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Inspection visit

Inspection

Advanced Rehabilitation and Healthcare of WichitaCMS #6758528 citations on this visit
8 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, interview and record review the facility failed to ensure the MDS assessment accurately relected the resident's status for 1 of 11 resident (Resident #4) reviewed for assessments. Residents Affected - Few The facility failed to address skin conditions under Section M (Skin Conditions) : This failure could place residents at risk of worsening of skin conditions. The findings include: Record review of Resident #4's face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included Acute and Chronic Respiratory Failure, (acute respiratory failure is a short-term condition. It occurs suddenly and is typically treated as a medical emergency. Chronic respiratory failure is ongoing. It develops gradually and requires long-term treatment.) Heart Disease, Seizure Disorder, (epilepsy is a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures.) Obesity, Edema, (swelling caused by too much fluid trapped in the body's tissues.) Anxiety, Paralytic Gait, (a type of spastic gait in which the legs are usually slightly bent at the hip and in an adducted position) and Cerebral Palsy (a group of disorders that affect a person's ability to move and maintain balance and posture.). Resident #4 Record Review of Resident #4's Nursing Home MDS Effective 10/01/2023 in Section C Cognitive Patterns a BIMS summary Score of 13 (cognitively intact). Under Skin Conditions was not checked. Under skin conditions, no skin conditions were present. Interview and observation with Resident #4 on 11/15/2023 at 09:25 AM, Resident #4 said he had skin issues for an extended period. Observation of the skin areas revealed affected skin lesions covering a large majority of his body's torso and private areas which included the peri area, upper back, folds under breasts, groins, abdominal folds, buttock folds, pubic area, lower abdomen, upper inner thighs, right front shoulder and neck fold . Interview and observation on 11/15/2023 at 09:25 AM, CNA #B observed Performing skin and peri care for Resident #4. She showed a tube of cream named: Renew (PERIPROTECT skin Protectant Moisture Barrier Cream). She said she had been using this cream to affected skin areas. CNA #B revealed she had been doing Resident #4's peri and skin care for at least for a couple of months. CNA said she applied this cream to his skin for comfort to all areas which included the peri area, upper back, folds under breasts, groins, abdominal folds, buttock folds, pubic area, lower abdomen, upper inner thighs, right front shoulder and neck fold. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 12 Event ID: 675852 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Wichita 4810 Kemp Blvd Wichita Falls, TX 76308 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641 Level of Harm - Minimal harm or potential for actual harm In an interview with RN-Case Mix Manager on 11/17/2023 at 11:00 AM said she relied on the staff that do direct care of Resident's to report and maintain records that she would review to update MDS Assessment. She said she was positive that the MDS had not been identified for skin issues. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675852 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Wichita 4810 Kemp Blvd Wichita Falls, TX 76308 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding which included but not limited to aspiration, pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for one of 1 resident (Resident #) reviewed for enteral nutrition. RN D failed to check placement of Resident #17's g-tube before starting the medication administration via g-tube feeding as required to avoid medical complications. This failure could place residents at risk for aspiration pneumonia and ineffective medication absorption. Findings include: Record review of Resident #106's face sheet, dated 11/17/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #106 had diagnoses which included dementia (problems with thinking, memory, and behavior) dysphagia (difficulty swallowing), muscle wasting, severe protein calorie malnutrition (inadequate intake of food as an essential source of protein, calories, and other essential nutrients). Record review of Resident #106's Quarterly MDS assessment, dated 10/18/23, reflected the resident required a g-tube (a tube place through the abdominal wall and directly into the stomach for all his medication administration and nutritional intake). Record review of Resident #106's physician orders, dated 11/17/23, reflected an order to flush Resident 106's g-tube with 30 cc of water via his g-tube prior to and after medications administration. Record review of Resident #17's care plan dated revised 3/22/23, reflected Resident #106 required g-tube feedings related to swallowing difficulties. The goal was for the resident to remain free of complications of tube feeding through the next review date. One intervention was to check placement and patency of feeding tube before each feeding or medication administration. Observation of medication administration for Resident #106 on 11/16/23 at 8:00 a.m. revealed LVN B did not check residual or placement before administering the resident's 30 cc bolus of water. She measured out 30 cc of water in a medication cup. LVN B did not check residual on the g-tube feeding (to avoid the risk of regurgitation and aspiration). LVN B proceeded to give the medication to Resident #106. After the administration of the 30 cc of water LVN B stated he made a mistake and he should have checked for placement of the g-tube before administration of the medication . In an interview with LVN B on 11/16/23 at 8:00 AM, he stated he failed to check placement and residual before he administered Resident #106 medication through the g-tube. He explained the placement should be checked to ensure that the tube was in the resident's stomach . LVN B said he forgot to check for placement because he was nervous. He said failure to do so could result in aspiration or infection . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675852 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Wichita 4810 Kemp Blvd Wichita Falls, TX 76308 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the ADON on 11/16/23 at 1:41 p.m., revealed she expected all nurses to follow the facility policy in administering medication via g-tube which included checking placement and residual to ensure the tube was still in the stomach and the resident's stomach was not too full. Record review of the facility policy on g-tube feeding, dated 2/10/2020, reflected, .enteral tube placement must be checked by auscultation (listening to the gastric sound with a stethoscope) checking residual, or both prior to administering a type of medication or fluid into the tube. Record review of Fundamental of Nursing Ninth Edition, , dated 2017, reflected the following: .Steps 14. Assess gastric residual, Draw up 30 cc's of air into a 60 cc syringe, connect to feeding tube, and flush with air. Then pull back slowly to aspirate gastric contents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675852 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Wichita 4810 Kemp Blvd Wichita Falls, TX 76308 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview and record review the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift that was in a clear and readable format and in a prominent place readily accessible to residents and visitors for 1 of 4 reviewed for nursing services. Residents Affected - Many 4 The facility failed to update and post the daily nurse staffing information on 11/17/2023. This failure could place residents at risk of not having access to information regarding staffing data and facility census. The findings include: Observation on 11/17/2023 at 2:30 PM revealed the daily nurse staffing pattern was not posted on the front door in the location designated for it. In an interview on 11/17/2023 at 2:35 PM, the ADON stated, I'm sorry I failed to change the staffing today because I've been so busy and have not gotten around to it yet. In an interview on 11/17/23 at 2:53 PM, the Administrator stated, My expectation is that the ADON follow our policy regarding staffing posting. he further stated, The staffing posting is checked on a daily basis by the DON, however she's out today and I failed to check it today. He said not posting the information would give the public inaccurate information. Record review of a facility policy titled, Nurse Staffing Posting dated, 11/04/2017 reflected in-part: 1. The nurse staffing information will be posted on a daily basis and will contain the following information. ? the total number and the actual hours worked by the following categories of licensed and unlicensed staff directly responsible for resident care per shift ? Registered Nurses ? Licensed Vocational Nurses ? Certified Nurse Aides 2. The facility will post the nurse staffing data at the beginning of each shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675852 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Wichita 4810 Kemp Blvd Wichita Falls, TX 76308 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident for 9 of 9 residents (Residents #40, #33, #36, #130, #68, #49, #26, #124 and #145) reviewed for pharmacy services. The facility failed to accurately monitor and document controlled drugs for 9 residents with medications stored on 1 of 4 Medication carts (2300 hall medication cart) reviewed for narcotic reconciliation. This failure could place residents at risk of medication overdose, medication under-dose, and ineffective therapeutic outcomes, and drug diversion. Findings included : 1. Record review of Resident # 33's physician orders, dated 11/17/23, reflected Pregabalin 100 mg 2 capsules two times a day. Record review of Resident #33 's MAR reflected Resident #40 had received Pregabalin 100 mg 2 tablets at 6:30 AM. Record Review of Resident # 33's narcotic count sheet for Pregabalin (a controlled drug for nerve pain)100 mg reflected the documented count of the Pregabalin 100 mg was 78 capsules. Observation of the medication card on 11/17/23 at 11:00 AM which contained the Pregabalin s revealed a total count of 76 capsules. In an interview with Resident #33 on11/17/23 at 11 :30 AM, she stated she believed she had all of her medications that morning . 2. Record review of Resident # 36 physician orders, dated 11/17/23, reflected Norco 10/325 mg 1 every 4 hours as needed for pain and Alprazolam 0.5 mg 1 tablet 5 times a day. Record review of Resident # 36's medication administration record reflected she received Alprazolam 0.5 mg and Norco 10/325 mg at 6:52 AM. Review of the narcotic count sheets at 10:15 AM revealed Alprazolam 0.5 mg count was 80. Observation of the Card on 11/17/23 at 11:00 AM containing the alprazolam 0.5 mg was 79. Review of the narcotic count sheet for the Narco 10/325 mg was 80 and observation of the medication card containing the narco revealed there were 79 tablets. 3. Record review of Resident # 40's physician orders dated 11/17/23, included the following Methadone10 mg 21/2 tablets every 8 hours. Record review of Resident ID #40 's MAR on 11/17/2023 at 10:15 AM revealed Resident ID #40 had received Methadone 10 mg tablets 2 ½ tablets at 7:30 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675852 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Wichita 4810 Kemp Blvd Wichita Falls, TX 76308 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755 Level of Harm - Minimal harm or potential for actual harm Record Review of Resident # 40's narcotic count sheet for Methadone 10 mg at revealed the documented count of the Methadone 10 mg was 61 doses (2 ½ tablets). Observation of the medication card containing the Methadone on 11/17/23 at 10:15 AM revealed a total count of 60 prefilled doses. Residents Affected - Few In an interview with Resident ID # 40 at 3:30 PM she stated she believed she had all of her medications that morning. 4. Record review of Resident #130's active physician orders as of 11/17/23, included the following controlled drug Hydrocodone/APAP 10/325 mg 1 by mouth 3 time daily. Record review of the Resident ID #130's MAR on 11/17/23 at 10:15 AM revealed Resident ID #130 had received Hydrocodone 10/325 mg 1 tablet by mouth at 7:37 AM. Record review of Resident ID #130's Narcotic count sheet for Hydrocodone/APAP 10/325 on 11/17/23 at 10/15 AM revealed the documented count of the Hydrocodone/APAP mg was 20 tablets. Observation of the medication card containing the Hydrocodone/APAP 10/325 mg on 11/17/23 at 10:15 AM revealed a total count of 19. 5. Record review of Resident #68's active physician orders as of 11/17/23, included the following controlled drugs Lorazepam 1 mg 1 tablet 3 times a day routinely and every 4 hours as needed for anxiety. Record review of the Resident ID #68's MAR on 11/17/2023 at 10:15 AM revealed Resident # 68 had received 1 Lorazepam 1 mg by mouth at 8:00 AM. Record review of Resident ID #68's narcotic count sheet for Lorazepam 1 mg capsules on 11/17/23 revealed the documented count of the Lorazepam tablets was 49 tablets. Observation of the medication card on 11/17/23 at 10:15 AM containing lorazepam tablets revealed a total count of 48 tablets. 6. Record review of Resident #49's active physician orders as of 11/17/2023, included the following controlled drugs Alprazolam 0.25 mg 1 by mouth 2 times a day and every 4 hours as needed for anxiety. Record review of the Resident ID 49's MAR on 11/17/23 revealed Resident ID #4 had received Alprazolam 0.25 mg at 8:00 AM Record review of Resident #49's narcotic count sheet for lorazepam 0.25 mg tablets on 11/17/2023 at 10:30 AM revealed the documented count was 26 tablets. Observation of the medication card on 11/17/23 at 10:30 AM containing the Alprazolam 0.25 mg tablets revealed a total count of 25 tablets. 7. Record review of Resident # 26's active physician orders dated 11/17/23 revealed orders for Lorazepam 2 mg three times daily and every 4 hours as needed for anxiety and clonazepam 1 mg 2 times a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675852 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Wichita 4810 Kemp Blvd Wichita Falls, TX 76308 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755 day, and Hydrocodone /APAP 5/325 mg 1 every 6 hours as needed for pain. Level of Harm - Minimal harm or potential for actual harm Record review of Resident # 26's MAR revealed had received: Lorazepam 2 mg at 7:48 AM, Clonazepam 1 mg, at 7:48 AM and Hydrocodone / APAP 5/325 mg at 7:48 AM Residents Affected - Few Review of the narcotic count sheet for Resident #26's Lorazepam 2 mg revealed a count of 52 tablets. Observation on 11/17/23 at 10:15 AM revealed There were 51 tablets of Lorazepam 2 mg in the medication card., Clonazepam Narcotic sheet showed a count of 20 and there were 19 of the Clonazepam tablets in the card. 8. Record review of Resident #124's active physician orders as of 11/17/2023, included the following controlled drugs Lyrica 100 mg 1 tablet 2 times daily. Record review of the Resident 's #124's medication administration record on 11/17/23 at 8:45 AM PM revealed Resident ID #124 had received Lyrica at 8:45 AM. Record review of Resident #124's narcotic count sheet for Lyrica 100 mg tablets on 11/17/2023 at 10:30 AM revealed the documented count was 49 tablets. Observation of the medication card containing Lyrica 100 mg on 11/17/23 at 10:15 AM revealed a total count of 48 tablets. 9. Record review of Resident #145's active physician orders as of 11/17/2023, included the following controlled drugs Alprazolam 5 mg 2 tabs underneath the tongue 2 times daily. Record review of Resident 's #124's medication administration record on 11/17/2020 at 10:30 AM revealed Resident ID #124 had received Alprazolam 5 mg tablet 2 tabs at 8:45 AM. Record review of Resident #124's narcotic count sheet for Alprazolam 5 mg on 11/17/2023 at 10:30 AM revealed the documented count was 78 tablets. Observation of the medication card containing Lyrica 100 mg on 11/17/23 at 10:15 AM revealed a total count of 76. In an interview and observation with LVN at 10:10 AM, she stated she had not signed out for the medication on the narcotic sheet at the time of administration as she should have done, and had only recorded the time of administration when she administered the medications. She stated she was signing for the medications at that time. She stated the proper procedure for administration of any narcotic was to sign out on the narcotic control count sheet for the drug immediately after administering the medication. She stated she was training a new nurse at the facility and had just started at the facility today, and she was in a hurry and failed to sign the controlled drug sheet upon administration of her narcotics during the 8:00 AM medication pass . She stated this could result in a medication error. An interview with the ADON on 6/22/2020 at 3:00 PM revealed she expected nurses to sign for controlled medication immediately when administering them , and to count narcotics with the oncoming nurse at the end each shift. She stated she did not know LVN C had not signed for her controlled drugs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675852 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Wichita 4810 Kemp Blvd Wichita Falls, TX 76308 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few when administering them. She stated she did not know why LVN C would not sign for her narcotics immediately upon administering them and would in-service her immediately on the facility's-controlled medication procedure. She stated the failure to sign for narcotics could result in a medication error. In a record review of the facility's Policy and Procedure, , dated 2018, titled Storage of Controlled Medications, documented [in part]: Medications classified by the Drug Enforcement Administration as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility as required by state, federal and other applicable laws and regulations. Agency Disposition of controlled substances is maintained on the sheet supplied by the pharmacy for all schedule 2,3,4, and 5 controlled substances. Entries are to be made in pen each time a controlled substance is used. The nurse administering the medication will record the following information: date and time drug is administered, amount of drug administered, remaining balance of drug, and signature of nurse administering drug. If the pharmacy does not provide a controlled substance audit sheet, the nursing staff will utilize the facility's-controlled drug audit sheet and fill in all of the required information from the prescription label of the medication audited. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675852 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Wichita 4810 Kemp Blvd Wichita Falls, TX 76308 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 4 medication carts (2300 hall med cart) reviewed for medication storage . The facility failed to ensure the 2300 hall medication cart did not contain loose pills. This failure could place residents at risk of receiving incorrect medications or ineffective therapeutic doses. The findings include: An observation on 11/17/23 at 10:00 AM of the 2300 Hall Medication Cart revealed the second drawer contained several unidentified pills littering the bottom of the drawer. In an interview and observation with LVN C on 11/17/23 at 10:10 AM, she stated it was each nurse's responsibility to see the medication carts were clean and orderly. She stated her cart did not normally contain loose, unidentified pills. She stated she had not checked the cart for cleaning today. She stated she was training a new nurse and had not had time to clean the cart the medications and the loose pills were due to the cart containing so many medication cards. She denied knowledge of what pills were laying in the bottom of the drawer. She stated unidentified pills laying in the med cart could result in a drug diversion, or residents not receiving the correct dosage of medication. In an interview on 11/17/23 at 10:45 AM, ADON B revealed it was each nurse's responsibility to ensure medication carts were kept clean. She stated it was her expectation that drugs should be stored in the original labeled packaging and nurses be responsible for cleaning their own carts. She stated carts were checked by the pharmacy consultant during their monthly visit. Record review of the facility policy titled Storage of Medications, effective March 2011, reflected in part: Procedures: N. Medication storage areas are to be kept clean, well-lit, and free of clutter. O. Medication storage conditions are monitored by the consultant pharmacist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675852 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Wichita 4810 Kemp Blvd Wichita Falls, TX 76308 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain clinical records on each resident that were complete and accurately documented for 1 of 11 residents (Resident #4) reviewed for clinical records. The facility failed to ensure Resident #4's electronic record reflected the residents skin conditions including the appearance, and treatment. This failure could place residents at risk of worsening skin integrity and decline in comfort level . The findings include: Record review of Resident #4's face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included Acute and Chronic Respiratory Failure,(acute respiratory failure is a short-term condition. It occurs suddenly and is typically treated as a medical emergency. Chronic respiratory failure is ongoing. It develops gradually and requires long-term treatment.) Heart Disease, Seizure Disorder, (epilepsy is a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures.) Obesity, Edema, (swelling caused by too much fluid trapped in the body's tissues.) Anxiety, Paralytic Gait, (a type of spastic gait in which the legs are usually slightly bent at the hip and in an adducted position) and Cerebral Palsy (a group of disorders that affect a person's ability to move and maintain balance and posture.). Record review of Resident #4 electronic record for skin assessment and skin conditions reflected no accurate and sufficient information for staff to provide and maintain Resident #4's skin integrity including progress notes, MD orders or MDS Assessment. In a Record Review of Resident #4's Nursing Home Quarterly MDS Effective 10/01/2023, revealed Cognitive Patterns reflected a BIMS summary Score of 13, which indicated the resident was cognitively intact. Under Section M Skin Conditions was checked, no skin conditions were present. Interview and observation on 11/15/2023 at 09:25 AM, CNA #B observed Performing skin and peri care for Resident #4. She showed a tube of cream named: Renew (PERIPROTECT skin Protectant Moisture Barrier Cream). She said she had been using this cream to affected skin areas. CNA #B revealed she had been doing Resident #4's peri and skin care for at least for a couple of months. CNA said she applied this cream to his skin for comfort to all areas which included the peri area, upper back, folds under breasts, groins, abdominal folds, buttock folds, pubic area, lower abdomen, upper inner thighs, right front shoulder and neck fold. In an interview on 11/16/2023 at 4:45 pm, the DON said the barrier cream on his skin areas would not be harmful due to Resident #4 having dry skin. In an interview on 11/16/2023 at 5:00 pm, with Treatment Nurse A revealed she believed he had chronic eczema. When asking for her wound care notes she said she could not provide before exit but had one picture in system from 10/27/2023 of area on top of back. She said did not have measurements or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675852 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Wichita 4810 Kemp Blvd Wichita Falls, TX 76308 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete notes regarding Resident #4's skin. Writer requested Policy and procedure on skin care and documentation. The Policy for Skin Care was not provided before exiting facility. In an interview with the RN-Case Mix Manager on 11/17/2023 at 11:00 AM revealed she relied on the staff that do direct care of residents to report and maintain records that she would review to update the MDS Assessment. She said she was positive the MDS had not identified skin issues for Resident #4. Event ID: Facility ID: 675852 If continuation sheet Page 12 of 12

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Citations

8 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0761GeneralS&S Dpotential for harm

    F761 - Labeling of Drugs and Biologicals

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  • 0842GeneralS&S Dpotential for harm

    F842 - Resident-identifiable information

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0039GeneralS&S Fpotential for harm

    Conduct testing and exercise requirements.

  • 0324GeneralS&S Epotential for harm

    Provide properly protected cooking facilities.

  • 0641GeneralS&S Dpotential for harm

    F641 - Accuracy of Assessments

    Ensure each resident receives an accurate assessment.

  • 0693GeneralS&S Dpotential for harm

    F693 - Assisted nutrition and hydration

    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

  • 0732GeneralS&S Cno actual harm

    F732 - Nurse Staffing Information

    Post nurse staffing information every day.

  • 0755GeneralS&S Dpotential for harm

    F755 - Pharmacy Services

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

FAQ · About this visit

Common questions about this visit

What happened during the November 17, 2023 survey of Advanced Rehabilitation and Healthcare of Wichita?

This was a inspection survey of Advanced Rehabilitation and Healthcare of Wichita on November 17, 2023. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Advanced Rehabilitation and Healthcare of Wichita on November 17, 2023?

Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional princip..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.