [DATE] with a diagnosis of Unspecified Dementia (Memory Loss), Heart Failure (Loss of heart Function), Pressure Ulcer Sacral Region (Wound to Buttock), Heart Disease (Blocked Arteries in the Heart), Muscle Wasting and Atrophy (Loss of Muscles). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 7 out of 15 indicating the resident was severely cognitively impaired. Resident #1 required extensive assistance with bed…

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 observation, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's respect and dignity for 1 (Resident #1) of 5 residents reviewed for dignity. The facility failed to provide dignity and respect for Resident #1 by leaving the residents privacy bag off his foley bag exposing the full urinary bag to open doorway. This failure placed resident and could place other residents at risk for embarrassment and low self esteem. Findings: Record review of Resident #1's Face Sheet revealed an [AGE] year-old male who was admitted on [DATE] with a diagnosis of Unspecified Dementia (Memory Loss), Heart Failure (Loss of heart Function), Pressure Ulcer Sacral Region (Wound to Buttock), Heart Disease (Blocked Arteries in the Heart), Muscle Wasting and Atrophy (Loss of Muscles). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 7 out of 15 indicating the resident was severely cognitively…

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 observation, interview and record review, the facility failed to maintain an infection control program designed to ensure a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 5 staff (CNA B) observed for hand hygiene. The facility staff failed to use proper handwashing technique when assisting Resident #3. This failure could place Resident #3, other residents and staff at risk for infection. Findings: Record review of Resident #3 s Face Sheet revealed a [AGE] year-old male who was admitted on [DATE] with diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety (Memory Loss), Unspecified Protein Calorie Malnutrition (Lack of Nutrition), Type 2 Diabetes (High Blood Sugars), Dysphagia (Difficulty Swallowing). Record Review of residents quarterly MDS dated [DATE] revealed a BIMS score of 0 out of 15 indicating severely cognitively impaired.…

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.