Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wheat State Manor during CMS and state inspections, most recent first.
A facility admission agreement signed by residents or their representatives stated that money, jewelry, documents, furs, and other valuable personal items brought in by residents or third parties were not the facility’s responsibility. An admin staff member stated the wording was incorrect and that residents were allowed to bring valuables, while facility policy said residents were not to be asked to waive liability for personal property.
Failure to implement an effective antibiotic stewardship program and infection tracking system. Administrative staff stated the facility did not have an effective infection control program, including an Antibiotic Stewardship Program, and that logs were still being started. An administrative nurse said the doctor tried to use McGeer criteria to judge antibiotic appropriateness, but if a resident saw another doctor, the facility would give the prescribed antibiotic even when it did not meet the criteria. The facility policy stated the IPCP objective was to monitor, prevent, detect, investigate, and control infections.
Unmonitored call light display monitors led to extended response times. Two visual monitors were the only alert system for resident bedroom and bathroom call lights, but staff were not consistently present at the egressed nurse stations to watch them. At one point, a help call from one resident's room had been active for over 35 minutes and another for nearly 25 minutes. Staff confirmed there were no audible alarms or other indicators, and call lights were only noticed when someone walked by the monitors.
Inadequate hand hygiene occurred during wound care and IV antibiotic administration. An LPN used unclean scissors, continued a dressing change with soiled gloves, and returned supplies from a resident’s room to the cart. Another LPN donned gloves and a gown without hand hygiene, touched the bed and bedding, handled a PICC line and IV setup, left and returned without hand hygiene, and emptied a catheter urine bag without cleaning the port.
Failure to obtain informed consent for psychotropic meds: Five residents had active orders for antidepressants, antianxiety meds, a sleep med, and antipsychotics, but their EMR records lacked consent forms or other evidence that the resident or representative was informed of the risks and treatment details. Social Services stated there were no informed consents for psychotropic meds, and an RN stated notification was required before starting or changing these meds, with the nurse and Social Services handling the process.
Resident dining preferences were not consistently honored. A resident received a room tray with barely warm soup, and multiple residents said they stopped eating in their rooms because trays arrived late or staff told them they were not supposed to eat in their rooms. A CNA said the facility had a rule to serve room trays last, while admin staff said no such rule existed and that resident preferences should be accommodated.
A resident with severe cognitive impairment, a wheelchair, and an indwelling urinary catheter was observed being transported through common areas with his urine collection bag visible and without a dignity cover. The bag was hanging under the footrest of his Broda chair in the lobby area and later during transport from the hall to the main lobby. A CNA and an Administrative Nurse stated the catheter bag should have been below the bladder and covered or placed in a dignity bag.
Failure to provide bed-hold and transfer notifications: A resident with CHF, paroxysmal AFib, and a pacemaker developed fluid retention, SOB, and low O2 saturation, was sent to the hospital by EMS, and was admitted the same day. The EMR lacked evidence of written transfer notification and a bed-hold notice to the resident or representative, and the facility could not show that the LTCO was notified.
A resident with dementia, severely impaired cognition, wandering behaviors, and a fall history had her call light out of reach when it was found coiled at the foot of the bed and dropped between the bed and wall. Staff also propelled the resident in a wheelchair without foot pedals in place, even though an admin nurse stated feet should be on the pedals when staff are pushing the chair.
Failure to monitor bowel movements and follow bowel protocol orders for a resident with constipation and multiple fractures. The resident was dependent on staff for toileting and had a care plan that identified constipation as a side effect of pain meds. EMR review showed 13 consecutive days without a documented BM or constipation treatment, and the MAR lacked evidence that the ordered bowel protocol was given. Staff interviews showed inconsistent understanding of the bowel protocol and follow-up expectations.
Failure to Complete Ordered Wound Dressing Changes: A resident with dementia, anxiety, and depression had a wound on the bottom of the L foot with an order for cleansing and a Hydrofera Blue/Optifoam dressing changed 3x/week. The MAR showed missed dressing changes, and when an LPN removed the dressing it was dated several days earlier and had not been changed in about a week; no Hydrofera Blue was present.
Significant medication errors occurred when ordered meds were not administered for multiple residents. A resident with multiple fractures and non-weight-bearing status missed several doses of enoxaparin, a resident with OCD/anxiety missed multiple doses of Risperdal, and a resident with DM missed doses of Lantus and Novolog. The MARs and EMR lacked reasons for the missed doses, and staff confirmed meds should be given and documented as ordered.
Posted nurse staffing sheets were missing required actual hours worked information. Observations showed the sheets lacked this data on multiple occasions, and record review confirmed the same issue on prior staffing sheets. An Administrative Nurse stated the posted sheet should include an accurate census, total staff per shift, and actual and total hours worked, consistent with facility policy.
The facility failed to ensure that three residents received the required CMS forms related to Medicare/Medicaid coverage and potential liability for services not covered. The facility did not issue CMS 10123 or CMS 10055 for these residents, resulting in a lack of information about their rights to expedited review for discontinuation of therapies and the estimated cost of continuing therapies.
The facility failed to ensure residents received up-to-date COVID-19 vaccinations and opportunities to rescind previous declinations. Medical records of five residents showed no COVID-19 vaccinations were offered in 2023, despite the facility's policy requiring staff to offer the vaccine and allow residents to change their decision. This was confirmed by an interview with the Administrative Nurse.
The facility failed to obtain a reassessment for a resident with schizophrenia and other mental health issues as required by the PASRR program. Despite a temporary 12-month period for stabilization indicated in the PASRR determination letter, the facility did not follow up for a reassessment after the Covid pandemic crisis ended. Interviews confirmed the oversight, and the facility lacked a policy for PASRR.
The facility failed to review and revise the care plan for a resident with a cerebral infarction regarding the use of eyeglasses. Despite the resident's intact cognition and need for glasses, the care plan lacked instructions on their use. The resident reported her glasses had been broken for a long time, and staff confirmed no action had been taken to fix them or update the care plan.
A resident with a diagnosis of cerebral infarction and intact cognition reported that her glasses had been broken for a long time and that she had informed the staff, but no action had been taken. As a result, she had to wear her old glasses, which did not provide adequate vision. Multiple staff members were unaware of the issue, and the facility lacked a policy regarding resident eyeglasses. The issue was only addressed after it was brought to the attention of Social Services staff.
The facility failed to ensure reevaluation of PRN clonazepam for a resident beyond the 14-day period and did not conduct AIMS assessments for another resident on antipsychotic medication. This resulted in non-compliance with the facility's policies on psychotropic medication use and monitoring for adverse effects.
The facility failed to display accurate, publicly accessible, and identifiable staffing information daily for its 38 residents. A review of the Daily Staffing Sheets revealed that the actual hours worked had not been completed. An Administrative Nurse was unaware of the requirement to include actual hours worked. The facility's policy required this information, but it was not properly completed.
Admission Agreement Improperly Waived Responsibility for Residents’ Valuables
Penalty
Summary
The facility failed to establish and implement an admissions agreement that protected residents’ right to personal property when its admission agreement, signed by residents or their representatives at admission, stated that money, jewelry, documents, furs, and other personal articles of significant monetary value brought into the facility by residents and third parties were in violation of the paragraph and would not be the responsibility of the facility. The facility identified a census of 31 residents and reviewed a sample of 12 residents. During interview, Administrative Staff A stated the admission agreement statement was incorrect, that residents were encouraged not to bring highly valuable items, that lock boxes were provided and encouraged for use, and that residents were allowed to bring and have whatever valuables they would like. The facility’s admission agreement policy stated the facility did not ask or require residents or potential residents to waive facility liability for personal property, and the Resident Funds and Valuables Policy stated valuables would be inventoried but suggested valuables not be brought to the facility.
Failure to Implement Antibiotic Stewardship and Infection Tracking Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program that included an effective system to monitor antibiotic use and an effective system to track and trend infections in the building for the Infection Prevention and Control Program. During interview, Administrative Staff D stated the facility did not have an effective infection control program at the time, including an Antibiotic Stewardship Program. Administrative Nurse D stated she was working on starting logs but had not started them yet. She also stated the doctor tried to enforce McGeer criteria for documenting the appropriateness of antibiotics, but acknowledged that if a resident saw another doctor, the facility would give what the other doctor prescribed even if it did not meet the criteria. The facility policy on Infection Prevention and Control stated the objective was to monitor, prevent, detect, investigate, and control infections in the facility and maintain a safe, sanitary place.
Unmonitored call light display monitors led to extended response times
Penalty
Summary
The facility failed to ensure an adequate resident call system when the only alert system for bedroom and bathroom call lights consisted of two visual display monitors that were left unmonitored. The facility had a census of 31 residents over four resident halls. On observation, an egressed nurse station on the 200-hall and another on the 400-hall each had a display monitor showing call requests, but no staff were present at either station. On a later observation, both stations were again unattended while the monitors remained active. At 1:13 PM on 01/07/26, the 400-hall display monitor showed a help call alert from R27's room that had been active for 35 minutes and 17 seconds, and another alert showed R33's call light had been activated for 24 minutes and 49 seconds. Review of the Call Light Log showed the lights were last checked in December 2025 with no issues noted. CNA M stated staff had to walk by the monitors to know when a resident's call light was activated, that there were only two monitors, and that there was no audible alarm or other indicator in the rooms or halls. She also stated staff were not always present at the stations and that it was sometimes a real problem to know which lights were going off. Administrative Staff A confirmed the monitor was typically at the 200-hall nurse cubby, that staff were alerted only by visually seeing the display, and that there was no audible or other way to know when a call light was activated. The facility did not provide a policy.
Inadequate Hand Hygiene During Wound Care and IV Administration
Penalty
Summary
The facility failed to use adequate hand hygiene during resident care, including wound care and IV medication administration. On 01/07/26, a licensed nurse obtained scissors and dressing supplies, entered a resident’s room, washed her hands, and applied gloves, but did not clean the scissors before use. She removed the old dressing, washed the wound, and then continued the dressing change with the same soiled gloves while applying Hydrofera Blue and an Optifoam dressing. After discarding trash and removing her gloves, she carried unused supplies into the bathroom, laid them on the back of the commode while washing her hands, and then returned the supplies to the cart. The resident involved had a wound requiring dressing care. On 01/08/26, another licensed nurse entered a resident’s room to administer IV antibiotics and donned gloves and a gown at the doorway without performing hand hygiene first. She touched the bed and bedding with gloved hands, handled the IV setup, and after dropping a syringe in the trash, left the room, removed her gown and gloves, and exited without hand hygiene before going to another hall and returning with a new syringe. She again donned gloves without hand hygiene, re-entered the room, flushed the resident’s PICC line, started the IV antibiotic, and later emptied the resident’s catheter urine collection bag without cleaning the urine collection port before or after access. She then removed her gown and gloves and left the room without performing hand hygiene before handling the medication cart.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents and/or their representatives about the risks related to psychotropic medications before use or changes in therapy for five sampled residents. Record review showed that R6, R2, R4, R5, and R28 had active orders for psychotropic medications, including antidepressants, antianxiety medication, a sleep medication, and antipsychotic medications, but their scanned EMR records did not contain consent forms or other evidence of informed consent for the listed medications. The medications included sertraline for depression, bupropion for anxiety and depression, lemborexant for insomnia, fluoxetine for OCD, risperidone for OCD, lorazepam for anxiety, and quetiapine and mirtazapine for depression and dementia with behaviors. During interviews, Social Services stated there were no informed consents for psychotropic medications. Administrative Nursing staff stated the resident or legal representative was to be notified before a psychotropic medication was started and that notification was also required when the medication changed, with the nurse receiving the order and social services responsible for the notification and consent process. The facility policy on Psychotropic Medication Use, dated 02/2025, stated that before initiating, increasing, or switching a psychotropic medication, staff and the physician would review non-pharmacological alternatives, the indication and rationale, the potential risks and benefits, and the resident's and/or representative's right to accept or decline treatment before documented consent or refusal was obtained.
Resident Dining Preferences Not Facilitated
Penalty
Summary
The facility failed to allow and facilitate residents to exercise dining preferences related to when room trays were delivered and whether residents ate in their rooms or in the main dining area. On 01/06/26 at 12:13 PM, Resident 14 received lunch in his room, and the chicken noodle soup was observed with clear wrap and foil over the bowl; the resident reported the soup was barely warm. During interviews, Resident 6 stated he now went to the dining room because it took a long time to get his food in his room and the food would not be hot, although he preferred to eat in his room. Resident 14 stated he had started eating in the dining room because it took a long time for his food to reach his room, the food would not be hot, and his lunch would not arrive until after 12:00 PM. He also stated that residents who ate in their rooms ate last, after the kitchen closed. Resident 9 reported he used to eat in his room, but staff told him he was not supposed to eat there, so he began going to the dining room. A CNA stated the facility had made a rule that residents who ate in their rooms were to receive meal trays last, after everyone in the dining area was served. Administrative staff stated there was no rule or policy requiring room trays to be served last and said staff should discuss resident preferences and accommodate them, while the facility policy on Resident Rights stated residents had the right to self-determination and to be treated with respect, kindness, and dignity.
Failure to Protect Resident Dignity During Transport
Penalty
Summary
The facility failed to protect the dignity of a resident with an indwelling urinary catheter when he was transferred through the facility without a dignity cover on his urine collection bag, leaving the urine visible to other residents and visitors. The resident had diagnoses of benign prostatic hyperplasia with lower urinary tract symptoms, overactive bladder, and urinary retention, and his quarterly MDS documented a BIMS score of 3, indicating severe cognitive impairment. The assessment also documented that he used a wheelchair for mobility, was dependent on staff for all care and ADLs, and had an indwelling urinary catheter. On observation, the resident was seated in a Broda chair in the front lobby area near the fireplace, across from the entryway and nurse's station, with his urine collection bag visible under the footrest and approximately half full of pale-yellow urine. A later observation showed a CNA pushing the resident from the 100 Hall to the main lobby with the urine collection bag still hanging under the footrest and still lacking a dignity cover, with pale-yellow urine visible. During interviews, a CNA and an Administrative Nurse stated the urinary collection bag should have been placed below the bladder and covered or placed in a dignity bag. The facility's Resident Rights policy stated residents have the right to a dignified existence.
Failure to Provide Bed-Hold and Transfer Notifications
Penalty
Summary
The facility failed to provide a bed-hold notice and written transfer notification for a resident with congestive heart failure, paroxysmal atrial fibrillation, and a cardiac pacemaker. The resident’s EMR showed a Discharge with Expected Return MDS dated 11/09/25, but no BIMS was documented. The resident’s health conditions section noted shortness of breath at rest and with exertion, and the care plan documented altered cardiovascular status related to the pacemaker, heart failure, and CAD, with interventions to monitor and report changes in lung sounds, edema, and weight. On 11/09/25, progress notes documented continued fluid retention, SOB, oxygen saturation of 90% on room air, and only one void that morning. The resident’s representative agreed the resident needed to return to the hospital for evaluation and treatment, and the resident was transported by EMS and admitted to the hospital later that day. The EMR lacked evidence that the facility provided written notification of the transfer and a bed-hold notice to the resident and/or representative, and the facility could not provide evidence that the LTCO was notified. During interviews, Social Services stated the bed-hold had not been done or sent and that no discharge notification had been sent to the Ombudsman or family, and Administrative Nurse D stated the SSD was responsible for initiating the bed hold within 24 hours of discharge.
Call Light Out of Reach and Wheelchair Used Without Foot Pedals
Penalty
Summary
The facility failed to provide an environment free from accident hazards for a resident with dementia, osteoporosis, severely impaired cognition, wandering behaviors, and a history of falls. The resident’s care plan directed staff to ensure the call light was within reach and to encourage use as needed, but on observation the call light was coiled at the foot of the bed on the opposite side of the resident and had dropped between the bed and the wall, leaving it out of reach while the resident sat on the edge of the bed and appeared to be seeking help. A CNA later retrieved the call light and stated the resident sometimes threw it toward the end of the bed. The facility also failed to ensure safe wheelchair use when staff propelled the resident without foot pedals in place. A CMA pushed the resident in a wheelchair while she wore socks and the chair had no foot pedals, and the resident pedaled her feet so they lightly touched the floor. The CMA stated the resident sometimes self-propelled and did not need foot pedals, but confirmed that foot pedals should be placed on the wheelchair when staff propel it. An administrative nurse stated staff were expected to ensure residents’ feet were on the foot pedals when being pushed and that foot pedals should be stored in a bag on the back of the wheelchair if needed.
Failure to Monitor Bowel Movements and Follow Constipation Orders
Penalty
Summary
The facility failed to monitor bowel movements and follow physician-ordered constipation treatment for a resident with constipation and pain due to acute trauma. The resident was admitted after a motor vehicle incident with multiple fractures, had intact cognition with a BIMS score of 15, and was dependent on staff for toileting, bathing, dressing, bed mobility, and transfers. Her care plan directed staff to monitor and document side effects of pain medication, including constipation, and her physician orders included a bowel protocol with prune or apple juice/prunes on day one, Milk of Magnesia on day two, and a laxative suppository on day three as needed for constipation. Review of the EMR showed the resident went 13 consecutive days without a documented bowel movement or treatment, from 12/26/25 at 8:14 PM through 01/08/26 at 5:50 AM. The December 2025 and January 2026 MAR lacked evidence that the bowel protocol medications were administered, and the EMR lacked evidence of a clinical assessment related to the lack of bowel movements during that interval. Staff interviews indicated the CNAs documented bowel movements and nurses were expected to follow up when needed, but one nurse stated she was unsure of the bowel protocol, and another administrative nurse stated nurses were to assess the resident, provide the proper medication, and document the assessment and medication when no bowel movement occurred.
Failure to Complete Ordered Wound Dressing Changes
Penalty
Summary
The facility failed to provide care and services according to physician orders for a resident with dementia, anxiety, and depression who had a wound on the bottom of the left foot. The resident’s record showed a wound identified on readmission, and the physician ordered the wound to be cleansed with normal saline, patted dry with gauze, then covered with Hydrofera Blue and an Optifoam dressing, with the dressing to be changed every Monday, Wednesday, and Friday. The care plan identified a potential or actual skin impairment and instructed staff to use caution when transferring the resident, but it did not mention any wounds. The January MAR documented that the dressing change was not completed on two scheduled occasions. When the resident was observed with the dressing still in place, the dressing was dated several days earlier, and the licensed nurse who removed it verified that it had not been changed in about a week. She also found that no Hydrofera Blue was present when the dressing was removed. The administrative nurse stated that nurses should complete treatments as ordered and document them, and the facility policy required staff to verify the order before completing a dressing change and document after it was completed.
Significant Medication Errors for Multiple Residents
Penalty
Summary
The facility failed to ensure residents received medications as ordered, resulting in significant medication errors for three residents. The survey found that the facility had a census of 31 residents and reviewed a sample of 12 residents. Based on observation, record review, and interview, medications were not administered as prescribed for R2, R4, and R6, and the EMR and MARs documented multiple missed doses without supporting documentation for why the medications were not given. R2 was admitted after a motor vehicle incident with multiple fractures and injuries, including to the face, both legs, right arm, and spine, and was dependent on staff for care with non-weight-bearing status. R2 had an order for enoxaparin sodium injection twice daily related to long-term anticoagulant use, but the MAR documented numerous missed doses across late December 2025 and early January 2026. The record lacked documentation explaining the missed administrations, and on observation R2 was lying in bed and stated she could not get out of bed due to her non-weight-bearing status. R4 had diagnoses including OCD and anxiety, with intact cognition documented on the MDS, and was receiving psychotropic medications including Risperdal, bupropion, and fluoxetine. R4’s MAR documented missed doses of Risperdal on multiple evenings in December 2025. R6 had diabetes mellitus and was dependent on insulin; orders included Novolog after meals and Lantus at bedtime. R6’s MAR documented missed doses of both insulins in December 2025 and January 2026, and the EMR lacked information on why the insulin was not given. Staff interviews confirmed that medications should be given and documented as ordered, and that if a medication was not given or was held, the reason, provider notification, and appropriate documentation should be present.
Posted Nurse Staffing Sheets Missing Required Hours Worked
Penalty
Summary
The facility failed to ensure the posted daily nurse staffing sheets included accurate and identifiable information, including the actual hours worked. The facility had a census of 31 residents. During observations on 01/06/26 at 08:20 AM, 01/07/26 at 09:30 AM, and 01/08/26 at 10:30 AM, the posted staffing sheet lacked the actual hours worked. Review of the daily staffing sheets from 12/25/25 and 01/05/25 also showed that the staffing sheets lacked the actual hours worked. During an interview on 01/08/26 at 08:20 AM, Administrative Nurse D stated the posted staffing sheet should have documented an accurate census, the total number of medical staff per shift, and the actual hours and total hours worked. The facility policy, Posting Direct Care Daily Staffing Numbers, dated 08/2022, required the staffing sheet to be posted in a prominent location and include the facility name, current date, resident census at the beginning of the shift, the 24-hour shift schedule, the shift being posted, the type and category of nursing staff working during the shift, the actual time worked during the shift for each category and type of nursing staff, and the total number of licensed and non-licensed nursing staff working for the posted shift.
Failure to Issue Required CMS Forms for Medicare/Medicaid Coverage
Penalty
Summary
The facility failed to ensure that three residents received the required CMS forms related to Medicare/Medicaid coverage and potential liability for services not covered. Specifically, Resident 40 was discharged from skilled therapy on 12/21/23, but the facility did not issue CMS 10123 or CMS 10055. The resident remained in the facility and was placed on hospice services on 01/02/24. Resident 95's skilled services ended on 10/18/23, and while CMS 10055 was issued to the responsible party by email on 10/23/23, CMS 10123 was not issued. This resident also remained in the facility and went on hospice services on 10/27/23. Resident 96's skilled services ended on 11/19/23, and although CMS 10055 was issued, it was incomplete and did not include the estimated cost of continued services. CMS 10123 was not issued, and the resident discharged from the facility on 11/20/23. An interview with Administrative Staff B on 03/11/24 revealed that neither she nor Social Service Staff X knew to issue CMS 10123 for skilled services and that the facility did not have a policy for the issuance of these forms. The facility lacked a policy for CMS 10123 or CMS 10055 at the time of the required issuance for the above residents but did develop a policy on 03/11/24. The facility's failure to issue CMS 10123 and CMS 10055 meant that residents and their responsible parties were not informed of their rights to expedited review for discontinuation of therapies and the estimated cost of continuing therapies as required.
Failure to Offer Timely COVID-19 Vaccinations and Rescind Declinations
Penalty
Summary
The facility failed to ensure that residents received up-to-date COVID-19 vaccinations and were given opportunities to rescind previous declinations. Specifically, the medical records of five residents were reviewed, revealing that none of them were offered COVID-19 vaccinations in 2023. For instance, one resident received a COVID-19 vaccination in November 2022 but was not offered another in 2023. Another resident who declined the vaccine in January 2021 was not given further opportunities to change their decision in 2022 or 2023. These findings were confirmed by an interview with the Administrative Nurse, who acknowledged the lack of documentation indicating that COVID-19 vaccinations were offered in 2023. The facility's policy, revised in May 2023, instructed staff to ensure each resident is offered the COVID-19 vaccine unless medically contraindicated or fully vaccinated, and to allow residents to change their decision regarding vaccination acceptance or declination. However, the facility did not adhere to this policy, resulting in a failure to offer timely COVID-19 vaccinations and opportunities for residents to make informed decisions about their vaccination status.
Failure to Obtain PASRR Reassessment for Resident
Penalty
Summary
The facility failed to obtain a reassessment for a resident (R20) to determine mental health needs as required by the Pre-admission Screening and Resident Review (PASRR) program. R20's medical record revealed diagnoses including schizophrenia, psychotic disorder, delusions, hallucinations, and osteomyelitis. Despite an Annual Minimum Data Set (MDS) indicating normal cognitive status, the resident had recent delusions resulting in a transfer to an inpatient psychiatric facility and was receiving antipsychotic medication. The PASRR determination letter indicated a temporary 12-month period for stabilization, after which a reassessment was needed. However, the medical record lacked documentation of this reassessment. Interviews with Social Services Staff X and Administrative Staff A confirmed that the facility failed to follow up with the State Agency for a reassessment in a timely manner after the Covid pandemic crisis ended. Additionally, the facility lacked a policy for PASRR, further contributing to the oversight. The deficiency was identified during a review of the facility's census, which included 13 residents selected for review, highlighting the facility's failure to request a reassessment for R20 to determine continued care needs in a nursing facility for mental health as required.
Failure to Revise Care Plan for Resident's Eyeglasses
Penalty
Summary
The facility failed to review and revise the care plan for Resident 19 regarding the use of eyeglasses. Resident 19, who has a diagnosis of cerebral infarction and intact cognition as indicated by a BIMS score of 14, required glasses for her vision. Despite this, the care plan revised on 02/01/24 lacked staff instructions on the resident's use of eyeglasses. The resident reported on 03/06/24 that her glasses had been broken for a long time and had not been repaired, forcing her to wear old glasses and impairing her vision. Staff interviews confirmed that the resident's glasses had been broken for an extended period, and no action had been taken to fix them or update the care plan accordingly. On 03/11/24, both a Licensed Nurse and an Administrative Nurse acknowledged that eyeglasses should have been included in the resident's care plan. The facility's policy for Care Plans, revised in March 2022, states that assessments of residents are ongoing and care plans should be revised as information about the resident changes. However, the facility did not adhere to this policy, resulting in the failure to address the resident's need for functional eyeglasses in her care plan.
Failure to Repair Resident's Glasses in a Timely Manner
Penalty
Summary
The facility failed to ensure that a resident received adequate assistive devices to maintain proper vision by not repairing her glasses in a timely manner. The resident, who had a diagnosis of cerebral infarction and an intact cognition score, reported that her glasses had been broken for a long time and that she had informed the staff, but no action had been taken. As a result, she had to wear her old glasses, which did not provide adequate vision. Multiple staff members, including CNAs and nurses, were unaware of the issue, and the facility lacked a policy regarding resident eyeglasses. The resident's electronic medical record and care plan did not include instructions on the use of eyeglasses, and the Quarterly MDS did not assess her vision. Despite the resident's repeated complaints, the issue was not addressed until it was brought to the attention of Social Services staff, who then took steps to have the glasses repaired. The facility's failure to act promptly on the resident's need for functional eyeglasses resulted in a deficiency in providing necessary assistive devices for proper vision.
Failure to Reevaluate PRN Psychotropic Medication and Monitor for Side Effects
Penalty
Summary
The facility failed to ensure that one resident (R13) received reevaluation for the continued use of PRN clonazepam beyond the 14-day initial period as required. R13 had diagnoses including cerebral infarction, aphasia, anxiety, and dementia. The resident's care plan instructed staff to monitor for side effects of psychotropic medication and document occurrences of anxiety. Despite receiving multiple doses of clonazepam over several months, the facility did not follow up on the pharmacy's recommendation to reevaluate the PRN use and indicate a length of time for its use. The administrative nurse confirmed that the physician did not reevaluate the medication as required by the facility's policy on psychotropic medication use, which mandates reassessment beyond 14 days unless otherwise documented by the prescriber. This oversight was confirmed through interviews and record reviews, revealing a failure to adhere to the policy and ensure proper medication management for R13. Additionally, the facility failed to monitor another resident (R11) for side effects of antipsychotic medication using the Abnormal Involuntary Movement Scale (AIMS). R11 had diagnoses of delusional disorder and malignant neoplasm of the bladder and lung. The resident's care plan instructed staff to monitor for side effects of Haldol, an antipsychotic medication prescribed for delusional disorder. However, the resident's electronic medical record lacked documentation of an AIMS assessment, which is essential for detecting tardive dyskinesia, a potential side effect of antipsychotic medications. Interviews with licensed nurses and administrative staff confirmed that AIMS assessments should be completed upon the initiation of antipsychotic medication and periodically thereafter, but this was not done for R11, indicating a failure to adequately monitor for adverse consequences as required by the facility's policy.
Failure to Display Accurate Daily Staffing Information
Penalty
Summary
The facility failed to display accurate, publicly accessible, and identifiable staffing information daily for the 38 residents residing in the facility. A review of the facility's Daily Staffing Sheets from 02/11/24 through 03/11/24 revealed that the actual hours worked had not been completed on the daily staffing sheets. On 03/11/24 at 11:33 AM, an Administrative Nurse stated she was unaware that the actual hours worked were to be included on the daily staffing sheets. The facility's policy for Posting Direct Care Daily Staffing Numbers, revised in August 2022, required that the information recorded on the form include the actual time worked during the shift for each category and type of nursing staff. The facility failed to properly complete the daily staffing sheets for the residents of the facility.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Whitewater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kansas Christian Home | 11.4 mi | ★★★★★ | 13 | 0 |
| Newton Presbyterian Manor | 11.6 mi | ★★★★★ | 11 | 0 |
| Paramount Community Living And Rehab Inc | 11.8 mi | ★★★★★ | 22 | 0 |
| Bethel Health Care Center | 13.7 mi | ★★★★★ | 0 | 0 |
| Catholic Care Center, Inc | 14.5 mi | ★★★★★ | 3 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.