Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Whitney Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with neurogenic bladder, paraplegia, schizophrenia, and spina bifida, who was always incontinent per his care plan, was sent to multiple medical appointments wearing two briefs and without a change of clothes or toiletries. CNAs were responsible for dressing him, but no staff recalled preparing him that day, and the LVN only transported him to the exit. The non-CNA transportation driver later observed his clothes were wet and learned at the urology office that both briefs were saturated; the clinic had to provide clean pants and a new brief. The resident reported he could not toilet himself, believed staff forgot to change him, and felt embarrassed sitting in soiled clothing. The DON stated vans should be stocked with briefs, linens, and clothing and confirmed that double briefing was against facility practice and policy, which emphasized dignity and respect.
Surveyors found expired medication and supplies in the medication storage room, including 2 expired Central Line Dressing Change Trays and 1 opened bottle of 70/30 Mix Insulin Aspart that was past its discard date. The REG stated the facility did not have a policy for medication storage or destruction of expired medications, while other staff said expired meds and supplies should be removed immediately and discarded.
The facility failed to review risks and benefits of bed rails and enabler/grab bars with residents or their representatives and did not obtain informed consent prior to installation for six residents. Observations and interviews revealed that residents were unaware of the risks, and there was no documentation of assessments or consents. Staff interviews indicated a lack of clarity regarding the facility's policy on the use of grab bars.
A long-term care facility was found to have a medication error rate of 6.14%, exceeding the acceptable 5% threshold. Errors involved incorrect insulin dosage for a resident due to difficulty reading syringe measurements and improper administration of blood pressure medication without rechecking vitals. Staff interviews highlighted inconsistencies in following medication protocols, emphasizing the need for adherence to the five rights of medication administration.
A facility failed to secure medication carts and properly label insulin, affecting two residents with diabetes. Insulin in Cart A was undated or expired, risking potency issues. Cart B was left unlocked and unattended, accessible to unauthorized individuals. The ADON and DON confirmed policy violations regarding cart security and insulin labeling.
A long-term care facility failed to maintain an effective infection prevention and control program, as a medication aide did not sanitize a blood pressure cuff between residents, and an LVN did not use proper PPE or hand hygiene during catheter care. The aide was unaware of the need for sanitation, and the LVN misunderstood the facility's policy on enhanced barrier precautions, leading to potential infection risks.
Two residents were inaccurately documented as having urinary catheters in their MDS assessments, despite no supporting orders or care plans. Observations and interviews confirmed the absence of catheters, and the MDS Coordinator acknowledged the errors in documentation.
A resident with diabetes was administered insulin that was not used within the recommended 28 days of opening, leading to a potential medication error. The LVN involved failed to verify the correct opening date of the insulin vial and initially prepared an incorrect dosage. Interviews with facility leadership highlighted the importance of adhering to medication administration protocols to prevent such errors.
The facility failed to protect residents from misappropriation of medications, involving the unauthorized removal of morphine sulfate and lorazepam by an LPN. Two residents with severe and moderate cognitive impairments, respectively, had discrepancies in their medication counts, leading to an investigation and reporting to local authorities.
A resident with multiple health issues experienced a decline in condition, including confusion, incontinence, and vomiting. The facility failed to collect a urinalysis, notify the physician, or inform the family about the resident's refusal to provide a urine sample and fall incidents. This lack of communication and documentation led to the resident's hospitalization and subsequent death from sepsis.
A facility failed to prevent neglect, resulting in a resident's death from sepsis due to an untreated UTI. The facility did not collect a urinalysis, failed to identify changes in the resident's condition, and did not notify the physician or responsible party. Staff interviews revealed lapses in protocol adherence, documentation, and incident reporting.
A facility failed to ensure a resident received appropriate treatment and care, leading to the resident's death from sepsis related to a UTI. Despite receiving a new order for a urinalysis, the resident's condition deteriorated, and no further attempts were made to collect the sample or take the resident to a clinic. The facility's documentation was inconsistent, and staff interviews revealed a lack of adherence to protocols.
A facility failed to maintain clinical laboratory services for a resident, leading to her death from sepsis. Despite a physician's order for a urinalysis to check for a UTI, the test was not completed due to the resident's refusal and lack of follow-up by staff. The resident's condition deteriorated, and she was eventually diagnosed with sepsis and aspiration pneumonia at the hospital, where she died.
Resident Sent to Appointments in Double Briefs Without Change of Clothing
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to dignity by sending him to multiple medical appointments in double briefs and without adequate provisions for incontinence care or a change of clothing. The resident was an adult male with neurogenic bladder, paraplegia, psychotic disorder, schizophrenia, and spina bifida, with a BIMS score of 15 indicating intact cognition. His MDS and care plan documented that he was always incontinent of bowel and bladder and had a goal to remain clean, dry, and free from odors, with interventions including assistance with applying briefs and keeping his skin clean and dry. On the day in question, staffing records showed specific LVN and CNA assignments on the resident’s hall, but no clear assignment of responsibility for preparing him for his appointments. During transport to two appointments, the transportation driver observed that the resident’s clothes were wet and later learned at the urology office that he was wearing two urine-soaked briefs. The physician’s office had to provide a clean pair of pants and a new brief because the resident had no change of clothes or toiletries with him. The resident reported that he remembered wearing double briefs, that he was incontinent and unable to toilet himself, and that he believed staff had forgotten to change him, resulting in his briefs becoming very full. He stated that he was embarrassed to sit in soiled clothing at the doctor’s office. Interviews with staff revealed that CNAs were responsible for dressing the resident, but none of the interviewed CNAs recalled preparing him that morning, and some stated that night shift often got residents ready for early or out-of-town appointments. The LVN recalled only pushing the resident to the side door for transport and stated that CNAs were responsible for dressing and that double briefing was against facility rules. The transportation driver, who was not a CNA, stated she did not bring extra clothes or supplies, did not realize the resident was double briefed until the second appointment, and did not notify management of the incident. The DON stated that the transportation driver was responsible for keeping vans stocked with briefs, linens, and clothing, that residents did not typically carry personal bags for appointments, and that double briefing was never acceptable. The facility’s Quality of Life policy and mission statement emphasized caring for residents in a manner that promotes dignity and respect, which was not followed in this incident.
Expired insulin and dressing trays found in medication storage room
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored properly in the medication storage room. During observation, surveyors found 2 Central Line Dressing Change Trays that had expired and 1 bottle of 70/30 Mix Insulin Aspart that had been opened on 9/20/25 with a discard date of 10/20/25 still present in the storage room. The report states this was the only medication storage room reviewed for drug storage. During interviews, the REG stated the facility did not have a policy for medication storage or destruction of expired medications, and that it was only a standard expectation that expired items be discarded. Other staff members stated that expired medications and supplies were to be removed immediately and placed in the discard bin, and that insulin vials are only good for 30 days after opening. Record review of the facility medication policy could not be completed because the facility did not have a policy for medication storage or destruction of expired medications. The manufacturer package insert for 70/30 Insulin Aspart stated to dispose after 28 days once opened.
Failure to Obtain Informed Consent for Bed Rails
Penalty
Summary
The facility failed to review the risks and benefits of bed rails and enabler/grab bars with residents or their representatives and did not obtain informed consent prior to installation for six residents. This deficiency was identified through observations, interviews, and record reviews. The facility did not have evidence of informed consent, assessment of the resident for risk of entrapment, or care planning for the quarter bed rails/enabler bars for the residents involved. For Resident #7, the facility did not conduct an assessment for the safe use of bed rails/grab bars, nor was there any documentation of consent or care plan addition for their usage. The resident, who had moderate cognitive impairment and multiple health issues, was observed with grab bars on her bed but did not recall any discussion about their risks or benefits. Similarly, Resident #11, who had intact cognition, was found to have grab bars installed without any documented assessment, consent, or care plan addition, and she did not remember any discussion about the grab bars. Residents #26, #29, #41, and #143 also had grab bars installed without documented assessments, consents, or care plan additions. These residents had varying degrees of cognitive impairment and physical disabilities. Interviews with some of these residents revealed that they were either unaware of the risks associated with the grab bars or did not recall any discussions about them. Staff interviews indicated a lack of clarity regarding the facility's policy on the use of grab bars and the necessary assessments and consents required before their installation.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6.14% error rate during a medication pass observation. This deficiency involved two residents, Resident #24 and Resident #96, who were affected by medication administration errors. For Resident #24, the error occurred when LVN B administered insulin. Despite the sliding scale indicating 8 units of insulin for a blood sugar reading of 265, LVN B initially drew 10 units into the syringe. The surveyor intervened, and the excess insulin was removed before administration. LVN B cited difficulty in reading the syringe measurements as the reason for the error, noting a preference for syringes with larger numbers. Resident #96 experienced a medication error involving the administration of Metoprolol, a blood pressure medication. The order specified that the medication should be held if the systolic blood pressure (SBP) was less than 120. MA D administered the medication without rechecking the blood pressure, relying on a previous reading taken by LVN A. The facility's policy required rechecking vitals if they were taken more than an hour before medication administration. MA D, who usually worked evening shifts and was not accustomed to taking vitals, did not verify the blood pressure before giving the medication, assuming the nurse would inform her if there was an issue. Interviews with facility staff, including LVN A, LVN C, the ADON, and the DON, revealed inconsistencies in following medication administration protocols. The staff acknowledged the importance of verifying vitals and adhering to the five rights of medication administration. The DON emphasized the potential harm of medication errors, including the risk of overmedication or underdosing residents. The facility's policy required medication labels to be legible and for staff to verify the right resident, medication, dosage, time, and route before administration.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to properly store and secure medications, as observed with two medication carts. Nurse medication Cart A contained insulin that was either undated or expired, which was not in compliance with the manufacturer's recommendation to use insulin within 28 days of opening. This affected two residents, one of whom had a history of respiratory failure, dementia, and diabetes, and another with a history of stroke, kidney disease, and diabetes. The lack of proper labeling and dating of insulin could lead to the administration of expired medication, potentially affecting the potency and effectiveness of the insulin. Additionally, medication Cart B was left unlocked and unattended by a medication aide while inside a resident's room, out of the aide's view. This cart was accessible to unauthorized individuals, posing a risk of drug diversion and unauthorized access to medications. The medication aide acknowledged the oversight and the potential risk it posed to residents. Interviews with the ADON and DON revealed that the facility's policy required medication carts to be locked when not in use or out of sight. The DON confirmed that the responsibility for ensuring insulin was properly dated and labeled fell on the nursing staff. Despite a recent audit by the pharmacist, the issues with insulin labeling and cart security were not addressed, indicating a lapse in adherence to facility policies and procedures.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper sanitation of a blood pressure cuff used on multiple residents. A medication aide (MA D) was observed using a blood pressure cuff on three residents without sanitizing it between uses. The aide placed the cuff on her own wrist before using it on the residents, further contaminating it. Despite having completed in-service training for infection control, MA D was unaware of the need to sanitize the cuff between residents, which she attributed to her lack of experience with taking vitals during her evening shifts. Additionally, the facility failed to ensure proper use of personal protective equipment (PPE) and hand hygiene during catheter care for a resident. An LVN did not wear a gown or sanitize the bedside table before and after performing catheter care. The LVN also touched the resident's urostomy bag without gloves and did not have hand sanitizer readily available during the procedure. The LVN was under the impression that enhanced barrier precautions were not necessary unless handling bodily fluids, which was a misunderstanding of the facility's policy. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) revealed that they were responsible for ensuring staff compliance with infection control policies. Both acknowledged the risks associated with the observed deficiencies, including the potential spread of infection. The ADON admitted to possibly confusing staff regarding the need for enhanced barrier precautions, which contributed to the improper practices observed.
Inaccurate Resident Assessments for Urinary Catheters
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, resulting in incorrect documentation of urinary catheters. Resident #24, a female with respiratory failure, dementia, and diabetes, was documented as having an indwelling catheter in her MDS, despite no orders or care plans indicating such. Observations and interviews confirmed she did not have a catheter, and the MDS Coordinator acknowledged the error in her soft file. Similarly, Resident #32, with diagnoses including intestinal obstruction and heart failure, was also inaccurately documented as having a catheter. Her MDS reflected this error, but no orders or care plans supported the presence of a catheter. Interviews with staff, including the MDS Coordinator, confirmed the mistake, as neither resident had a catheter during their stay. The MDS Coordinator admitted to marking both residents as having catheters in their soft files without a clear reason. The Director of Nursing was informed of these errors, which were corrected, but the initial inaccuracies could have been construed as falsification. The facility's policy on MDS error correction outlines procedures for addressing such errors, emphasizing the importance of accurate resident assessments.
Failure in Insulin Administration and Documentation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for Resident #24, specifically in the administration of insulin. The resident, an elderly female with a history of respiratory failure, convulsions, dementia, and uncontrolled type 2 diabetes, was administered insulin that was not used within the recommended 28 days of opening. This oversight was observed during an interaction where LVN B administered insulin to the resident without verifying the correct opening date of the insulin vial, which had two different dates marked on it. During the observation, LVN B was seen preparing to administer 10 units of insulin instead of the required 8 units, indicating a potential medication error. The surveyor intervened to correct the dosage before administration. LVN B admitted to difficulties in reading the small numbers on the syringe and expressed a preference for larger syringes, which were not available at the facility. This situation highlighted the risk of administering expired insulin, which could lead to ineffective blood sugar control for the resident. Interviews with the ADON and DON revealed that the facility's staff were expected to adhere to medication administration protocols, including verifying medication details and documenting administration or refusal. The ADON acknowledged the risk of potency inaccuracy with expired insulin and emphasized the importance of proper documentation. The DON reiterated the expectation for staff to follow the 5 Rights of medication administration to prevent errors that could harm residents.
Misappropriation of Medications
Penalty
Summary
The facility failed to ensure each resident had the right to be free from misappropriation of property, specifically involving the misappropriation of medications for two residents. Resident #1, a female with severe cognitive impairment and multiple health conditions including COPD, Alzheimer's Disease, and Heart Failure, had her morphine sulfate solution misappropriated. The resident was on hospice care and required pain management, which included the administration of morphine sulfate. The facility's records indicated that the morphine sulfate was missing from the medication cart, and there were discrepancies in the narcotic count sheets for both morphine and lorazepam, another medication prescribed to Resident #1 for anxiety. LVN A was identified as the alleged perpetrator who took the morphine sulfate out of the facility and later returned it, claiming it was accidentally taken home in her pocket. This incident was reported to the local police department and the state offices, and an investigation was initiated. The facility's policies on controlled substances and drug diversion were violated by LVN A, who did not count the medications with the oncoming staff member and removed the medication from the premises without authorization. The facility's records and staff statements corroborated the discrepancies in the medication counts and the unauthorized removal of the morphine sulfate by LVN A. Resident #2, a male with moderate cognitive impairment and multiple health conditions including Vascular Dementia and Anxiety Disorder, also had discrepancies in the count of his lorazepam medication. The facility's records indicated that lorazepam tablets were missing from Resident #2's medication bottle, and the count was corrected to reflect the missing tablets. The facility's policies on controlled substances and drug diversion were violated, and the incident was reported to the local police department and the state offices. Staff statements and records corroborated the discrepancies in the medication counts and the unauthorized removal of the medications by LVN A.
Failure to Notify Physician and Family of Change in Condition
Penalty
Summary
The facility failed to ensure the physician was consulted for a change of condition for a resident, leading to the resident's death from sepsis and complications of a urinary tract infection (UTI). The resident, an elderly female with multiple diagnoses including Type 2 diabetes mellitus, depression, and chronic obstructive pulmonary disease, was admitted for a short respite stay. Despite showing signs of intermittent confusion, incontinence, and increased weakness, the facility did not collect a urinalysis as ordered, nor did they notify the physician or the resident's family about the resident's refusal to provide a urine sample and subsequent fall incidents. The resident's condition continued to deteriorate, with episodes of vomiting and low oxygen levels, yet there was a lack of proper documentation and communication regarding these changes. The facility staff failed to document the resident's fall and did not complete an incident report. Additionally, the resident's primary care physician was not informed about the resident's refusal to provide a urine sample or the fall, which could have prompted further medical intervention. Interviews with facility staff revealed a lack of clarity and adherence to protocols for handling changes in a resident's condition. The Director of Nursing (DON) and other nursing staff admitted to not following up on the resident's condition adequately, failing to notify the physician and the resident's responsible party about significant changes. This lack of communication and documentation ultimately led to the resident being transported to the hospital in a critical state, where she was diagnosed with sepsis and later died.
Failure to Prevent Neglect Leading to Resident's Death
Penalty
Summary
The facility failed to ensure that residents are free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, the facility did not provide necessary goods and services to a resident, leading to the resident's death from sepsis and complications of a urinary tract infection (UTI). The facility did not collect a urinalysis (UA) and provide treatment for the UTI, despite the resident showing signs of intermittent confusion, incontinence, and increased weakness. The resident's condition deteriorated, and she eventually died from sepsis related to the untreated UTI and aspiration pneumonia. The facility also failed to identify a change in the resident's condition and notify her physician, including a decline in cognitive status and a fall. The resident experienced multiple incidents of vomiting and a significant drop in oxygen levels, yet there was no proper documentation or timely medical intervention. The resident's responsible party was not informed about the need for a UA, the resident's fall, or the necessity to take the resident to her primary care physician (PCP) upon discharge from respite care. Interviews with facility staff revealed that there were lapses in following protocol for documenting changes in condition, notifying the physician and responsible party, and completing incident reports. The Director of Nursing (DON) and other staff members acknowledged that the resident's refusal of the UA was not properly managed, and no further attempts were made to collect the UA or take the resident to the clinic. The facility's policies on resident rights, accidents and incidents, change in condition, and lab and diagnostic test results were not adhered to, leading to the resident's neglect and subsequent death.
Failure to Provide Appropriate Treatment and Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the facility did not collect a urinalysis (UA) for a resident who was showing signs of a urinary tract infection (UTI). Despite receiving a new order for a UA, the resident's condition deteriorated, leading to increased confusion, incontinence, and vomiting. The resident's family was not adequately informed about the resident's refusal to provide a UA sample, and no further attempts were made to collect the sample or take the resident to a clinic for the test. The resident eventually developed sepsis and was transported to the hospital, where she was diagnosed with sepsis related to the UTI and aspiration pneumonia. The resident subsequently died from these complications. The facility's documentation was inconsistent and incomplete. There were multiple instances where changes in the resident's condition were not properly documented in the nursing progress notes. For example, the resident had a fall that was not reported, and there were no incident or accident reports related to this fall. Additionally, the facility staff failed to document the resident's refusal to provide a UA sample and did not notify the resident's primary care physician (PCP) about the continued refusal. The facility's policies on change in condition, lab and diagnostic test results, and charting and documentation were not followed, leading to a lack of proper communication and documentation. Interviews with facility staff revealed a lack of clarity and adherence to protocols. The Licensed Vocational Nurse (LVN) and Registered Nurse (RN) involved were unsure about the resident's baseline cognitive status and did not follow up on the UA order. The Director of Nursing (DON) acknowledged that the resident had the right to refuse treatment but admitted that the PCP should have been notified about the refusal. The facility's failure to follow its own policies and procedures contributed to the resident's decline and eventual death. The Immediate Jeopardy (IJ) was identified, and the facility was required to implement a Plan of Removal to address the deficiencies.
Failure to Maintain Laboratory Services Leads to Resident's Death
Penalty
Summary
The facility failed to maintain clinical laboratory services to meet the needs of a resident, leading to a severe outcome. An elderly female resident with multiple diagnoses, including Type 2 diabetes mellitus, depression, anorexia, chronic obstructive pulmonary disease, constipation, and glaucoma, was admitted for a short respite stay. Despite being alert with some confusion and initially able to ambulate short distances, her condition deteriorated, and she became incontinent of urine and experienced increased weakness. A urinalysis was ordered to check for a urinary tract infection (UTI), but the test was not completed due to the resident's refusal and lack of follow-up by the facility staff. The resident's condition continued to decline, with episodes of vomiting and decreased oxygen levels. Despite these alarming symptoms, there was no documentation of further attempts to obtain the urinalysis or notify the physician about the resident's refusal. The resident's responsible party was also not informed about the need for the urinalysis or the resident's fall. Eventually, the resident was transported to the hospital, where she was diagnosed with sepsis related to the UTI and aspiration pneumonia. She subsequently died from sepsis. Interviews with facility staff, including the LVNs, DON, and the resident's PCP, revealed a lack of communication and documentation regarding the resident's condition and the necessary medical interventions. The staff failed to follow the facility's policies for handling changes in condition, falls, and lab orders, leading to a critical lapse in care that contributed to the resident's death.
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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 Whitney
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Hillsboro | 13.6 mi | ★★★★★ | 15 | 0 |
| Goodall Witcher Nursing Facility | 13.7 mi | — | 0 | 0 |
| Town Hall Estates | 13.9 mi | ★★★★★ | 13 | 2 |
| West Rest Haven | 16.3 mi | ★★★★★ | 5 | 1 |
| Avir At Itasca | 17.9 mi | ★★★★★ | 5 | 0 |
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