Whispering Oaks

In the surveyor’s words

From the most serious findings on record at Whispering Oaks, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 1, 2023

  Based on observations, review of medical records, facility policies, and interviews with facility staff and a family member, the facility neglected to provide services and supervision to one (Resident #1) of three sampled for high-risk elopement. Resident #1 was an ambulatory, vulnerable resident, who previously expressed wishes to leave the facility, and previously made elopement attempts. Documented concerns by nursing staff showed they feared Resident #1 would be able to exit the facility by jumping the fence. Resident #1 had been assessed to be an elopement risk, requiring 1 to 1 supervision when smoking. […]

• Immediate jeopardy, isolatedF689Feb 1, 2023

  Based on observations, review of medical records, facility policies, and interviews with facility staff and a family member, the facility failed to provide supervision to one (Resident #1) of three residents sampled for high-risk of elopement. Resident #1 was severely cognitively impaired, ambulatory, repeatedly expressed a wish to leave the facility and had attempted to leave the facility before January 25, 2023. Resident #1 was assessed to be an elopement risk and was care planned to have 1 to 1 supervision when smoking. On January 25, 2023, Resident #1 was able to exit the facility unbeknownst to staff and was found 2.9 walking miles from the facility 44 hours later. […]

• Actual harm, isolatedF699Feb 1, 2023

  Based on resident interview, staff interview, physician interview, record review, and hospital record review the facility failed to ensure one resident (#2) out of 3 residents reviewed for trauma informed care received the services to mitigate triggers and prevent re-traumatization related to a facility staff member physically abusing Resident #2 on 4/30/22. Resident #2 was retraumatized on the evening of 12/28/22 when a male caregiver was providing care to Resident #2's roommate and Resident #2 believed the staff member was the same staff member who abused him. […]

• No harm, potential for more than minimal, patternF644Feb 12, 2026

  Based on record review and staff interview the facility failed to complete and submit for review the Pre-admission Screening and Resident Review (PASARR) Level II upon acquiring new or qualifying mental health diagnoses for 6 residents (#24, #7, #84, #6, #4 and #241) out of 11 residents sampled for PASARRs.Findings included: 1.) Review of the admission record for Resident #24 revealed the resident was admitted to the facility on [DATE] with diagnoses to include a primary diagnosis of schizophrenia, anxiety disorder, bipolar, major depressive disorder, and schizoaffective disorder. Review of the resident's record revealed a level I PASARR (Preadmission Screening and Resident Review) dated 12/5/23. […]

• No harm, potential for more than minimal, patternF645Feb 12, 2026

  Based on record review and staff interviews, the facility failed to ensure the Preadmission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability with qualifying mental health diagnosis, were completed accurately for 5 residents (#7, #84, #11, #208, and #241) of 11 residents sampled.Findings included: 1. Review of the admission record for Resident #7 revealed the resident was admitted to the facility on [DATE] with diagnosis to include Bipolar disorder, major depressive disorder, seizures, and personal history of traumatic brain injury (TBI).Review of a Level I PASARR for Resident #7 dated 10/30/24 reveled in section B the seizure and TBI diagnoses were not checked. […]