Whitesboro Health and Rehabilitation Center

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two of ten residents (Resident #1 and Resident #2) reviewed for abuse and neglect. The facility failed to ensure Resident #1 was free from abuse when Resident #2 hit him on 01/04/2026. This failure could place residents at risk of abuse and emotional stress.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not break the window in her room, exit the window, and walk to the staff smoking area where she was found lying on a bench on 10/20/2025 at 8:10 PM, approximately 30 minutes after she was noted to be missing. The non-compliance was identified as PNC (Past Non-Compliance) on 10/22/2025 and the IJ template was provided to the facility on [DATE] at 3:21 PM. The noncompliance began on 10/20/2025 and ended 10/21/2025. The facility corrected the non-compliance before the survey began. This failure could place the residents at risk of serious harm, injury and death from wandering outside the facility in unfamiliar surroundings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 4 (Resident #1) residents reviewed for dignity. The facility failed to treat Resident #1 with dignity and promote enhancement of his quality of life when the resident was not provided a privacy bag for his urinary catheter bag (collection bag for urine) on 09/10/2025. This failure could place residents at risk of not having their right to a dignified existence maintained.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 10 (Resident #2) residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #2's room was in a position accessible to the resident on 09/10/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased 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 5 (Resident #3) residents reviewed for infection control. The facility failed to ensure CNA B changed gloves and washed his hands while providing incontinence care for Resident #3 on 09/10/2025. This failure could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #147) of five residents reviewed for dignity. The facility failed to treat Resident #147 with dignity and promote enhancement of his quality of life when the resident was not provided a privacy bag for his foley bag (collection bag for urine) on 05/13/2025. This failure placed residents at risk of not having their right to a dignified existence maintained.

Inspectors wroteBased 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 3 (Residents #24, #23, and #1) of 12 residents reviewed for infection control. The facility failed to ensure LVN C cleaned the blood pressure cuff between residents when administering medication to Residents #24, #23, and #1 on 05/14/2025. These failures could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the resident environment remained as free from accident hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #41) of 8 residents reviewed for accident hazards. The facility failed to ensure Resident #41's fall mat was not folded up and leaned against a wall when Resident #41 was lying in bed on 05/13/2025. This failure could place residents at risk of harm and serious injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 (Resident #41 and Resident #24) of 10 residents reviewed for infection control. 1. The facility failed to ensure Resident #41's foley catheter (tube that drains urine) bag was not touching the floor when the resident was lying in bed on 05/13/2025. 2. The facility failed to ensure CNA D wiped from front to back when providing incontinent care to Resident #24 on 05/15/2025. These failures could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedure that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 (Resident #1) of four residents reviewed for pharmaceutical services. A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator and DON on 03/20/2025 at 3:45 PM. The noncompliance began on 01/25/2025 and ended on 01/28/2025. The facility corrected the noncompliance before the investigation began. The facility failed to administer Resident #1's Lacosamide (anti- seizure medication) according to medication administration orders. Resident #1 did not receive her antiepileptic medication for two days (01/25/25 and 01/26/25). [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents are free from any significant medication error for 1 (Resident#1) of 4 residents reviewed for medication errors. A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator and DON on 03/20/2025 at 3:45 PM. The noncompliance began on 01/25/2025 and ended on 01/28/2025. The facility corrected the noncompliance before the investigation began. The facility failed to administer Resident #1's Lacosamide (anti- seizure medication) according to medication administration orders. Resident #1 did not receive her antiepileptic medication for two days (01/25/25 and 01/26/25). [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for accidents and supervision. The facility failed to transport the resident in a safe manner by using the rollator walker as a wheelchair resulting in the resident falling forward and sustaining fractures to her left elbow, and right hip. A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator and DON on 03/20/2025 at 3:45 PM. The noncompliance began on 02/15/2025 and ended on 02/21/2025. The facility corrected the noncompliance before the investigation began. This failure could place residents at risk of injury and a decreased quality of life. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure refrigerator and freezer items were dated, labeled, and sealed. 2. The facility failed to ensure Dietary Manager wore an effective hair restraint and performed hand hygiene during lunch meal preparation on 03/19/24. 3. The facility failed to ensure kitchen trash cans with food debris were covered. 4. The facility failed to ensure fryer was cleaned after use. 5. The facility failed to ensure 3-compartment sink water temperature logs were documented and monitored to ensure minimum water temperature log for wash and rinse sink. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (medication cart) of 1 medication cart reviewed for pharmacy services in that: The facility failed to ensure the insulin pen for Resident #2 had an opened date. This failure could affect residents and staff resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food prepared by methods, which conserved the nutritive value, flavor, texture, and appearance for one (Lunch 03/19/24) of one meal observed for pureed food. Dietary Manager failed to prepare pureed bread with jelly/peanut butter for Resident #6 on 03/19/24 by following recipe in order to maintain the appropriate texture and nutritive value. This failure could place residents at risk of decline in nutrition status, loss of appetite and decreased intake placing them at risk for the potential of aspiration and of unplanned weight loss.