Whitesboro Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Whitesboro Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF755Mar 20, 2025

  Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedure that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 (Resident #1) of four residents reviewed for pharmaceutical services. A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator and DON on 03/20/2025 at 3:45 PM. The noncompliance began on 01/25/2025 and ended on 01/28/2025. The facility corrected the noncompliance before the investigation began. The facility failed to administer Resident #1's Lacosamide (anti- seizure medication) according to medication administration orders. […]

• Immediate jeopardy, patternF760Mar 20, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure that residents are free from any significant medication error for 1 (Resident#1) of 4 residents reviewed for medication errors. A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator and DON on 03/20/2025 at 3:45 PM. The noncompliance began on 01/25/2025 and ended on 01/28/2025. The facility corrected the noncompliance before the investigation began. The facility failed to administer Resident #1's Lacosamide (anti- seizure medication) according to medication administration orders. Resident #1 did not receive her antiepileptic medication for two days (01/25/25 and 01/26/25). […]

• Immediate jeopardy, isolatedF689Oct 22, 2025

  Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not break the window in her room, exit the window, and walk to the staff smoking area where she was found lying on a bench on 10/20/2025 at 8:10 PM, approximately 30 minutes after she was noted to be missing. The non-compliance was identified as PNC (Past Non-Compliance) on 10/22/2025 and the IJ template was provided to the facility on [DATE] at 3:21 PM. The noncompliance began on 10/20/2025 and ended 10/21/2025. […]

• Immediate jeopardy, isolatedF689Mar 20, 2025

  Based on observations, interviews, and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for accidents and supervision. The facility failed to transport the resident in a safe manner by using the rollator walker as a wheelchair resulting in the resident falling forward and sustaining fractures to her left elbow, and right hip. A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator and DON on 03/20/2025 at 3:45 PM. The noncompliance began on 02/15/2025 and ended on 02/21/2025. […]

• No harm, potential for more than minimal, widespreadF812Mar 21, 2024

  Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure refrigerator and freezer items were dated, labeled, and sealed. 2. The facility failed to ensure Dietary Manager wore an effective hair restraint and performed hand hygiene during lunch meal preparation on 03/19/24. 3. The facility failed to ensure kitchen trash cans with food debris were covered. 4. The facility failed to ensure fryer was cleaned after use. 5. […]