Wonder City Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Wonder City Rehabilitation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689May 7, 2026

  Based on observation, resident and staff interviews, clinical record review, and facility document review, the facility failed to store hazardous chemicals in a manner to minimize accidents and hazards on two of two units, which had the potential to affect residents on both units. The deficient practice resulted in the identification if immediate jeopardy (IJ) and substandard quality of care. Following the verification and removal of IJ, the scope and severity was lowered to level two, pattern. The findings included:The facility staff failed to ensure that hazardous chemicals were stored in a manner to prevent resident access where the liklihood of exposure and/or accidental ingestion was present, which would likely result in severe injury, harm, or even death. […]

• Immediate jeopardy, isolatedF686Nov 3, 2023

  Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care consistent with standards of practice to promote the healing of and prevent infection of pressure ulcers for one Resident (Resident #214) in a survey sample of four Residents reviewed for pressure ulcers, resulting in harm for Resident #214. Immediate Jeopardy (IJ) was identified on 10/31/23 at 3:10 PM, at which time the facility Administrator and Director of Nursing were made aware. Following verification of the removal of immediacy the facility abated the IJ on 11/3/23 at 3:15 PM. The scope and severity was lowered to a level 3, isolated. […]

• Immediate jeopardy, isolatedF689Nov 3, 2023

  Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free from accident hazards for one Resident (#223) in a survey sample of 32 Residents. Immediate Jeopardy (IJ) was identified on 11/2/23 at 12:10 PM, at which time the facility Administrator and Director of Nursing were made aware. Following verification of the removal of immediacy the facility abated IJ on 11/3/23 at 4:15 PM. The scope and severity were lowered to a level 2, pattern. The findings included: For Resident # 223 the facility staff failed ensure the mattress was secured to the bed so that it did not slide off the bed frame. […]

• Immediate jeopardy, isolatedF689Jul 14, 2023

  Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents received adequate supervision and assistance prevent accidents for 1 Residents (#331) in a survey sample of 61 Residents. Resident #331 who was supposed to be on one-to-one (1:1), went out a second story window and sustained injuries. Immediate Jeopardy was called for Resident #331 on 7/13/23 at 9:10 am. The Immediate Jeopardy began on 6/17/23 and was removed on 7/14/23 at 12:40 PM. […]

• Immediate jeopardy, isolatedF689Jul 25, 2022

  Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure freedom from accidents and hazards for 2 Residents (#'s 9 & 4) in a survey sample of 13 Residents. Immediate Jeopardy was found to start on 07/20/2022, called on 7/21/22 at 4:02 PM, and removed on 7/22/22 at 5:10 PM. The findings included: 1. For Resident #9 the facility staff failed to ensure the Resident was provided a safe smoking environment and supervised by staff for safety while smoking. On 7/20/22 at approximately 3:00 PM Surveyors B, C, and D were walking to their respective vehicles and it was observed 2 Residents sitting in wheelchairs in the parking lot area, smoking by the dumpsters. […]