Whispering Pines Nursing and Rehab, LLC

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide care and treatment to promote healing and/or prevent new pressure injuries from developing for 1 resident (R) (R3) of 3 sampled residents. R3 was at risk for the development of pressure injuries and had a care plan intervention for a left heel boot to be worn at all times. On 6/8/26, R3 was observed without a left heel boot for over four hours.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide adequate supervision to prevent accidents for 1 resident (R) (R2) of 3 sampled residents. R2's care plan indicated they required supervision while eating. On 6/8/26, R2 was observed eating in their room without supervision.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure appropriate respiratory care was provided for 2 residents (R) (R5 and R6) of 2 sampled residents. R5 received oxygen therapy with humidification. A bottle of distilled water used for oxygen therapy was left uncovered. In addition, the bottle was dated 6/2 which was 3 days beyond the expiration date per the facility's policy. R6 received oxygen therapy with humidification. A bottle of distilled water used for oxygen therapy was not dated when opened in accordance with the facility's policy.

Inspectors wroteBased on staff interview and record review, the facility did not provide pharmacy services to ensure the accurate administration of medication for 1 resident (R) (R2) of 4 sampled residents. R2 had an order for a carbidopa-levodopa (orally disintegrating) 25-250 milligrams (mg) tablet every 8 hours (used to treat motor symptoms of Parkinson's disease, including stiffness, tremors, and slowness). The order was entered for 8:00 AM, 12:00 PM, and 4:00 PM.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide adaptive eating equipment for 1 resident (R) (R2) of 3 sampled residents. R2 was not provided with a lipped plate (a plate with raised edges to assist in guiding food onto utensils and prevent spills), a rocker knife (a curved blade designed to cut through food using a back-and-forth rocking motion) or built-up utensils (adaptive eating aids with enlarged handles) as indicated in their plan of care.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the safety of 1 resident (R) (R17) of 2 sampled residents. R17 was at high risk for wandering and had a Wanderguard (WG) bracelet. R17 exited the facility on 4/1/26 between 4:00 AM and 4:30 AM through an unalarmed door. R17 was found approximately 1.1 miles away at 6:40 AM at R17's apartment. R17 sustained a broken finger during the elopement. (This is being cited at past non-compliance.)

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 34 residents residing in the facility. Staff did not consistently monitor food holding temperatures. Toasters in the main kitchen contained dried food debris. Staff did not follow sanitation practices when using a thermometer to check cooking temperatures.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure a call light was within reach for 1 resident (R) (R34) of 12 sampled residents. On 4/12/26, R34 was observed in R34's room without a call light within reach. The facility's Call Light Use and Response policy, dated 1/14/19, indicates: .4. When providing care to the residents, position the call light conveniently for the resident and within easy access for use .9. Be sure call lights are placed within reach at all times. On 4/12/26, Surveyor reviewed R34's medical record. R34 was admitted to the facility on [DATE] and had diagnoses including osteoporosis with current pathological fractures and right humerus fracture related to fall. [...]

Inspectors wroteBased on staff interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when allegations of abuse were not reported to local police department and/or State Agency (SA) for 3 residents (R) (R13, R20, and R51) of 4 sampled residents. R13 touched R20 inappropriately on 3/29/26. The allegation of abuse was not reported to the SA or local police department. R13 kissed R51 in the dining room on 1/12/26. The potential allegation of abuse was not reported to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure Pre-admission Screening and Resident Review (PASRR) requirements were met for 1 resident (R) (R20) of 5 sampled residents. R20 had a mental illness diagnosis as indicated on R20's PASRR Level I Screen. A PASRR Level II Screen was not completed.

Inspectors wroteBased on staff interview and record review, the facility did not provide the necessary edema care and treatment for 1 resident (R) (R16) of 1 sampled resident. R16 had an order for Tubigrips for diagnoses of lymphedema and congestive heart failure (CHF). The Tubigrips were not consistently applied. In addition, R16's care plan did not contain interventions to address lymphedema.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 2 errors occurred during 30 opportunities which resulted in a 6.67% medication error rate that affected 1 resident (R) (R27) of 3 residents observed during medication administration. During the AM medication pass on 4/13/26, R27's insulin aspart (for diabetes) was administered late. In addition, the wrong dose of Slow Magnesium (a supplement containing magnesium chloride with calcium) was administered.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the Ombudsman was notified of transfers and discharges for 5 residents (R) (R29, R26, R2, R16, and R13) of 5 sampled residents. R29 was discharged home on [DATE]. The facility did not notify the Ombudsman of R29's discharge. R26 was discharged home on [DATE]. The facility did not notify the Ombudsman of R26's discharge. R2 was transferred to the hospital on 7/11/24. The facility did not notify the Ombudsman of R2's transfer. R16 was transferred to the hospital on 5/28/24. The facility did not notify the Ombudsman of R16's transfer. R13 was transferred to the hospital on [DATE] and 12/28/24. The facility did not notify the Ombudsman of R13's transfers.

Inspectors wroteBased on staff and resident interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 resident (R) (R22) of 15 sampled residents. R22 reported to staff that a staff member stole R22's soda. The facility did not report the allegation of misappropriation to the State Agency (SA) or local law enforcement.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure an allegation of misappropriation was thoroughly investigated for 1 resident (R) (R22) of 15 sampled residents. R22 reported that staff stole R22's soda. The facility did not thoroughly investigate the allegation of misappropriation.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure proper surgical wound treatment was provided for 1 Resident (R) (R131) of 1 resident. R131 had a right below-the-knee amputation (BKA). R131's wound dressing was not changed per the physician's order. In addition, a weekly in-house wound assessment was not completed for R131's surgical wound.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infection for 2 residents (R) (R283 and R131) of 3 sampled residents. R283 was on contact precautions. During observations on 1/13/25 and 1/14/25, staff did not wear appropriate personal protective equipment (PPE) when they entered R283's room. R131 was on enhanced barrier precautions (EBP). During an observation on 1/14/25, staff did not wear appropriate PPE when providing care for R131.

Inspectors wroteBased on staff interview and record review, the facility did not ensure food was prepared in a form designed to meet individual needs for 1 Resident (R) (R1) of 7 residents on mechanically altered diets. R1 had a mechanically altered diet. R1's diet was not followed on 11/7/23, which resulted in a choking episode that required intervention by nursing staff and emergency medical services (EMS) to clear R1's airway. R1 passed away on 11/7/23 as a result of the choking episode. Failure to ensure foods were served to residents in the appropriate texture created a finding of Immediate Jeopardy (IJ), which began on 11/7/23. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 11/9/23 at 3:45 PM. The immediate jeopardy was removed on 11/9/23; however, the deficient practice continues at a severity/scope level of D as the facility continues to implement its removal plan.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and served in a safe and sanitary manner. This practice had the potential to affect 37 of 37 residents residing in the facility. Kitchen and food services areas were not in a clean and sanitary condition.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure alleged violations were reported to the appropriate agencies, including local law enforcement and the State Agency (SA), for 1 Resident (R) (R3) of 7 sampled residents. R3 reported R3's wallet and money were missing. The facility did not report the missing money to the SA or local law enforcement.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure an allegation of misappropriation was thoroughly investigated for 1 Resident (R) (R3) of 7 sampled residents. R3 reported R3's wallet and money were missing. The facility did not complete a thorough investigation that included other resident interviews.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure staff performed proper hand hygiene during the provision of cares for 1 Resident (R) (R2) of 1 resident. Certified Nursing Assistant (CNA)-C and CNA-D did not consistently perform hand hygiene during the provision of perineal care for R2 on 10/12/23.