Wharton Nursing and Rehabilitation Center

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for tracheostomy care. 1. The facility failed to ensure staff caring for Resident #1 were aware of the location of emergency equipment or how to use it in case of accidental extubation of his tracheostomy (a medical emergency where the tracheostomy tube is inadvertently removed. A tracheostomy is a surgically created opening in the neck leading into the trachea to assist with breathing, often using a tube to maintain the airway). 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets to care for resident's needs, as identified through resident assessments and described in the plan of care for 4 of 8 nurses (RN A, LVN O, DON and RCS) reviewed for competency.1. The facility failed to ensure RN A and LVN O, who were assigned to care for Resident #1, were aware of the location of emergency equipment or how to use it in case of accidental extubation of his tracheostomy. 2. The facility failed to ensure the DON and RCS were aware of tracheostomy sizes and the size Resident #1 required based on his physician's order. An Immediate Jeopardy (IJ) situation was identified on 2/5/26. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and supervision: The facility failed to supervise Resident #1 who eloped from the facility on 12/5/2024. An Immediate Jeopardy (IJ) was identified as past non-compliance on 03/05/25. The non-compliance began on 12/05/24 and ended on 12/06/24. The facility had corrected the non-compliance before the investigation began on 03/04/25. This deficient practice could place at-risk for elopement residents at-risk of harm, serious injury, or death.

Inspectors wroteBased on interviews and record reviews the facility failed to provide routine and emergency drugs and biologicals to residents for 1 of 6 residents (Resident #2) reviewed for pharmacy services. The facility failed to administer Resident #2's dementia medication, Memantine 10mg twice daily (a cognitive enhancer also known as Namenda) as prescribed, as the medication was never added to her MAR until the day she was discharged . As a result of this failure, Resident #2 missed all doses of her Memantine 10mg twice daily for 47 days between 07/12/2024 through 08/27/2024. This failure could place residents at risk of not achieving the therapeutic effects intended by the physician.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.