Whispering Oaks

Inspectors wroteBased on record review and staff interview the facility failed to complete and submit for review the Pre-admission Screening and Resident Review (PASARR) Level II upon acquiring new or qualifying mental health diagnoses for 6 residents (#24, #7, #84, #6, #4 and #241) out of 11 residents sampled for PASARRs.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the Preadmission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability with qualifying mental health diagnosis, were completed accurately for 5 residents (#7, #84, #11, #208, and #241) of 11 residents sampled.

Inspectors wroteBased on observations, interview and facility policy review, the facility did not ensure the kitchen was maintained in a safe and sanitary manner related to food storage, cross contamination of food prep surfaces, general cleanliness and maintaining appropriate dishwashing sanitization levels in one kitchen (main) of one observed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective infection prevention and control program to control the spread on infection related to: 1. failing to ensure the proper isolation signage was posted for one (Resident #246) of five residents sampled; 2. failing to ensure personal protective equipment (PPE) was available and hand hygiene was performed in room [ROOM NUMBER]; 3. failing to ensure proper placement of medical equipment to prevent infection; and 4: failing to ensure 3 (Staff U, Staff V, and the DON) of 3 staff fingernails did not create a safety or infection control issue.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure an assessment for self-administration related to enteral feedings was completed for one resident (#16) out of one resident reviewed.

Inspectors wroteBased on observations interviews and record review, the facility failed to ensure a safe environment was provided related to the use of a fan for one resident (#34) out of one resident observed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to update and implement an individualized person-centered care plan related to an indwelling urinary catheter device for one resident (#12) of one resident reviewed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide residents who are unable to carry out activities of daily living (ADLs) the necessary services to maintain good grooming and personal hygiene for two (#84 and #151) out of three sampled residents.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure residents were monitored for antipsychotic medication behaviors and side effects, for two out of six residents, (#15 and #17), sampled.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to prevent the right to be free from verbal abuse for one of three sampled residents (#3) related to verbal abuse during activities of daily living care.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure 1. One of one walk in freezer unit was maintained in a manner to prevent frosting and heavy ice build up on shelving and packaged food items and 2. Failed to ensure one of one dish washing machine was operating within wash and rinse water temperature specification requirements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of allegations of abuse, neglect, exploitation, or mistreatment for one (Resident #113) of three sampled residents.

Inspectors wroteBased on observations, record review, and interview, the facility failed to confirm the accuracy of a Pre-admission Screening and Resident Review (PASRR) and to correct the document for seven (Residents #172, #205, #28, #81, #82, #110 and #130) of forty residents sampled when mental illness or suspected mental illness diagnoses were identified and added to the resident's medical diagnoses .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and services to prevent further decrease in range of motion for one (Resident #3) of three sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to follow physician orders related to side effect monitoring for psychotropic medications for one (Resident #161) out of five sampled residents.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed and two errors were identified for two (#87 and #106) of six residents observed. These errors constituted a 8% medication error rate.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure 1. one (secured 400-hall) out of five treatment carts were locked while unattended by authorized personnel on two separate occasions, 2. a tube of medicated topical ointment prescribed for a resident was not left on the dresser in a room that the resident did not reside, and 3. one (2-High) out of eight medication carts did not contain an unopened vial of Insulin Lispro.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one (Resident #37) of one resident reviewed for dental services was provided with dental follow-up for missing dentures.

Inspectors wroteBased on record review and interview, the facility failed to ensure all residents/representatives was appropriately informed and provided consent for Pneumococcal and influenza vaccinations for four (Resident #59, #81, #82, #141) of five residents reviewed for immunizations.

Inspectors wroteBased on interview and record review the facility failed to honor resident's rights related to their choice of food preferences for five (Residents #37, #122, #160, #171, #193) of 59 sampled residents.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure that two (#36 and #68) out of five residents on one of the two secured units who required extensive assistance with eating were identified in a dignified manner.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure that each resident was afforded the right to personal privacy for one (Resident #168) of 59 sampled residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide a complete written notification of a Transfer & Discharge notice to the Resident representative and the Ombudsman for one (Resident #81) of five residents sampled for discharge.

Inspectors wroteBased on interviews and record reviews the facility failed to provide written notification of the facility Bed Hold Policy to the Resident representative for one (Resident #81) of five residents sampled for discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident assessments reflected the resident's status accurately for two (#29, #32) of 59 sampled residents.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to revise the care plan for one (#153) out of fifty-nine sampled residents in related to the implementation of positioning devices while the resident was in bed.

Inspectors wroteBased on observation, interview and record review the facility failed to provide prompt dental service when a residents dentures do not fit appropriately for one (Resident #29) of 59 sampled residents.