Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wharton Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with ESRD, DM, and malnutrition did not have dialysis communication forms completed with snack or food before transport, chair time, or post-dialysis assessment details. Meal intake, refusals, and substitutions were not consistently documented, and staff and family reported the resident often missed meals, did not receive alternatives, and had a hypoglycemic episode after insulin when he refused a meal tray.
Failure to provide and document contracture management for a resident with limited ROM. A resident with stiffness, muscle wasting, unsteadiness, cognitive deficits, and poly osteoarthritis had a left hand contracture and left palm abrasion, but the care plan and orders did not consistently include the foam roll/splint/orthotic equipment or the frequency of use. OT documented decreased hand and wrist ROM, recommended foam tubing progressing to an orthotic device, and set goals for wearing the tubing with minimal redness, swelling, discomfort, or pain.
A resident with dementia, prior septic shock, and a history of falls was on 72‑hour neuro checks after a fall with head injury when BP and HR dropped well below his established baseline, triggering first‑time use of PRN Midodrine ordered for SBP <90. An LVN administered the PRN Midodrine and documented it as effective, but there was no documented follow‑up assessment, no contemporaneous neuro‑check findings addressing the episode, and no notification to the provider despite the facility’s policy requiring consultation for significant changes in condition and new treatment. The next morning, staff observed new left‑sided facial droop, weakness, and inability to mouth words, EMS was called for possible stroke, and the resident was sent to the hospital, where he was found to be hypotensive and diagnosed with bilateral pneumonia, septic shock, and acute metabolic encephalopathy.
A resident with dementia, COPD, prior septic shock, and a history of falls had been placed on neuro checks after a recent fall with head injury. Despite previously stable BPs and pulses, the resident developed hypotension (81/48) and bradycardia (HR 55), for which an LVN administered PRN Midodrine per order. After this administration, there was no contemporaneous documentation of further assessment or monitoring of the resident’s condition, and neuro assessment entries for that day were signed late. The care plan did not address hypotension or bradycardia, the episode was not treated as a change in condition, and the NP and MD were not notified. About 21 hours later, the resident developed left-sided facial droop and weakness, was sent to the hospital, and was diagnosed with bilateral pneumonia, septic shock, and acute metabolic encephalopathy, leading surveyors to cite a quality of care deficiency and identify Immediate Jeopardy.
A resident with a tracheostomy and severe cognitive impairment experienced two trach dislodgement events during which nursing staff demonstrated lack of competency and preparedness in trach management. During one event, an RN found the trach out and sent the resident to the ED for replacement; during another, the trach came out while trach ties and gauze were being changed, and the RN reported not feeling comfortable replacing the full trach. Another nurse initially inserted a smaller trach because that was what was available at bedside, then later replaced it with the correct size after direction from the NP. Surveyor interviews showed that some nurses did not know how to replace a trach, were unaware of or could not locate complete emergency trach equipment at the bedside, and were unclear about trach sizing and the specific size ordered for the resident. Central supply and leadership staff also showed confusion about trach size designations, and the facility had no written respiratory or trach care policy, relying instead on an external nursing manual.
A resident with severe cognitive impairment, respiratory disorders, and a tracheostomy required ongoing trach care and had care plan directions for emergency management if the tube was coughed out. On two occasions, the trach became dislodged while nurses were providing care, leading to hospital transfers; in one case, staff reinserted the trach but were unsure of correct placement. Interviews showed that an RN and an LVN assigned to the resident did not feel comfortable or did not know how to replace a dislodged trach and were unaware of or untrained in using emergency equipment, while another LVN knew how to replace the trach but had not received trach training or a skills checkoff at this facility. The DON and RCS demonstrated confusion about trach sizes and the specific size ordered for the resident, despite documentation that nurse trach competencies had been marked as met, and the prior ADON reported that most nurses, including those involved, had not attended prior hands-on trach training and were uncomfortable with this care. These findings led surveyors to determine that the facility failed to ensure competent nursing staff for tracheostomy care and emergency response.
A resident with dementia and multiple chronic conditions, who had a known behavior of spitting on floors and walls, was found to have dried, thick mucus covering a large area of the dresser and surrounding walls, along with crayon or pen scribbles on the wall near the bed. Staff, including a CNA and supervisory personnel, acknowledged awareness of the spitting behavior and reported frequent need for cleaning, yet the room was observed in an unsanitary and unpleasant condition. This occurred despite a facility housekeeping policy requiring each occupied room to be cleaned and put in order daily and as needed.
A CNA with a recent assault conviction was hired and worked in the memory care unit after a background check revealed a disqualifying offense, in violation of state law and facility policy. The oversight occurred due to improper screening and lack of follow-up by the previous HRC, and was only discovered during a later personnel file audit.
The facility failed to adhere to food service safety standards, including improper storage of a soiled mop, inadequate air drying of dishes, and the presence of personal food items in the kitchen. These actions could risk foodborne illness for residents.
A facility failed to include depression as a focus area in a resident's comprehensive care plan, despite it being an active diagnosis. The omission occurred when the resident discontinued psychotropic medications, and the focus area listing the medications was removed, inadvertently excluding the depression diagnosis. The MDS RN and Regional Nurse Consultant acknowledged the oversight, emphasizing the importance of monitoring and addressing the resident's depression.
A facility failed to maintain proper infection control when an LVN did not change gloves between administering medications and checking a resident's blood sugar, leading to cross-contamination. The resident, with Type 2 diabetes and impaired cognition, was at risk due to this lapse. The LVN, recently hired and not fully trained in infection control, admitted to the error during a state surveyor's observation.
A resident with Alzheimer's disease and severe cognitive impairment, identified as an elopement risk, was able to leave the facility unsupervised by climbing over a fence using a chair. Staff initially failed to detect the resident's absence despite alarm activation and head counts, and the resident was later found at a nearby location. The facility did not provide adequate supervision or maintain a secure environment, resulting in a deficiency related to accident hazards and resident safety.
A resident with severe cognitive impairment and Alzheimer's disease did not receive her prescribed Memantine 10mg twice daily for 47 days because the medication was not added to her MAR upon admission, despite physician orders and care plan documentation. The omission was only discovered at discharge after family inquiry, and staff confirmed the medication should have been administered throughout the resident's stay.
A resident with diabetes and severe cognitive impairment experienced a critically low blood sugar level, but the nurse on duty did not notify the physician or family, believing the resident was not in distress. The resident's blood sugar dropped to 47 mg/dl, and although it returned to normal after a snack, the incident was not reported as required by facility policy, leading to a delay in medical treatment.
Dialysis Nutrition and Communication Documentation Not Completed
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care and services for a resident with ESRD, dialysis dependence, moderate protein-calorie malnutrition, and type 2 DM with hyperglycemia. The resident’s care plan identified dialysis needs and also identified unplanned weight loss and risk for malnutrition, with interventions to monitor and record food intake at each meal and provide supplements as ordered. The resident’s active orders included Nepro three times daily for weight loss and decreased appetite, as well as a renal-liberalized diet with a high-protein snack between meals. Record review of the dialysis communication forms showed that on multiple dialysis days the resident was sent to dialysis without a snack or food. The forms also did not document the day and/or chair time for treatment on several dates, and they did not show completion of assessment and observation after dialysis on some dates. Progress notes from the same period did not document daily food intake for each meal, refusals, or substitutions. The record also did not show that the resident was sent to dialysis with a high-calorie snack or received a meal prior to dialysis when a scheduled time at the facility was missed. The resident and family reported that the resident often did not eat facility meals, that family brought food for him, and that staff did not offer another meal or snack when he did not like the food. The resident reported refusing meals because food was cold and said staff did not warm it or offer anything else. A progress note documented that the resident had a hypoglycemic episode after receiving scheduled insulin and then refusing the meal tray; the note also stated he did not eat a snack or lunch tray and received a meal replacement shake after the episode occurred. Staff interviews confirmed expectations that dialysis residents should receive food or a snack before dialysis and that meal refusals should be addressed with an alternative, but the DON stated the facility did not have a dialysis policy because it did not provide the treatment.
Failure to Provide and Document Contracture Management for Left Hand ROM
Penalty
Summary
The facility failed to ensure a resident with limited range of motion received the treatment and services needed to increase range of motion and that the care plan included specific, person-centered interventions for left hand contracture. Resident #4 was an older male with diagnoses including stiffness of unspecified joint, muscle wasting and atrophy of the upper arm, unsteadiness on feet, cognitive communication deficit, unspecified intellectual disabilities, and poly osteoarthritis. The record showed a care plan for skin integrity problems related to an abrasion to the left palm, pain related to arthritis and left hand contracture, and physical mobility related to weakness and a contracted left hand, with interventions including a foam roll to the left hand, abductor wedge, halo bars, and monitoring for worsening contracture and skin breakdown. Record review showed the active order summary did not include an orthotic device or foam roller/abduction wedge for mobility intervention, and the task list did not indicate the frequency of foam roller use or splint use. Occupational therapy documentation stated the resident received therapy for contracture management and had decreased hand and wrist ROM, with recommendations to begin with foam tubing in the left palm and progress to larger tubing and eventually an orthotic carrot. OT goals included wearing orthotic foam tubing in the left palm for up to 2 hours, then up to 8 hours with minimal redness, swelling, discomfort, or pain. The OT progress report also noted the facility did not have a restorative program and nursing staff would continue promoting participation in ADL tasks such as contracture management after OT discharge.
Failure to Notify Provider of Significant Hypotension and Bradycardia During Neuro Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely physician notification of a significant change in condition for one resident who was under 72‑hour neurological monitoring following a fall with head injury. The resident was an older male with COPD, dementia, depression, anxiety, dysphagia after stroke, cognitive communication deficit, lack of coordination, and gastrostomy status. His admission MDS showed short‑ and long‑term memory impairment, moderate impairment in decision‑making, fluctuating inattention and disorganized thinking, altered level of consciousness, and wandering 4–6 days per week. He had a history of two or more falls with injury since admission. His care plan addressed falls, helmet use, and neurological checks per facility protocol, but did not identify problems or interventions related to hypotension or bradycardia. Prior to admission to the facility, the resident had been hospitalized for septic shock secondary to pneumonia and influenza A, requiring ICU care, vasopressors, antibiotics, and mechanical ventilation, and was started on Midodrine for hypotension. At the facility, he sustained a fall on 11/19 with a forehead laceration; he was evaluated in the ER, where CT imaging was negative for intracranial bleeding or fracture, and he returned to the facility for continued neurological assessments. Neurological assessment entries on 11/20 and 11/21 documented stable vital signs and normal findings, although one scheduled assessment on 11/21 at 9:45 PM was not documented. On 11/22 at 5:45 AM, a neurological assessment entry documented normal findings and stable vital signs, and additional neurological entries for that date were later signed, but there was no contemporaneous documentation of abnormal neurological findings. The resident’s MAR showed that from 11/8 through 11/21, his BP readings were consistently above 110/60 and his pulse consistently above 60 bpm. On 11/22, his day‑shift BP dropped to 97/52 with a pulse of 56, and a vital signs log entry at 9:09 AM documented a further drop to 81/48 with HR 55. A PRN order for Midodrine 5 mg q8h PRN for systolic BP <90 had been in place since 11/7 but had never been used before. At 9:06 AM on 11/22, an LVN administered Midodrine due to the BP of 81/48 and HR 55 and documented the administration as effective, but there was no further assessment or monitoring documented after this episode and no documentation that the physician was notified of the hypotension, bradycardia, or first‑time use of the PRN Midodrine. Progress notes for 11/22 contained no additional entries after 9:06 AM regarding the resident’s status. On the following day, 11/23 at 5:57 AM, vital signs were recorded as BP 110/56 and HR 60, and a progress note at 5:58 AM documented that the prior PRN Midodrine dose was effective, without describing how effectiveness was determined. At approximately 6:30 AM, staff observed the resident with new left‑sided weakness and facial drooping after a shower, and he was unable to mouth words as he typically did. A change in condition note at 7:08 AM documented left‑sided facial droop, left‑sided weakness, hemiparesis, and vital signs including BP 102/58 and pulse 51. EMS was called for possible stroke, and EMS records noted a pulse of 45 bpm and bilateral lower extremity swelling, with staff reporting onset of symptoms around 6:30 AM. Hospital records later documented that upon evaluation in the emergency department, the resident was hypotensive and diagnosed with bilateral pneumonia, septic shock, and acute metabolic encephalopathy. Interviews with the DON, NP, and MD confirmed that the provider was not notified at the time of the 11/22 hypotension and bradycardia episode, and the DON stated she would not have considered the decrease in BP and HR with first‑time PRN Midodrine use to be a change in condition requiring physician notification, despite the facility’s Notification of Changes policy requiring consultation with the physician for significant changes in condition or new treatment.
Failure to Assess and Monitor Resident After Hypotension and PRN Midodrine Use
Penalty
Summary
The deficiency involves the facility’s failure to assess, monitor, and respond appropriately to a resident’s episode of hypotension and bradycardia, and to provide care in accordance with professional standards of practice and the resident’s person-centered care plan. The resident was an older male with COPD, dementia, depression, anxiety, dysphagia after stroke, cognitive communication deficit, lack of coordination, and a gastrostomy. His admission MDS showed short- and long-term memory impairment, moderate impairment in decision-making, fluctuating inattention and disorganized thinking, altered level of consciousness, wandering several days per week, and a history of two or more falls with injury since admission. His care plan addressed falls with interventions such as helmet use and neurological checks per facility protocol, but there were no identified problems or interventions related to hypotension or bradycardia, despite a documented history of severe hypotension and septic shock in a prior hospitalization where he had been treated with vasopressors and started on Midodrine. In the days preceding the cited event, the resident had a fall with a head injury, was sent to the ER, and returned with negative CT results. The facility initiated neurological assessments after the fall, with multiple entries showing stable vital signs and normal neurological findings. However, documentation gaps were present: there was no neurological assessment entry for one scheduled time on 11/21, and several neurological assessment entries for 11/22 were signed late by a nurse who was scheduled as ADON and whose timesheet reflected only a few hours worked that day. The resident’s routine vital signs from 11/8 through 11/21 showed systolic blood pressures consistently above 110 and pulses above 60 bpm. On 11/22, his day-shift blood pressure dropped to 97/52 with a pulse of 56, and the vital signs log recorded a further drop that morning to 81/48 with a heart rate of 55. At approximately 9:06 AM on 11/22, an LVN administered PRN Midodrine 5 mg for the blood pressure of 81/48 and heart rate of 55, in accordance with an existing order to give Midodrine every 8 hours as needed for systolic blood pressure less than 90. The MAR documented this administration as effective, but the progress notes contained no further assessment or monitoring documentation after the 9:06 AM entry on that date, and there were no additional notations on 11/22 indicating ongoing monitoring of the resident’s condition following the hypotensive and bradycardic episode. The neurological assessment form for 11/22 showed normal vital signs and findings at several times, but these entries were signed late, and there was no contemporaneous documentation of assessment immediately after the low blood pressure and heart rate. The NP and MD later confirmed they were not notified of the hypotension and bradycardia on 11/22. Approximately 21 hours after the abnormal blood pressure and heart rate, the resident developed left-sided facial droop and weakness, was found by staff with stroke-like symptoms, and was transferred to the hospital, where he was diagnosed with bilateral pneumonia, septic shock, and acute metabolic encephalopathy and admitted to the ICU. The facility’s Notification of Changes policy required informing and consulting with the physician when there is a significant change in the resident’s physical condition, including life-threatening conditions or clinical complications, and when circumstances require a need to alter treatment, such as new treatment. The facility did not have a policy for neurological assessments and the Notification of Changes policy did not include guidance for assessment, identification, or monitoring of a change in condition. The DON stated that neurological assessments were used after unwitnessed falls or possible head injury and that vital signs were part of these assessments, but she did not consider the resident’s decrease in blood pressure and heart rate below baseline, along with the need for PRN Midodrine that had not been previously used at the facility, to be a change in condition requiring physician notification, as the medication was documented as effective. The NP and MD both indicated they would expect administration of PRN Midodrine for low blood pressure and would expect notification if the medication was ineffective, but they were not notified of this episode. The surveyors concluded that the facility failed to assess the resident after the blood pressure of 81/48 and heart rate of 55, failed to monitor and assess his condition after PRN Midodrine was administered, and failed to identify and manage this as a change in condition while neurological assessments were ongoing, leading to the cited quality of care deficiency and the identification of Immediate Jeopardy. An Immediate Jeopardy (IJ) was identified on 4/17/2026 at 4:47 PM related to these failures, and the IJ was removed on 4/19/2026, with the facility remaining out of compliance at a lower severity level while monitoring of corrective actions continued.
Failure to Ensure Competent Tracheostomy Care and Emergency Preparedness
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care, including tracheostomy care and tracheal suctioning, to a resident with a tracheostomy, in accordance with professional standards, the care plan, and physician orders. The resident had a history of tracheostomy related to laryngeal injury, shortness of breath, other specified respiratory disorders, and severe cognitive impairment, and required trach care and suctioning. The care plan and orders specified use of a Shiley size 6 trach inner cannula, routine trach care every shift, and maintenance of an extra trach tube and obturator at the bedside for tube-out procedures. On two separate occasions, the resident’s trach became dislodged. On the first occasion, an RN entered the room and found the trach out; the resident did not appear in respiratory distress, and the RN notified the nurse practitioner, who ordered transfer to the emergency room. Hospital records documented that the resident was sent for trach replacement due to a dislodged trach, and the trach was replaced via bronchoscopy. On the second occasion, during trach care while the RN was changing the gauze and trach ties, the resident coughed and the trach “blew out.” The RN reported she did not know this could happen and did not feel comfortable replacing the entire trach, only the inner cannula. Another nurse replaced the trach, the resident had difficulty breathing, was placed on oxygen, and was again sent to the hospital, where the ED noted the trach had been reinserted by facility staff who were unsure of correct placement. Surveyor interviews and observations showed that staff caring for the resident were not consistently aware of the location of emergency trach equipment or how to use it in the event of accidental extubation. One LVN stated that if the trach fell out, she would call for help, call the nurse practitioner, and send the resident to the hospital because that was how he breathed, and she would not know how to replace it; when she showed the surveyor the resident’s supplies, there was no trach kit with insertion tool at the bedside. Another RN who assisted during the second dislodgement reported inserting a smaller-sized trach because that was what was available at the bedside, and later replacing it with the correct size after being instructed by the nurse practitioner, but she could not recall the sizes used. Additional interviews with central supply, the DON, and other clinical staff revealed confusion and lack of clear understanding regarding trach sizing, the specific size ordered for the resident, and which emergency trach sizes were present at the bedside. The facility also lacked a written policy on respiratory or trach care and relied on an external nursing manual instead of a facility-specific protocol. These findings led surveyors to identify an Immediate Jeopardy situation related to failure to ensure staff competency, equipment availability, and correct trach sizing for this resident. The Immediate Jeopardy determination was based on three core failures: staff caring for the resident were not consistently aware of the location of emergency trach equipment or how to use it in case of accidental extubation; the resident did not have a same-size trach immediately available at the bedside on at least one occasion when the trach became dislodged; and staff were not consistently knowledgeable about trach sizes or the specific size required by the resident per physician order. These failures occurred despite the resident’s documented need for trach care and suctioning and the care plan requirement to keep an extra trach tube and obturator at the bedside for tube-out procedures.
Removal Plan
- Assess Resident #1 by the Respiratory Therapist related to respiratory and tracheostomy status with no concerns noted.
- Validate that physician orders and plan of care for Resident #1's tracheostomy care are being followed.
- Observe the bedside and emergency tracheostomy equipment for Resident #1 and confirm the presence of size 6, size 5 and size 4 tracheostomies, as well as an Ambu bag for emergency use.
- Reeducate the Director of Nursing by the Respiratory Therapist and provide 1:1 education with return demonstration on tracheostomy care (including supplies), emergency response to accidental extubation (including reinsertion, size identification, equipment location/use), and daily shift observation/documentation for compliance with physician orders and presence of emergency equipment at bedside.
- Reeducate Licensed Nurses on responsibility for checking and stocking tracheostomy supplies each shift and as needed.
- Reeducate LVN A by the Director of Nursing, Respiratory Therapist and/or designee and provide 1:1 education with return demonstration on tracheostomy care, emergency response to accidental extubation (including reinsertion, size identification, equipment location/use), and daily shift observation/documentation for compliance with physician orders and presence of emergency equipment at bedside.
- Reeducate RN A by the Director of Nursing, Respiratory Therapist and/or designee before her next shift and provide 1:1 education with return demonstration on tracheostomy care, emergency response to accidental extubation (including reinsertion, size identification, equipment location/use), and daily shift observation/documentation for compliance with physician orders and presence of emergency equipment at bedside.
- Reeducate 100% of Licensed Nurses 1:1 by the Director of Nursing, Respiratory Therapist and/or designee with return demonstration on tracheostomy care, emergency response to accidental extubation (including reinsertion, size identification, equipment location/use), and daily shift observation/documentation for compliance with physician orders and presence of emergency equipment at bedside.
- Complete re-education with return demonstration for Licensed Nurses who are out on PTO/FMLA/Leave of Absence prior to the start of their next scheduled shift.
- Provide this training to newly hired licensed nurses and require passing a return demonstration during orientation prior to providing care to residents.
- Review new admissions/readmissions with tracheostomies by the Director of Nursing and/or designee for compliance with physician orders for tracheostomy size and for the presence of appropriate tracheostomy sizes, equipment and Ambu bag at bedside.
Failure to Ensure Competent Nursing Staff for Tracheostomy Care and Emergency Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed nurses had the specific competencies and skills necessary to care for a resident with a tracheostomy, as required by the resident’s assessments and care plan. The resident was an older male with diagnoses including epileptic seizure, shortness of breath, other specified respiratory disorders, and a tracheostomy related to laryngeal injury. His care plan identified him as being at risk for alterations in respiratory status and directed that a disposable Shiley #6 inner cannula be changed every shift, with extra trach tube and obturator kept at bedside and specific steps to follow if the tube was coughed out. The resident’s MDS showed severe cognitive impairment, dependence for personal care, shortness of breath when lying flat, and a need for trach care and suctioning. On two separate dates, the resident’s tracheostomy became dislodged while under the care of facility nursing staff. In one incident, a progress note documented that a nurse found the trach no longer in place; the resident’s oxygen saturation was 94% and he denied shortness of breath, and he was sent to the hospital where the trach was replaced via bronchoscopy. In a later incident, another progress note documented that while a nurse was replacing the trach tie, the resident coughed and the trach came out; the trach was replaced, the resident had difficulty breathing, was given 2L of oxygen, and was again sent to the hospital. The hospital emergency department record for the second event stated that nursing home staff had put the trach back in after it became dislodged and were unsure if it was in the correct position, though it appeared appropriately positioned on evaluation. Interviews with staff revealed gaps in tracheostomy-related competencies and knowledge. One RN reported that the resident’s trach had dislodged twice on her shifts, that another nurse had to replace the trach on one occasion, that she did not feel comfortable replacing the entire trach (only the inner cannula), and that she did not know the trach could be expelled by coughing. She stated her last trach training was likely in 2023. An LVN assigned to the resident stated that if the trach fell out, she would call the nurse practitioner and send the resident to the hospital immediately and that she would not know how to replace it. Another LVN demonstrated awareness of the emergency trach kit in the room and stated she would replace the trach using the correct size, but also reported she had not received trach training or a skills checkoff at this facility since starting work there. Additional interviews showed that key clinical leaders lacked full understanding of trach sizes and the specific size required for this resident. The DON stated she was not the most knowledgeable about trach sizes and could not explain the different sizes of trachs and inner cannulas. During an observation in the resident’s room, the DON and RCS reviewed trach supply boxes labeled with product codes and the RCS initially interpreted inner cannula diameters from package diagrams, then later reported she had spoken with the RT to clarify that the first number in the label indicated size and that the resident used a size 6 Shiley trach. The nurse practitioner stated that the resident’s trach order for a size 6 inner cannula meant a 6 mm inner cannula and that nursing staff should use a 6 mm inner cannula. The RT explained the meaning of the trach product code and that emergency supplies should include the resident’s trach size and a smaller size. Record review showed that competency assessments for two nurses had been marked as “met” for trach care and emergency decannulation procedures, but the prior ADON reported that most nurses, including these two, had not attended prior hands-on trach training and that they did not feel comfortable providing that type of care. The surveyors determined that these findings demonstrated that multiple licensed nurses, as well as the DON and RCS, lacked the necessary competencies and knowledge regarding tracheostomy care, emergency response to accidental decannulation, and trach sizing for this resident. This failure to ensure competent nursing staff for tracheostomy management led to an Immediate Jeopardy determination related to the resident’s care.
Removal Plan
- Resident #1 was assessed by the Respiratory Therapist related to respiratory and tracheostomy status with no concerns noted.
- The Respiratory Therapist validated that physician orders and plan of care for Resident #1's tracheostomy care were being followed.
- The Respiratory Therapist observed the bedside and emergency tracheostomy equipment for Resident #1 and confirmed the presence of size 6, size 5 and size 4 tracheostomies, as well as an Ambu bag for emergency use.
- The Director of Nursing was reeducated by the Respiratory Therapist and received 1:1 education with passed return demonstration on tracheostomy care, emergency response during accidental extubation (including reinsertion, size identification, equipment location/use), and daily shift observation/documentation for compliance with physician orders and presence of emergency equipment at bedside.
- Licensed nurses were reeducated on responsibility for checking and stocking tracheostomy supplies each shift and as needed.
- LVN A was reeducated by the Director of Nursing, Respiratory Therapist and/or designee and received 1:1 education with passed return demonstration on tracheostomy care, emergency response during accidental extubation (including reinsertion, size identification, equipment location/use), and daily shift observation/documentation for compliance with physician orders and presence of emergency equipment at bedside.
- RN A will be reeducated by the Director of Nursing, Respiratory Therapist and/or designee before her next shift and will receive 1:1 education with passed return demonstration on tracheostomy care, emergency response during accidental extubation (including reinsertion, size identification, equipment location/use), and daily shift observation/documentation for compliance with physician orders and presence of emergency equipment at bedside.
- Licensed nurses were reeducated 1:1 by the Director of Nursing, Respiratory Therapist and/or designee with passed return demonstration on tracheostomy care, emergency response during accidental extubation (including reinsertion, size identification, equipment location/use), and daily shift observation/documentation for compliance with physician orders and presence of emergency equipment at bedside.
- Licensed nurses who are out on PTO/FMLA/leave of absence will have the re-education completed and return demonstration prior to the start of their next scheduled shift.
- Newly hired licensed nurses will receive this training and pass a return demonstration during orientation prior to providing care to residents.
- New admissions/readmissions with tracheostomies will be reviewed by the Director of Nursing and/or designee for compliance with physician orders for tracheostomy size and the presence of appropriate tracheostomy sizes, equipment and Ambu bag at bedside.
- The Director of Nursing and/or designee will monitor compliance with physician orders for tracheostomy care and presence of accurate emergency tracheostomy equipment at the bedside by validating through rounding on residents with a tracheostomy.
- The Director of Nursing and/or designee will monitor compliance with licensed nurse competency in tracheostomy care via observations and competency checks.
- The Director of Nursing and/or designee will monitor compliance with daily verification and documentation of presence of emergency supplies at resident bedside (extra tracheostomy in current size, one size down, and Ambu bag) by rounding on residents with tracheostomy.
- An Ad Hoc QAPI meeting was held with the Medical Director, Facility Administrator, Director of Nursing, Regional Clinical Specialist and Regional President of Operations to discuss the immediate jeopardy and review the plan of removal.
Failure to Maintain Clean and Sanitary Resident Room Environment
Penalty
Summary
Surveyors identified a failure to maintain a safe, clean, comfortable, and homelike environment for one resident whose room contained extensive dried biological material and wall markings. The resident, an older adult with Alzheimer's disease, heart failure, bipolar disorder, GERD, and COPD, had a documented behavior care plan noting a problem of spitting on the floors and walls, with interventions focused on anticipating needs, providing positive interaction, and discussing and reinforcing why the behavior was inappropriate. During an observation, the resident's dresser and adjacent walls were found covered in dried, thick streaks of mucus in brown, red, and pink colors over an area of approximately 5 feet by 5 feet, and the wall next to the bed had multicolored crayon and/or pen scribbles about 2 feet by 1 foot in size. A CNA reported hearing the resident spit on the walls and stated that nurses and nurse managers were aware of this behavior. The Environmental Supervisor stated that the resident spit so much that staff sometimes had to clean the room twice daily and that if the material stayed too long it became difficult to clean, while also stating the room had been cleaned the previous night. The ADON indicated she did not believe housekeeping was removing the mucus from the walls daily because there was so much present. The facility’s general housekeeping policy stated that each occupied resident room is to be cleaned and put in order daily and as needed, and that sufficient housekeeping and maintenance personnel, equipment, and supplies are to be provided to maintain a safe, clean, orderly, and attractive interior. Despite this policy and awareness of the resident’s spitting behavior, surveyors observed the room in an unsanitary and unpleasant condition, constituting the deficiency.
Failure to Screen Employee with Disqualifying Criminal Background
Penalty
Summary
The facility failed to ensure compliance with state regulations and its own abuse prevention policy by employing an individual who was found guilty of a criminal offense that bars employment in direct care positions. Specifically, a CNA was hired and worked in the memory care unit despite having a recent conviction for assault causing bodily injury, a Class A misdemeanor, for which she received probation. The CNA's personnel file showed that a national background check was conducted at the time of hire, revealing the offense and disposition, but she was still allowed to work with residents. The facility's policy required screening for abuse, neglect, and exploitation, including background checks, but this process was not properly followed in this case. The CNA worked multiple shifts in the memory care unit, which had a census of 19 residents, before her employment was terminated after the new Human Resources Coordinator (HRC) discovered the background check results during a personnel file audit. Interviews with the CNA, HRC, and Interim Administrator confirmed that the CNA's background should have disqualified her from employment, and that the previous HRC had not obtained the necessary documentation or followed up appropriately. The failure to adhere to screening protocols resulted in the employment of an individual with a disqualifying criminal history in a direct care role.
Food Service Safety Deficiencies
Penalty
Summary
The facility was found to have several deficiencies in its food service safety practices. During an observation, a soiled mop was improperly stored head-side down in a mop bucket with dirty water in the utility closet, contrary to the facility's policy that mops should be stored upright to dry properly and prevent bacterial growth. Additionally, in the dish room, plastic bowls and cups were stored face-down on wet trays without air-drying nets, which is against the facility's policy requiring air drying to prevent contamination. Further inspection of the kitchen revealed personal food and beverage items in the food preparation area. A quart-sized container with chopped salad and a large Styrofoam cup with a brown liquid, both belonging to a staff member, were found without proper labeling or covering. This violated the facility's policy that prohibits personal food items in food preparation areas and requires beverages to be covered. These practices could potentially expose residents to foodborne illnesses.
Failure to Include Depression in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which is consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3). The deficiency was identified for a resident diagnosed with Alzheimer's disease, depression, and hyperlipidemia. The resident's comprehensive care plan did not include depression as a focus area, despite it being an active diagnosis in the resident's admission MDS. This oversight occurred when the resident discontinued the use of all psychotropic medications, and the focus area listing the medications was removed from the care plan, inadvertently removing the diagnosis of depression as well. During interviews, the MDS RN acknowledged the omission and stated that the diagnosis of depression should have been noted as a focus area to ensure the resident was monitored for signs and symptoms of depression and received appropriate treatment and care. The Regional Nurse Consultant also confirmed that the diagnosis of depression needed to be a focus area in the resident's care plan, even if the resident was not taking medication, to ensure all her needs were addressed. The facility's policy requires comprehensive care plans to include measurable objectives and timeframes to meet the resident's needs as identified in the comprehensive assessment.
Infection Control Breach by LVN
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by an incident involving a Licensed Vocational Nurse (LVN) who did not adhere to proper infection control practices. During an observation, the LVN administered morning scheduled GT medications to a resident while wearing gloves and then proceeded to check the resident's blood sugar without changing gloves. This action was identified as cross-contamination, increasing the risk of infection for the resident. The LVN acknowledged the error, attributing it to nervousness due to being observed by a state surveyor. The resident involved was an elderly male with a history of Type 2 diabetes, hyperlipidemia, and hypertension, and had severely impaired cognition. The Assistant Director of Nursing (ADON) confirmed that the LVN should have sanitized or washed her hands between glove changes to prevent the spread of germs. It was noted that the LVN was recently hired and had not been checked off on infection control practices, despite previous staff training. The facility's policy on infection prevention and control mandates hand hygiene in accordance with established procedures, which was not followed in this instance.
Failure to Prevent Elopement of Resident with Cognitive Impairment
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent an elopement. A resident with Alzheimer's disease, severe cognitive impairment (BIMS score of 00), and a history of wandering was identified as an elopement risk. The resident's care plan included interventions such as providing diversions, structured activities, and reorientation strategies, but these measures were not sufficient to prevent the resident from leaving the facility. On the night of the incident, staff reported that alarms sounded at different times, but initial head counts indicated all residents were present, including the resident at risk. Later, it was discovered that the resident was missing, and evidence suggested the resident had used a chair to climb over a fence in the courtyard. The resident was found by a staff member at a nearby drycleaner, fully dressed and carrying personal belongings. Interviews with staff revealed that the resident had not previously attempted to exit the facility, and staff had assumed the resident had basic safety awareness despite cognitive deficits. The facility's failure to provide adequate supervision and to maintain a secure environment allowed the resident to elope. The incident was identified as Immediate Jeopardy due to the risk of harm, serious injury, or death for residents at risk for elopement. The deficiency was based on direct observations, interviews, and record reviews that confirmed the resident's risk status and the facility's lack of effective preventive measures at the time of the event.
Failure to Administer Prescribed Dementia Medication Due to Omission from MAR
Penalty
Summary
The facility failed to provide routine and emergency drugs and biologicals to a resident by not administering a prescribed dementia medication, Memantine 10mg twice daily, as ordered by the physician. The medication was not added to the resident's Medication Administration Record (MAR) until the day of discharge, resulting in the resident missing all doses for a period of 47 days. The resident, an elderly female with diagnoses including metabolic encephalopathy and Alzheimer's disease, was admitted with a physician's order to continue Memantine, which was also documented in her care plan and physician progress notes. However, review of the MARs for July and August showed the medication was not listed or administered during her stay. Interviews with facility staff confirmed that the medication order was present but not transcribed onto the MAR, and the omission was only discovered during the discharge process when the family inquired about the medication. The family member reported noticing increased confusion in the resident during her stay, which was also observed by nursing staff. Facility policy required medication reconciliation at admission, including comparing orders to hospital records and transcribing them accordingly, but this process was not followed, resulting in the resident not receiving her prescribed dementia medication throughout her stay.
Failure to Notify Physician and Family of Resident's Low Blood Sugar
Penalty
Summary
The facility failed to immediately notify a resident's physician and representative when there was a need to alter treatment due to a change in the resident's condition. The resident, who had a history of end-stage renal disease, hypertension, type 2 diabetes, and severe cognitive impairment, experienced a significant drop in blood sugar levels. On the day of the incident, the resident's blood sugar was recorded at 47 mg/dl, which is critically low. Despite this, the nurse on duty did not contact the resident's physician or family, as she believed the resident was not in distress and the blood sugar level returned to normal after providing a snack. The nurse, identified as LVN A, administered a snack and drink to the resident and monitored her condition, noting that the resident did not display symptoms of hypoglycemia. However, the nurse did not consider the low blood sugar reading as a change of condition that required notification to the physician or family. This oversight was later acknowledged by the nurse, who admitted that a blood sugar level of 47 could lead to severe consequences such as coma or loss of consciousness. Interviews with the resident's relative and facility staff, including the Director of Nursing (DON) and Assistant Director of Nursing (ADON), revealed that the incident was not reported to the appropriate parties in a timely manner. The DON and ADON both stated that the nurse should have notified the physician and family immediately, as per the facility's policy on notification of changes. The failure to follow this protocol resulted in a delay in medical treatment and placed the resident at risk of worsening symptoms.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 63 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wharton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paradigm At The Creek | 2 mi | ★★★★★ | 3 | 0 |
| Paradigm At The Prairies | 14.1 mi | ★★★★★ | 15 | 2 |
| Spjst Rest Home No 2 | 15.7 mi | ★★★★★ | 9 | 0 |
| S.p.j.s.t. Rest Home 3 | 19.9 mi | ★★★★★ | 8 | 0 |
| Fort Bend Healthcare Center | 21.9 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.