Whispering Pines Nursing and Rehab, LLC

In the surveyor’s words

From the most serious findings on record at Whispering Pines Nursing and Rehab, LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF805Nov 20, 2023

  Based on staff interview and record review, the facility did not ensure food was prepared in a form designed to meet individual needs for 1 Resident (R) (R1) of 7 residents on mechanically altered diets. R1 had a mechanically altered diet. R1's diet was not followed on 11/7/23, which resulted in a choking episode that required intervention by nursing staff and emergency medical services (EMS) to clear R1's airway. R1 passed away on 11/7/23 as a result of the choking episode. Failure to ensure foods were served to residents in the appropriate texture created a finding of Immediate Jeopardy (IJ), which began on 11/7/23. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 11/9/23 at 3:45 PM. […]

• Actual harm, isolatedF686Aug 27, 2026

  Based on observation, interview, and record review, the facility did not ensure care and treatment were provided to prevent the development of pressure injuries and/or promote healing for 2 residents (R) (R3 and R7) of 2 sampled residents in a total sample of 18 residents. R3 is being cited at severity level 3 (actual harm/isolated). R2 is being cited at severity level 2 (potential for more than minimal harm).R3 was determined to be at risk for pressure injury development. Interventions were not implemented upon this determination. R3 developed multiple pressure injuries within 12 days of admission. Treatment orders in R3's medical record were not consistent with written orders and were not correctly followed or consistently completed. […]

• Actual harm, isolatedF689Apr 14, 2026

  Based on staff interview and record review, the facility did not ensure the safety of 1 resident (R) (R17) of 2 sampled residents.R17 was at high risk for wandering and had a Wanderguard (WG) bracelet. R17 exited the facility on 4/1/26 between 4:00 AM and 4:30 AM through an unalarmed door. R17 was found approximately 1.1 miles away at 6:40 AM at R17's apartment. R17 sustained a broken finger during the elopement. (This is being cited at past non-compliance.)Findings include: The facility's Elopement Risk and Prevention policy, dated 8/1/2015, indicates: The facility shall ensure all residents receive adequate supervision and assistive devices to prevent accidents, including elopement, wandering, and unsafe exits.Between 4/13/26 and 4/14/26, Surveyor reviewed R17's medical record. […]

• No harm, potential for more than minimal, widespreadF812Apr 14, 2026

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 34 residents residing in the facility.Staff did not consistently monitor food holding temperatures.Toasters in the main kitchen contained dried food debris.Staff did not follow sanitation practices when using a thermometer to check cooking temperatures.Findings include:On 4/12/26 at 9:24 AM, Surveyor completed an initial tour of the kitchen with Dietary Manager (DM)-C who stated the facility follows the Federal Food Code.Food Cooking/Holding Temperatures:The facility's Food Temperature Record policy, dated 6/28/22, indicates: It is the policy of the facility to ensure foods and beverages are held and… […]

• No harm, potential for more than minimal, widespreadF812Nov 1, 2023

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and served in a safe and sanitary manner. This practice had the potential to affect 37 of 37 residents residing in the facility. Kitchen and food services areas were not in a clean and sanitary condition. Findings include: On 10/30/23 at 9:00 AM, Surveyor began an initial tour of the kitchen with Dietary Manager (DM)-C who indicated the facility followed the Food and Drug Administration (FDA) Food Code. The FDA Food Code 2022 documents at 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. […]