Whitestone Care Center

In the surveyor’s words

From the most serious findings on record at Whitestone Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF678Nov 18, 2024

  Based on a review of clinical records, facility investigative reports select facility policies, and American Heart Association guidelines and staff interviews it was determined the facility failed to provide prompt cardio pulmonary resuscitation intervention consistent with a resident's advanced directives for one resident (Resident CR1) out of five residents sampled. This failure placed 33 facility residents of 86 residents residing in the facility, desiring cardiopulmonary resuscitation (CPR), in immediate jeopardy to their health and safety with the potential for death because of a similar occurrence. […]

• Actual harm, isolatedF600Apr 29, 2025

  Based on a review of clinical records, the facility's abuse prohibition policy, select investigative reports and staff interview, it was determined the facility failed to ensure the provision of care and services necessary to avoid physical harm and maintain the physical health of one resident out of two sampled (Resident 18) resulting in a serious injury, a fractured femur (thigh bone). This deficiency is cited as past non-compliance. Findings include: A review of the facility policy titled Pennsylvania Resident Abuse: Abuse, Neglect and Exploitation last reviewed by the facility on April 24, 2025, revealed it is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation… […]

• Actual harm, isolatedF600Jun 4, 2024

  Based on a review of the facility's abuse prohibition policy, select investigative reports and clinical records, and interviews with staff and the resident's family it was determined that the facility neglected to provide the care and services necessary to avoid physical harm and maintain physical health for one resident out of six residents sampled (Resident 1) resulting in serious injuries, a fractured thumb and closed head injury. Findings include: The facility's policy entitled Abuse Policy dated as reviewed by the facility August 30, 2023 revealed that The facility will not tolerate abuse, neglect, exploitation of residents, and misappropriation of resident property by anyone. Facility staff must immediately report all such allegations to the administrator/abuse coordinator. […]

• Actual harm, isolatedF686May 21, 2021

  Based on a review of clinical records and select facility policy, observations and staff and resident interviews, it was determined that the facility failed to timely assess and consistently provide recommended treatment and services, consistent with professional standards of practice, to prevent new pressure sore development, promote healing and prevent worsening of existing pressure sores, which resulted in the development of pressure sores for two of 6 residents reviewed with pressure ulcers (Resident 7 and Resident 30). […]

• No harm, potential for more than minimal, widespreadF835Nov 18, 2024

  Based on a review of clinical records, select facility policy and reports, and employee job descriptions and staff interview it was determined the facility's administration failed to effectively use its resources to promote resident safety by failing to implement established procedures to provide timely cardiopulmonary resuscitation (CPR) in the event of cardiac arrest according to a resident's advanced directive for one out of five sampled residents (Resident CR1). Findings included: Review of the facility's policy and procedure titled Cardiopulmonary Resuscitation (CPR is an emergency treatment that's done when someone's breathing or heartbeat has stopped) last reviewed by the facility [DATE], revealed, licensed nurses, respiratory therapists and van drivers will hold active CPR… […]