Whitney Nursing and Rehabilitation Center

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident's right to a dignified existence for 1 of 4 residents (Residents #1) reviewed for dignity. 1. The facility failed on 01/20/2026 to promote Resident #1's dignity by dressing him with 2 diaper briefs, leading to urine leakage over his clothes when he was not changed timely. 2. The facility failed on 01/20/2026 to provide Resident #1 with a change of clothes or extra toiletries when he had to be out of the facility all day for appointments. This failure placed residents at risk of embarrassment and a loss of dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1of 1 Medication storage room reviewed for drug storage. The facility failed to ensure 1 expired 70/30 Mix Insulin Aspart, and 2 expired Central Line Dressing Trays were removed from the medication storage room. This failure could place residents at risk for receiving medications that are not at therapeutic levels.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to review the risks and benefits of bed rails and enabler/grab bars (smaller 1/8 size bars affixed to the bed frame used by the person in bed to reposition themselves), with the resident or resident representative and obtain informed consent prior to installation for six (Residents #7, #11, #26, #29, #41, and #143) of six resident rooms observed and reviewed for bed rails/grab bars. The facility failed to have evidence of informed consent, assessment of the resident for risk of entrapment, and care planning for the quarter bed rails/enabler bars for Residents #7, #11, #26, #29, #41, and #143. [...]

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure the medication error rate was not 5 percent (5%) or greater for 2 of 31 opportunities resulting in a 6.14 % medication error rate for two of nine residents observed for medication pass (Resident #24 and Resident #96). 1. The facility failed to ensure Resident #24's insulin was administered according to the sliding scale as physician ordered by LVN B 2. The facility failed to ensure Resident #96's blood pressure medication Metoprolol was held and not administered by MA D as physician had order for blood pressure reading of 105/65. These failures could place residents at risk for significant medication errors and jeopardize the resident health and safety.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for one of two nurse medication carts (Cart A) and one of two med aide medications cart (Cart B) that were reviewed for security and storage of drugs and biologicals. The facility failed to ensure nurse medication Cart A had dated insulin and unexpired insulin in it for Resident # 24, and Resident #25 per manufactueres recommendation to be used in 28 days after opening the insulin. The facility failed to ensure MA D locked and secured medication Cart B when it was unattended and out of view while inside Resident # 96's room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 disease and infections for four of ten residents (Residents #1, #6, #17, and #143) reviewed for infection control. 1. The facility failed to ensure MA D sanitized blood pressure cuff in-between residents use on Residents # 1, #6, and Resident #17. 2. The facility failed to ensure LVN A wore PPE for EBP, cleaned bedside table, and performed hand hygiene during catheter care for Resident #143. These failures could place residents at risk of infectious diseases and cross contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status for two (Residents #24 and #32) of 24 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #24's and Resident #32's most recent comprehensive assessments did not inaccurately reflect the residents each having a urinary catheter (a tube inserted into the body to allow urine to drain). This failure could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #24) of 8 residents reviewed for pharmacy services. The facility failed to ensure Resident #24's insulin was used within 28 days of opening date [DATE] prior to LVN B administering it. These failures could place residents at risk for medication errors, ineffective relief from pain medication, and drug diversion of controlled substances.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident had the right to be free from misappropriation of property for 2 of 6 residents (Resident #1 and #2) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #1's morphine sulfate (concentrate) solution 30 mg/ml, a medication to help with pain. This failure placed residents at risk for not receiving prescribed medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was consulted for a change of condition for 1 of 7 residents reviewed for notification of changes. (Resident #1) The facility failed to ensure a UA was collected, notify the physician, family, and provide treatment to Resident #1 died of sepsis and complications of a urinary tract infection because of her change in condition. The facility failed to identify a change in condition and notify her physician including a decline in cognitive status and a fall. On 03/18/24 at 12:00 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 3/19/24 at 6:15PM, the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents are free from abuse, neglect, misappropriation of resident property, and exploitation; the facility failed to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress for 1 (Resident #1) of 7 residents reviewed for neglect. The facility failed to ensure a UA was collected and provide treatment to Resident #1 who subsequently died of sepsis and complications of a urinary tract infection. The facility failed to identify a change in condition and notify her physician including a decline in cognitive status and a fall. ON 03/15/2024 an Immediate Jeopardy (IJ) was identified. The POR was accepted on 03/17/2024 at 10:00 AM and verified. Additional IJs were called 03/18/24 and the IJs were removed on 03/19/24 at 6:15PM. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one 1 (Resident #1) of 7 residents reviewed for quality of care. The facility failed to ensure a UA was collected and provide treatment to Resident #1 who subsequently died of sepsis and complications of a urinary tract infection. On 03/18/24 at 12:00 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 3/19/24 at 6:15PM, the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk for decreased quality of care by failing to treat infections which could impact their health causing sepsis and even death. Findings Included: [...]

Inspectors wroteBased on record review and interviews, the facility failed to maintain clinical laboratory services to meet the needs of each resident for 1 of 7 residents (Resident #1) reviewed for laboratory services. The facility failed to ensure a UA was collected and provide treatment to Resident #1 who subsequently experienced a change in condition, died of sepsis and complications of a urinary tract infection. On 03/18/24 at 12:00 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 3/19/24 at 6:15PM, the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of failing to treat infections which could impact their health causing sepsis and even death.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Resident #22, Resident #27, Resident #39) of 16 residents reviewed for ADLs (Activities of Daily Living). The facility failed to ensure Resident #22, Resident #27, and Resident #39 had their fingernails and toenails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to 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 three of five (CNAs B, CNA D, and LVN K) staff observed for infection control. CNAs (Certified Nursing Assistance) B, and D failed to change gloves, and perform hand hygiene during incontinence care for Resident #18. LVN (licensed Vocational Nurse) K failed to change gloves, and perform hand hygiene during blood sugar check for Resident #38 These failures could place residents at risk for infection through cross-contamination.