Above 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 Hills Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Failure to Provide Written Bed Hold Notices and Notify Ombudsman: The facility failed to provide written bed hold authorization letters to two cognitively intact residents when they were transferred to the hospital. One resident had COPD, dysphagia, HTN, anxiety, and depression and was sent out for SOB and diaphoresis; the other had osteomyelitis, unhealed pressure ulcers, depression, and paraplegia and was transferred for lab testing related to his wounds. In both cases, the bed hold notices were handled by phone only, and the Ombudsman was not notified of one resident’s hospitalization.
Failure to provide fingernail care for a dependent resident. A resident with impaired cognition, DM2, vascular dementia, and dependence for personal hygiene was observed with long fingernails, chipped nail polish, and dark debris under the nails. Records showed nail trimming was documented once, with no further evidence of regular nail care, and a CNA confirmed staff should be assisting with cleaning and trimming on a regular basis.
Failure to complete audiology follow-up for a resident with hearing concerns. An audiology exam found impacted cerumen in both ears after the resident was referred for decreased hearing, and Debrox was recommended with follow-up in 1-3 months. The resident’s care plan included an audiology referral for a hearing deficit, but the resident was later observed pointing to their ears while trying to communicate, and the SW confirmed no follow-up audiology appointment was scheduled.
Inappropriate trach care was observed for a resident with a trach, dysphagia, and other diagnoses. An RN removed the speaking valve and placed it on a bedside table, allowed suction tubing to fall into the clean trach-cleaning solution, let the trach cannula come out of the stoma and reinserted it, and then reused a speaking valve after it had fallen on the floor. The RN confirmed these actions during interview, and the facility policy required aseptic technique for trach care.
A resident with schizoaffective disorder and other behavioral health diagnoses missed a scheduled Invega Sustenna dose when the monthly order was not resumed after a one-time order was used. Staff noted the medication was on order, then delivered, but the original psychiatric prescriber was not contacted and the resident later went without the routine monthly injection until a one-time lower dose was given after the resident asked about it. The DON confirmed the missed dose and that the one-time order led to the omission.
Failure to provide specialized rehab services occurred when a resident with dysphagia, TBI, schizophrenia, MDD, type II DM, and cognitive impairment had significant wt loss and recent teeth extractions, prompting the RD to request an SLP eval to assess swallowing and diet appropriateness. No documentation showed the eval was completed, and the TM confirmed the speech therapist had not seen the resident since July 2025. The DON was unaware the SLP eval had not been completed.
Incomplete medical records were found for two residents. One resident with dysphagia and trach status was observed receiving clear liquids while the chart still showed an NPO order, and an LPN later entered the clear liquid order into the EMR after confirming it had been communicated to dietary. Another resident with high fall risk had fall investigations completed on paper and kept in the DON's office instead of the chart, and the DON verified the reports did not document whether non-skid footwear was worn or whether the bed was in low position.
Infection control procedures were not followed during a PEG tube dressing change for a resident with Parkinson's disease, dementia, dysphagia, and malnutrition. An LPN removed the soiled dressing, did not remove gloves or perform hand hygiene before cleaning the site, and placed the wound cleanser bottle on the resident's bed and over-the-bed table before returning it to the treatment cart. The LPN confirmed the actions, and the facility policy required handwashing and proper disposal of the soiled dressing.
A resident with an indwelling catheter and cognitive impairment was started on Macrobid for a UTI before culture and sensitivity results were available. The MAR showed the resident received Macrobid until the results showed the infection was resistant, and the antibiotic was then changed to Levofloxacin. The DON verified the antibiotic was started before the C&S came back, which was not consistent with the facility’s antibiotic stewardship guidance.
The facility's arbitration agreement failed to inform residents or their representatives of their rights to communicate with officials and to cancel the agreement within thirty days without written notice. This affected 37 residents, as confirmed by a review of records and an interview with the Administrator.
The facility's arbitration agreement failed to ensure a neutral and fair process by mandating arbitration through the American Arbitrators Association (AAA) or another association chosen solely by the facility, without allowing residents or their representatives to participate in selecting a neutral arbitrator or agreeing on a convenient venue. This affected 37 residents who signed the agreement, with one resident not signing upon admission. The facility also lacked a policy for arbitration agreements.
The facility did not provide required behavioral health training to staff during orientation or annually, despite accepting residents with psychiatric disorders. Personnel files for various staff, including a dietary aide, housekeeper, LPN, and CNAs, showed no evidence of such training. An interview with the Administrator confirmed the lack of documentation for behavior training, although an in-service was scheduled for later.
The facility failed to provide pureed foods at a smooth consistency for residents on a mechanically altered diet. During preparation, the Dietary Manager switched to pureed peas, but the resulting puree contained pieces of pea shells. This inconsistency was confirmed by the Regional Director of Culinary, affecting four residents prescribed pureed diets.
A resident with serious medical conditions felt unsafe in the bathroom due to the absence of a visible call light. The care plan required a call light within reach, but during an observation, it was found that the call light was not clearly marked. The Maintenance Director confirmed the call light was a light switch without a red cord or label.
The facility failed to notify a resident's representative when the resident left against medical advice and did not inform a physician of a new diabetes diagnosis for another resident. One resident left the facility without the emergency contact being notified, and another resident's diabetes was not managed properly due to a lack of communication and documentation. These deficiencies highlight issues in the facility's processes for handling changes in residents' conditions.
A facility failed to document and notify a physician before a resident's hospital transfer. The resident, with conditions including diabetes and chronic kidney disease, requested emergency room care due to a bloated stomach. The Vice President of Operations confirmed missing transfer papers and lack of physician notification, contrary to the facility's policy requiring detailed observations before such actions.
A resident with type II diabetes mellitus did not receive appropriate diabetic care at the facility. Despite a care plan outlining necessary interventions, there was no blood glucose monitoring or antidiabetic medication administered from June to late October. The resident was hospitalized with high blood glucose levels, and it was revealed that the facility had not implemented the required care plan interventions. Staff interviews confirmed the oversight, and the Medical Director was unaware of the diabetes diagnosis.
The facility failed to document irregularities or recommendations in monthly drug regimen reviews for three residents from June to October 2024. Despite receiving various medications, the reviews for these residents lacked documentation of any findings, contrary to the facility's policy requiring comprehensive reports to physicians and the DON.
Failure to Provide Written Bed Hold Notices and Notify Ombudsman
Penalty
Summary
The facility failed to ensure that Resident #44 and Resident #13 received written bed hold authorization letters when they were transferred to the hospital. Resident #44 was admitted with diagnoses including COPD, sequelae of cerebral infarction, dysphagia, hypertension, anxiety disorder, and depression, and was cognitively intact with a BIMS score of 14. After he became short of breath, diaphoretic, and panicking, he was transferred to the hospital, and the Business Office Manager documented that his sister was notified by telephone; however, Resident #44 did not sign or date the bed hold authorization, and the written notice was not issued to him at the time of transfer. Resident #13 was admitted with diagnoses including osteomyelitis, depression, unhealed pressure ulcers, and paraplegia, and was cognitively intact with a BIMS score of 15. He was transferred to the hospital for further laboratory testing related to unhealed pressure ulcers with osteomyelitis, and the Business Office Manager documented that he was contacted by telephone regarding the bed hold letter; however, he did not sign or date the authorization and did not receive a written bed hold notice upon transfer. The report also states that the Ombudsman was not notified of Resident #44's hospitalization, and the Business Office Manager confirmed she did not notify the Ombudsman of that discharge to the hospital.
Failure to Provide Fingernail Care
Penalty
Summary
The facility failed to assist a dependent resident with fingernail care. Resident #3 was admitted with diagnoses including respiratory failure, type 2 diabetes, depression, history of stroke, and vascular dementia. The resident’s care plan stated that staff were to provide encouragement and assistance with self-care tasks, and the MDS showed impaired cognition, wheelchair use, and dependence on staff for personal hygiene. Review of shower documentation showed fingernails were trimmed on 01/22/26, with no further documentation of nail trimming afterward. During observation on 02/17/26, Resident #3 was resting in bed with chipped light blue fingernail polish, long fingernails, and dark-colored substances under the nails. A CNA later confirmed the resident had long dirty fingernails and that staff should be assisting with cleaning and trimming on a regular basis. The facility policy stated that nail care includes daily cleaning and regular trimming.
Failure to Complete Audiology Follow-Up for Resident with Hearing Concerns
Penalty
Summary
The facility failed to ensure Resident #18 had audiology follow-up completed after an audiology exam identified impacted cerumen in both ears. Resident #18 was admitted on 05/16/25 and had diagnoses including type II diabetes without complications, essential hypertension, peripheral vascular disease, acquired absence of the right leg above knee, plasma cell leukemia not in remission, solitary plasmacytoma not in remission, need for assistance with personal care, adjustment disorder with mixed anxiety and depressed mood, and bilateral hypertensive retinopathy. The 360 care audiology appointment dated 09/29/25 documented that the resident was referred by the facility due to decreased hearing, and the exam found impacted cerumen in both ears with Debrox recommended for cerumen management and follow-up in 1-3 months. The quarterly MDS dated 01/25/26 showed a BIMS score of 15 and noted minimal difficulty with hearing and no hearing aids. The care plan identified a communication deficit related to hearing deficit and included an intervention to refer to audiology for hearing consult as ordered. During observation on 02/17/6, Resident #18 was seen pointing to their ears while attempting to communicate. On 02/18/26, the Social Worker confirmed the resident was not scheduled for a follow-up audiology appointment.
Inappropriate Trach Care During Resident Observation
Penalty
Summary
Appropriate trach care was not provided for Resident #34, who was admitted with diagnoses including malignant neoplasm of the tongue, protein-calorie malnutrition, dysphagia, and anxiety. The MDS indicated the resident had intact cognition and required daily tracheostomy care. Physician orders directed trach care per protocol and use of a speaking/[NAME] Muir valve to the trach as tolerated, with the cuff deflated before placement of the speaking valve. During observation of trach care, RN #315 removed the speaking valve from the trach and placed it on the bedside table, suctioned the resident, and then placed the suction tubing on the bedside table, where the end fell into the clean hydrogen peroxide/normal saline solution being used to clean the trach area. The RN continued trach care, removed the trach collar to clean under it with the same solution, let go of the trach cannula, and the resident coughed the outer trach tube cuff out onto the chest. The RN quickly picked up the trach cannula and reinserted it into the trach stoma, then picked up the speaking valve after it had fallen on the floor and secured it back on the trach cuff. In interview, RN #315 confirmed the suction tubing had fallen into the clean solution, that the outer trach cuff fell out and was put back in without obtaining a new trach tube cuff, and that the speaking valve that fell on the floor should not have been reused.
Missed Scheduled Antipsychotic Dose
Penalty
Summary
The facility failed to ensure Resident #20 received the scheduled antipsychotic medication Invega Sustenna as ordered, resulting in a significant medication error. Resident #20 was admitted with diagnoses including schizoaffective disorder bipolar type, borderline intellectual functioning, and Asperger's syndrome, and the care plan identified the need for psychotropic/mood stabilizer medications for behavior management. A psychiatric note documented that the resident received Invega Sustenna 156 mg/mL IM every 28 days for schizoaffective disorder, and the resident was also noted to have delusions and to receive antipsychotic medications on the MDS. The record showed that Invega was on order in November, then delivered the next day, and the physician was notified and agreed to a one-time administration of Invega 156 mg/mL, with no record that the psychiatrist who issued the original medication order was contacted. There was no record that the resident received the monthly Invega dose in December 2025. In January 2026, the resident asked about the routine injection, and staff contacted the psychiatric provider for clarification, but the facility instead obtained a one-time order from the on-call medical provider for Invega 117 mg IM and administered it the next day. A later psychiatric clarification order stated the resident was to receive Invega 156 mg/mL on 01/27/26 and then every 28 days. The DON verified that the resident missed the scheduled December dose and stated the nurse obtained a new one-time order when the medication arrived, which resulted in the monthly Invega order not being resumed and the dose being omitted.
Failure to Complete SLP Evaluation for Resident With Dysphagia
Penalty
Summary
Provide or get specialized rehabilitative services as required for a resident was not met when the facility failed to provide a required SLP evaluation for Resident #17, who had diagnoses including dysphagia, traumatic brain injury, schizophrenia, major depressive disorder, type II diabetes mellitus, and other chronic medical conditions. The resident’s comprehensive MDS reflected cognitive impairment. The RD’s weight review documented significant weight loss and noted the resident had recently had teeth extracted, then requested an SLP evaluation to assess swallowing function and determine whether the current diet order remained appropriate. Review of physician orders and therapy documentation showed no evidence that the SLP evaluation was completed after the RD’s recommendation. During interview, the TM stated therapy typically received referrals verbally from nursing staff and confirmed the speech therapist had not seen the resident since July 2025, adding that documentation would be present if an evaluation had been completed. The DON and Regional DON stated staff enter therapy orders and verbally notify therapy when referrals are made, and the DON acknowledged being unaware that the SLP evaluation had not been completed for Resident #17.
Incomplete Medical Records for Diet Orders and Fall Investigations
Penalty
Summary
The facility failed to ensure complete and accurate medical records for 2 residents. One resident was admitted with diagnoses including malignant neoplasm of the tongue and mouth, dysphagia, and tracheostomy status, and had an active NPO order in the record. Although the resident was observed with clear liquids at the bedside on two occasions, the clear liquid diet order was not in the medical record at the time of observation. An LPN confirmed the resident had been receiving clear liquids and stated there was no order in the record, then entered the order into the EMR. The order/change of diet communication sheet showed the resident was upgraded to clear liquids and was signed by the LPN, and the Rehab Director and Regional Nurse confirmed the clear liquid order had been communicated to the kitchen before clarification was received. Another resident with diagnoses including fracture of sacrum, major depressive disorder, and adjustment disorder with anxiety had repeated fall risk assessments showing high fall risk and a care plan addressing fall precautions. The resident experienced multiple falls, including being found on the knees beside the bed and later on the floor next to the bed. Fall Scene Investigation Reports were completed for the falls, but the DON verified that the investigations for two of the falls were completed on paper forms and kept in the DON's office rather than in the medical record, and that related risk management forms were also not part of the medical record. The DON also verified that those fall investigations did not document whether the resident was wearing non-skid footwear or whether the bed was in a low position.
Infection Control Failure During PEG Tube Dressing Change
Penalty
Summary
The facility failed to ensure infection control procedures were followed during a dressing change for one resident with a PEG tube. The resident had diagnoses including Parkinson's disease, dementia associated with Parkinson's disease, muscle weakness, contractures, dysphagia, and recurrent urinary tract infections. The medical record showed an order for the PEG tube site to be cleansed with wound wash, patted dry, and covered with split gauze every shift, and the care plan noted the resident required tube feeding due to dysphagia, swallowing problems, and malnutrition. During observation of the dressing change, the LPN washed her hands, applied gloves, and removed the split gauze from the PEG tube site, which had a small amount of reddish/brown drainage. The LPN did not remove her gloves or perform hand hygiene before using the wound cleanser on the site. She placed the wound cleanser bottle on the resident's bed, then on the over-the-bed table, and later returned it to the treatment cart without cleaning the bottle. The LPN confirmed she did not remove her gloves after removing the soiled dressing and verified she placed the wound cleanser in the resident's bed and returned it to the cart before cleaning the bottle. The facility policy stated hands should be washed and dried thoroughly, the soiled dressing removed, and the dressing discarded into a plastic or biohazard bag, followed by hand washing and drying.
Antibiotic started before culture results
Penalty
Summary
The facility failed to follow antibiotic stewardship guidelines when Resident #37 was started on Macrobid before culture and sensitivity results were obtained. The resident was admitted with diagnoses including fracture of sacrum, major depressive disorder, adjustment disorder with anxiety, obstructive and reflux uropathy, and benign prostatic hyperplasia without urinary tract symptoms. The December infection control log showed a urinary tract infection with an onset date of 12/31/25, and a progress note on that date documented that the resident’s urinalysis was reviewed and Macrobid 100 mg twice a day was ordered until culture results were received. The MAR showed the resident received Macrobid from the evening of 12/31/25 through the morning of 01/02/26. A progress note on 01/02/26 documented that the hospital was contacted for final culture and sensitivity results, the nurse practitioner was notified, and new orders were received. The Macrobid was stopped and Levofloxacin 750 mg daily for five days was started after the culture and sensitivity results showed the infection was resistant to Macrobid. The resident’s MDS showed a BIMS score of nine and an indwelling catheter, and the care plan identified the resident as at risk for urinary retention with monitoring for signs and symptoms of UTI. The DON verified in interview that the resident was started on Macrobid before the culture and sensitivity results came back and that the infection was resistant to Macrobid.
Deficient Arbitration Agreement Lacks Required Information
Penalty
Summary
The facility failed to ensure that their arbitration agreement included necessary information regarding the rights of residents or their representatives. Specifically, the agreement did not inform signatories that they could communicate with federal, state, or local officials, including surveyors and representatives of the Office of the State Long-Term Care Ombudsman. Additionally, the agreement did not clearly state that residents or their representatives had the right to cancel the arbitration agreement within thirty days without needing to provide written notice. This deficiency affected 37 out of 38 residents who signed the arbitration agreement, with one resident not signing the agreement upon admission. During the survey, a review of the facility's admission packet and resident medical records confirmed the omission of this critical information in the arbitration agreements. An interview with the Administrator further verified that the facility's arbitration agreement lacked the necessary clauses about communication rights and the cancellation policy. The facility also did not have a policy in place for arbitration agreements, contributing to the oversight.
Facility's Arbitration Process Lacks Neutrality and Fairness
Penalty
Summary
The facility failed to provide a neutral and fair arbitration process for its residents, as evidenced by the arbitration agreement included in the admission packet. The agreement mandated that any disputes be resolved through binding arbitration administered by the American Arbitrators Association (AAA), or another arbitration association chosen solely by the facility if AAA does not enforce pre-dispute arbitration agreements. This arrangement did not allow residents or their representatives to participate in the selection of a neutral arbitrator, nor did it ensure that the venue for arbitration was convenient for both parties. This deficiency affected 37 out of 38 residents who signed the arbitration agreement, with one resident not signing upon admission. The facility's arbitration agreement further stipulated that if a court found any portion of the agreement unenforceable, those provisions would be replaced with a waiver of jury trial, with the venue set at the closest proper venue to the facility's principal place of business. This clause also did not allow for resident or representative agreement on the venue. An interview with the Administrator confirmed that the facility's arbitration agreement did not ensure a neutral and fair arbitration process. Additionally, the facility lacked a policy for arbitration agreements, contributing to the deficiency.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide behavioral health education to all staff during orientation and annually thereafter, as required by their facility assessment. The assessment indicated that the facility accepted residents with psychiatric disorders, including impaired cognition, mental disorders, bipolar disorder, schizophrenia, post-traumatic stress disorder, anxiety disorder, and behaviors requiring interventions. However, a review of personnel files for various staff members, including a dietary aide, housekeeper, LPN, and several CNAs, revealed no evidence of training on mental health behaviors. The deficiency was further confirmed during an interview with the Administrator, who acknowledged the lack of documentation for behavior training provided to staff at orientation or within the previous twelve months. Although an annual in-service for behavioral training was scheduled for December 2024, there was no evidence that such training had been conducted previously. This oversight had the potential to affect all 38 residents residing in the facility, who may have required specialized care due to their psychiatric conditions.
Failure to Provide Smooth Consistency Pureed Foods
Penalty
Summary
The facility failed to serve pureed foods at a smooth consistency for residents on a mechanically altered diet. During an observation of puree preparation, the Dietary Manager changed the puree vegetable for lunch to pureed peas, stating that squash sometimes does not puree correctly due to the rind. However, the pureed peas prepared by a staff member were not of a smooth consistency and contained pieces of pea shells. This was confirmed by the Regional Director of Culinary, who recommended further pureeing. The facility identified four residents who were prescribed pureed diets, and the facility's policy stated that foods should be pureed to ensure the desired consistency.
Resident Safety Compromised Due to Unlabeled Call Light
Penalty
Summary
The facility failed to ensure that a resident was aware of the location and operation of the bathroom call light, which is a critical safety feature. The resident, who was admitted with serious conditions including necrotizing fasciitis, Fournier gangrene, and diabetes mellitus, expressed feeling unsafe in the bathroom due to the absence of a visible call light. The care plan for the resident, who was at risk for falls due to weakness from a recent hospital stay, included the intervention of having a call light within reach. However, during an observation and interview, it was noted that there was no indication of a call light being available in the bathroom. The Maintenance Director confirmed that a light switch next to the toilet tissue served as the call light, but it lacked a red cord or label to identify it as such.
Failure to Notify and Manage Resident Conditions
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative following a change in condition and did not notify a physician promptly after a new diagnosis of diabetes mellitus for another resident. Resident #39, who was cognitively intact and independent in activities of daily living, left the facility against medical advice (AMA) without the emergency contact being notified. The nurse on duty witnessed Resident #39 leaving with a visitor in a vehicle, and although the daughter was reportedly called, there was no documentation to confirm this. The facility's policy required prompt notification of changes in a resident's condition to the resident, their physician, and representative, which was not adhered to in this case. Resident #21, who had a history of traumatic brain injury and other conditions, was diagnosed with type II diabetes mellitus upon readmission to the facility. Despite this diagnosis being added to the care plan, there was no monitoring of blood glucose levels or administration of antidiabetic medications until several months later when the resident was sent to the hospital with high blood glucose levels. The Director of Nursing confirmed that the diagnosis was added in June, but the physician was not notified, and the necessary interventions were not implemented. The Medical Director was unaware of the diagnosis and stated that appropriate orders would have been made if informed. The facility's failure to follow its policy and the American Diabetes Association's standards for managing diabetes in long-term care settings resulted in inadequate care for Resident #21. The lack of communication and documentation regarding Resident #39's departure and Resident #21's diabetes management highlights deficiencies in the facility's processes for handling changes in residents' conditions.
Failure to Document and Notify Physician Before Hospital Transfer
Penalty
Summary
The facility failed to ensure proper documentation and physician notification before the hospitalization of a resident. The resident, who was cognitively intact and required setup assistance for activities of daily living, was admitted with diagnoses including diabetes mellitus, chronic kidney disease, and malignant neoplasm of the duodenum. On the day of the incident, the resident requested to go to the emergency room due to a bloated stomach, and emergency services were called. However, there was no documentation in the medical record indicating that the resident was assessed prior to the hospital transfer. An interview with the Vice President of Operations confirmed that the hospital transfer papers were missing from the medical chart, and there was no evidence that the doctor was notified about the transfer. The facility's policy on changes in a resident's condition or status, revised in December 2016, requires nurses to make detailed observations and gather relevant information before notifying the physician or healthcare provider. This policy was not followed in the case of the resident's transfer to the hospital.
Failure to Provide Diabetic Care for Resident
Penalty
Summary
The facility failed to provide diabetic care in accordance with professional standards for a resident diagnosed with type II diabetes mellitus. The resident was admitted with multiple diagnoses, including type II diabetes mellitus, but there was no evidence of blood glucose monitoring or administration of antidiabetic medications from June to late October. The care plan included interventions for diabetes management, but these were not implemented, leading to the resident experiencing significantly elevated blood glucose levels. The resident was sent to the hospital in late October due to unsteadiness and shortness of breath, where it was discovered that their blood glucose level was in the mid-500s. The hospital recommended insulin administration, which had not been provided at the facility. Upon return to the facility, the resident's blood glucose levels remained high, ranging from 153 mg/dL to 536 mg/dL over the following weeks. Interviews with the resident and staff revealed that the diagnosis of diabetes was added in June, but the necessary monitoring and medication orders were not put in place. The Director of Nursing and the MDS nurse confirmed that the diabetes diagnosis was added upon the resident's return from the hospital in June, but the physician was not notified, and the care plan interventions were not executed. The Medical Director was unaware of the diabetes diagnosis and stated that appropriate orders would have been made if informed. The facility's policy on diabetes management emphasizes the importance of monitoring and medication management, which was not adhered to in this case.
Failure in Monthly Drug Regimen Review Documentation
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a comprehensive monthly drug regimen review for three residents, as required by their policies and procedures. The pharmacy reviews for Residents #10, #29, and #33 did not indicate any irregularities or recommendations from June 2024 through October 2024. This oversight affected the residents' medication management, as there was no documentation of any identified irregularities or recommendations for these residents during the specified months. Resident #10, who was admitted with multiple diagnoses including bipolar disorder and major depressive disorder, received various medications such as antianxiety, antidepressant, and opioid medications. Despite the monthly pharmacy reviews conducted in June, July, September, and October 2024, there were no documented irregularities or recommendations. Similarly, Resident #33, with diagnoses including congestive heart failure and anxiety, received medications like antianxiety and antidepressant drugs. The pharmacy reviews for this resident also lacked documentation of any irregularities or recommendations during the same period. Resident #29, diagnosed with conditions such as diabetes mellitus and chronic kidney disease, was also affected by the lack of documented pharmacy review findings. The facility's policy required the consultant pharmacist to document findings and provide a written report to the physicians and the DON. However, the pharmacy representative only sent individual recommendations via email to the DON without a comprehensive list of residents with recommendations, leading to a failure in ensuring that all recommendations were received and addressed by the physician.
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What surveyors actually found near you
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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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Nursing homes near Mount Vernon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Laurels Of Mt Vernon The | 0.6 mi | ★★★★★ | 1 | 0 |
| Country Court | 1.3 mi | ★★★★★ | 9 | 1 |
| Country Club Retirement Center | 1.4 mi | ★★★★★ | 2 | 0 |
| Als Mount Vernon Inc | 1.4 mi | ★★★★★ | 15 | 0 |
| Ohio Eastern Star Hlth Care Ctr The | 2 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.