Wheeler Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete, accurately documented, readily accessible, and systemically organized for 1 of 5 residents (Resident #1) reviewed for medical records. The facility failed to ensure RN A accurately documented the ordered care of suprapubic catheter care for Resident #1 on 03/18/2026, and 04/04/2026. This failure could place residents at risk of having records that did not reflect their current status or needs.Findings included: Record review of Resident #1's admission record, dated 04/23/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included, but were not limited to Quadriplegia, C1-C4 (spinal cord injury resulting in paralysis of all four limbs), cognitive communication deficit (communication and memory impairment) and personal history of urinary tract infections. Record…

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.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure proper hand hygiene and glove use was practiced. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include:In an observation and interview on 8/26/25 at 12:05 pm [NAME] A was observed with gloved hands to touch food trays, the kitchen prep table, and serving utensils. [NAME] B picked up a tortilla with tongs, placed it on the plate filled the tortilla with meat and then folded the tortilla over using her hand. [NAME] B then continued to pick up serving utensils and plated the rest of the foods. [NAME] A did not wash her hands or change her gloves. [NAME] A stated she realized she had used her hand and stated she had just forgotten to use the tongs. She stated the consequence of touching food was food borne illness.In an interview on 6/24/24 at 2:20 PM,…

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 Based on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #2) of 12 residents reviewed for accuracy of assessments. On Resident #2's MDS the facility inaccurately coded Resident #2 as receiving anticoagulant medication. This failure could place residents at risk of not receiving necessary care. Findings Included: Record review of Resident #2's admission record dated 08/27/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, hyperlipidemia (high cholesterol), orthostatic hypotension (form of low blood pressure that happens when standing after sitting or lying down), dysphagia (difficulty producing speech), and chest pain. Record review of Resident #2's quarterly MDS assessment revealed a completion date of 08/25/25. Section C (Cognitive Patterns) revealed a BIMS score of 15 which indicated the resident's cognition was intact. Section N revealed Resident #2 was…

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 Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #2) of12 residents reviewed for care plans. The facility inaccurately care planned that Resident #2 was receiving Anticoagulant therapy. This failure could place residents at risk of not receiving desired and necessary care and treatmentFindings Included: Record review of Resident #2's admission record dated 08/27/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, hyperlipidemia (high cholesterol), orthostatic hypotension (form…

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 Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure the freezer items were properly stored, labeled, and dated. 2. The facility failed to ensure refrigerator and pantry foods were properly stored, labeled, and dated. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: Observation of the freezer on 7/8/24 at 10:20 am revealed the following: 1. (1) box of country fried steak, open to air. 2. (1) box of sweet roll dough, open to air. 3. (1) plastic bag of frozen meat patties, not in original box with no label. 4. (1) plastic bag of frozen sausage patties, not in original box with no label. 5. (1) plastic bag of frozen okra, not in original box with no label. Observation of the kitchen pantry area on 7/8/24 at 10:30 am revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure within 14 days after the facility determined, or should have determined, that there was a significant change in the resident's physical or mental condition for 2 of 14 residents (Residents #1 and #25) reviewed for comprehensive assessments . 1. The facility failed to complete a significant change MDS for Resident #1 within 14 days of 01/23/24-the date he elected to receive hospice care. 2. The facility failed to complete a significant change MDS for Resident #25 within 14 days of 03/27/24-the date she tested positive for COVID 19. These failures could place residents at risk of not receiving the necessary care/treatment. Findings Include: 1. Record review of Resident #1's admission record reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included, but were not limited to, chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough…

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.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 staff (LVN A) reviewed for infection control. -LVN A did not wash her hands or change her gloves while performing wound care. This deficient practice could place residents at risk for the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene. Findings include: During an observation on 07-09-2024 at 12:49 PM LVN A was observed performing wound care on Resident #5's left decubitus heel wound. LVN A was observed washing her hand and donning gloves. LVN A then removed the old dressing, cleaned the wound with gauze wet with wound cleanser, dried the wound with gauze, cleaned the resident's left foot toes with a gauze pad soaked with betadine. LVN A then packed the left heel decubitus ulcer with collagen powder, covered the decubitus wound with a…

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 Based on observation, interview and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 6 residents (Resident #1) reviewed for accommodation of needs. Resident #1's call light was not within her reach. This failure could place residents at risk of not having their needs met and a decline in their quality of care and life. Findings include: Record review of Resident #1's face sheet, dated 05/01/2024, revealed that a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses that included but not limited to Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting left dominant side (weakness following a stroke), contracture of muscle-multiple sites, dysphagia (difficulty in swallowing), muscle wasting and atrophy, cognitive communication, gastro-esophageal reflux disease without esophagitis, shortness of breath, other abnormalities of…

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 Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods was properly labeled and dated. 2. The facility failed to ensure expired foods were discarded. These failures could place residents who ate the food from the kitchen at risk for food-borne illness. Findings included: Observation of the refrigerator on 6/13/23 at 9:54AM revealed the following: 1. 3 loose fresh tomatoes in a box, no date. 2. 1 5-pound chub of hamburger meat with an expiration date of 6/7/23. 3. 1 food service bag of boiled eggs, no date Observation of the freezer on 6/13/23 at 10:12AM revealed the following: 1. 3 food services bags of frozen, chopped spinach, no date. 2. 2 2-pound bags of frozen cauliflower, no date. 3. 1 food service bag of frozen meat pies, no date. 4. 20 pounds of frozen peas, open to air, no date. 5. 1…

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 Based on interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life by failing to assure rights of residents, dignity and respect were provided for 2 of 15 residents (Resident #18 and Resident #31) reviewed for resident's rights, dignity and respect issues. Resident #18 stated that if a complaint is made, staff will ignore her or be rude to her for the remainder of the staff member's shift. Resident #18 could not give a specific date, due to it being a daily occurrence. Resident #31 stated that staff have been intimidating to Resident #31 since the resident council meeting on 06/13/2023. Staff have been short tempered, rude, giving dirty looks to Resident #31. This failure could cause residents to feel uncomfortable, disrespected, and unsafe in their home environment. Findings include: Record review of Resident #18's clinical record revealed…

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 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. The facility administered expired insulin medication to resident #24 on 9 different occasions. The facility had two expired medications in their e-kit. This deficient practice had the potential to affect all resident in the facility resulting in them receiving medication that could not be affective resulting in exacerbation of their condition and deterioration in their health. Finding include: Record review of Resident #24's face sheet dated 6-14-2023 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), muscle weakness (a lack of muscle strength), malnutrition (lack of proper nutrition),…

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.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections for 2 (#10, #26) of 30 Residents 1. ADON broke sterile field during a sterile procedure. 2. LVN C failed to use proper hand hygiene techniques when preparing and administering medication to Resident. 3. Admin and Maintenance Supervisor was unable to provide any information regarding the process followed testing for Legionella which is bacteria that promotes pneumonia by inhaling water droplets. These failures had the potential to affect all residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: During an observation 06/13/23 10:55 AM Observed ADON perform a straight catheter on Resident #26. The ADON provided privacy for Resident #26, ADON washed hands…

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.

Based on interview, and record review, the facility failed to respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means of other than a postal service. This failure effected 2 (Resident #18 and Resident #23) of 15 residents. Resident #18 and Resident #23 both have received mail that has been opened without their consent. Neither resident could remember the specific dates. This failure violates the resident's right to privacy and confidentiality, this could cause residents to feel uncomfortable, disrespected, and unsafe in their correspondence with others. Findings include: During Resident Council meeting held on 06/13/23 02:53 PM, the question was asked, do you get mail unopened, Resident #18 stated that she gets her boxes opened, and the staff does not open the boxes in front of her. Other…

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.