Whispering Pines Rehabilitation and Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 17, 2026

  Based on interviews, observations, clinical record review, and review of facility policy for the only sampled resident reviewed for respiratory care (Resident #37), the facility failed to ensure a safe environment for a resident on continuous oxygen by allowing the resident (Resident #37) to self-administer a petroleum-based ointment into the nose without physician orders, proper assessment, or staff interventions. Staff failed to recognize and act on posted safety signage (Oxygen in use-no petroleum lotions), did not remove the flammable material from the room, and did not educate the resident on the danger of using petroleum products with oxygen therapy. […]

• Immediate jeopardy, isolatedF678Jun 21, 2021

  Based on clinical record review, review of facility documentation and policies and interviews for one sampled resident (Resident #1) who was a recent admission and had acknowledged full Cardio-Pulmonary Resuscitation (CPR) in the advance directive and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 was a full code. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had severe cognitive impairment, required extensive assistance of two (2) staff with transfers in and out of the bed and chair and extensive one (1) person assistance with toilet use. […]

• No harm, potential for more than minimal, patternF580Mar 17, 2026

  Based on interviews, review of the medical record, facility documentation, observations, and facility policy for 3 of 3 residents (Resident #7, Resident #14 and Resident #20) reviewed for urinary tract infections, the facility failed to ensure the Advanced Practice Registered Nurse (APRN) was notified when a medication was unavailable and therefore not administered. The findings include: 1.Resident #7 was admitted to the facility in October 2025 with diagnoses that included dementia, urinary retention with chronic foley use and urinary tract infections (UTI).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 was severely cognitively impaired and required set up for meals, moderate assistance for activities of daily living (ADLs) and had a urinary foley… […]

• No harm, potential for more than minimal, patternF684Mar 17, 2026

  Based on review of the clinical record, facility policy, and interviews for 1 of 4 residents (Resident #3) reviewed for hospitalization, the facility failed to perform fingerstick glucose levels for a diabetic resident as indicated by the providers note and for 3 of 3 residents (Resident #7, Resident #14 and Resident #20) reviewed for urinary tract infections, the facility failed to ensure medications were administered per physician's orders. Additionally, for 1 of 3 residents (Resident #65) reviewed for non-pressure skin conditions, the facility failed to identify a change in wound status. […]

• No harm, potential for more than minimal, patternF687May 16, 2024

  Based on observations, review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #67) reviewed for Activities of Daily Living (ADL's), the facility failed to provide podiatry services to a long-term resident. The findings include: Resident #67's was admitted to the facility in August of 2023 with diagnoses that included type II diabetes mellitus, muscle weakness, difficulty in walking, and repeated falls. An admission physician's order dated 8/29/23 directed that Resident #67 may have podiatry services as needed. […]