Wheeler Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Wheeler Nursing & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jul 21, 2023

  Based on interviews, and record reviews, the facility failed to ensure that Residents are free from abuse for 6 of 6 residents (Residents #3, #5, #13, #14, #26, #29) reviewed for abuse. 1. The facility failed to prevent Resident #29 from being verbally abused by a facility staff member. 2. The facility failed to keep Residents #3, #5, #13, #14, #26, #29 free from verbal abuse from a facility staff member for extended periods of time resulting in an unsafe and hostile environment. These failures place Residents at risk for psychosocial harm, fearful of retaliation, being uncomfortable, impaired quality of life and abuse as a result of the verbal abuse. An Immediate Jeopardy (IJ) was identified on 7/19/2023 at 5:08PM. […]

• Immediate jeopardy, patternF607Jul 21, 2023

  Based on interviews, and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents for 6 of 6 residents (Residents #3, #5, #13, #14, #26, #29) reviewed for abuse. The facility failed to implement written abuse and neglect policies to prohibit and prevent abuse for Residents #3, #5, #13, #14, #26 and #29. These failures place Residents at risk for psychosocial harm, fearful of retaliation, being uncomfortable, impaired quality of life and abuse as a result of the verbal abuse. An Immediate Jeopardy (IJ) was identified on 7/19/2023 at 5:08PM. […]

• Immediate jeopardy, isolatedF689Apr 27, 2022

  Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 12 residents (Resident #29) reviewed for accident hazards. CNA A transferred Resident #29 by herself from a wheelchair to a shower chair in preparation for bathing when Resident #29 required two staff participation with transfers. Resident #29 sustained a fall during the transfer resulting in a right leg fracture (broken bone in leg), right elbow fracture, and hematoma (bleeding outside of blood vessels, due to trauma.) Resident #29 was sent to the hospital and subsequently placed on hospice care (type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to… […]

• No harm, potential for more than minimal, widespreadF812Aug 28, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF812Jul 10, 2024

  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. […]