Whispering Oaks Rehab & Nursing

In the surveyor’s words

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

• Immediate jeopardy, widespreadF812May 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions for 1 of 1 kitchen reviewed for food served under sanitary conditions. Food from the walk-in refrigerator, with readings in the danger zone for 3 days, was served to residents. An Immediate Jeopardy was identified on 5/23/25 at 4:15 pm. While the Immediate Jeopardy was removed on 5/24/25 at 9:00 pm, the facility remained out of compliance at a scope of widespead and a severity level of no actual harm with potential for more that minimal harm that is not Immediate Jeopardy due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. […]

• Actual harm, isolatedF684Oct 2, 2021

  Based on record review and interviews, the facility failed to ensure that resident had the right to be free from neglect and recieve services that met professional standards of quality for 1 of 5 resident whose care was reviewed for Quality of Care in that: The facility failed to follow structured policies to prevent neglect and provide care by professional standards were not implemented when: 1.The facility failed to conduct, document or implement intervention of neurological checks for a resident who had a fall hit her head leaving a hematoma on the back of her head on [DATE]. Resident #1 subsequently died on [DATE]. […]

• No harm, potential for more than minimal, patternF641Jun 14, 2024

  44020 Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 3 of 17 Residents (Resident #5, Resident #11 and Resident #42) whose MDS records were reviewed for accuracy. 1. Facility failed to ensure Resident #5's comprehensive MDS, dated [DATE] assessment accurately reflected that he had a suprapubic catheter. 2. The facility failed to ensure Resident #11's quarterly MDS assessment dated [DATE] accurately reflected she had a significant weight loss. 3. […]

• No harm, potential for more than minimal, patternF551Jan 18, 2024

  Based on observations, interviews and record review, the facility failed to ensure that the resident representative had the opportunity to exercise the resident's rights for 3 of 7 residents (Resident #s 2, 3, and 10) reviewed for resident rights in that: The facility failed to inform the residents ' responsible parties that the heater on A hall was not working and offer the choice to move the residents to another room or sister facility. This deficient practice could affect residents and place them at risk for hypothermia and/or decline in health due to exposure to low temperatures. […]

• No harm, potential for more than minimal, isolatedF842Aug 7, 2026

  Based on observation, interviews and record reviews, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for two (2) of two (2) residents (Resident #1 and Resident #2) reviewed for clinical records. 1. The facility failed to ensure Resident #1's foley (a tube inserted into the bladder to drain urine) outputs (the volume of urine collected from a foley catheter) were accurately documented on his Nurse Medication Administration Record (NMAR) for 4 (07/03/2026 at **10p, 07/07/2026 at **Day, 07/20/2026 at **10p, and 07/26/2026 at **Eve) of 109 treatments scheduled between 07/01/2026 to 08/06/2026 **Day. 2. […]