Wheeler Nursing & Rehabilitation

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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]. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.