The Wheatlands Health Care Center

The facility reported a census of 45 residents and identified one centralized medication storage room, four medication carts, and one nurse treatment cart. Based on observations and interviews, the facility failed to provide a safe environment for seven residents, identified as cognitively impaired and independently mobile by the failure to ensure the medication storage room door remained closed and secured when not in use. This deficient practice had the potential to lead to accidental ingestion of prescription and non-prescription medications that could be harmful to the residents. Findings included: - On 12/04/24 at 06:15 AM, the door to the medication room located off of the main lobby was observed to be propped open by a trash can attached to the nurse's treatment cart with no staff present and remained open until 12/04/24 at 06:24 AM when Licensed Nurse (LN) K moved the nurse treatment cart and closed the door. On 12/04/24 at 06:24 AM, LN K stated the medication storage room door should never be propped open and identified the medication storage room contained prescription and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 45 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility. Findings included: - On 12/02/24 at 09:44 AM during an initial tour of the main kitchen, refrigerator and dry food storage areas with Dietary Manager C, the following areas of concern were observed: One container of dry drink mix observed sitting on the floor, unopened. One container of dry potatoes mix observed sitting on the floor, unopened. One bottle of sweet and sour sauce with an expiration date of 09/27/24 found on a shelf. One sealed package of pork loins dated 07/20 and located in the freezer. One sealed package of beef pot roast with a package date of 01/17/23, with ice growing off of it. One unsealed/open bag of chicken wings spread out throughout the freezer, without a date or label. Three sealed bags of unknown meat, without a date or label and located in the freezer. 16 boxes of frozen food items observed sitting on the floor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 45 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed transport clean and distribute clean laundry to the residents of the facility when staff failed to perform hand hygiene between resident room contacts. The facility further failed to maintain an effective infection control program related to enhanced barrier precautions (EBP - a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms [MDROs] in nursing homes) when providing catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care for Resident (R) 1, wound care on R9, and peri-care (cleaning of the area between the genitals and anus) for R198. Additionally, the facility failed to provide respiratory care consistent with professional standards of care for R4 regarding the use and storage of oxygen supplies that were not stored in a clean manner or changed when appropriate. These deficient practices had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 45 residents with 12 residents sampled. Based on interview, observation, and record review, the facility failed to protect the privacy and dignity of Resident (R) 24, who stood in her room partially dressed in pants and an undergarment, when a staff member walked by R24's room, looked into R24's room and continued to walk down the hallway without intervening. This practice had the potential to lead to negative psychosocial effects related to dignity. Findings included: - The Electronic Health Record (EHR) included the diagnoses of major depressive disorder (MDD - a major mood disorder which causes persistent feelings pf sadness) and dementia (a progressive mental disorder characterized by failing memory, confusion). The 05/13/24 Significant Change Minimum Data Set (MDS) documented R24 had a Brief Interview of Mental Status score of 12, which indicated moderately impaired cognition. The assessment documented R24 required supervision/setup assistance with bathing, eating, and oral hygiene and was otherwise independent with cares. The Cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 45 residents, with 12 residents sampled, and one resident reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, interviews, and record review, the facility failed to provide a pressure reducing device on the bed to prevent a pressure injury for Resident (R) 9. Additionally, the facility utilized the incorrect size full body sling when transferring R9 in and out of bed with the mechanical lift. Findings included: - Resident (R)9 's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type two (DM2-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and muscle weakness. The Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 11, which indicated moderately impaired cognition. R9 required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 45 residents with 12 residents in the sample and ## residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide an environment that remained free from accident hazards for five residents. The facility failed to use the appropriate size full body lift sling for transfers with a mechanical lift for Resident (R)9. The facility failed to follow R26's care plan and left R26 unattended in the bathroom and connected to a mechanical lift, which resulted in a non-injury fall. Additionally, R1 who had lower extremity weakness, the facility failed to apply foot pedals to wheelchair, which resulted in a non-injury fall. These deficient practices could potentially result in an injury. Findings included: - Resident (R) 9 's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type two (DM2-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and muscle weakness. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 50 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly. Findings included: - On 01/17/23 at 10:58 AM, during a kitchen tour with Dietary Staff AA, revealed two dumpsters which had open lids. Several bags of garbage piled above the dumpster opening, whereas the lids were unable to close. Dietary Staff AA confirmed the findings and reported the dumpsters should be closed to maintain dispose of garbage and refuse for the facility. On 01/19/23 12:15 AM, observation with dietary staff AA, revealed two dumpsters with lids propped open over bagged garbage which prevented the lid to close and contain the facility garbage. Dietary staff AA confirmed the findings and stated staff should close the dumpster lids to maintain dispose of garbage and refuse for the facility. The facility lacked a policy for maintaining and disposal of garbage and refuge. The facility failed to maintain the dumpster area in a sanitary condition, and/or dispose of kitchen garbage and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 50 residents that resided on 3 halls. Based on observation, interview and record review, the facility failed to ensure a clean, sanitary environment by the failure of housekeeping staff to know the manufacturer's contact wet times of the cleaners used to clean the resident rooms. This failure had the potential to affect all the resident areas. Findings Included: - On 01/19/23 at 09:15 AM, observation revealed housekeeping staff U as she cleaned rooms on the 100 hall. She completed a room clean, and stood at her housekeeping cart. Interview on 01/19/23 at 09:15 AM, Housekeeping staff U reported she used a disinfectant called AF-79 (a multi-purpose germicidal detergent that disinfects, cleans and deodorizes) to clean the bathroom surfaces. Housekeeping staff U reported she did not know how long the disinfectant needed to stay wet or what germs/bacteria it was designed to be effective to kill. She then looked at the label of the spray bottle and the bottle failed to list a contact wet time or specific surfaces, germs/bacteria designed to clean. She…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 41 residents, with one main kitchen. Based on observation and interview the facility failed to store foods in a safe and sanitary manner by the failure of staff to date open items, date and reseal opened food items, and failure to discard expired food items. Findings included: - On 06/14/21 at 08:30 AM during initial tour of the main kitchen the following expired items were observed: One can of Rotel that expired on 05/27/19. One can of diced peppers that expired on 03/15/20. One bottle of red wine that expired on 03/08/21. One jar of chicken base that expired on 06/04/21. Two jars of horseradish that expired on 04/21/21. Five bags of Bran Flakes that expired on 05/21/20. Six boxes of Nestle Hot Cocoa that had expired on 04/20. Three bags of Raisin Bran cereal that expired on 05/20. One jar of relish that expired on 04/21. 13 bags of Au Jus mix that expired on 08/20/19. The following items without expiration dates with, a one-year shelf life per the facility policy were further observed during the initial tour of the main kitchen on 06/14/21 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 41 residents with 12 sampled including one for respiratory care. Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice for Resident (R) 24 by not changing and dating a humidifier bottle and tubing for oxygen therapy. Findings Included: - Review of Resident (R) 24's Electronic Health Record (EHR) documented the diagnoses of chronic bronchitis (an inflammation and irritation of the bronchial tubes). Review of R 24's Significant Correction Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental status (BIMS) of 8, indicating moderately impaired cognition. R24 used oxygen. Review of R24's ADL Function/ Rehabilitation Potential Care Area Assessment (CAA) dated 05/05/21 documented R24 required extensive one to two-person assistance with activities of daily living and had oxygen continuously. Review of R24's Care Plan dated 09/03/13 documented the resident required oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 41 residents with five residents reviewed for unnecessary medications. Based on interview, and record review the facility failed to ensure one of five residents did not receive unnecessary medications due to the failure of not providing sliding scale insulin as per blood glucose parameters for Resident (R)12. Finding included: - Review of the Physician's Order Electronic Medication Record (EMAR) dated 03/31/21 revealed R12 had the following diagnoses: diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). Review of the admission Minimum Data Set (MDS) dated [DATE] revealed R12 had a Brief Interview for Mental Status (BIMS) of 11, indicating moderately impaired cognition and received insulin daily. Review of the Cognitive Loss/Dementia Status Care Area Assessment (CAA) dated 04/07/21 revealed R12 usually understood others and was usually understood when communicating with staff. Review of Depression Care Plan revised…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.