Whispering Oaks Rehab & Nursing

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 resident (Residents #21) reviewed for privacy, in that: LVN B left her computer screen open showing Resident #'21's protected information while administering medications. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 resident (Resident #4) reviewed for incontinent care, in that: While providing incontinent care for Resident #4, CNA C used a back to front motion to clean Resident #4's buttocks. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure that CNAs were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 1 of 6 residents (Resident #4) by 1 of 4 CNAs (CNA C) reviewed for competent staff, in that:The facility failed to ensure CNA C used the right technique to clean Resident #4 while providing incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 of 3 medication carts (Treatment cart) reviewed for storage, in that: RN A left the treatment cart unlocked on 1 occasion. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed medications.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide a therapeutic diet, in the appropriate form as prescribed by a physician for 1 of 8 residents (Resident #19) observed for therapeutic diets. The facility failed to provide Resident #19 a CCHO (Controlled Carbohydrate) NAS (No Added Salt) diet, as ordered by the physician. This failure could affect residents with physician orders for therapeutic diets and could result in consumption of inappropriate food items which could cause elevated blood sugars and a decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 8 residents (Resident #12) reviewed for accuracy of medical records. The facility failed to ensure Residents #12 had transcribed orders for suction from the hospice orders to the resident's EMR (Electronic Medical Record). This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to 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 disease and infection for 1 of 6 residents (Resident #4) reviewed for infection control, in that: While providing incontinent care for Resident #4, CNA C failed to use proper infection control. These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure that 44 out of 44 resident rooms provided a minimum of 80 square feet of floor space per resident. Forty-Four of the two-bed resident rooms measured 155, 156 or 157 square feet per room leaving 77.5, 78 or 78.5 square feet per bed. This deficient practice could affect residents living in these rooms by restricting the amount of resident care equipment and resident's personal effects that could be accommodated in these rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions for 1 of 1 kitchen reviewed for food served under sanitary conditions. Food from the walk-in refrigerator, with readings in the danger zone for 3 days, was served to residents. An Immediate Jeopardy was identified on 5/23/25 at 4:15 pm. While the Immediate Jeopardy was removed on 5/24/25 at 9:00 pm, the facility remained out of compliance at a scope of widespead and a severity level of no actual harm with potential for more that minimal harm that is not Immediate Jeopardy due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. This failure could affect residents by placing them at risk for food contamination, food borne illness and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 3 of 17 Residents (Resident #5, Resident #11 and Resident #42) whose MDS records were reviewed for accuracy. 1. Facility failed to ensure Resident #5's comprehensive MDS, dated [DATE] assessment accurately reflected that he had a suprapubic catheter. 2. The facility failed to ensure Resident #11's quarterly MDS assessment dated [DATE] accurately reflected she had a significant weight loss. 3. The facility failed to ensure Resident #42's Quarterly MDS assessment dated [DATE] accurately reflected she had received a therapeutic diet while a resident at the facility. This failure could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 9 residents (Resident #9 and Resident #46) reviewed for care plans. 1. The facility failed to ensure Residents #9's care plan reflected her dental issues of missing teeth. 2. The facility failed to ensure Resident #46's comprehensive care plan, dated 05/28/2024, reflected nurses might replace plunger back into syringe and push in gently when flushing because the resident had Jejunostomy feeding tube. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to review and revise the comprehensive person-centered care plan for one resident (Resident #28) out of 24 residents reviewed for comprehensive care plans timing and revision. Resident #28's annual MDS assessment dated [DATE] reflected she was incontinent of bowel and her comprehensive care was not revised by the MDS Nurse to reflect she was incontinent of bowel. This deficient practice could affect residents who are assessed and have care plans and places them at risk for not receiving necessary care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #5) reviewed for supra-pubic catheter care. When CNA B moved Resident #5 to his bed from his wheelchair on 06/13/2024 at 2:00 PM he took Resident #5's urinary drainage bag out of the privacy bag tied to the wheelchair and hooked it onto the low rail of his bed. The uncovered urinary catheter bag and drainage spout touched the floor. Resident #5 did not have a strap to secure his catheter tubing to his leg. This deficient practice could place residents with in dwelling urinary catheters at-risk for urinary tract infections and/or pain related to injury from the unsecured catheter tube pulling on the bladder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 resident (Resident #46) of 1 resident reviewed for J tube feeding. The facility failed to follow the facility policy regarding checking the placement of Resident #46's Jejunostomy feeding tube by auscultation (the action of listening to sounds) of growl sounds with injecting the air into the feeding port, but the facility policy indicated checking Jejunostomy feeding tube placement by the visualization and comparison of tube markings to prior check. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care consistent with professional standards of practice for 1 of 2 residents (Resident #11) reviewed for oxygen in that: Resident #11's oxygen was administered at 3 Lpm, instead of 2.0 Lpm, via nasal cannula as ordered by physician. This failure could place residents who received oxygen at risk of developing respiratory complications and a decreased qualify of care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 1 of 2 (LVN C) nurses reviewed for competent nursing care. The facility failed to ensure LVN C followed the facility policy regarding checking the placement of Resident #46's Jejunostomy feeding tube by auscultation of growl sounds with injecting the air into the feeding port, but the facility policy indicated checking Jejunostomy feeding tube placement by the visualization and comparison of tube markings to prior check. These deficient practices affect residents who depend on nursing care and could place residents at risk for injury, infection, and harm.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 medication cart (400 Hall) and 1 Treatment cart of 4 carts observed for secure biologicals and drugs. LVN A left the medication cart and treatment carts unsecured on 400 Hallway on 06/13/2024 at 08:15 a.m. when she prepared to perform wound treatments for a resident. This deficient practice could place residents at risk for misappropriation, misuse or tampering of medications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 residents (Residents #5 and #11) of 24 residents reviewed for infection control. 1. CNA B hooked Resident #5's catheter urinary drainage bag to the low rail of his bed on 06/13/2024 at 2:00 PM, and the uncovered bottom of the bag, and loosened drainage spout touched the floor. 2. LVN A re-entered Resident #11's room, who was on EBP on 06/13/2024 at 08:40 a.m., 3 times and failed to sanitize her hands prior to re-entering the room when she left and re-entered the room to get more treatment supplies when she performed wound treatments for Resident #11. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the maintenance of mechanical, electrical, and patient care equipment in safe operating condition for 1 (Residents #11) of 20 residents reviewed for safe environment, in that: Resident #11's wheelchair on 06/12/2024 at 9:39 a.m. had the left and right armrest vinyl torn and sharp and appeared worn and damaged. The deficient practice could affect residents who rely on facility equipment for mobilization and could result in skin tears or injuries.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure that 44 out of 44 resident rooms provided a minimum of 80 square feet of floor space per resident. Forty-Four of the two-bed resident rooms measured 155, 156 or 157 square feet per room leaving 77.5, 78 or 78.5 square feet per bed. This deficient practice could affect residents living in these rooms by restricting the amount of resident care equipment and resident's personal effects that could be accommodated in these rooms.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that the resident representative had the opportunity to exercise the resident's rights for 3 of 7 residents (Resident #s 2, 3, and 10) reviewed for resident rights in that: The facility failed to inform the residents ' responsible parties that the heater on A hall was not working and offer the choice to move the residents to another room or sister facility. This deficient practice could affect residents and place them at risk for hypothermia and/or decline in health due to exposure to low temperatures.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 2 of 8 residents (Resident #5 and #6) reviewed for advanced directives, in that: Resident #5's Out-of-Hospital Do Not Resuscitate (OOHDNR) form did not have the physician's printed name and license number on the spaces indicated on the form. Resident #6's Out-of-Hospital Do Not Resuscitate (OOHDNR) form did not have the resident's signature at the bottom of the form as required. This deficient practice could place residents at-risk for not having their end of life wishes honored and of having CPR performed against their will.

Inspectors wroteBased on interviews and record reviews, the facility failed to accurately reflect the resident's status for two residents (#4 and #9) of eight residents reviewed for accurate MDS assessments in that: 1. Resident #4's quarterly MDS assessment with an ARD of 02/13/2023 reflected she was always incontinent of bowel and bladder when she was frequently incontinent. 2. Resident #9's quarterly MDS assessment with an ARD of 01/27/2023 reflected she had a pressure sore and did not reflect what stage. This deficient practice could affect residents who receive care based on assessment and could result in missed or inaccurate treatment provided.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment for one resident (#34) of 8 residents reviewed for comprehensive care plans in that: Resident #34's DNR status was not in her comprehensive person-centered care plan. This deficient practice could affect residents who have comprehensive person-centered care plans and could result in their advanced directive wishes not done.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure review and revision of comprehensive care plans for two residents (#4 and #9) of eight residents reviewed for comprehensive care plan revisions in that: 1. Resident #4's comprehensive person-centered care plan updates did not address her bowel status. 2. Resident #9's comprehensive person-centered care plan updates reflected she had a pressure sore. This deficient practice could affect residents and place them at risk of not having care plans that are reviewed/revised when needed affecting their care.who have comprehensive person-centered care plans and could result in missed treatments.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to ensure that resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for one resident (#31) of two residents reviewed for incontinent care in that: CNA A wiped Resident #31 from back to front instead of front to back during incontinent care. This deficient practice could affect residents and place them at risk of disease and infections.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure that 44 out of 44 resident rooms provided a minimum of 80 square feet of floor space per resident in that: Forty-Four of the two-bed resident rooms measured 156 square feet per room leaving 78 square feet per bed. This deficient practice could affect residents living in these rooms by restricting the amount of resident care equipment and resident's personal effects that could be accommodated in these rooms.