Wharton Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Wharton Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF695Feb 6, 2026

  Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for tracheostomy care. 1. The facility failed to ensure staff caring for Resident #1 were aware of the location of emergency equipment or how to use it in case of accidental extubation of his tracheostomy (a medical emergency where the tracheostomy tube is inadvertently removed. […]

• Immediate jeopardy, patternF726Feb 6, 2026

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

• Immediate jeopardy, isolatedF689Mar 7, 2025

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

• Actual harm, isolatedF755Mar 7, 2025

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

• Actual harm, isolatedF689Aug 18, 2021

  Based on interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 1 of 3 residents reviewed for transfers (Resident #274). NA G initiated a mechanical lift transfer without the assistance of additional staff for Resident #274. The facility did not make sure two staff members were always available during a mechanical lift transfer for Resident #274 who sustained a fractured left femur. This failure could place residents who required assistance with transfers at risk for discomfort, pain and injury. […]