Wheat State Manor

Inspectors wroteThe facility identified a census of 31 residents. The sample included 12 residents. Based on record reviews and interviews, the facility failed to establish and implement an admissions agreement that protected residents' right to personal property when the facility's admission agreement, signed by residents or their representatives at time of admission, asked the resident to waive facility responsibility for loss of personal property while being a resident in the facility.

Inspectors wroteThe facility reported a census of 31 residents. The sample included 12 residents. Based on observation, interview and record review, the facility failed to use adequate hand hygiene when caring for residents including during a dressing change and intravenous (IV-administered directly into the bloodstream via a vein) treatment.

Inspectors wroteThe facility reported a census of 31 residents. Based on interview and record review the facility failed to implement an effective antibiotic stewardship program that included an effective system to monitor antibiotic use, and/or an effective system to track and trend infections in the building for the facility's Infection Prevention and Control Program (IPCP).

Inspectors wroteThe facility identified a census of 31 residents over four resident halls. Based on observation, record review, and interviews, the facility failed to ensure an adequate resident call system when the two call light visual display monitors, which were the only alert system for resident bedroom and bathroom call lights, were left unmonitored resulting in extended call light response times.

Inspectors wroteThe facility reported a census of 31 residents, the sample included 12 residents. Based on interview and record review, the facility failed to inform Resident (R) 6, R2, R4, R5 and R28 and/or their representative regarding the risks related to psychotropic (alters mood or thoughts) medications.

Inspectors wroteThe facility reported a census of 31 residents, the sample included 12 residents. The facility failed to allow and facilitate residents to exercise dining preferences related to timing of receiving room trays and eating in the room versus the main dining area.

Inspectors wroteThe facility reported a census of 31 residents; the sample included 12 residents. Based on interview, observation, and record review, the facility failed to protect the dignity of resident (R) 8; when he was transferred through the facility without a dignity cover on his urine collection bag, leaving his urine visible to other residents and visitors.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents with three residents reviewed for hospitalization. Based on interview and record review, the facility failed to provide a bed hold and written notification transfer for Resident (R) 30. The facility additionally failed to notify the Office of the Long-Term Care Ombudsman (LTCO). This placed the resident at risk for impaired rights related to returning to the facility.

Inspectors wroteThe facility identified a census of 31 residents. The sample included five residents with five residents sampled for quality of care. Based on observation, interview, and record review, the facility failed to provide care and services for no pressure related skin issues for Resident (R) 33 when staff failed to change the dressing as ordered by the physician.

Inspectors wroteThe facility identified a census of 31 residents; the sample included 12 residents with six reviewed for accident hazards. Based on observation, interview, and record review, the facility failed to provide an environment free from accident hazards for Resident (R)11 when staff did not ensure the resident had a call light within reach and propelled the residents in a wheelchair without foot pedals.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 12 residents including five residents reviewed for unnecessary medications. Based on record review, interview and observation, the facility failed to monitor bowel movements for Resident (R) 2 and follow the physician orders to administer medications for constipation after a 13 day interval with no bowel movements documented.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to prevent significant medication errors for Resident (R) 2, R4, and R6, who did not receive medications as ordered.

Inspectors wroteThe facility reported a census of 31 residents. Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing sheets included accurate and identifiable information to include the actual hours worked, as required.

Inspectors wroteThe facility reported a census of 38 residents with three residents reviewed for Medicare Advance Beneficiary and Medicare Non-Coverage Notices. Based on interview and record review, the facility failed to ensure three Resident (R) 40, R95 and R 96 received the Center for Medicare/Medicaid Services (CMS) form 10123 (for the right of expedited review of discontinuation of services) as required when skilled services ended. In addition, the facility failed to issue CMS 10055 (the right to continue skilled services and cost of the services) to R40 as required.

Inspectors wroteThe facility reported a census of 38 residents with five residents reviewed for Covid-19 vaccinations. Based on interview and record review, the facility failed to ensure the residents of the facility received up to date Covid vaccinations, if desired, and failed to ensure residents were given the opportunity to rescind previous year declination.

Inspectors wroteThe facility reported a census of 38 residents with 13 residents selected for review, which included one Resident (R)20, reviewed for Pre-admission Screening and Resident Review (PASRR) Level two. Based on observation, interview, and record review, the facility failed to obtain a reassessment for R20 to determine mental health needs as required.

Inspectors wroteThe facility reported a census of 38 residents with 13 residents sampled. Based on observation, interview, and record review, the facility failed to review and revise the care plan for one Resident (R)19 regarding the use of eyeglasses.

Inspectors wroteThe facility reported a census of 38 residents with 13 residents sampled, including one resident reviewed for vision. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)19 received adequate assistive devices to maintain proper vision, by failing to have her glasses repaired in a timely manner.

Inspectors wroteThe facility reported a census of 38 residents with 13 residents selected for review, which included five residents selected for review for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)13 received reevaluation for continued use of as needed (PRN) psychotropic (medication that alters mood or thought) , and R11 related to lack of an abnormal involuntary movement scale (AIMS) to monitor for adverse effects of antipsychotic medications.

Inspectors wroteThe facility reported a census of 38 residents. Based on observation, record review, and interview, the facility failed to display accurate, publicly accessible, and identifiable staffing information, daily, for the 38 residents who reside in the facility.

Inspectors wroteThe facility reported a census of 39 residents with 16 residents sampled, which included three residents for pressure ulcer/injury. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure of staff to change gloves and perform proper hand hygiene between phases of wound care for Resident (R)2 and R3. This deficient practice has the potential to lead to cross contamination between residents and negatively affect the residents that resided in the facility.

Inspectors wroteThe facility reported a census of 39 residents, with three residents sampled. Based on interview and record review, the facility failed to ensure the resident/resident's representative for Resident (R) 8, the right to be fully informed, in advance, of the risks and benefits of proposed care (initiation of antipsychotic [class of medications used to treat psychosis and other mental emotional conditions] and of treatment and treatment alternatives, as well as the right to choose options/treatments. On 11/14/23, R8's provider ordered Rexulti (atypical antipsychotic medicine for depression and agitation that may happen with dementia due to Alzheimer's disease) and failed to notify the resident's representative of the new order for the Rexulti.

Inspectors wroteThe facility reported a census of 39 residents, with one resident reviewed for unnecessary medication. Based on interview and record review, the facility failed to ensure Resident (R)1, received the physician's ordered medication of Fentanyl patch (a controlled medication patch used for severe pain), when staff applied Fentanyl 200 micrograms (mcg), when the physician ordered 112 mcg. The facility failed to notify the physician, perform any necessary clinical interventions, record the medication as given in the clinical record, observe, assess outcome of the elder and document in the clinical record, record any actions, clinical interventions necessary, report the error on the incident report and record notification of family in clinical record with any stated response, education and questions. Facility staff also failed to notify the facility administrative staff.

Inspectors wroteThe facility reported a census of 46 residents with seven selected for review and one resident reviewed for abuse. Based on observation, interview, and record review the facility failed to protect the residents from verbal abuse from Licensed Nurse (LN) G. On the morning of 08/26/23, Certified Nurse Aide (CNA) M heard LN G threaten to hit Resident (R) 2 and CNA N heard LN G threaten R2 if she hit her again, she would be sorry. CNA N failed to report the verbal abuse and CNA M reported the verbal abuse to LN H. LN H failed to notify Administrative Nurse D. LN G worked three shifts after the verbal abuse on 08/26/23, 08/27/23, and 08/28/23 until Administrative Nurse D was made aware of the occurrence on 08/31/23. Failure to report the verbal abuse to Administrative Nurse D immediately placed all residents in the facility in immediate jeopardy.

Inspectors wroteThe facility reported a census of 46 residents with seven selected for review and one resident reviewed for abuse. Based on observation, interview, and record review the facility failed to protect the residents from verbal abuse from Licensed Nurse (LN) G. On the morning of 08/26/23, Certified Nurse Aide (CNA) M heard LN G threaten to hit Resident (R) 2 and CNA N heard LN G threaten R2 if she hit her again, she would be sorry. CNA N failed to report the verbal abuse and CNA M reported the verbal abuse to LN H. LN H failed to notify Administrative Nurse D. LN G worked three shifts after the verbal abuse on 08/26/23, 08/27/23, and 08/28/23 until Administrative Nurse D was made aware of the occurrence on 08/31/23.

Inspectors wroteThe facility reported a census of 47 residents. Based on interview and record review, the facility failed to ensure nursing staff proactively followed the principles of antibiotic stewardship to ensure antibiotics were used in a safe and effective manner to prevent adverse effects of antibiotics to the residents of the facility.

Inspectors wroteThe facility reported a census of 47 residents with 15 residents sampled, including two residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to provide privacy to enhance two dependent Residents (R)36 and R 42, dignity while performing perineal hygiene cares.

Inspectors wroteThe facility reported a census of 47 residents with 15 selected for review. Based on observation, interview and record review, the facility failed to review and revise the care plan for one of the 15 residents (R12) when the resisdent slept in and staff failed to administer morning medications as ordered by the physician.

Inspectors wroteThe facility reported a census of 47 residents with 15 selected for review, with three reviewed for activities of daily living. Based on observation, interview and record review, the facility failed to provide bathing, grooming and oral care for one resident (R)12, of the three residents reviewed for activities of daily living.

Inspectors wroteThe facility reported a census of 47 residents with 15 residents included in the sample, including two residents reviewed for pressure ulcers (PU). Based on interview, record review and observation, the facility failed to reposition one Resident (R)42 timely to prevent the development of PUs and failed to appropriately change the dressing for R 10's pressure ulcer.

Inspectors wroteThe facility reported a census of 47 residents with 15 selected for review with two residents reviewed for restorative services/range of motion. Based on observation, interview and record review, the facility failed to provide one of the two residents, (R)12 with a finger positioning device to assist in maintaining anatomical alignment of this resident's hand.

Inspectors wroteThe facility reported a census of 47 residents with 15 residents sampled, including four residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to keep one dependent Resident (R)14 safe while drinking hot coffee, failed to safely propel one dependent resident R36 in a wheelchair, and failed to initiate interventions following two falls for R 36.

Inspectors wroteThe facility reported a census of 47 residents with 15 residents sampled, including four residents reviewed for bowel and bladder. Based on observation, interview and record review, the facility failed to provide appropriate peri-care for two Residents (R)33 and R 36 to prevent urinary tract infections and failed to provide catheter care appropriately to prevent urinary tract infections for one R 37.

Inspectors wroteThe facility reported a census of 47 residents with 15 selected for review and 6 reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to accurately administer physician ordered medications for one of the six sampled residents, (R)12, on at least seven occasions.

Inspectors wroteThe facility reported a census of 47 residents with six selected for review for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure timely and follow up on the pharmacist recommendations for two of the six residents reviewed, including resident (R) 33and 13.

Inspectors wroteThe facility reported a census of 47 residents with 15 selected for review which included six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to monitor physician ordered daily weights for one of the six sampled residents (R)28 to determine appropriate administration need for Lasix (a medication used to remove fluid from the body) as needed, per the physician's order.

Inspectors wroteThe facility reported a census of 47 residents with six residents selected for unnecessary medication use. Based on observation, interview and record review, the facility failed to ensure as needed psychotropic medications did not exceed the 14-day administration without physician reevaluation, specification of target symptoms, and duration, for two of the six residents (R)33 and R13.