Wheatland Manor

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 15, 2026

  Based on clinical record review, facility policy review and staff interviews the facility failed to ensure staff used a gait belt during a transfer of a resident who required moderate assistance which resulted in an arm fracture for 1 of 3 (Resident #48) residents reviewed for falls. The facility reported a census of 44 residents. Findings include:Review of the Minimum Data Set (MDS) assessment for Resident #48, dated 10/29/25, revealed a list of diagnoses which included hypertension, hyperlipidemia, diabetes and history of a fracture. The Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicated a mild cognitive impairment. […]

• Actual harm, isolatedF689Jan 9, 2025

  Based on observation, clinical record review and staff interviews, the facility failed to provide adequate supervision to prevent a fall which resulted in a fracture requiring a surgical repair for 1 out of 2 residents reviewed for falls.(Resident #5). The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 9/25/24, listed diagnoses for Resident #5 which included orthostatic hypotension (a drop in blood pressure that occurs when standing up from a sitting or lying position), right hip fracture, and coronary artery disease. The MDS indicated Resident #5 required partial to moderate assist of staff to sit to stand, chair/bed-to-chair transfer, toilet transfer, and walk 10 feet to 50 feet. […]

• No harm, potential for more than minimal, patternF812Feb 1, 2024

  Based on observation, staff interview, and facility policy review, the facility failed to check the temperature of cabbage served and further failed to perform hand hygiene when picking up an item from floor during meal service for 1 of 1 meal services observed. The facility reported a census of 41 residents. Findings Include: On 1/30/24 at 12:00 PM, Dietary Supervisor checked the temperature on the following items being served: grilled turkey sandwich, sweet potato fries, coleslaw, and Jell-O, just before meal service. Noted an additional item, steamed cabbage, kept on the stove top that had been served for residents whom required mechanically altered and soft food. […]

• No harm, potential for more than minimal, isolatedF550Feb 1, 2024

  Based on clinical record review, observations, staff interviews and facility policy review, the facility failed to provide residents with privacy and dignity during transport to the shower room when residents were pulled backwards in a shower chair with skin exposed for 3 of 3 residents reviewed for dignity (Residents #9, #21, and #95). The facility reported a census of 41 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment, dated 12/29/23 for Resident #9, revealed the Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicative of intact cognition. Resident #9 identified dependent on staff for transfers and bathing. Diagnoses included right femur fracture, cancer, and arthritis. […]

• No harm, potential for more than minimal, isolatedF641Feb 1, 2024

  Based on clinical record review, staff interview and Resident Assessment Instrument (RAI) Manual review, the facility failed to code 2 out of 5 Minimum Data Set (MDS) Assessments correctly for residents reviewed (Resident #5 and #20). The facility reported a census of 41 residents. Findings Include: 1. The Minimum Data Set (MDS) for Resident #20 dated 11/15/23, showed she took an antidepressant medication in the seven day look back period. The Medication Administration Record (MAR) dated November 2023, failed to include documentation Resident #20 took an antidepressant during the reference period. On 1/31/24 at 1:56 PM, the Director of Nursing (DON), confirmed Resident # 20 failed to utilize an antidepressant at the time of the MDS dated [DATE]. 2. […]