Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Wheatcrest Hills Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia and dependence for mobility developed a stage II pressure ulcer on her foot after her foot was resting on a heel lift wedge instead of being properly floated, and Prevalon boots were not started until after the injury was identified. Another resident with diabetes, neuropathy, and weakness developed a buttocks wound that progressed from an abrasion to a stage IV pressure ulcer, with staff documenting it as an abrasion even after it became a deep open wound and not implementing pressure-relieving measures until later. The wound clinic documented the buttocks wound as a stage III and then stage IV pressure ulcer, and staff acknowledged the wound had a pressure component and that the foot injury was preventable.
Improper Hand Hygiene and Glove Use During Meal Service: Staff were observed in the kitchen and dining room handling food, utensils, and resident meals without washing hands between glove changes, after touching surfaces, or between residents. A FANS cook used the same gloves across multiple food prep tasks, and CNAs and a hairdresser served residents and handled food without hand hygiene. Interviews confirmed staff expected hand hygiene before, between, and after glove use and after contact with surfaces, consistent with the facility's handwashing policy.
Hand hygiene was not performed during multiple medication administration opportunities by a CNA/CMA and an LPN, and an LPN did not wear a gown while assessing a resident’s wound despite the resident being on EBP. Two residents with wounds and one resident with a urinary catheter were identified as being on EBP, and staff interviews confirmed gown and glove use was required for high-contact care such as wound care, catheter care, transfers, toileting, and bathing.
A facility failed to ensure side rail safety and to document alternate interventions before installing bed rails for multiple residents. Two cognitively intact residents had side rails with openings and mattress gaps that staff confirmed could allow body parts to become entrapped, while two other residents also had side rails without documented safety evaluations. Maintenance checks focused on whether rails were secure and functioning, but did not assess entrapment risk, and the administrator acknowledged the facility had not followed its policy for trying alternatives before installation.
Surveyors found that the facility did not consistently provide restorative nursing programs as care planned for all sampled residents at risk for decline in range of motion (ROM). Documentation showed infrequent or missing records of restorative interventions, and staff confirmed that restorative sessions were often missed due to reassignments. Some residents and family members expressed concerns about the adequacy of restorative care, and EMR reviews revealed that required exercises and training were not completed as ordered.
A CNA performed a full-body mechanical lift transfer for a resident without the required assistance of a second staff member, contrary to the care plan, facility policy, and manufacturer's instructions. During the transfer, the lift's metal hanger bar struck the resident's forehead, causing a laceration that required emergency medical care. The resident had multiple medical conditions and was moderately cognitively impaired. The CNA was aware of the two-person requirement but proceeded alone due to short staffing.
A resident received a burn due to the facility's failure to follow nebulizer machine instructions. The resident, with moderately impaired cognition, was found with blisters on his thigh after the nebulizer was placed on his bed. Despite a physician's order to discontinue self-administration, the resident continued to handle the machine. Staff did not remain in the room during treatment, and the RN was unaware of the manufacturer's warning against placing the machine on soft surfaces.
The facility failed to honor residents' rights to dignity and self-determination, as evidenced by grievances involving the certified food manager (CFM) D. Residents were denied snacks and alternative food options, with some experiencing verbal abuse when requesting different meals. Staff interviews confirmed these issues, revealing a pattern of neglect in addressing dietary needs and a lack of communication regarding food availability.
The facility failed to respond promptly to residents' call lights, affecting several residents. One resident was left on a commode for nearly an hour, while another waited 45 minutes for assistance. A third resident experienced a 30-minute delay in receiving help, and a fourth did not receive requested medication until the next morning. Despite previous efforts to address these issues, staff were observed remaining at the nurse's station while call lights were active, particularly during the evening shift.
The facility failed to provide meal alternatives to several residents, leading to dissatisfaction and concerns about food quality. Residents reported issues such as burned food, lack of meal options, and fear of retaliation from the certified food manager. The discontinuation of menu cards, which allowed residents to select meal alternatives, contributed to the deficiency. Staff were unaware of the change, and residents were not informed. Despite a performance improvement plan, the deficiency persisted due to inadequate communication and execution of meal service policies.
Dietary staff failed to follow proper glove use and thermometer sanitization protocols during meal services. Observations revealed that dietary cook I and certified food manager D did not wash hands before changing gloves and used a cleaning rag instead of alcohol pads to sanitize thermometers. Dietary cook O also used the thermometer without proper sanitization. The regional dietitian confirmed that staff were expected to adhere to hand washing and sanitization policies.
The provider failed to follow the individualized care plan for a resident requiring denture removal after meals, leading to an emergency department visit. Additionally, five residents did not receive their scheduled weekly baths, and there was no documentation of sponge baths being provided. The DON confirmed the lack of monitoring and awareness of these deficiencies.
Failure to Prevent and Properly Manage Pressure Ulcers
Penalty
Summary
The provider failed to identify and implement pressure ulcer prevention interventions for two residents who developed pressure injuries. One resident with weakness, polymyalgia rheumatica, and dementia developed a stage II pressure ulcer on the outer side of her right foot. Staff documented that her foot had been resting on a heel lift wedge when the blister and non-blanchable area were first identified, and the Prevalon boots were not started until three days later. The resident was dependent on staff for positioning and mobility, and staff confirmed the heel floatation cushion had been used for a long time but her foot was resting on it rather than being properly floated when the injury developed. A second resident with seizures, tremors, polyneuropathy, diabetes, and weakness developed a wound on her right buttocks that progressed from an abrasion to a stage III and then a stage IV pressure ulcer. The resident reported the wound began after she was scratched by a whirlpool tub chair, but staff later recognized a pressure component because of the wound’s location over a bony prominence and the resident’s tendency to lean to her right side when seated. The wound became open, deep, tunneled, and required repeated debridement and surgery. The resident stated that pressure-relieving interventions such as an air mattress and recliner cushion were not in place until after the wound had already worsened, and she also reported that the air mattress had a hole and was not replaced for several months. Record review showed the right buttocks wound was repeatedly documented as an abrasion even after it became a deep open wound, while the wound clinic documented it as a stage III pressure ulcer and later a stage IV pressure ulcer. The resident had a donut cushion in her recliner until the wound clinic advised against it, and staff acknowledged the wound should not have continued to be documented as an abrasion once it became open. The facility policy required skin inspections, weekly skin audits, notification of the medical provider and resident representative, and implementation of new interventions when skin impairment was noted, but the records and interviews showed these pressure ulcer prevention measures were not identified and implemented in time for either resident.
Improper Hand Hygiene and Glove Use During Meal Service
Penalty
Summary
The provider failed to ensure proper hand washing and glove use during meal service and food preparation. In the kitchen on 12/1/25 at 5:21 p.m., a FANS cook was observed measuring temperatures of food, handling utensils, opening cupboards and drawers, documenting temperatures, and preparing multiple food items while wearing the same gloves, removing gloves without washing hands, and putting on new gloves without hand hygiene. The cook also handled ready-to-eat foods and meal components, including buns, cheese, chili, pudding, plates, and serving utensils, while using the same gloves across multiple tasks. During the dining room meal service, staff were observed assisting residents and serving food without performing hand hygiene between residents or after touching surfaces. A CNA set up one resident's meal, returned to the kitchen serving window, and then assisted another resident without hand hygiene before or after those tasks. Other CNAs served multiple residents, adjusted hair or clothing, touched surfaces such as drawers, and continued serving meals without washing hands. A hairdresser also walked among residents, touched residents' shoulders, gave two residents hot water, and handled bread and chicken with bare hands without performing hand hygiene before or after those actions. Interviews confirmed the expected practice was hand hygiene before, between, and after glove use, after touching surfaces, and before assisting residents. The FANS cook acknowledged he knew he should not touch surfaces and then touch ready-to-eat foods, and agreed he had not washed his hands when changing gloves. The facility's August 2025 Handwashing/Hand Hygiene policy stated hand hygiene is performed after hands become contaminated, before and after direct resident contact, before and after meal assistance, and after contact with potentially contaminated surfaces or items in the resident's environment.
Hand Hygiene and EBP Gown Use Not Followed
Penalty
Summary
The provider failed to ensure infection prevention and control practices were followed during resident care and medication administration. During observation of a morning medication pass, a CNA/CMA did not perform hand hygiene before preparing medications for resident 32, before preparing medications for resident 24, or before preparing medications for resident 19, and did not perform hand hygiene after administering medications to resident 24. During an insulin administration, an LPN applied gloves without performing hand hygiene and removed the gloves without performing hand hygiene afterward. The provider also failed to ensure appropriate gown use for a resident on enhanced barrier precautions (EBP). Resident 36 had a urinary catheter, a wound on her buttocks, and a care plan updated to include EBP. When the LPN assessed resident 36's wound, she entered the room, washed her hands, applied gloves, and did not put on a gown. She rolled the resident toward her so the resident's bare skin came into contact with her uniform, then rolled the resident back, removed her gloves, and washed her hands. Resident 36 stated staff wore gloves when they transferred her, helped her get dressed and undressed, and emptied her urinary catheter, but they did not wear a gown. A second resident on EBP, resident 9, also had a wound on her buttocks and stated staff used to wear a gown and gloves when providing care, but now staff had only used gloves. Observation and interview confirmed gowns and gloves were available in the room, but resident 9 reported staff had not worn a gown during dressing changes to her wound. Staff interviews stated residents with wounds, urinary catheters, and feeding tubes were to be on EBP, and that gown and glove use was required for high-contact care such as wound care, catheter care, transfers, toileting, and bathing.
Side Rail Entrapment Risk and Missing Pre-Installation Evaluation
Penalty
Summary
The facility failed to ensure safety and prevention of potential entrapment or injury for four sampled residents who had side rails on their beds, and it failed to document alternate interventions attempted before side rail installation for two recently admitted residents. Resident 9 had a side rail on the left side of the head of the bed that was upside down U-shaped, with an opening measuring seven inches wide by 17 inches high. The side rail was attached to a wooden board under an air mattress and secured with a black strap. During observation and interview, the resident stated she used the side rail to reposition herself and sit up, and the air mattress was not secured and moved from side to side, creating a five-inch gap between the mattress and the side rail. The resident was cognitively intact, had signed informed consent for the side rail, and there were no evaluations in the EMR for safety related to potential entrapment risk. Resident 1 had a white side rail on the right side of the head of the bed with openings that were not outside the recommended guidance for size of an opening within a side rail to prevent entrapment and injury. The resident stated he used the side rail for repositioning and to transfer in and out of bed, and that it had been installed shortly after admission. He was cognitively intact, had given verbal consent for the side rail, and the Device and Bed Rail/Enabler Evaluation stated that interventions attempted before installation were not applicable because he was a new admission. No evaluations for safety related to potential entrapment risk were documented in his EMR. Resident 15 had bilateral side rails and stated they helped her roll over, though she did not use them much. Her EMR showed a BIMS score of 15 and Device and Bed Rail/Bed Enabler Evaluations completed on multiple dates, but the evaluations did not indicate what measures were tried before implementing the side rail. No documentation was found showing that entrapment risk had been evaluated before side rail implementation. Resident 27 had a side rail on the left side of the head of the bed with the same upside down U-shaped design and a seven-inch by 17-inch opening. She had a BIMS score of 8, her care plan identified the side rail as a grab bar to assist with positioning/transfers, and informed consent had been signed, but there were no evaluations for safety related to potential entrapment risk documented in her EMR. Maintenance staff reported that monthly bed checks focused on whether the side rail was secure, functioning properly, and free of missing or broken items, but they did not evaluate side rails for entrapment or other safety risks. The maintenance supervisor confirmed the gap between Resident 9's air mattress and side rail posed a potential entrapment risk, and he verified that the openings in Residents 9 and 27's side rails were large enough for a resident's head or other body part to fit through and posed a potential entrapment risk. The administrator stated the facility had not followed its policy by not attempting alternate interventions before installing side rails, and also stated maintenance was responsible for entrapment assessments even though the bed checklist did not include such an assessment. The provider's policy required risk/benefit review, consent, care plan updates, and device evaluation, and the bed manual stated to use only accessories specifically identified for the bed; the side rails on Residents 9 and 27's beds were not identified as accessories in the manual.
Failure to Provide Consistent Restorative Nursing Program for Residents at Risk for ROM Decline
Penalty
Summary
Surveyors identified that the facility failed to ensure an ongoing restorative nursing program was completed according to the care planned needs for all twelve sampled residents at risk for a decline in range of motion (ROM). Observations, interviews, and record reviews revealed that restorative programs were not consistently provided as ordered or care planned. For example, one resident expressed a desire for daily restorative exercises and noted that his program was only completed once a week, with significant gaps in documentation and actual provision of services. The restorative aide confirmed that she was frequently reassigned to CNA duties, resulting in missed restorative sessions for residents. Review of electronic medical records (EMRs) for all twelve residents showed inconsistent and infrequent documentation of restorative care. Many days were marked as 'Not Applicable' for the provision of ROM exercises, and in several cases, there were only a handful of days within a 30-day period where restorative interventions were documented as completed. Some residents were noted as 'Not Available' or 'Refused,' but the majority of days lacked any indication that restorative care was attempted or provided, despite care plans and referral forms specifying the frequency and type of interventions required. Interviews with residents and staff further corroborated the lack of consistent restorative care. While some residents reported satisfaction with the program, others, including family members, questioned the adequacy of services, especially in relation to discharge planning and maintenance of function. Staff interviews revealed that the restorative aide's frequent reassignment to CNA duties directly impacted the ability to deliver restorative programs as scheduled. The facility's own documentation and staff statements confirmed that the restorative nursing program was not implemented as care planned for residents at risk for ROM decline.
Failure to Use Required Two-Person Assistance During Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) performed a full-body mechanical lift transfer for a resident without the required assistance of a second staff member. The CNA was aware that two staff were needed for such transfers, as directed by the facility's policy, the manufacturer's instructions, and the resident's care plan, but proceeded alone after being unable to locate another staff member. During the process of unhooking the sling from the lift's metal hanger bar, the bar swung back and struck the resident on the forehead, resulting in a laceration that required emergency medical attention and surgical staples. The resident involved had multiple medical conditions, including diabetes mellitus type 2, acute kidney failure, chronic ulcers, polyneuropathy, and depression, and was moderately cognitively impaired. Her care plan specifically required the use of a full-body mechanical lift with a large sling and the assistance of two staff members for all transfers. The incident occurred when the CNA, despite being aware of the policy and having previously signed an acknowledgment of the requirement, chose to perform the transfer alone due to short staffing on the shift. Interviews and documentation confirmed that the facility did not have a separate written policy for mechanical lifts but relied on the manufacturer's instructions, which also indicated that two caregivers may be necessary depending on the situation and the patient's condition. The CNA involved admitted to knowing the requirement for two staff and acknowledged that she should not have completed the transfer alone. The incident was witnessed and reported by other staff, and the resident required medical intervention for the injury sustained during the transfer.
Failure to Follow Nebulizer Instructions Leads to Resident Burn
Penalty
Summary
The facility failed to follow the nebulizer machine manufacturer's instructions, resulting in a resident receiving a burn. The incident involved Resident 12, who was found with a reddened area and fluid-filled blisters on his right outer thigh. The resident had requested that the nebulizer machine be placed on his bed during his 8:00 p.m. breathing treatment, which likely led to the burn when the machine was moved next to his skin. Despite the physician's order to discontinue the resident's self-administration of nebulizer treatments after the burn incident, the facility did not adhere to this directive. Observations and interviews revealed that the nebulizer machine was placed on a nightstand, and staff did not remain in the room during the treatment, allowing the resident to potentially handle the machine himself. The resident, who had a moderately impaired cognitive status, reported that the machine was heavy and difficult to handle, and he sometimes turned it off himself. The registered nurse (RN) involved in the incident admitted to placing the nebulizer on the bed due to the short tubing and was unaware of the manufacturer's warning against placing the machine on soft surfaces. The facility's policies and procedures were not followed, as evidenced by the RN leaving the resident alone during the nebulizer treatment and the lack of awareness regarding the manufacturer's instructions. The director of nursing acknowledged that education had been provided to staff not to place nebulizer machines on beds, but the incident still occurred. The resident's medical record indicated a discontinuation of self-administration orders, yet the practice continued, contributing to the deficiency.
Failure to Honor Residents' Rights and Provide Adequate Food Service
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by multiple grievances and incidents involving the certified food manager (CFM) D. Resident 34 was denied a snack when requested, and was told that snacks were only available between 7:00 p.m. and 6:00 a.m. Additionally, a CNA reported that a resident's request for a sandwich was not fulfilled in a timely manner, which was critical due to the resident's diabetic condition. The CFM D's response indicated a lack of awareness of the resident's dietary needs and a failure to provide the requested food promptly. Further interviews revealed that residents were afraid to voice their concerns about the food quality and service due to fear of being berated by CFM D. Resident 26 expressed dissatisfaction with the food and recounted an incident where a burned grilled cheese sandwich was returned to her after she refused it. Resident 2 reported being yelled at by kitchen staff for inquiring about menu items, which made her hesitant to ask for alternative food options. These incidents highlight a pattern of verbal abuse and neglect in addressing residents' dietary needs. Staff interviews corroborated the residents' claims, with reports of CFM D yelling at residents and denying them food items like ice cream. The facility's executive director and director of nursing were unaware of these issues until a reportable incident was filed. It was noted that sandwiches were not routinely available at the nurse's station, contrary to what was communicated to residents. The lack of communication and failure to address grievances contributed to the deficiency in honoring residents' rights to a dignified existence and self-determination.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to ensure that residents' call lights were answered in a timely manner, affecting four sampled residents. Resident 3 reported being left on a commode for almost an hour during the day shift, and this occurred again a few days later. Resident 32 experienced a 45-minute wait for assistance while on the toilet and noted that staff did not round on her at night. Resident 7 had to wait over 30 minutes for help after turning on his call light at 7:00 a.m. Resident 43 waited up to 25 minutes for assistance while in the bathroom and did not receive requested Tylenol until the following morning, despite a staff member acknowledging the request. Interviews with the director of nursing revealed that the call light system was designed to alert staff at the nurse's station, but the facility lacked a formal call light policy. Resident council meeting minutes indicated ongoing issues with call light response times, with residents reporting that staff often remained at the nurse's station while call lights were active. Although the director of nursing had previously educated staff to address these concerns, the problem persisted, particularly during the 2:00 p.m. to 10:00 p.m. shift.
Failure to Provide Meal Alternatives and Address Resident Concerns
Penalty
Summary
The facility failed to provide meal alternatives to nine out of twelve sampled residents, leading to dissatisfaction and concerns about food quality and availability. Residents expressed their grievances during interviews and a resident council meeting, highlighting issues such as burned food, lack of meal options, and fear of retaliation from the certified food manager (CFM D) when requesting alternatives. One resident reported a choking episode and the inability to obtain suitable food, while another mentioned being yelled at by kitchen staff for inquiring about menu items. The discontinuation of menu cards, which previously allowed residents to select meal alternatives, contributed to the deficiency. The dietitian and other staff members were unaware that the process had stopped, and residents were not informed of the change during council meetings. The director of nursing (DON B) and CFM D decided to halt the menu card process due to an increase in substitution requests, but this decision was not communicated effectively to the residents. Interviews with various staff members, including the occupational therapy assistant and speech/language pathologist, revealed ongoing complaints about the food service and a lack of follow-through on addressing these concerns. The facility's policy required appealing food options to be offered to residents, but this was not consistently implemented. The administrator acknowledged the issue and mentioned a performance improvement plan, but the deficiency persisted due to inadequate communication and execution of the facility's meal service policies.
Improper Glove Use and Thermometer Sanitization in Dietary Services
Penalty
Summary
The provider failed to ensure proper glove use and hand hygiene during meal services, as observed with two dietary staff members, dietary cook I and certified food manager D. Dietary cook I was seen using a thermometer to check the temperature of various food items without sanitizing it properly between uses. He used a cleaning rag, which was in a bucket with sink and surface cleaner, to wipe the thermometer instead of using alcohol pads as required. Additionally, he did not wash his hands before putting on gloves or when changing them, which is against the facility's glove use policy. Certified food manager D also demonstrated improper glove use and hand hygiene. She put on gloves without washing her hands, handled food items, and changed gloves without washing her hands in between. During another observation, she removed her gloves, handled food items, and put on new gloves without washing her hands. She also used a food thermometer without sanitizing it properly, setting it back on the counter without cleaning it after use. Dietary cook O was observed using the same thermometer that CFM D had used without proper sanitization. She used a sanitizer wipe to clean the thermometer but did not change her gloves throughout the process. The regional dietitian confirmed that dietary staff had completed an in-service for hand washing and were expected to follow the policy for proper glove use and food thermometer sanitizing. The provider's policies clearly outlined the need for hand washing before and after glove use and the use of alcohol swabs for sanitizing thermometers, which were not adhered to during the observations.
Failure to Follow Individualized Care Plans for Denture Removal and Bathing
Penalty
Summary
The provider failed to follow the individualized care plan for a resident who required the removal of dentures after meals. On the evening of the incident, the resident was observed making a whistling noise, and a small portion of his lower partial denture was visible in his mouth before it disappeared. The on-call provider was notified, and the resident was transferred to the emergency department (ED) for evaluation, where the denture was removed. The certified nursing assistant (CNA) responsible for the resident admitted to forgetting to remove the dentures, despite being aware of the care plan requirement. The director of nursing (DON) confirmed that the intervention to remove the dentures was included in the care plan prior to the incident. Additionally, the provider failed to follow the individualized care plans for bathing for five residents. Interviews and record reviews revealed that these residents did not receive their scheduled weekly baths and there was no documentation of sponge baths being provided when full baths were missed. The DON acknowledged that there was no policy for monitoring bathing to ensure compliance and was unaware that some residents had gone more than seven days without a bath. The CNA job description and the baseline plan of care policy indicated that CNAs were responsible for providing assistance with bathing and other activities of daily living (ADLs), but these duties were not consistently performed as required by the care plans.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 12 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Britton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Four Seasons Health Care Inc | 22.4 mi | ★★★★★ | 12 | 0 |
| Strand-kjorsvig Community Rest Home | 24.3 mi | ★★★★★ | 0 | 0 |
| Avantara Groton | 28.4 mi | ★★★★★ | 11 | 0 |
| Good Samaritan Society - Oakes | 28.8 mi | ★★★★★ | 11 | 1 |
| Sun Dial Manor | 30.9 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Wheatcrest Hills Healthcare Center.
100% money-back within 48 hours.
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.