Worth County Convalescent Center

Inspectors wroteBased on interview and record review, the facility failed to inform residents and/or their responsible parties, in advance of the risks and benefits of proposed care, when the facility failed to obtain written consent before beginning psychotropic medications (medications that affect the mind, emotions, and behavior) for four (Resident #3, Resident #4, Resident #5, and Resident #30) of the 12 sampled residents. The facility census was 33. Review of the facility's Resident Participation - Assessment/Care Plans policy, revised 2016, showed the residents/representatives have the right to be informed, in advance (by the physician, practitioner, or professional) of the risks and benefits of the care or treatment proposed. 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to establish and maintain a system that assured a full and complete, separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf when monthly personal funds reconciliation showed an accumulating reimbursement deficit to the account due to monthly bank charges owed by the facility. This affected four of 12 sampled residents (Resident #3, #4, #7, and #12). The facility census was 33. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered plan which included measurable objectives and timeframes to address resident needs and preference when the care plans did not include Resident #29's preference for life saving measures or address Resident #34's desire to return to the community. The deficient practice affected two of the 12 sampled residents. The facility census was 33. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assure staff followed acceptable standards of practice for one sampled resident (Residents #4) of 12 sampled residents when facility licensed staff did not follow wound care orders correctly which placed the resident at risk for decline in physical health. The facility failed to ensure the setting on the low air loss mattress was correct for Resident #24. Additionally, the facility failed to ensure staff administered insulin correctly which affected three sampled residents (Resident #2, #7 and 11) of 12 sampled residents. The facility census was 33. The facility did not provide a policy for the Drive Low Air Loss Mattress (LAL mattress, is a therapeutic mattress designed to help prevent and treat pressure ulcers by controlling pressure and keeping the skin cool and dry). 1. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff provided a safe and effective administration system that was free of significant medication errors when staff failed to prime insulin pens prior to administering insulin which affected three of the 12 sampled residents, (Resident #2, #7 and #11). The facility census was 33. The facility did not provide a policy for administration of insulin or the use of insulin pens. 1. Review of Resident #2's Physician Order Sheet (POS) dated February 2026 showed: - Start date: 2/14/23 - Blood sugar per glucometer twice daily for diabetes mellitus. - Humalog insulin injection 12 units three times daily with meals for diabetes mellitus. Review of the resident's Medication Administration Record (MAR) dated February 2026 showed: - 2/25/26 - Blood sugar documented by staff as 184. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff properly labeled and dated opened insulin pens, which affected five of the 12 sampled residents, (Resident #2, #7, #11, #29, and #34), staff preset medications for Resident #10, #22 and #31. Additionally, staff taped seven Lorazepam (used to treat anxiety) tabs into the medication card which affected Resident #30. Resident #24 had an undated opened bottle of Morphine Sulfate (an Opioid used to treat moderate to severe pain) which was filled on 7/19/24. The facility census was 33. Review of the facility's policy for Drug/Medication Administration for Oral Medications, dated 7/29/13 showed: - The facility is committed to providing a safe environment for residents and staff. Medications will be administered in a safe and professional manner. [...]

Inspectors wroteBased on observation and interview, the facility failed to prepare and serve food in accordance with professional standards for food service safety when facility staff failed to properly monitor food storage temperatures. This had the potential to affect all residents in the facility. The facility census was 33. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow policy and screen six out of 10 employees for tuberculosis (TB - an infection disease characterized by the growth of nodules in the tissues, especially the lungs) prior to employment. The facility census was 33 residents. Review of facility policy, Employee Screening for Tuberculosis (TB) Policy and Procedure, revised 5/16/23, showed:- Each newly hired employee will complete a 2-step tuberculosis test prior to offer of employment and prior to employee's duty assignment. - Screening includes a baseline test, individual risk assessment and symptom evaluation.- All employees will complete a 1-step annual test following the new hire 2-step testing. - All potential employees will complete baseline testing prior to hire and before entering the facility. 1. [...]

Inspectors wroteBased on record review and interview, facility staff failed to prevent the misappropriation of one resident's (Resident #1) credit card which was used without authorization of the resident or the resident's financial guardian. The credit card was used between the dates of November 30, 2024 and February 22, 2025 with total charges to the card of $348.23. The facility census was 27 residents. Review of the facility policy titled,Abuse and Neglect, dated 4/10/24 showed: -It is the policy that all residents be free from financial exploitation; -Financial exploitation is a misappropriation of resident property. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful use of a resident's belongings, or money without the resident's consent; -The Administrator will conduct all investigations. A formal investigation shall begin immediately and include: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to maintain documentation and complete a thorough investigation of an alleged violation of misappropriation of resident funds after the facility was informed by the resident's Financial Power of Attorney, that Resident #1's debit card had unapproved charges from November 30, 2024 to February 22, 2025. The facility census was 27. Review of the facility policy tilted, Abuse and Neglect, dated 4/10/24 showed: -Financial exploitation is a misappropriation of resident property. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful use of a resident's belongings, or money without the resident's consent; -The Administrator will conduct all investigations. A formal investigation shall begin immediately and include: [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to update and revise the care plan with fall interventions for four of four sampled residents (Resident #1, #2, #3, and #4) who had experienced falls. The facility census was 27. Review of facility fall policy and procedure, dated 7/29/13. showed: -Falls are the most common injury sustained by residents in the long term healthcare setting. They are a major cause of injury and death among the elderly and debilitated patients. Environmental, physical, and psychological factors contribute to patient falls and the ensuing injuries. The goal of the fall program is to identify the resident who is at risk to fall, institute proactive efforts to reduce the occurrence of fall related incidents, respond, and provide a safe environment. [...]

Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate an allegation of injury of unknown origin when one resident (Resident #1) was found to have bruising that spread across his/her abdomen, perineal area, and legs. The facility failed to implement the abuse and neglect policy and failed to provide documentation that all staff working were interviewed, failed to interview facility residents, and failed to provide complete and thorough documentation of the investigation. This affected one of four sampled residents. The facility census was 27. Review of facility policy, abuse and neglect, dated 1/1/23, showed: -It is the policy of the facility that all residents will be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion, and financial exploitation. -All allegations of abuse will be investigated and documented. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when they did not close doors to COVID positive rooms, did not change gowns between COVID positive rooms, brought the roommate of a COVID positive resident to dining room for meals, and took off their N95 mask and applied a surgical mask prior to entering COVID positive rooms. The facility also failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections, when the facility failed to follow their policy regarding employee tuberculosis testing when they did not administer the second step of the test which affected five of 10 staff member selected for review. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they developed a comprehensive person-centered plan of care consistent with measurable objectives and timeframe to meet the residents medical, nursing, mental, and psychosocial needs for one (Resident #22) of twelve residents sampled residents. The facility census was 24. Review of the facility care plan policy, dated 2/2/17 showed: -Within 48 hours of admission all residents will have a baseline care plan which included the instructions needed to provide effective and person-centered care that meets professional standards of quality of care. - During the care plan process, the facility will include the resident and or resident representative and the assessment will include residents' strengths and needs and residents' personal and cultural preferences will be used in developing care plan goals. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop, review and revise comprehensive care plans with resident's specific conditions and needs, which affected eight of 12 sampled residents (Resident #5, #7 #9, #10, #15, #16, #18, and #25). The facility census was 24. Review of the facility's Care Plan policy, dated 2/2/17, showed: - It is the policy of the facility that each resident received the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being consistent with the resident's comprehensive assessment and care plan. - The facility wants to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan and the resident's choices. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform one of 12 sampled resident's (Resident #22) responsible party after the resident had an elopement from facility and staff applied a wander guard device to signal if he/she attempted to elope again. The facility census was 24. The facility did not provide policy regarding notifications. Review of Resident #22's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 5/5/23 showed: - Brief Interview Mental Status (BIMS), a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility, of 3 indicating the resident had severely impaired cognition; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete entrapment assessments for one of 12 sampled residents with side rails (Residents #20) to ensure the environment remained safe and free of accident hazards. The facility census was 24. Review of facility policy Bed Safety and Bed Rails, dated August 2022, showed: -Bed frames, mattresses, and bed rails are checked for compatibility and size prior to use -Bed dimensions are appropriate for resident's size -Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the FDA. -Maintenance staff routine inspects all beds and related equipment to identify risks and problems including potential entrapment risks. [...]