Whitehouse Country Manor

Inspectors wroteBased on medical record review, staff interview, review of the facility's Self-Reported Incident (SRI), review of the facility's investigation, and policy review, the facility failed to timely report an incident of potential sexual abuse. This affected two (#11 and #12) of three residents reviewed for abuse. The facility census was 81.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to store food in a safe and sanitary manner. This had the potential to affect all but five (#16, #32, #48, #50, and #64) residents who eat food from the kitchen. The facility census was 84.

Inspectors wroteBased on observation, medical record review, staff interview, review of the Centers for Disease Control and Prevention (CDC) website, and review of an infection control facility assessment document, the facility failed to ensure staff members wore appropriate personal protective equipment (PPE) while handling soiled laundry and failed to wear, dispose of, and perform adequate hand hygiene after removing PPE while in resident rooms who were on infection control precautions due to COVID-19 infection. This had the potential to affect all 84 residents in the facility. The census was 84.

Inspectors wroteBased on observation, resident and staff interviews, medical record review, and policy review, the facility failed to ensure residents were afforded the ability to smoke during designated smoking times. This affected one (#69) of one residents reviewed for smoking. The facility census was 84.

Inspectors wroteBased on observation, resident and staff interview, and policy review, the facility failed to repair or replace broken window blinds. This affected two (#15 and #68) of three residents reviewed for environmental concerns. The facility census was 84.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure fall interventions were in place as ordered and care planned. This affected two (#27 and #33) of three residents reviewed for falls. The facility census was 84. Findings Include: 1. Review of the medical record for Resident #27 revealed an admission date of 11/13/17. Diagnoses included acute and chronic respiratory failure with hypoxia, atrial fibrillation, history of COVID-19, atherosclerotic heart disease, generalized muscle weakness, neurosyphilis, seizures, bipolar disorder, unspecified abnormalities of gait and abnormalities, schizophrenia, hypothyroidism, and dementia. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 01/21/25, revealed Resident #27 was cognitively intact. [...]

Inspectors wroteBased on observation, staff interview, medical record review, review of facility policy, and review of manufacturers instructions, the facility failed to ensure Novolog insulin was properly removed from use after it was opened past 28 days. This affected one (#10) of 21 residents with orders for insulin. The facility census was 84. Findings Include: Review of Resident #10's medical record revealed an admission date of 10/12/18 with diagnoses including hemiplegia, vitamin D deficiency, bipolar disorder, type two diabetes mellitus, hypertension, and schizoaffective disorder. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. Observation on 02/12/25 at 9:42 A.M. [...]

Inspectors wroteBased on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure information contained in a resident's medical record was accurate. This affected one (#33) of three residents reviewed for falls. The facility census was 84. Findings Include: Review of the medical record for Resident #33 revealed an admission date of 12/03/21 with diagnoses of dementia and epilepsy. Review of the modified quarterly Minimum Data Set (MDS) assessment, dated 12/18/24, revealed Resident #33 had impaired cognition and was mobile with a walker and/or wheelchair. Further review revealed Resident #33 had no falls since the previous assessment. Review of a current physician order initiated 05/02/23 revealed Resident #33 should have a motion sensor alarm above bathroom door for fall prevention. [...]

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure the resident call light system was functioning appropriately and relaying the calls to a centralized staff work area or to a staff member. This affected two (#204 and #207) of 24 rooms located on the 200 Hall. The census was 84. Findings Include: Observation on 02/18/25 at 9:05 A.M. revealed the call lights for room [ROOM NUMBER] and room [ROOM NUMBER] were illuminated in the hall above the doors entering the room. Continued observation revealed both call lights were not relaying the call to a staff member or a monitoring system located at the centralized staff work area. Interview on 02/18/25 at 9:08 A.M. [...]

Inspectors wroteBased on observation, medical record review, staff interview, and clean dressing change policy review, the facility failed to prevent cross- contamination between soiled elimination containers, clean wound dressings, food, and beverages. This affected one (#1) of three residents reviewed for infection control interventions in a facility census of 80.

Inspectors wroteBased on observation, resident interview, family interview, and staff interview, the facility failed to maintain a clean and homelike environment. This affected five (#9, #10, #11, #41, and #51) of five residents reviewed for environment. The facility census was 87.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a clean, functional, sanitary, and homelike environment for its residents. This had the potential to affect all 43 (#44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85 and #86) residents residing on the east wing of the building and affected seven residents (#3, #4, and #12) of 43 residents residing on the west wing of building. The facility censuses were 86.

Inspectors wroteBased on review of the Centers for Medicare & Medicaid Services (CMS) Payroll Based Journal (PBJ) report, staff interview, review of posted daily staff levels, and review of staff timecards, the facility failed to ensure eight hours of daily registered nurse (RN) coverage. This affected all 80 residents of the facility.

Inspectors wroteBased on observation, staff interview, review of the Pot Sink Sanitation Record, review of manufacturer's recommendations, review of work orders, and review of facility policy, the facility failed to ensure foods were properly stored and labeled after opening. Additionally, the facility failed to ensure adequate sanitization of dishes. This affected all 79 residents who received food from the kitchen. The facility identified one resident (#69) who did not receive food from the kitchen. The facility census was 80.

Inspectors wroteBased on observation, staff interview, and review of maintenance work orders, the facility failed to maintain a clean and sanitary environment for 41 residents (Resident #05, #07, #08, #09, #14, #15, #16, #17 #18, #22, #23, #24, #29, #32, #33, #39, #41, #42, #43, #45, #47, #48, #53, #55, #56, #57, #60, #63, #66, #67, #68, #72, #73, #74, #76, #130, #131, #132, #133, #134, and #230) residing on the secured unit. The facility census was 80.

Inspectors wroteBased on observation, resident interview, record review, staff interview and review of facility policy, the facility failed to assess a resident for self-administration of medications. This affected one (#46) of one resident reviewed for self-administration of medications. The facility census was 80.

Inspectors wroteBased on medical record review, staff interview and review of facility policies, the facility failed to ensure timely physician notification and failed to notify the dietitian of a significant weight change for one (#46) of three residents reviewed for nutrition. The facility census was 80.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure resident rooms were maintained in good repair. This affected two (#37 and #75) of four residents reviewed for homelike environment. The facility census was 80.

Inspectors wroteBased on observation, resident and staff interview, and review of facility policies, the facility failed to ensure nail care was provided to residents dependent for care. This affected one (#75) of three residents reviewed for activities of daily living. The facility census was 80.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to follow physician's orders to [NAME] tubigrips to prevent and reduce edema for one (#44) of one resident reviewed for edema. The facility census was 80.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to weigh a resident daily per physician order. This affected one (#46) of three residents reviewed for nutrition. Additionally, the facility failed to ensure nutritional supplements were provided as recommended by the dietitian. This affected one (#44) of three residents reviewed for nutrition. The facility census was 80.

Inspectors wroteBased on record review, staff interview, resident interview, and facility policy review, the facility failed to follow physician orders for post dialysis assessments, monitoring the fistula site for complications, and monitoring the fistula for the thrill and bruit for one (#31) of one residents reviewed for dialysis. The facility census was 80.

Inspectors wroteBased on record review, staff interview, resident interview, and facility policy review, the facility failed to administered medications as ordered to one (#31) out of six residents reviewed for unnecessary medications. This had the ability to affect all residents. The facility census was 80.

Inspectors wroteBased on medical record review, resident and staff interview, review of a fall report and review of facility policy, the facility failed to ensure a resident's medical record reflected information related to a fall for one (#75) of one resident reviewed for falls. The facility census was 80.

Inspectors wroteBased on personnel record review and staff interview, the facility failed to complete State Tested Nurse Aide (STNA) performance evaluations timely. This affected two (#370 and #324) of four personnel records reviewed for performance evaluations. This had the potential to affect all 80 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a register nurse worked eight hours a day, seven days a week. This had the potential to affect all 81 resident residing at the facility. The facility census was 81.

Inspectors wroteBased on observation, staff interview, and review of facility policies, the facility failed to store and prepare foods in a safe and sanitary manner. This had the potential to affect all 81 residents who received food from the kitchen. The facility census was 81.

Inspectors wroteBased on staff interview, review of facility trust account information, and review of facility surety bond, the facility failed to ensure the surety bond was efficient to cover the total balance of the resident account balances. This affected 74 current residents identified by the facility with current trust accounts handled by the facility. Resident #5, #19, #25, #29, #46, #74, and #278 did not have personal fund accounts handled by the facility. Facility census was 81.

Inspectors wroteBased on medical record review, resident interview, staff interview, review of facility Self-Reported Incidents, and review of facility policies, the facility failed to follow their policy to investigate and report of allegations of sexual abuse to the state survey agency. This affected four (#3, #4, #8, and #63) of four reviewed for abuse. The facility census was 81.

Inspectors wroteBased on medical record review, resident interview, staff interview, review of facility Self-Reported Incidents, and review of facility policy, the facility failed to report of allegations of sexual abuse to the state survey agency. This affected four (#3, #4, #8, and #63) of four reviewed for abuse. The facility census was 81.

Inspectors wroteBased on medical record review, resident interview, staff interview, review of facility investigations, and review of facility policies, the facility failed to thoroughly investigate allegations of sexual abuse. This affected four (#3, #4, #8, and #63), of four reviewed for abuse. The facility census was 81.

Inspectors wroteBased on observation, staff interview, review of daily temperature log, nd review of manufacturer's storage recommendations, the facility failed to store medication requiring refrigeration at the proper temperature in accordance with manufacturer recommendations. This had the potential to affect nine residents (# 8, #13, #18, #21, #23, ##39, #42, #68, and #128) identified by the facility as having orders for medications being stored in the refrigerator. The census was 81.

Inspectors wroteBased on record review, staff interview, review of the facility investigation, and review of facility policy on abuse, the facility failed to prevent resident to resident sexual abuse when one resident (#8) was fondled without consent by another resident (#3). This affected one (#8) of four residents reviewed for abuse. The facility census was 81.

Inspectors wroteBased on medical record review, and staff interview, the facility failed to provide written notification of hospital transfer to residents, the residents' representatives, and to the Ombudsman for one (#64) of three residents reviewed for transfer/discharge. The facility census was 81. Findings nclude: Review of Resident #64's medical record revealed an admission date of 02/01/07. Resident #64 was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included contracture of right knee, hypokalemia, hypertension, paraplegia, abnormal posture, contracture of left shoulder, anemia, hernia, convulsion, chronic sinusitis, anxiety disorder, sepsis, and multiple sclerosis. Review of Resident #64's Minimum Data Set (MDS) assessments revealed a Discharge MDS assessment with return anticipated was completed on 09/03/19. [...]

Inspectors wroteBased on medical record review, staff interview, and review of policy, the facility failed to provide notification of bed hold policy to one (#64) of three residents reviewed for transfer/discharge. The facility census was 81.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure a pressure reducing cushion was in place as care planned for one (#69) of two residents reviewed for skin breakdown. The facility had seven residents with pressure ulcers. The facility census was 81 residents.

Inspectors wroteBased on observation, record review, staff interview and facility policy, the facility failed to implement a care plan intervention for falls. This affected one (#3) of two residents review for falls. The facility census was 81.