Whitewater Health Services

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean, homelike environment when it was identified a refrigerator used to supply resident supplement drinks were not cleaned. In addition, during dining, meals were served on trays. This failure had an opportunity to affect all residents who received supplemental drinks and who received meals in the dining rooms.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain equipment in good working order for 1 kitchen dishwashing system and surrounding area.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain dignity when it was identified a brace was not cleaned regularly for 1 of 1 resident (R1) reviewed for dignity.

Inspectors wroteBased on interview and record review facility failed to notify the physician with a change of condition for 1 of 1 resident (R31) reviewed for discharge.

Inspectors wroteBased on interview and record review the facility failed to appropriately assess and reevaluate interventions discussed in a timely manner to help prevent future falls for 1 of 4 residents (R1) reviewed for accidents who had 23 falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow care plan interventions requested by the resident for 1 of 1 resident (R5) reviewed for bladder incontinence.

Inspectors wroteBased on interview and record review the facility failed to maintain a medical record that was complete, accurate and readily accessible for 1 of 1 resident (R29) reviewed for death record.

Inspectors wroteBased on interview and document review, the facility failed to develop a baseline care plan to ensure enhanced barrier precaution (EBP) needs were identified and addressed for 2 of 3 residents (R1 and R2) reviewed for indwelling catheters.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the required nurse staffing information was posted daily. This had the potential to affect all 33 residents residing in the facility and/or visitors who may wish to see the information.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure staff consistently implemented enhanced barrier precautions (EBP) in accordance with Centers for Disease Control (CDC) guidelines to reduce the risk of infection spread for 1 of 3 residents (R1) reviewed for an indwelling catheter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from misappropriation of property for five of eight residents (R2, R4, R5, R6, R8) reviewed when multiple nursing staff took medication belonging to one resident to administer to another resident when their medication supply ran out.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that alleged violations involving misappropriation of resident medications were reported to the state agency not later than 24 hours of the incidents for five of eight residents (R2, R4, R5, R6, and R8). The facility knew about the misappropriation of resident medications on 6/9/25 and did not report to the state agency.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate allegations of misappropriation of resident medications for five of eight residents (R2, R4, R5, R6, and R8) when the facility found out about these allegations on 6/9/25, placed DON-A on administrative leave pending an investigation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure residents medications were ordered in advanced and medications were administered as prescribed for five of eight residents (R2, R4, R5, R6, R8) reviewed when residents were administered other resident's medications when their supply ran out.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a self-administration of medication (SAM) assessment was completed for 1 of 1 resident's (R16) reviewed for medication administration.

Inspectors wroteBased on interview and document review, the facility failed to complete and implement a baseline care plan within 48 hours of admission for 1 of 2 residents (R125) reviewed for new admissions.

Inspectors wroteBased on observation, interview and document review, the facility failed to identify, treat, follow up on pain and offer non-pharmacological interventions for 1 of 1 resident (R125) reviewed for pain management who was newly admitted .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed proper infection control practices for 1 of 1 resident (R11) reviewed for urinary catheter. Staff failed to ensure a mechanical transfer lift was cleaned and disinfected after resident use for 1 of 1 resident (R125) observed for infection control. Furthermore, staff failed to ensure proper personal protective equipment (PPE) was used for 2 of 2 residents (R125, R126) observed for proper PPE.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the facility's state survey results were kept in a location readily accessible to all residents and/or visitors. This had the potential to affect all 22 residents and/or visitors who could wish to review the information.

Inspectors wroteBased on interview and record review, the facility failed to identify, comprehensively assess, implement interventions, and provide timely physician notification for a sudden change in condition for 1 of 3 residents (R1) reviewed for change in condition. This resulted in an immediate jeopardy (IJ) when R1 became unresponsive causing a delay in hospitalization. Immediate Jeopardy (IJ) began on [DATE] when the facility did not complete comprehensive assessments and communicate sudden change of condition to the physician when R1 became unresponsive and remained unresponsive for at least seven (7) hours before the ambulance arrived. The administrator and director of nursing (DON) were notified of the IJ on [DATE] at 4:58 p.m. The immediacy of the IJ was removed on [DATE] at 12:43 p.m. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure proper hand hygiene after meal service and during personal cares for 3 of 3 resident (R1, R2, R4) observed for hand hygiene.