Whitney Oaks Care Center

In the surveyor’s words

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

• Actual harm, isolatedF600Jul 12, 2024

  Based on interviews and record review, the facility failed to protect two of three sampled residents' (Resident 1 and Resident 2) right to be free from physical abuse when they were attacked by Resident 3. This failure resulted in Resident 1 to sustain a laceration (cut) to the left side of the head, a blunt head trauma injury, and chest wall contusion (bruising). Resident 2 sustained a laceration to the back of his head and multiple skin tears. Findings: During a review of Resident 1's face sheet, Resident 1 was admitted to the facility on [DATE] with diagnoses that included cellulitis (skin infection) of left lower limb and congestive heart failure (CHF-heart can't pump enough blood). […]

• No harm, potential for more than minimal, widespreadF812May 23, 2025

  Based on observation, interview and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food served safety when: 1. Several various sizes metal pans were stacked wet at the clean and ready-to-use areas; 2. Found meats were not thawed in a proper procedure in the walk-in refrigerator; 3. The blade of the can opener was not well maintained; 4. Dietary Aide (DA) 1 was not able to verbalize the proper process of manual dishwashing by the 3-comparment sink; and, 5. […]

• No harm, potential for more than minimal, widespreadF814Jun 21, 2024

  Based on observation, interview, and record review, the facility failed to ensure the facility garbage dumpsters were not accessible to insects and vermin when the dumpster lids were not kept closed. This failure had the potential to harbor pests and other types of vermin capable of spreading disease for a census of 123. Findings: On 6/21/24 at 7:45 a.m., an observation of the facility's two (2) outside blue colored garbage dumpsters and 1 green colored recycling bin dumpster were found to be over filled. The two (2) blue colored garbage dumpster lids were not closed and sealed because it was overfilled with garbage. The recycling dumpster lid was also observed not closed because it was overfilled with cardboard boxes. […]

• No harm, potential for more than minimal, patternF755Sep 2, 2026

  Based on observation, interview, and record review, the facility failed to have proper training, written policies, procedures, or guidelines on handling Hazardous Drugs (HD) and pharmaceutical products when:Licensed Nurse (LN) 2 did not demonstrate how to don appropriate Personal Protective Equipment (PPE) when needed for handling HD.LN 3 also did not wear gloves when administering an HD.Loose pills were found at Resident 68's bedside, indicating improper handling and storage of medications. These failures increased staff's risk of exposure to HD and surface contamination and increased the risk of other residents being exposed to pharmaceutical products. Findings: 1. […]

• No harm, potential for more than minimal, patternF759Sep 2, 2026

  Based on observation, interview, and record review, the facility failed to ensure the medication rate did not exceed 5% for 1 of 2 sampled residents (Resident 100), when:1. A licensed nurse administered an incorrect dose of lovenox (medication used as a blood thinner) not according to the Physician's Order.2. A licensed nurse administered a dose of hydrocodone-acetaminophen (combination of two medications used for pain) 5/325 mg (milligram, unit of measure) for a pain level of zero against the Physician's Order.As a result, 2 errors were identified out of 28 opportunities for error during the observation of medication administration; the facility medication error was 7.14%.Findings: 1. […]