Wurtland Nursing and Rehabilitation

Inspectors wroteBased on interviews, record review, and review of the facility's documents and policy, the facility failed to ensure the physician was notified of a change in condition when the resident began showing signs of fluid overload. Resident (R) 117 experienced a significant weight gain of 17 pounds in 13 days, from [DATE] to [DATE], while a resident at the facility. The facility's failure to recognize and notify the physician of the resident's condition change beginning on [DATE] resulted in a delay in intervention and treatment for the resident. The resident was admitted to the hospital on [DATE] with diagnoses of fluid overload and myocardial infarction and expired at the hospital on [DATE], approximately eight hours and forty-five minutes after his arrival at the hospital. The deficient practice affected 1 of 35 residents reviewed for physician notification. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's documents and policies, the facility failed to develop and implement a comprehensive care plan to ensure the care plan met each of the resident's medical, nursing, mental and psychosocial needs identified on his/her comprehensive assessment for 1 of 35 residents reviewed for comprehensive care plans, Resident (R) 117. R117 gained 17 pounds in 13 days while a resident at the facility from [DATE] through [DATE], a significant weight gain with exhibited signs of edema. The resident was sent to the hospital on [DATE] and admitted with diagnoses of fluid overload and myocardial infarction (heart attack). The resident expired at the hospital on [DATE], approximately eight hours and forty-five minutes after his arrival at the hospital. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policies, the facility failed to recognize a change in a resident's condition, to ensure the resident received quality of care based on the facility's identified care and treatment needs for the resident and failed to ensure professional standards of practice for the resident's care were provided that would meet the resident's physical, mental, and psychosocial needs for 1 of 35 sampled residents reviewed for quality of care concerns, Resident (R) 117. R117 gained 17 pounds in 13 days, a significant weight gain with exhibited signs of edema, while a resident at the facility from [DATE] through [DATE]. The facility's failure to recognize the weight gain as a sign of a change in condition beginning on [DATE] resulted in a delay in intervention and treatment for the resident. [...]

Inspectors wroteBased on observation, interview, record review, review of the facility's incident report, and review of the facility's documents and policy, the facility's staff failed to follow a menu for a resident on a puree diet for 1 of 11 sampled residents, Resident (R) 76. Review of the facility's Incident Report, revealed R76 was provided the wrong texture of diet on 01/08/2026, which caused the resident to choke. Actual harm was identified with the highest scope and severity (S/S) of a G.The facility provided an acceptable Removal Plan alleging the removal of the G on 01/28/2026, prior to the State Survey Agency (SSA) initial entrance to the facility on [DATE]. The SSA validated removal of the G and determined the G to be past noncompliance.

Inspectors wroteBased on observation, interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policies, the facility failed to 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 diseases and infections for 2 of 28 sampled residents, Resident (R) 13 and R84.

Inspectors wroteBased on review of the facility's documents contained in the facility provided binder and interview, the facility failed to ensure results of their surveys, certifications and complaints, made during the three preceding years, and any related plans of correction, were available for any individual to review upon request, which would potentially affect all 111 current residents in the facility.

Inspectors wroteBased on interview, record review, and review of the facility's documents and policy, the facility failed to provide a required transfer form to the resident's representatives for 2 of 2 residents reviewed for hospitalizations, Resident (R) 36 and R117.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop and/or implement a comprehensive person-centered care plan to meet the needs of five (Resident (R) 80, R27, R52, R36, and R124) of 32 sampled residents The facility failed to develop specific, effective interventions for staff to follow and /or ensure that approaches were implemented to meet each resident's needs.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to provide necessary services to maintain good personal and oral hygiene for six (Resident (R)362, R27, R90, R52, R79, and R22) of 14 sampled residents investigated for activities of daily living care, The facility failed to provide timely incontinence care for R362, R27, R90, R52, and R79, with residents expressing feelings of embarrassment and humiliation due to the facility's failure to provide incontinence care as needed to meet the needs of the residents. Interviews with the residents and their family members revealed they complained the residents often waited a long time (approximately 4 hours) before staff could change the residents resulting in the residents urinating in their beds and lying in urine for long periods. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for three residents (Resident (R)124, R80, and R36) reviewed for quality of care. Facility staff failed to ensure medicated shampoo was applied correctly for R80, who had ongoing itching from a scalp condition. In addition, staff failed to provide appropriate services when providing care to R36's prosthetic eye. Staff failed to ensure a dressing was changed according to physician orders for R124.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents received care to prevent pressure ulcers from developing and promote healing consistent with professional standards of practice for two (Resident (R) 27 and R10) of six sampled residents reviewed for pressure ulcers. R27 and R10, who were dependent on staff for pressure prevention interventions including prompt incontinence care and turning/repositioning, each developed facility-acquired pressure ulcers.

Inspectors wroteBased on observation, interview, record review, review of facility staffing documentation and review of the facility's Payroll Based Journal (PBJ) [NAME] report, the facility failed to have an effective system in place to ensure sufficient, qualified, nursing staff with the appropriate competencies and skill sets was present in sufficient numbers to provide nursing and related services to residents. The facility failed to provide nursing services to meet the assessed needs of the residents according to each resident's care plan and in a manner that promoted each resident's rights, physical, mental, and psychosocial well-being. A lack of sufficient, competent staff has the potential to affect the total census of 109 residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive for eight of 13 sampled residents reviewed for advanced directives. (Resident (R) 93, R124, R17, R102, R5, R76. R12, and R36).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to notify the resident and/or the resident's representative(s) in writing of the specific reasons for transfer to another facility for five (Residents (R) 6, R61, R62, R12, and R84) of seven residents reviewed for hospitalization.

Inspectors wroteBased on observations, interview, record review, and review of the manufacturer's instructions, the facility failed to store medications at the correct temperature. Insulin was stored below the recommended temperature range of 36 degrees Fahrenheit (F) and 46 degrees F in two of four medication refrigerators.

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of manufacturer's directions for use (DFU), and review of the facility's policies, the facility failed to implement its infection prevention and control policies and procedures and identify and correct problems relating to infection prevention practices to help prevent the development and transmission of communicable diseases and infections. Additionally, the facility failed to ensure that food items used during medication administration were properly dated when opened and kept on ice during use, for 5 of 5 medication carts observed, 3 medication carts on the Back Hall and 2 medication carts on the Front Hall. 1. Observation of room [ROOM NUMBER], a droplet precaution room, on 03/31/2025 revealed a CDC Droplet Precaution sign on the door. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a reasonable accommodation of resident needs related to call lights for three (Resident (R) 21, R27, and R91) of six residents reviewed for environmental concerns. Call lights were out of reach and not accessible to residents, two of whom were verbally calling out for assistance.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to develop a baseline care plan within 48 hours that included the minimum instructions needed to provide effective and person-centered care that met professional standards of quality care for one of 32 sampled residents (Resident (R) 93). The facility admitted R93 with pressure ulcers present; however, neither the identification nor treatment of R93's pressure ulcers were addressed on his baseline care plan.

Inspectors wroteBased on observation, interview, record review, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines, it was determined the facility failed to provide care and treatment to prevent and/or treat urinary tract infections (UTI) in accordance with accepted standards of practice for two (Resident (R) 1 and R125) of seven sampled residents who had an indwelling urinary catheter. R1 and R125's catheter collection bags were not secured and were, instead, on the floor. In addition, the facility failed to take immediate action when R1 presented with indicators of a urinary tract infection.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure residents received appropriate treatment and services to prevent complications of enteral feeding for one (Resident (R) 62) of two sampled residents reviewed for tube feeding. After failing to receive all ordered nutrition and fluids via gastrostomy tube (g-tube), R62 was hospitalized with severe dehydration and hypernatremia (elevated blood sodium levels).

Inspectors wroteBased on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure pain management was provided as ordered for one (Resident (R) 119) of five sampled residents reviewed for pain. The facility failed to ensure pain medication was reordered timely and available to the resident per the physician's orders and comprehensive care plan.

Inspectors wroteBased on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for the Front Hall Medication Storage Room and the Back Hall Medication Storage room. Observations on 10/23/19 revealed one (1) expired vial of PPD (purified protein derivative, diluted Aplisol 5TU/0.1ml) in the Back Hall Medication Storage Room Refrigerator. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for one (1) of twenty-four (24) sample residents, (Resident #20), that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Resident #20 was prescribed the medication (Depakote) for behaviors but there was no documented evidence the facility developed and implemented a care plan specific to his/her behaviors.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the Medication Regimen Review (MRR) was completed for one (1) of twenty-four (24) sampled residents, (Resident #20). Record review revealed no documented evidence the MRR was completed for Resident #20 for the month of September 2019.