Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Whispering Oaks during CMS and state inspections, most recent first.
PASARR Level II reviews were not completed for multiple residents with qualifying MI diagnoses or related conditions. Record review showed Level I PASARRs for several residents with diagnoses such as schizophrenia, bipolar disorder, major depressive disorder, seizures, TBI, epilepsy, and dementia either were incomplete or did not properly mark qualifying conditions, and no Level II determinations were found in the records. The SSD stated schizophrenia was a serious mental health condition and that a Level II should have been conducted, but documentation was not available.
Incomplete PASARR screening and missing Level II reviews: The facility failed to accurately complete PASARR Level I screens for multiple residents with qualifying mental health and related diagnoses, including schizophrenia, bipolar disorder, dementia with psychotic disturbance, and unspecified psychosis. In several cases, diagnoses were not marked on the Level I form and no Level II review was submitted, despite records showing conditions such as SMI, seizures, TBI, and dementia. The SSD stated schizophrenia, bipolar disorder, and schizoaffective disorder were conditions that should trigger Level II review.
Unsafe food storage, cross-contamination, and dishwashing sanitization failures were observed in the kitchen. Surveyors found grime on vents and prep areas, personal items and employee jackets in food prep and clean dish areas, dirty rags and sponges, and debris on carts. In the cooler, wilted lettuce with bio growth, sticky food boxes, expired ham and salads, undated desserts, and raw chicken stored above other foods were observed. Staff also did not know the required sanitizer level for the dish machine, and repeated testing showed inadequate sanitizer until the machine was adjusted.
Infection control failures involved contact precautions, PPE, hand hygiene, equipment placement, and staff nail standards. A resident on contact precautions for ESBL was observed without PPE available at the door, and staff entered the room without hand hygiene or gown and gloves while providing care and handling items. In another room, staff touched resident belongings and left without hand hygiene, and a resident’s trach humidifier reservoir was found in a garbage can. The DON, an LPN, and an RN were also observed with long or artificial nails with rhinestones, contrary to the facility’s dress code.
Failure to Assess Self-Administration of Enteral Feedings: A resident with dysphagia, gastrostomy status, and adult failure to thrive was observed self-administering Jevity 1.5 bolus feedings and water flushes through a PEG tube, despite stating he had not received his scheduled dose and normally gives himself his enteral feedings. The resident’s self-administration assessment indicated he could not state when medications were due, could not remember to take them, could not measure the correct amount, and was not deemed able to safely self-administer. The RD, ARNP, and DON were unaware the resident was taking his own bolus feedings, and the care plan and orders reflected nurse-administered enteral nutrition and flushes.
Unsafe Fan Placement Near Resident in Bed: A resident with generalized muscle weakness and a BIMS score of 15 had a box fan placed between the headboard and pillow, with the pillow resting on the fan next to the resident’s head. The resident said he liked it there so he could easily turn it on or off, but the RN/UM, VPO, and ANHA all observed the setup and stated it was unsafe because the fan was too close to the resident and the rotating blades could cause injury.
A resident with obstructive/reflux uropathy, urethral disorders, and BPH had an indwelling urinary catheter identified on the MDS, but the care plan did not include a catheter-related care area. After a significant change and new NP orders for straight cath/Foley placement, the resident was observed with the catheter hanging and draining at the bedside, and staff acknowledged the IDT overlooked the catheter orders and did not update the care plan.
Failure to Provide Complete ADL Hygiene Care: Two residents who needed assistance with ADLs were observed with unmet grooming needs. One resident with severe cognitive impairment had overgrown fingernails, and another resident with intact cognition had facial hair and reported ear pain related to needing cleaning. Records showed hygiene tasks were documented as completed, but specific nail care, shaving, and ear cleaning were not documented as provided, despite staff stating these services were part of routine personal hygiene care.
Failure to Monitor Antipsychotic Behaviors and Side Effects: The facility did not ensure that two residents receiving antipsychotic medications were monitored and documented for behaviors and side effects. One resident with psychosis, dementia, schizophrenia, and other psychiatric diagnoses had repeated behaviors such as yelling, refusing care, and staying in bed, yet the ordered every-shift behavior monitoring record had no entries for months. Another resident with bipolar disorder, psychosis, and dementia was prescribed haloperidol and other psychotropics, but no behavior or side effect monitoring orders were found, despite care plan directions and psychiatry notes to monitor for adverse effects such as dyskinesia and EPS.
Verbal Abuse During ADL Care: A resident with major mobility and communication impairments reported that a CNA used vulgar language, refused to provide his phone and call light, and made threatening comments while assisting with turning and other ADL care. The resident said he felt helpless, humiliated, and scared. The DON documented that the resident described mistreatment and threats, while the CNA denied using expletives or making threats.
PASARR Level II Reviews Not Completed for Residents With Qualifying Mental Health Diagnoses
Penalty
Summary
The facility failed to complete and submit PASARR Level II reviews for residents with qualifying mental health diagnoses or related conditions. Record review showed this issue for 6 of 11 sampled residents: Resident #24, Resident #7, Resident #84, Resident #6, Resident #4, and Resident #241. In each case, the Level I PASARR either indicated no serious mental illness or did not have qualifying diagnoses properly marked, and no Level II evaluation/determination was found in the medical record or provided by the facility. Resident #24 had diagnoses including schizophrenia, anxiety disorder, bipolar disorder, major depressive disorder, and schizoaffective disorder, but the Level I PASARR dated 12/5/23 marked question 6 as No for serious mental illness and no Level II was submitted. Resident #7 had diagnoses including bipolar disorder, major depressive disorder, seizures, and a history of traumatic brain injury; the Level I PASARR dated 10/30/24 did not check seizure and TBI diagnoses, marked question 6 as No for related neurocognitive disorder, serious mental illness, or intellectual disability, and was incomplete, with no Level II submitted. Resident #84 had schizophrenia, anxiety disorder, unspecified convulsions, cognitive communicative disorder, vascular dementia, epilepsy, and major depressive disorder; the Level I PASARR checked anxiety disorder, depressive disorder, and schizophrenia but did not check epilepsy or dementia, and no Level II was submitted. The SSD stated schizophrenia was a serious mental health condition and that a Level II screening should have been conducted, but the facility could not produce documentation showing it had been completed.
Incomplete PASARR screening and missing Level II reviews
Penalty
Summary
The facility failed to ensure PASARR Level I screenings were completed accurately for residents with mental disorders or intellectual disabilities, and Level II reviews were not submitted when qualifying diagnoses were present. Surveyors identified 5 residents whose records showed incomplete or inaccurate PASARR documentation, including missing or unmarked diagnoses and no Level II submission for review. Resident #7 was admitted with diagnoses including bipolar disorder, major depressive disorder, seizures, and a history of traumatic brain injury, but the Level I PASARR did not check the seizure and TBI diagnoses and marked that the individual did not have a related neurocognitive disorder, serious mental illness, or intellectual disability. Resident #84 was admitted with schizophrenia, generalized anxiety disorder, cognitive communicative disorder, vascular dementia, epilepsy, and major depressive disorder; although the Level I screen checked anxiety, depressive disorder, and schizophrenia, epilepsy and dementia were not checked, and no Level II was submitted. The social services director stated schizophrenia was a serious mental health condition and a Level II should have been conducted, but documentation confirming this was not available. Resident #11 had diagnoses including unspecified dementia with psychotic disturbance, mood disturbance, anxiety, seizures, and depression, but the Level I screen showed no qualifying diagnoses marked under MI or suspected MI. Resident #208 had diagnoses including psychoactive substance dependence, unspecified psychosis, anxiety disorder, and adjustment disorder with depressed mood, but the Level I screen only marked anxiety. Resident #241 had diagnoses including traumatic subdural hemorrhage, bipolar disorder, alcohol abuse, schizophrenia, seizures, and insomnia, but the Level I screen did not mark qualifying MI diagnoses and no Level II was submitted. The SSD stated the team reviewed PASARRs during morning meetings, adjusted Level I screens when needed, and would submit for Level II review when diagnoses such as schizophrenia, bipolar disorder, or schizoaffective disorder were identified.
Unsafe Food Storage, Cross-Contamination, and Dishwashing Sanitization Failures
Penalty
Summary
The kitchen was not maintained in a safe and sanitary manner during observations of the main kitchen. Surveyors observed brown-grease stains and built-up grime above the stove, a personal water bottle on the cook’s prep station, a ceiling vent with dirt, debris, and brown matter above the cooking area, and a juice machine filter covered with dust, grime, and debris. The floor area between the juice machine and service table had black substances, food particles, dust, and debris. Two employee jackets were hanging on the clean dish rack and touching clean dishes, and desserts intended for lunch were left on a cart in the hallway outside the cooler instead of being stored in the cooler. The walk-in cooler contained multiple food storage concerns. A box with bags of lettuce was observed wilted, discolored, and with white bio growth. Food boxes had brown sticky residue on them. A log of ham dated 2/3/26 was stored on a middle shelf without a tray, and the RD stated it should be thrown out because it was no longer good and cooked foods should not be served after three days. Numerous plated salads dated 2/2/26 through 2/5/26 were also observed, and the RD stated they should have been discarded on 2/5/26. An undated tray with served portions of ice cream and brown cake was observed, and the RD could not confirm when the desserts were prepared. Raw chicken dated 2/6 was stored on the top shelf directly above food boxes and not on a tray. On the second tour, the same ceiling vents remained dirty, and additional cross-contamination concerns were observed, including an employee jacket hanging near the stove with boiled eggs set on top of it and a muffin pan touching the jacket. Unsanitary dishwashing rags and used cleaning sponges were observed discolored with brown surfaces, and a food service utility cart had napkins, food pieces, and debris on it. During dishwashing, Staff X stated he tested water temperature but did not identify the need to test sanitization or know the required level. The RD then tested the low-temp dish machine and repeatedly obtained no color or white test-strip results, indicating insufficient sanitizer; the Regional RD later assisted and obtained levels between 50 and 100 PPM after changing and priming the sanitizer bucket. The Kitchen Manager stated dishes run previously would be re-washed, and the RD later stated staff had been in-serviced and should test the water for acceptable PPM every time it is changed.
Infection Control Failures With Contact Precautions, Equipment Placement, and Staff Nail Standards
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program related to contact precautions, PPE use, hand hygiene, equipment placement, and staff fingernail standards. Surveyors observed that Resident #246 was on contact precautions for ESBL after a new admission, but there was no PPE available on the door or nearby when the resident was first observed. Staff V, RN confirmed the resident had arrived the previous day and stated staff should wear full PPE for direct care contact. During observations in Resident #246’s room, Staff W, CNA entered the room to assist with a meal without washing hands and without putting on gloves or a gown, despite PPE being available on an over-the-door shelf. Staff W was also observed moving a chair with a paper towel and placing it in the middle of the shared room after assisting the resident. Staff W later confirmed she did not wear a gown or gloves when feeding the resident and stated she should have worn them. Staff M, LPN/UM stated staff should wash hands before entering and should wear gown and gloves when working directly with the resident, including assisting with meals. In another room on contact precautions, Staff A, CNA entered without hand hygiene or PPE and touched multiple resident items, including a bedside table, eyeglasses, telephone, blanket, and a Styrofoam cup with water. Staff A later entered the room again without PPE and was observed leaving with a resident meal tray. For Resident #16, who had diagnoses including chronic respiratory failure, COPD, laryngeal disease, bronchitis, and malignant neoplasm of the larynx, surveyors observed the connected humidifier reservoir for the resident’s tracheostomy placed in a garbage can. Staff C, LPN stated the humidifier bag should not be on the ground and confirmed it should not be in a garbage can. The report also documented that the DON, Staff U, LPN, and Staff V, RN had long or artificial nails with rhinestones or nail enhancements, and the facility handbook stated fingernails should be short and no artificial nails, appliqués, or studs may be worn.
Failure to Assess Self-Administration of Enteral Feedings
Penalty
Summary
The facility did not ensure that an assessment for self-administration of enteral feedings was completed for one resident. Resident #16 had diagnoses including dysphagia, oropharyngeal phase, gastrostomy status, other disease of the larynx, and adult failure to thrive, and had physician orders for Jevity 1.5 cal bolus enteral feedings six times per day through a PEG tube, along with ordered water flushes. During observation, the resident stated he had not received his scheduled 4:00 p.m. Jevity dose and said he would take care of it himself. He was observed walking to the sink, filling a cup with tap water, returning to his bed, opening a commercial eight-ounce container of Jevity 1.5, pouring it into another cup, and administering his Jevity with water flushes. Three unopened boxes of Jevity 1.5 were observed at the bedside, and the resident stated he normally gives himself his enteral feedings and water. Record review showed a Self-Administration of Medication Resident assessment dated and locked on 9/26/2025, but the assessment indicated the resident could not state what time or how often medication was to be taken, could not remember to take medication, could not correctly measure the appropriate amount from the container, and was not deemed able to safely self-administer medications or that it was clinically appropriate. The RD stated he was not aware the resident was self-administering bolus feedings and believed nurses would administer ordered bolus feedings. The ARNP stated that an order for enteral feeding boluses would be for nurses to implement, and the DON stated she was unaware the resident was self-administering his enteral feedings/boluses and that residents should be assessed for appropriate self-administration, with IDT input and a physician order.
Unsafe Fan Placement Near Resident in Bed
Penalty
Summary
The facility failed to ensure a safe environment for one resident when a box fan was placed between the resident’s headboard and pillow, with the pillow resting on the fan next to the resident’s head. During an observation and interview, the resident was lying in bed and stated he liked the fan there because he gets hot and cold quickly and it was easy for him to reach to turn on or off. The resident had diagnoses including generalized muscle weakness and need for assistance with personal care, and a BIMS score of 15 indicating cognitive intactness. The same fan placement was observed again on two later occasions in the resident’s bed. The RN/UM observed the fan and stated the placement was not good and was a risk, explaining that the rotating blades could cause injury if touched accidentally and that it was not safe. The VPO and ANHA also observed the fan and stated they did not like the placement, that it was a safety concern because of how close it was to the resident’s body, and that the fan should not be placed on the resident’s bed.
Failure to Update Care Plan for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to update and implement an individualized person-centered care plan for Resident #12 related to an indwelling urinary catheter. Resident #12 was admitted with diagnoses including obstructive and reflux uropathy, specified disorders of urethra, and benign prostatic hyperplasia. The resident’s MDS showed a BIMS score of 15, indicating cognitive intactness, and identified an indwelling catheter in the bladder and bowel section. On 2/9/2026 at 9:00 A.M., the resident was observed sleeping in bed with street clothes on and a urinary catheter hanging and draining at the side of the bed. Progress notes showed that on 1/9/2026, a nurse received new orders from the NP to straight catheterize the resident and, if greater than 500 mL, leave a Foley catheter in place. The resident was straight catheterized and over 700 mL of yellow urine was obtained, the NP was notified, and the Foley was left in as ordered. Review of the care plan showed no care plan area related to an indwelling urinary catheter. Staff stated care plans are updated with quarterly MDS assessments and significant changes, and that Resident #12 had a significant change on 1/9/2026 that should have triggered a care plan update. The CRD stated the IDT reviews order listing reports daily and that the indwelling urinary catheter orders were overlooked, so the care plan was not updated.
Failure to Provide Complete ADL Hygiene Care
Penalty
Summary
The facility failed to provide necessary ADL assistance to maintain good grooming and personal hygiene for two residents who were unable to complete those tasks independently. Resident #84 was observed with long, overgrown fingernails extending about half an inch past the fingertips. The resident had diagnoses including schizophrenia, secondary parkinsonism, muscle wasting and atrophy, generalized weakness, cognitive communication deficit, and vascular dementia, and had a BIMS score of 00 indicating severe cognitive impairment. The resident required partial/moderate assistance for personal hygiene and would need a helper to have nails trimmed. Record review for Resident #84 showed personal hygiene care was documented as completed over the review period, but nail care was not documented until one entry on 02/10/2026 at 1:46 PM, with no prior nail care found. There were no documented refusals of care. The care plan identified ADL self-care performance deficits and included interventions for one staff assist with personal hygiene, cues, and encouragement to accept assistance, but the observation still found the resident with overgrown nails. Staff interviews indicated that CNAs were responsible for nail care and that residents should receive hygiene care, including shaving, face washing, oral care, and nail care as needed. Resident #151 was observed with facial hair on the upper lip and chin/neck area, approximately a quarter of an inch long, and stated having ear pain due to needing to be cleaned. The resident had diagnoses including generalized weakness, peripheral vascular disease, atherosclerotic heart disease, dizziness, syncope and collapse, type 2 diabetes mellitus, legal blindness, and age-related physical debility. The resident had a BIMS score of 14 and required substantial/maximal assistance for personal hygiene, including help with clean ears and shaving. Personal hygiene records showed care was documented, but there was no specific documentation of ear cleaning or shaving, and staff stated the electronic record did not list those as specific tasks. Interviews with CNA, LPN, UM, and DON confirmed expectations that residents receive daily hygiene care, including shaving, face washing, ear cleaning during showers, and nail care, yet the observation showed the resident remained unshaven and reported ear discomfort.
Failure to Monitor Antipsychotic Behaviors and Side Effects
Penalty
Summary
The facility failed to ensure that residents receiving antipsychotic medications were monitored for behaviors and side effects. For Resident #15, staff observed behaviors including yelling, refusing care, refusing to get out of bed, voiding on herself, and covering her head with her shirt. The resident had diagnoses including unspecified psychosis, dementia with behavioral disturbance, schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, and generalized anxiety disorder. She was receiving aripiprazole 20 mg daily, and the physician order required behavior monitoring and documentation of side effects every shift, but the behavior monitoring record contained no entries from 11/01/2025 through 02/11/2026. Resident #15’s record also showed care plan focuses for behavioral symptoms and psychotropic medication use, with interventions to observe and document side effects and effectiveness, document behavior episodes, and report changes such as insomnia, nervousness, loss of interest, decreased concentration, repetitive movements, and other antipsychotic side effects. Staff interviews showed that CNAs and an RN were aware the resident had behaviors such as yelling, refusing care, and refusing to comply with dressing and changing, but the RN stated these refusals were not documented because they were not extreme or aggressive. The RN also stated there were no expectations for CNAs to perform the ordered monitoring, and that behaviors and side effects should have been documented regardless of whether the resident presented with behaviors. For Resident #17, the record showed diagnoses including mixed receptive-expressive language disorder, bipolar disorder with psychotic features, generalized anxiety disorder, and dementia. The resident was prescribed haloperidol 1 mg daily, haloperidol 2 mg in the evening, trazodone 50 mg at bedtime, and trihexyphenidyl 4 mg three times daily. No orders were found for behavior monitoring or side effect monitoring. The care plan included psychotropic medication use with goals for minimal side effects and interventions to observe and document side effects and effectiveness, but the record did not show the required monitoring. Psychiatry notes documented ongoing psychosis, mania, depression, and dementia, and specifically stated to monitor for adverse effects of haloperidol, particularly dyskinesia and extrapyramidal symptoms. Staff interviews indicated that monitoring was expected, but the DON stated monitoring was done by the team and psych provider, while other staff described inconsistent understanding of who was responsible for documenting behaviors and medication side effects.
Verbal Abuse During ADL Care
Penalty
Summary
The facility failed to prevent verbal abuse toward a resident who was dependent for multiple activities of daily living, including eating, toileting hygiene, bathing, and rolling in bed. The resident had diagnoses including spinal compression, functional quadriplegia, dysarthria/anarthria, cervical spinal stenosis, muscle weakness, cognitive communication deficit, diabetes, joint contracture, COPD, spondylosis with myelopathy, pulmonary hypertension, generalized anxiety disorder, hypertension, and recurrent major depressive disorder. The resident was cognitively intact on the quarterly MDS with a BIMS score of 15, but had significant communication limitations and relied on staff assistance for care. During an interview, the resident reported that a CNA, identified in the record as Staff C, was verbally abusive during care. The resident stated that when he asked for his phone and call light, the CNA told him to get it himself and closed the door. He also reported that when he was yelling for the nurse, the CNA said, "see if you get any food, get it yourself," despite knowing he could not lift his right arm. The resident stated that when she was turning him, she yelled, "you're not gonna break my fckn back," and rolled him without assistance. He further stated that pads under his buttocks were not replaced, that he felt helpless and humiliated, and that he was scared because he did not know what the CNA was capable of. The DON, NHA, and RM were notified of the allegation and interviewed the resident. The DON documented that the resident described being mistreated and said the CNA used vulgar language and made threats related to providing his call bell and phone. The DON stated the resident reported feeling humiliated and that the incident was reported to law enforcement. Staff C denied using expletives or making threats when questioned by the RM, but also stated she could not recall whether she turned the resident. Other staff interviewed stated they were not aware of the incident or had not observed changes in the resident, while the resident stated he felt safe overall and that other staff were great. The facility policy defined verbal abuse as oral, written, or gestured language that includes despairingly or derogatory terms, and mental emotional abuse as including humiliation, harassment, and threats of punishment or deprivation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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| Elon Manor Nursing And Rehabilitation Center | 1 mi | ★★★★★ | 10 | 0 |
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| Rehabilitation And Healthcare Center Of Tampa | 2.8 mi | ★★★★★ | 1 | 0 |
| Excel Care Center | 5.3 mi | ★★★★★ | 1 | 0 |
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