Wheat State Manor

In the surveyor’s words

From the most serious findings on record at Wheat State Manor, in the surveyor’s own words.

• Immediate jeopardy, widespreadF610Sep 13, 2023

  The facility reported a census of 46 residents with seven selected for review and one resident reviewed for abuse. Based on observation, interview, and record review the facility failed to protect the residents from verbal abuse from Licensed Nurse (LN) G. On the morning of 08/26/23, Certified Nurse Aide (CNA) M heard LN G threaten to hit Resident (R) 2 and CNA N heard LN G threaten R2 if she hit her again, she would be sorry. CNA N failed to report the verbal abuse and CNA M reported the verbal abuse to LN H. LN H failed to notify Administrative Nurse D. LN G worked three shifts after the verbal abuse on 08/26/23, 08/27/23, and 08/28/23 until Administrative Nurse D was made aware of the occurrence on 08/31/23. […]

• Immediate jeopardy, isolatedF600Jun 27, 2023

  The facility reported a census of 47 residents, with three residents reviewed for abuse and neglect. The facility identified eight residents that resided in the secured unit. Based on record review and interview, the facility failed to ensure the residents that resided in the secured unit remained free from physical abuse when R1, who had a history of physical aggression, hit two separate residents, R2 and R3, and R3 sustained fractures to her right radius (one of the bones going from the wrist to the elbow) and ulna (one of the bones going from the wrist to the elbow), and to her left index finger. […]

• Immediate jeopardy, isolatedF610Jun 27, 2023

  The facility reported a census of 47 residents, with three residents reviewed for abuse and neglect. The facility identified eight residents that resided in the secured unit. Based on record review and interview, the facility failed to ensure the protection of the residents from abuse, when the facility did not provide adequate supervision or care planned interventions to address physically aggressive behaviors of Resident (R) 1, who had a history of physical altercations with staff and residents. On 06/10/23 R1 grabbed CMA R's arm; on 06/11/23 R1 hit CMA H in the face which caused a small cut on her cheek and a black eye; on 06/12/23 R1 hit R3 in the chest and face. On 06/13/23 at 11:30 AM Licensed Nurse (LN) G reported R1 exited R2's room and stated, There's a war going on in here. […]

• Actual harm, isolatedF689Jan 27, 2022

  The facility reported a census of 45 residents with three residents sampled for accidents. Based on record review and interview, the facility failed to follow care planned fall prevention interventions for Resident (R) 3 to prevent falls from the lift chair when Physical Therapy Consultant GG plugged in the lift chair, and then left the remote within her reach. The resident raised the lift chair to the highest position, then fell forward on her face, which resulted in a nasal fracture (broken nose). […]

• No harm, potential for more than minimal, widespreadF620Jan 8, 2026

  The facility identified a census of 31 residents. The sample included 12 residents. Based on record reviews and interviews, the facility failed to establish and implement an admissions agreement that protected residents' right to personal property when the facility's admission agreement, signed by residents or their representatives at time of admission, asked the resident to waive facility responsibility for loss of personal property while being a resident in the facility.Findings included:- The facility's admission and Care Agreement revealed under Resident's Valuables on page eight, the Care Center maintains a secure area where personal articles of small size and limited dollar value may be stored. […]