Whitney Center

In the surveyor’s words

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

• Actual harm, isolatedF600Jun 18, 2026

  Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #77) reviewed for activities of daily living (ADL), the facility failed to provide care and services sufficient to ensure the resident was free from neglect and harm. The facility failed notify the physician when a rash developed and worsened, failed to apply an appropriate treatment, failed to complete ongoing accurate assessments of the area and instead erroneously documented that the skin was intact during which time the rash was worsening without treatment. […]

• Actual harm, isolatedF686Jun 18, 2026

  Based on review of the clinical record, facility documentation, facility policy and interviews for 4 of 7 residents (Resident #40, 42, 97 and 71) reviewed for pressure ulcers, the facility failed to consistently conduct weekly skin assessments, consistently monitor and comprehensively document pressure ulcers, report changes to the physician, and used multiple different wound assessment forms making it confusing to track progress. Physicians relied on licensed staff verbal reporting of wound condition which led to insufficient oversight, inadequate re-evaluation and delay in treatment changes. […]

• Actual harm, isolatedF760Nov 17, 2022

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one sampled resident (Resident #1) who was a new admission from the hospital, the facility failed to transcribe a medication order from the hospital discharge summary into the Electronic Medication Administration Record (EMAR) resulting in a change in condition and re-hospitalization . The findings include: Resident #1 was a new admission with diagnoses that included status post fracture of the left femur, osteoporosis and hypertension. The Hospital Discharge Summary dated 10/27/22 identified under hip fracture instructions, regarding blood clot prevention, an order directed to administer Enoxaparin 40 milligrams (mg)/0.4 milliliters (ml) syringe, Inject 0.4. […]

• No harm, potential for more than minimal, patternF684Jun 18, 2026

  Based on review of the clinical record, facility documentation, facility policy and interview for 4 of 5 residents (Resident #42, 29, 77, 18 and 21) reviewed for skin conditions, the facility failed to complete weekly skin assessments and wound assessments. The findings include: 1. Resident #42 was admitted to the facility in July 2025 with diagnoses that included myelodysplastic syndrome (abnormal blood cells that do not function properly), neoplasm of the colon and Alzheimer's disease. The quarterly MDS dated [DATE] identified Resident #42 was independent with bed mobility, transfers, toileting, ambulated with the assistance of a walker, was at risk for the development of pressure ulcers and did not have any unhealed pressure ulcers. […]

• No harm, potential for more than minimal, patternF692Jun 18, 2026

  Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 5 residents (Resident #21, 40 and 96) reviewed for nutrition the facility failed to monitor weights and document in the clinical record in accordance with physician orders. The findings include: 1. Resident #21 was admitted to the facility in August 2023 with diagnoses that included Alzheimer's disease and congestive heart failure. The quarterly MDS dated [DATE] identified Resident #21 was moderately cognitively impaired and required set up assist with eating. Physician orders dated 1/5/26 directed to obtain vital signs and weights every 15 days. Nutritional assessment dated [DATE] identified Resident #21weight was stable at 126 lbs. […]