Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wheeler Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with quadriplegia, intact cognition, and an indwelling suprapubic catheter had physician orders and a care plan for daily catheter site care each day shift, including cleaning the site and applying split gauze. Review of wound administration records showed that this ordered care was documented as completed on all applicable day shifts except for two specific days, when no entry was made. The RN assigned on those days reported that the resident sometimes declined care, that she left the electronic documentation window open while reattempting care, and that she failed to return to close out the entries to record either completion or refusal. Facility leadership confirmed that the nurse was expected to document the care or refusal and that incomplete documentation could leave staff unaware of the resident’s current status, contrary to the facility’s documentation policy.
The facility failed to properly store, label, and date food items in the kitchen, leading to potential risks of food-borne illness. Observations revealed open and unlabeled food in the freezer, pantry, and refrigerator. The dietary manager acknowledged the issues and was working to improve conditions, but the facility's policies on food storage were not adhered to.
The facility failed to complete significant change MDS assessments within the required 14-day period for two residents who experienced significant changes in their conditions. One resident elected hospice care, and another tested positive for COVID-19, but their MDS assessments were delayed. Interviews with staff revealed a lack of awareness regarding the timeframe for completing these assessments, potentially impacting resident care.
A facility failed to maintain proper infection control during wound care, as an LVN did not change gloves or wash hands between removing an old dressing and applying a new one on a resident's heel ulcer. This practice was against the facility's infection control policy, which requires glove changes and hand washing to prevent cross-contamination.
The facility failed to ensure that a resident had her call light within reach, despite her significant physical impairments. The resident was observed without her call light, which was confirmed by staff interviews. The staff acknowledged the oversight and the potential negative outcomes, and it was revealed that there was no specific policy regarding call light placement.
Incomplete Documentation of Suprapubic Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and properly documented medical records for a resident with a suprapubic catheter. The resident, a male with quadriplegia (C1–C4), cognitive communication deficit, and a history of urinary tract infections, had an intact BIMS score and an active care plan and physician’s order for daily suprapubic catheter site care each day shift, including cleaning the site, patting it dry, and applying split gauze. Review of the Wound Administration Records for March and April 2026 showed that catheter care was documented as completed on all applicable day shifts except for two specific dates, 03/18/2026 and 04/04/2026, when there was no documentation of the ordered care. The facility’s documentation policy required complete and accurate documentation for each resident on all appropriate clinical record sheets. During interviews, the resident reported no concerns about care and was unable to confirm whether catheter care had been provided. RN A, who worked the day shifts on the two dates with missing documentation, stated that the resident intermittently declined care, leading her to leave the documentation window open until care was completed. She acknowledged that on those two dates she failed to close the documentation window after providing care and that, if care had ultimately been refused by the end of the shift, she should have documented the refusal. The MDS LVN/Assistant DON and the DON both stated that RN A should have documented the care provided or the resident’s refusal and confirmed that incomplete documentation could result in staff being unaware of the resident’s current status. The facility’s policy, dated 02/13/2007, specified that complete and accurate documentation must be maintained for each resident.
Improper Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper storage, labeling, and dating of food items in the kitchen. Observations revealed multiple instances of food being left open to air in the freezer, such as boxes of country fried steak, sweet roll dough, and biscuits. Additionally, several plastic bags containing frozen meat patties, sausage patties, and okra were not in their original boxes and lacked labels. Similar issues were noted in the kitchen pantry, where white plastic bins holding packaged foods contained crumbs, and in the refrigerator, where items like hardboiled eggs, bacon, onions, and milk were not labeled or dated. Interviews with the dietary manager (DM) indicated that she had been working at the facility for four days and was in the process of improving kitchen conditions. She acknowledged that all foods should be covered, labeled, and dated to prevent cross-contamination and potential food-borne illnesses. The facility's policies, dated February 2016, outlined the requirements for labeling, dating, and properly storing leftover foods, milk, and refrigerated and frozen foods. However, these policies were not followed, leading to the deficiencies observed during the survey.
Failure to Timely Complete Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within the required 14-day period for two residents who experienced significant changes in their conditions. Resident #1, a male with multiple diagnoses including chronic obstructive pulmonary disease and cerebral infarction, elected to receive hospice care on January 23, 2024. However, the significant change MDS was not completed until February 19, 2024, which exceeded the 14-day requirement. The resident's care plan and orders reflected his hospice status, but the delay in completing the MDS could potentially impact the care provided. Similarly, Resident #25, a female with diagnoses including heart failure and COVID-19, tested positive for COVID-19 on March 27, 2024. The significant change MDS for this resident was not completed until April 17, 2024, again surpassing the 14-day timeframe. Her care plan and medical orders indicated her COVID-19 status and the precautions taken, but the late MDS completion could affect the management of her care. Interviews with facility staff, including the MDS Licensed Vocational Nurse (LVN), Director of Nursing (DON), and Administrator (ADM), revealed a lack of awareness regarding the specific timeframe for completing significant change MDS assessments. The staff relied on the Resident Assessment Instrument (RAI) policy but did not demonstrate an understanding of the potential negative outcomes of delayed MDS completion. The facility's failure to adhere to the required timeline for MDS assessments could place residents at risk of not receiving necessary care and treatment.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A during wound care for a resident. LVN A did not change gloves or wash hands after removing the old dressing and before applying a new one, which is a critical step in preventing cross-contamination. This oversight was observed during a wound care procedure on a resident's left heel decubitus ulcer, where LVN A only washed hands and donned gloves at the beginning and end of the procedure, neglecting to do so between the removal of the old dressing and the application of the new dressing. Interviews with LVN A and the Director of Nursing (DON) confirmed the expectation that gloves should be changed and hands washed between the dirty and clean portions of care to prevent cross-contamination. The facility's infection control policy also mandates glove changes and hand washing to prevent the transmission of microorganisms. Despite LVN A's acknowledgment of the correct procedure and the facility's policy, the failure to adhere to these practices during the observed wound care led to the identified deficiency.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that Resident #1 had her call light within reach, which is a reasonable accommodation of her needs and preferences. Resident #1, a cognitively intact individual with significant physical impairments including hemiplegia, hemiparesis, and dysphagia, was observed without her call light within reach. This was confirmed during an observation and interview where Resident #1 requested assistance to get her call light, which was found hanging on the wall behind her head, out of her reach. LVN A subsequently placed the call light on Resident #1's blanket within her reach. Interviews with LVN A, CNA B, and CNA C revealed that the aides had forgotten to place the call light within Resident #1's reach after assisting her to bed. All staff members acknowledged the potential negative outcomes of this oversight, including the risk of the resident being unable to call for help if needed. The Director of Nursing (DON) and the Administrator (ADM) confirmed that there was no specific policy regarding the accommodation of needs, including call light placement, and that it was considered common sense.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wheeler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mclean Care Center | 22.7 mi | — | 1 | 1 |
| Mesa View Senior Living | 30.2 mi | — | 8 | 0 |
| Hensley Nursing & Rehab | 37.4 mi | — | 0 | 0 |
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