Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0637
Assess the resident when there is a significant change in condition
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure within 14 days after the facility determined, or should
have determined, that there was a significant change in the resident's physical or mental condition for 2 of
14 residents (Residents #1 and #25) reviewed for comprehensive assessments .
Residents Affected - Few
1. The facility failed to complete a significant change MDS for Resident #1 within 14 days of 01/23/24-the
date he elected to receive hospice care.
2. The facility failed to complete a significant change MDS for Resident #25 within 14 days of 03/27/24-the
date she tested positive for COVID 19.
These failures could place residents at risk of not receiving the necessary care/treatment.
Findings Include:
1. Record review of Resident #1's admission record reflected a [AGE] year-old male who was admitted to
the facility on [DATE]. Resident #1 had diagnoses which included, but were not limited to, chronic
obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in
cough without mucus or phlegm, shortness of breath, and fatigue), cerebral infarction (occurs as a result of
disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke), hemiplegia
and hemiparesis (partial paralysis following stroke) following cerebral infarction affecting left non-dominant
side, acute respiratory failure (sudden failure of lungs to deliver oxygen to the body), altered mental status
(change in brain function) and cognitive communication deficit (difficulty with one or more of the following:
attention, memory, perception, language, problem-solving, and reasoning). Hospice Medicaid was listed as
primary payer. The name and phone number of Resident #1's hospice was listed under the external
facilities section of his admission record.
Record review of Resident #1's significant change MDS reflected it was signed as completed on 02/19/24
by the DON. Section C reflected a BIMS of 9, which indicated moderately impaired cognition. Section O
reflected Resident #1 was receiving hospice care while a resident.
Record review of Resident #1's care plan, completed on 01/30/24, reflected Resident #1 had a terminal
prognosis and was admitted to hospice care.
Record review of Resident #1's care plan, completed on 04/23/24 , reflected Resident #1 had a terminal
prognosis and was admitted to hospice care. The care plan reflected Resident #1 was receiving pain
medication related to hospice end of life care.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 8
Event ID:
675534
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675534
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheeler Nursing & Rehabilitation
1000 S Kiowa St
Wheeler, TX 79096
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0637
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Record review of Resident #1's active orders as of 07/08/24 reflected the following order with a start date of
01/23/24:
All hospice related meds must be re-ordered through hospice pharmacy.
Record review of Resident #1's discontinued or completed orders reflected the following order with a start
date of 01/23/24:
Admit to [name of hospice]
Record review of Resident #1's form titled Texas Medicaid Hospice Program Individual
Election/Cancellation/Update and dated 01/23/24 reflected Resident #1 elected hospice care and was
signed by a hospice representative, Resident #1, and the hospice physician.
2. Record review of Resident #25's admission record reflected a [AGE] year-old female who was admitted
to the facility on [DATE]. Resident #25 had diagnoses which included, but were not limited to, heart failure
(heart muscle fails to pump blood as it should), altered mental status (change in brain function), cognitive
communication deficit (difficulty with one or more of the following: attention, memory, perception, language,
problem-solving, and reasoning), and COVID-19.
Record review of Resident #25's significant change MDS reflected it was signed as completed on 04/17/24
by the DON. Section C reflected a BIMS of 4, which indicated severely impaired cognition. Section I
reflected COVID 19 under Additional active diagnoses. Section O reflected Resident #25 was on Isolation
or quarantine for active infectious disease while a resident.
Record review of Resident #25's care plan, completed on 07/03/24, reflected Resident #25 was positive for
COVID 19 on 03/27/24.
Record review of Resident #25's discontinued, completed, or struck out orders reflected the following
orders with start date of 03/27/24:
Zinc Oral Tablet 50 MG (Zinc) Give 2 tablet by mouth one time a day for covid for 10 Days
Quercetin Oral Tablet 250 MG (Quercetin) Give 1 tablet by mouth one time a day for covid for 10 days
Nac 600 Oral Capsule (Acetylcysteine [Nutrient]) Give 1 capsule by mouth one time a day for COVID for 10
Days
Droplet precautions: Resident will remain in room for isolation at all times including meals, bathing, and
therapy. Signing indicates that resident has received all care in room this shift. Resident has not left room.
Every shift for Covid/Covid Exposure
During an interview on 07/10/24 at 09:55 AM, the MDS LVN stated she worked for the facility for 2 weeks.
She stated she had one year of experience from 2015 as an MDS coordinator. She stated the RAI was the
policy she followed for completing MDS assessments. She stated according to the RAI a significant change
MDS had to be completed 14 days after the significant change occurred. The MDS LVN stated there was
probably a negative outcome of a significant change MDS not being completed timely. She stated she was
not employed when the significant change MDS' were completed for Resident #1 and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675534
If continuation sheet
Page 2 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675534
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheeler Nursing & Rehabilitation
1000 S Kiowa St
Wheeler, TX 79096
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0637
Resident #25 .
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 07/10/24 at 09:59 AM, the DON stated the policy used in completing MDS
assessments was the RAI. She stated she was not familiar with the time frame for completing a significant
change MDS as MDS LVN was responsible for completing the assessments timely. The DON stated the
former MDS nurse would call her or send her an email when it was time for her to sign off on an MDS
assessment. She stated she could not think of a negative outcome of a significant change MDS not being
completed timely.
Residents Affected - Few
During an interview on 07/10/24 at 10:04 AM, the ADM stated the MDS LVN was responsible for completing
MDS assessments. She stated the RAI was the policy for MDS'. The ADM stated she did not know the
timing for completing a significant change MDS. She stated she could not think of a negative outcome of a
significant change MDS not being completed timely .
Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version
1.18.11, dated October 2023, reflected the completion date of a significant change MDS assessment was
to be No Later Than 14th calendar day after determination that significant change in resident's status
occurred (determination date + 14 calendar days).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675534
If continuation sheet
Page 3 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675534
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheeler Nursing & Rehabilitation
1000 S Kiowa St
Wheeler, TX 79096
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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.
(1) plastic bag of frozen meat patties, not in original box with no label.
4.
(1) plastic bag of frozen sausage patties, not in original box with no label.
5.
(1) plastic bag of frozen okra, not in original box with no label.
Observation of the kitchen pantry area on 7/8/24 at 10:30 am revealed the following:
1.
(3) white plastic bins holding packaged foods with crumbs of food in the bottom.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675534
If continuation sheet
Page 4 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675534
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheeler Nursing & Rehabilitation
1000 S Kiowa St
Wheeler, TX 79096
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Observations of the kitchen refrigerator on 7/9/24 at 7:10 am revealed there were:
Level of Harm - Minimal harm
or potential for actual harm
1.
(1) ziplock baggie of hardboiled eggs, no label or date
Residents Affected - Many
2.
(1) box of bacon, open to air.
3.
(1) bowl of onions, no label or date
4.
(4) glasses of milk, on a plastic tray, not covered, labeled or dated.
Observations of the kitchen freezer on 7/9/24 at 7:15 am revealed there were:
1.
(1) box of sweet roll dough, open to air.
2.
(1) box of biscuits, open to air.
3.
(1) bag of hamburger patties, no label, not in original box.
Observations of the kitchen freezer on 7/10/24 at 8:55 am revealed there were:
1.
(1) box of sweet roll dough, open to air.
2.
(1) box of biscuits, open to air.
3.
(1) bag of hamburger patties, no label, not in original box.
In an interview with the DM on 7/10/24 at 9:00 am, the DM stated she had been in the facility for 4 days and
had been working on getting the kitchen in shape. She stated she had trained staff on what to do when
cleaning, serving and storing food. She stated all foods should be covered, labeled and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675534
If continuation sheet
Page 5 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675534
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheeler Nursing & Rehabilitation
1000 S Kiowa St
Wheeler, TX 79096
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
dated. She stated foods should be closed to air. The DM stated the consequences of crumbs in the bin, not
refrigerating foods appropriately or not labeling and dating the foods would cause cross contamination and
could possibly make the residents sick if consumed.
Record Review of the policy dated 2/2016 titled Leftover Foods documented: Leftover foods shall be dated,
labeled and properly stored in airtight containers after food service. The label should include an expiration
or use by date.
Record Review of the policy dated 2/2016 titled Leftover Foods documented: Milk must be covered with
disposable material, stored in ice in a drainable container, and stored in the refrigerator.
Opened packaged food or leftover food is to be tightly wrapped, or covered in clean airtight containers,
labeled and dated and stored in refrigerator.
Record Review of the policy dated 2/2016 titled Food Storage-Refrigerated and Frozen Foods documented:
Food must be stored in a properly covered container with a label and date identifying it. Any foods removed
from the [NAME] box must be dated and labeled.
Record Review of the policy dated 2/2016 titled Dry Food and Supply Storage documented: Containers are
to be cleaned regularly.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675534
If continuation sheet
Page 6 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675534
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheeler Nursing & Rehabilitation
1000 S Kiowa St
Wheeler, TX 79096
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to establish and maintain an infection
prevention and control program designed to provide a safe, sanitary, and comfortable environment and to
help prevent the development and transmission of communicable diseases and infections for 1 of 4 staff
(LVN A) reviewed for infection control.
Residents Affected - Few
-LVN A did not wash her hands or change her gloves while performing wound care.
This deficient practice could place residents at risk for the spread of infections, tissue breakdown, and
feelings of isolation related to poor hygiene.
Findings include:
During an observation on 07-09-2024 at 12:49 PM LVN A was observed performing wound care on
Resident #5's left decubitus heel wound. LVN A was observed washing her hand and donning gloves. LVN
A then removed the old dressing, cleaned the wound with gauze wet with wound cleanser, dried the wound
with gauze, cleaned the resident's left foot toes with a gauze pad soaked with betadine. LVN A then packed
the left heel decubitus ulcer with collagen powder, covered the decubitus wound with a dry gauze, then
wrapped the wound to include the ankle with Kerlex/Kling wrap. LVN A then removed her gloves and
washed her hands. LVN A did not change her gloves or wash her hands any time after starting the wound
care and before finishing the wound care.
During an interview on 07-09-2024 at 01:28 PM LVN A reported that she should have changed her gloves
and washed her hands after she removed Resident #5's old dressing because when you remove the old
dressing you could have drainage on your hands or gloves that could be passed on to the new dressing
and result in cross contaminating the resident which would negatively affect the resident.
During an interview on 07-09-2024 at 01:59 PM the DON reported that with wound care and incontinent
care she expects staff to change their gloves and wash their hands anytime they removed the old dressing,
before they put on the new dressing, complete the incontinent care, before they put on the new brief,
basically between the dirty and clean portion of the care. The DON reported that staff should also wash
their hands when their hands or gloves become soiled. The DON reported that following this process keeps
the infections down and will prevent cross-contamination with the residents.
Record review of the competency assessment titled When Hand Washing Should be Performed Check List
undated, revealed the following.
-After contact with blood, body secretions, excretions, mucous membranes, or non-intact skin. (marked
yes-in compliance)
-After handling items potentially contaminated with blood, body fluids, excretions, or secretion. (marked
yes-in compliance)
Signed by LVN A 11-7-2023.
Record review of the facility provided policy titled Infection Control Policy and Procedure Manual 2018
undated, revealed the following:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675534
If continuation sheet
Page 7 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675534
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wheeler Nursing & Rehabilitation
1000 S Kiowa St
Wheeler, TX 79096
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Gloving:
Level of Harm - Minimal harm
or potential for actual harm
Gloves are worn for three important reasons.
1.
Residents Affected - Few
To provide protective barrier and prevent gross contamination of the hands when touching blood, body
fluids, excretions, mucous membranes, and non-intact skin. The wearing of gloves is . mandatory for all
employees.
2.
To reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to
another resident during invasive or other resident care procedures .
3.
To reduce the likelihood that hands of personnel contaminated with microorganisms from a resident or a
fomite (objects or materials which are likely to carry infections such as cloths, utensils, and furniture) can
transmit these microorganisms to another resident; in this situation, gloves must be changed between
resident contacts, and hands washed after gloves are removed.
-Wearing gloves does not replace the need for hand washing because gloves may have small inapparent
defects or be torn during use, and hands can become contaminated during removal of gloves.
-Failure to change gloves between resident contacts is an infection control hazard.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675534
If continuation sheet
Page 8 of 8
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F637 - Within 14 days after the facility determines, or should have determined,
Assess the resident when there is a significant change in condition
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the July 10, 2024 survey of WHEELER NURSING & REHABILITATION?
This was a inspection survey of WHEELER NURSING & REHABILITATION on July 10, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WHEELER NURSING & REHABILITATION on July 10, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Assess the resident when there is a significant change in condition"
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.