Whitewater Health Services

In the surveyor’s words

From the most serious findings on record at Whitewater Health Services, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Aug 6, 2024

  Based on interview and record review, the facility failed to identify, comprehensively assess, implement interventions, and provide timely physician notification for a sudden change in condition for 1 of 3 residents (R1) reviewed for change in condition. This resulted in an immediate jeopardy (IJ) when R1 became unresponsive causing a delay in hospitalization . Immediate Jeopardy (IJ) began on [DATE] when the facility did not complete comprehensive assessments and communicate sudden change of condition to the physician when R1 became unresponsive and remained unresponsive for at least seven (7) hours before the ambulance arrived. The administrator and director of nursing (DON) were notified of the IJ on [DATE] at 4:58 p.m. The immediacy of the IJ was removed on [DATE] at 12:43 p.m. […]

• Immediate jeopardy, isolatedF578Oct 18, 2021

  Based on interview and document review, the facility failed to ensure a system was in place to clearly identify resident wishes for code status, cardiopulmonary resuscitation (CPR), for 6 of 34 residents (R13, R10, R32, R184, R26 and R86) reviewed for advanced directives. This failure resulted in an immediate jeopardy (IJ) for R13, R10, and R32, when their medical records failed to identify the residents wishes accurately. In addition to the residents in immediate jeopardy, the facility failed to ensure R184, R26, and R86's code status wishes were addressed with the resident or ordered by the physician. […]

• Immediate jeopardy, isolatedF600Jul 19, 2021

  Based on observation, interview and document review, the facility failed to ensure residents were free from physical abuse for 1 of 2 residents (R4) reviewed for abuse when R4 had received cares in a rough manner and was slapped in the face. This resulted in an immediate jeopardy (IJ) situation for R4 who was totally dependent on staff for all cares and cognitively unable to report any abuse. The immediate jeopardy began on 7/8/21 when it was identified by family member (FM)-D, R4 was treated rough while receiving cares and was identified on 7/15/21. The facility administrator and the director of nursing (DON) were notified of the immediate jeopardy at 6:19 p.m. on 7/15/21. […]

• Immediate jeopardy, isolatedF689Jul 19, 2021

  Based on observation, interview and document review the facility failed to prevent an elopement and provide safety for 1 or 2 residents (R1) identified at risk for elopement who successfully eloped from the building and was found outside. This deficient practices resulted in immediate jeopardy for R1. The IJ began on 7/7/21 at 7:00 p.m. when R1 exited the building and staff were unaware until staff saw R1 through a window and alerted staff of R1 being outside. The IJ was identified on 7/16/21 and the administrator and director of nursing (DON) were notified of the immediate jeopardy at 2:23 p.m. on 7/16/21. The IJ was removed on 7/19/21, but noncompliance remained at the lower scope and severity level of D, isolated with the potential to cause more than minimal harm. […]

• Actual harm, isolatedF686Oct 18, 2021

  Based on observation, interview and document review, the facility failed to notify the medical provider and obtain wound care orders when 1 of 1 residents (R10) reviewed for pressure ulcers, had developed a new coccyx pressure ulcer, and failed to transcribe and follow orders from a provider for a newly developed heel ulcer. This failure resulted in actual harm when R10's coccyx pressure ulcer became larger and the heel ulcer deteriorated from a stage 2 to a stage 3 ulcer. Findings include: Pressure Ulcer stages defined by the Minimum Data Set (MDS) per Center Medicare/Medicaid Services: Stage I pressure ulcer (An observable, pressure-related alteration of intact skin, whose indicators as compared to adjacent or opposite area on the body may include changes in one or more of the… […]