Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Whispering Pines Nursing And Rehab, Llc during CMS and state inspections, most recent first.
Failure to Follow Pressure Injury Prevention Interventions: A resident at risk for pressure injuries had a care plan calling for a left heel boot at all times and heels floated in bed, but surveyors observed the resident without the boot for over four hours and later in bed without the boot or floated heels. The resident had severe cognitive impairment, diabetes, MS, PVD, and an unhealed stage 4 pressure injury, and the DON confirmed the ordered heel protection and heel-floating interventions.
A resident with Parkinson’s disease, diabetes, epilepsy, and upper extremity impairment required supervision with eating per the MDS, care plan, and Kardex, but was observed eating lunch in their room without supervision. Staff placed the tray on the resident’s lap and left, despite the meal ticket indicating the resident should eat in the dining room. Interviews showed the CNA, DON, and RD did not consistently view room dining as requiring supervision, even though the resident had tremors, needed help feeding at times, and a risks versus benefits form later documented the recommendation for dining room meals with supervision.
Two residents receiving oxygen therapy with humidification had distilled water bottles that did not meet facility policy. One bottle was left uncovered and was dated beyond the 72-hour limit, while the other was open but not dated when opened. The residents had diagnoses including heart failure, pneumonia, and chronic pulmonary disease, and the DON verified the issues during observation.
Medication Order Not Updated on MAR: A resident with Parkinson's disease had an order for carbidopa-levodopa every 8 hours, but the MAR was not updated and continued to show the medication scheduled at fixed times of 8 AM, 12 PM, and 4 PM. The DON verified the discrepancy, and the MD noted the timing could affect Parkinson's symptoms.
A resident with Parkinson’s disease, left-side weakness, and impaired upper extremity function was supposed to receive a rocker knife, lipped plate, and built-up utensils for meals, but staff did not consistently provide the ordered adaptive equipment. Surveyors observed the resident struggling to cut food and eat with regular utensils, while staff only intermittently offered help and did not ensure the resident received the equipment listed on the care plan, Kardex, and meal ticket.
A resident with moderately impaired cognition, multiple medical conditions, and a Wanderguard bracelet for known wandering risk exited through an unalarmed, coded employees-only door after apparently observing staff enter the code. Night shift CNAs last saw the resident in the early morning hours but did not detect the absence until a therapist went to the room and found the resident missing, by which time the resident had already left the building. The resident traveled over a mile to a former apartment, where police later found the resident in bed, with the wheelchair and a foot pedal located on a stairwell. After return and subsequent evaluation, the resident was found to have sustained a fractured finger, which the resident reported occurred while slipping on the stairs en route to the apartment.
Kitchen Food Safety and Sanitation Deficiencies: The DM did not consistently document cooking and holding temps, holding temps were not checked during lunch service, two toasters had dried food debris, and a probe thermometer was used repeatedly without sanitizing it between uses or after contact with a dirty prep surface and cloth. The DM acknowledged the incomplete logs, the unclean equipment, and the missed sanitation steps.
The facility failed to follow its abuse reporting policy and federal requirements by not reporting resident-to-resident sexual contact incidents to the State Agency and, in one case, not to local law enforcement. In one event, a cognitively impaired resident inappropriately touched a cognitively intact resident’s vaginal area and made an “I love you” comment, which was documented by nursing staff but not reported to the SA or police. In another event, the same cognitively impaired resident grabbed another cognitively intact resident by the shoulders and kissed them on the mouth in the dining room; although the resident later minimized the incident, they later told surveyors they did not want or expect the kiss and felt the other resident was sometimes stalking them. Despite a written policy requiring reporting of sexual abuse allegations to both the SA and police, leadership stated they did not report these incidents because the involved residents said they were not affected and were their own decision makers.
A resident with osteoporosis, a right humerus fracture, and dependence on staff for transfers, toileting, and wheelchair locomotion was found in the room without a call light within reach. The resident stated staff had brought them back to the room and left, and they could not call for help while in pain. RN verified the call light was on the floor, and DON confirmed facility policy requires call lights to be within reach at all times.
PASRR requirements were not met for a resident with MI diagnoses including depression and anxiety. The resident had a PASRR Level I Screen identifying a current MI diagnosis, but the record did not contain a PASRR Level II Screen. The DON said the BOM was responsible for PASRRs, and the BOM verified the Level II Screen was missed.
A resident with BLE lymphedema, CHF, chronic wounds, and pain had an order for Tubigrips/compression wraps, but they were not consistently applied. Surveyors observed the resident with dependent legs, swollen feet, and later without Tubigrips, with the resident reporting increased swelling and pain. The care plan did not include specific lymphedema interventions, and the DON confirmed the discharge summary called for compression wraps.
Medication Error Rate Exceeded Allowed Threshold: During an observed AM med pass, an RN gave A resident’s insulin aspart late and administered the wrong dose of Slow Magnesium. The resident had diabetes, nutritional anemia, and moderate cognitive impairment. Surveyor review of the MAR and the medication bottle confirmed the insulin was ordered for 7:30 AM and the magnesium product given did not match the ordered dose, resulting in a 6.67% med error rate.
The facility failed to notify the Ombudsman of transfers and discharges for five residents, including those with CHF, sepsis, and other medical conditions. Notifications were sent months late, and the facility lacked proof of timely communication.
A resident reported a staff member stole their soda, but the facility failed to report the allegation of misappropriation to the State Agency or law enforcement. Despite discussions among the ADON, DON, and NHA, no documentation or reporting occurred, violating federal requirements.
A resident with moderate cognitive impairment reported that a staff member stole soda from their personal supply. The facility's ADON, DON, and NHA discussed the allegation but did not find it credible and failed to conduct a thorough investigation. Documentation related to the allegation was not provided, and an investigation was only initiated after surveyor inquiry.
A resident with a right below-the-knee amputation did not receive proper wound care as the dressing was not changed per physician's orders, and a weekly wound assessment was not conducted. The LPN confirmed the dressing was not changed due to the resident's absence for dialysis, and the ADON acknowledged the lack of a timely wound assessment.
The facility failed to maintain an effective infection control program, as staff did not use appropriate PPE for two residents on contact and enhanced barrier precautions. A resident with chronic C. diff infection was observed with staff entering the room without PPE, and another resident on enhanced barrier precautions was assisted with high-contact activities without gowns. Interviews revealed a lack of adherence to infection control policies, highlighting significant gaps in PPE usage.
Failure to Follow Pressure Injury Prevention Interventions
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident who was at risk for pressure injuries and had an individualized care plan intervention for a left heel boot to be worn at all times. The resident had diagnoses including metabolic encephalopathy, diabetes, multiple sclerosis, and peripheral vascular disease, and the MDS indicated severely impaired cognition, risk for pressure injuries, an unhealed stage 4 pressure injury, and use of pressure-reducing devices for bed and chair. The care plan, revised 5/14/26, included interventions for a heel boot to the left foot at all times and to float heels in bed. On 6/8/26, the resident was observed without the left heel boot for more than four hours. Surveyor observation showed heel boots on a chair in the resident’s room while the resident sat in a Broda chair without heel boots from 9:36 AM to 1:12 PM. The resident was then observed in bed from 1:12 PM to 2:05 PM without a left heel boot or floated heels. The medical record also showed a healing stage 4 coccyx pressure injury and a recently healed vascular injury on the left heel. The DON later verified that the resident’s heels should be floated in bed and that the left heel boot should be on at all times due to the resident’s risk for pressure injury development.
Failure to Provide Supervision During Meals
Penalty
Summary
The facility did not provide adequate supervision to prevent accidents for one resident who required supervision while eating. The resident had diagnoses including Parkinson’s disease, rhabdomyolysis, type 2 diabetes, and epilepsy. The resident’s MDS assessment showed intact cognition with a BIMS score of 14 out of 15, but also documented upper extremity impairment and a need for supervision or touching assistance with eating. The care plan and Kardex directed that the resident eat in the dining room with set-up and supervision, use adaptive eating aids, and be monitored for signs of dysphagia. On 6/8/26, the resident was observed eating lunch in their room in a recliner with the meal tray placed on their lap at their request. Two cups of chocolate milk were on the table, and the CNA told the resident to holler if they needed anything before leaving the room. The meal ticket indicated the resident should eat in the dining room. The surveyor observed mild tremors while the resident ate, and the resident stated they had trouble feeding themself because of Parkinson’s tremors and needed assistance at times. The CNA later confirmed the resident ate about half of the meal and said the resident liked to eat in the recliner with the tray on their lap. Additional interviews and records showed the resident had been encouraged to eat in the main dining room with set-up and supervision, but staff did not consistently provide supervision in the resident’s room during meals. The DON stated the resident did not need supervision during meals, and the RD stated the resident preferred to eat in their room where supervision was not provided. A risks versus benefits statement was completed stating the recommendation was eating in the dining room with supervision, and the resident signed to continue eating in their room. When interviewed, the resident said they understood only that there was a choking risk and stated staff had not clearly told them whether supervision would be provided. The RD, RN, and RDCS later discussed that supervision is supervision whether in the dining room or not, and that the issue would be corrected.
Improper Handling of Distilled Water for Oxygen Humidification
Penalty
Summary
Safe and appropriate respiratory care was not provided for two residents who were receiving oxygen therapy with humidification. The facility's policy required distilled water used for humidification to be dated and initialed when opened and discarded after 72 hours, but this was not followed for either resident. R5 was admitted for short-term rehab with a diagnosis of heart failure and had an order for oxygen at 4 liters per minute via nasal cannula. During observation, R5's oxygen concentrator and a gallon of distilled water used to fill the humidification bottle were on the bedside table, and the bottle was uncovered. The bottle had a handwritten date of 6/2, which was 3 days beyond the facility's 72-hour expiration period. R6 was admitted with pneumonia and had a pulmonary diagnosis of asthma, COPD, or chronic lung disease. R6 also received oxygen therapy, and during observation the distilled water used for the humidification bottle was open and not dated when opened, which the DON verified did not meet facility policy.
Medication Order Not Updated on MAR
Penalty
Summary
The facility did not provide pharmacy services to ensure accurate medication administration for one resident with Parkinson's disease. The resident had diagnoses including Parkinson's disease, rhabdomyolysis, type 2 diabetes, epilepsy, mood disorder, and insomnia, and had a BIMS score of 14 out of 15, indicating intact cognition. The resident had an order for carbidopa-levodopa 25-250 mg orally disintegrating tablets every 8 hours, but the medication administration record was not updated to reflect the every-8-hour order. Record review showed the resident's MAR continued to list carbidopa-levodopa as 1 tablet by mouth three times daily, scheduled for 8:00 AM, 12:00 PM, and 4:00 PM, based on an earlier order. A provider visit note and a discharge summary both contained the order for carbidopa-levodopa every 8 hours, but the MAR was not updated with the new administration times. The DON reviewed the MAR and verified the discrepancy between the documented order and the scheduled administration times. The MD stated the timing would not have increased seizures, but there may have been an increase in Parkinson's symptoms.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment and appropriate assistance for a resident with Parkinson’s disease, left-side weakness, diabetes, epilepsy, mood disorder, and insomnia. The resident’s MDS showed intact cognition with a BIMS score of 14 out of 15, upper extremity impairment, and a need for supervision or touching assistance with eating. The care plan, Kardex, and nutrition documentation identified the resident as needing a rocker knife, lipped plate, and built-up utensils, and noted the resident was at risk for malnutrition and had a history of weight loss and oral nutritional supplements. During observation, the resident was seen eating meals in a recliner with a tray on the lap or on a table in front of them, but did not have the ordered adaptive equipment. At lunch, the resident had a regular fork, knife, and spoon, attempted unsuccessfully to cut meat, and had tremors while eating. The resident stated staff did not offer help very often and said they had trouble eating because of tremors from Parkinson’s disease. The CNA who delivered the tray asked if help was needed cutting food, but the resident declined at that time and was told to call if anything was needed. At breakfast the next day, the resident again did not have a lipped plate or built-up utensils and was observed struggling to cut bacon, eggs, and toast. The CNA did not get up to assist and stated the resident did not usually ask to have food cut. The meal ticket still indicated a lipped plate, and dietary staff later acknowledged the resident had not received the lipped plate at breakfast. The DON stated the resident still required built-up silverware, and the dietary manager stated adaptive equipment orders were entered on the meal ticket and verbally communicated to staff.
Unalarmed Employees-Only Exit Allows High-Risk Resident Elopement and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for a resident at high risk for wandering and elopement. The facility had an Elopement Risk and Prevention policy requiring adequate supervision and assistive devices to prevent elopement, wandering, and unsafe exits. The resident, who had diagnoses including rhabdomyolysis, acidosis, an automatic cardiac defibrillator, and alcoholic liver disease, had a BIMS score of 10/15 indicating moderately impaired cognition and an activated POA for healthcare. Due to wandering throughout the facility and difficulty finding the resident’s room, staff placed a Wanderguard bracelet on the resident in mid-March. On the date of the incident, the resident exited the facility between approximately 4:00 AM and 4:30 AM through an employees-only door that required a code and was not alarmed. Night shift CNAs reported last seeing the resident between about 3:00 AM and 4:30 AM, either at the nurses’ station or in the resident’s room in a wheelchair facing the window, but the resident’s absence was not identified until the Therapy Director went to the room around 6:18 AM and found the resident missing. The resident later described leaving the room, traveling down the hallway, turning into another resident hallway, and exiting through the coded employees-only door, then going out an unalarmed exit door and through a courtyard to the front of the building. The Nursing Home Administrator believed the resident likely observed staff entering the door code and used it to exit. The resident traveled away from the facility and was reported to police around 4:30 AM as an elderly man in flannel pajama pants pushing a wheelchair near local cross streets and a business, though police did not locate him at that time. The resident ultimately reached a former apartment approximately 1.1 miles from the facility, where police later found the resident asleep in bed with the wheelchair under a stairwell and a foot pedal at the top of the stairs. The facility became aware of the resident’s location at about 6:40 AM. The resident was transported to the ER, where bloodwork was normal and no imaging was initially done due to lack of reported pain. The following day, during therapy, the resident reported numbness in the fingers progressing into the hand; an X-ray ordered by the physician revealed a fracture of the left ring finger, which the resident attributed to slipping on the stairs while going to the apartment.
Kitchen Food Safety and Sanitation Deficiencies
Penalty
Summary
Food was not consistently stored, prepared, and served in a safe and sanitary manner in the kitchen. During an initial tour, the Dietary Manager (DM-C) stated the facility followed the Federal Food Code and monitored cooking and holding temperatures, but the surveyor observed that holding temperatures were not obtained before, during, or after lunch service. Review of the facility’s Food Temperature Logs for the prior 30 days showed multiple incomplete entries for both cooking and holding temperatures across several weeks, and DM-C acknowledged that cooking and holding temperatures should be obtained for all meals and that the log entries were inconsistent. The surveyor also observed two toasters in the main kitchen that contained a significant amount of dried food debris and crumbs on both the interior and exterior. DM-C stated the toasters should be cleaned after each use or at least daily and acknowledged they should have been cleaned. The report cited the facility’s policy and the FDA Food Code requiring food-contact surfaces and cooking equipment to be kept clean and cleaned at least every 24 hours. In addition, the surveyor observed DM-C checking cooking temperatures with a probe thermometer without sanitizing it before use, after placing it on a prep counter with dried food debris, or after it contacted a cloth with food debris. DM-C repeated the temperature checks multiple times with the same thermometer without sanitizing it between uses. DM-C later confirmed the thermometer was not sanitized prior to use, after contact with the counter, or after contact with the used cloth, and verified that thermometers should be sanitized between uses.
Failure to Report Resident-to-Resident Sexual Abuse Allegations to Authorities
Penalty
Summary
The deficiency involves the facility’s failure to follow its own abuse and neglect prevention policy and federal requirements for reporting reasonable suspicion of a crime, specifically related to resident-to-resident sexual contact. The facility’s policy, dated 11/2017, requires reporting allegations of abuse, neglect, misappropriation, or exploitation to the State Agency (SA) within 24 hours and contacting law enforcement when concerns are criminal in nature, including sexual abuse. The policy also states that for allegations or incidents of sexual abuse, the facility is to make a police report with the local police department in addition to the preliminary report to the state health department. Surveyors determined that these reporting requirements were not followed for multiple incidents involving three residents. One incident involved a resident with early onset Alzheimer’s disease and dementia with behavioral disturbance, who had a BIMS score of 6/15 indicating severely impaired cognition, and another resident with multiple sclerosis and intact cognition (BIMS 15/15). A progress note documented that, in the evening, the cognitively impaired resident approached the cognitively intact resident outside the dining room. An agency nurse observed the cognitively intact resident looking uncomfortable and saw the other resident quickly move a hand away, though the nurse did not see the exact area touched. When questioned, the cognitively intact resident confirmed being touched and pointed to the vaginal area, nodded yes when asked if that area was touched, and reported that the other resident said, “I love you.” The facility completed an internal investigation, but surveyors noted that the incident was not reported to the SA or to the local police department, despite the sexual nature of the allegation. Another incident involved the same cognitively impaired resident and a different resident with intact cognition (BIMS 15/15) who had diagnoses including acute cystitis, psychophysical visual disturbances, and major depressive disorder. A progress note indicated that during supper, the cognitively impaired resident grabbed the other resident by the shoulders and kissed them on the mouth; the resident stated it did not feel good but was not upset at that time. A later progress note documented that the resident described the event as a joke and reported having no problem with the other resident. However, in a subsequent phone interview with the surveyor, the resident stated they did not want to be kissed, did not ask to be kissed, and were not expecting it, and described feeling that the other resident was sometimes “stalking” them. The facility’s investigation showed that this potential allegation of abuse was not reported to the SA, although it was reported to the police in the context of another incident. During interviews, facility leadership stated they used a resident-to-resident altercation flowchart and did not report these incidents because the involved residents indicated they were not affected and were their own decision makers, leading to the failure to report in accordance with policy and section 1150B of the Act.
Call Light Not Within Reach for Resident With Fracture
Penalty
Summary
The facility did not ensure a call light was within reach for one resident, R34, who was observed in the room without access to the call light. On 4/12/26, the surveyor found R34 in a wheelchair with the call light on the floor approximately 10 feet away, and R34 stated staff had brought the resident back to the room and left. R34 also stated being in pain, could not call staff, and needed a pain pill. The resident’s record showed diagnoses including osteoporosis with current pathological fractures and a right humerus fracture related to a fall, and the MDS indicated intact cognition with a BIMS score of 13 out of 15. R34’s record also showed the resident was dependent on staff for transfers, toileting, and wheelchair locomotion. The resident had fallen while self-transferring from a wheelchair to a recliner in the room on 3/23/26, resulting in a right humerus fracture. During the survey, RN-F verified the call light was on the floor and not within reach, and attached it to the wheelchair, stating it should always be within reach. The DON later verified the facility policy required call lights to be within reach and accessible at all times.
PASRR Level II Screen Not Completed for Resident With Mental Illness
Penalty
Summary
PASARR screening requirements were not met for one resident with a mental illness diagnosis. The resident, who was admitted to the facility and had diagnoses including multiple sclerosis, depression, and anxiety, had a MDS assessment dated 3/19/26 showing a BIMS score of 15 out of 15, indicating no cognitive impairment, and was responsible for healthcare decisions. The resident's medical record contained a PASRR Level I Screen dated 7/10/25 that identified a current mental illness diagnosis, and the resident's medical diagnoses included depression and anxiety. The resident's MDS assessment dated 7/10/25 also indicated depression and anxiety, but the medical record did not contain a PASRR Level II Screen. During interviews on 4/14/26, the DON stated the BOM was responsible for completing PASRRs, and the BOM verified that the resident did not have a PASRR Level II Screen and stated it should have been completed but was missed.
Inconsistent Compression Therapy and Missing Lymphedema Care Plan Interventions
Penalty
Summary
The facility did not provide necessary edema care and treatment for a resident with chronic wounds, bilateral lower extremity lymphedema, congestive heart failure, and chronic pain. The resident had an order for Tubigrips for compression, and the hospital discharge summary stated to continue compression wraps. The resident’s record also showed bilateral lower extremity edema, including 2+ edema and 2+ pitting edema, with pedal pulses present. However, the care plan did not contain interventions addressing lymphedema, such as elevating the legs or use of Tubigrips, and instead only included a general intervention to administer treatments as ordered. Survey observations and interviews showed the Tubigrips were not consistently applied. The resident was observed in a wheelchair with legs dependent and swollen feet while wearing Tubigrips, and later was found without them, with swollen and painful feet. The resident stated the Tubigrips had not been applied since they were removed the prior evening and reported pain and increased swelling in both legs. The DON stated the resident had not reported the issue during medication pass and that staff later learned the Tubigrips were missing; the DON also verified the discharge summary called for compression wraps and acknowledged the care plan did not address lymphedema until the survey date.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility did not ensure it remained free of a medication error rate of 5% or greater. During medication administration observations, 2 errors occurred during 30 opportunities, resulting in a 6.67% medication error rate that affected 1 resident, R27, during the AM medication pass. The facility’s policy required medications to be administered according to provider orders and verified for the right medication, dose, route, time, and resident identity. R27 was admitted with diagnoses including diabetes and nutritional anemia, and the MDS dated 1/22/26 showed a BIMS score of 9 out of 15, indicating moderate cognitive impairment. During observation, RN-D administered R27’s insulin aspart late and stated the insulin was being given late because RN-D did not like to administer insulin in the dining room. Surveyor review of the MAR showed insulin aspart was ordered for 7:30 AM. During the same medication pass, RN-D administered Slow Magnesium from a bottle containing magnesium 128 mg, chloride 373 mg, and calcium 212 mg, while the MAR ordered Slow Mag tablet delayed release 71.5-119 mg, 1 tablet daily. RN-D later compared the bottle to the MAR and acknowledged the dose was different, and the DON confirmed the Slow Magnesium administration was a medication error and that insulin aspart was late if given after 9:00 AM.
Failure to Notify Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to ensure timely notification to the Ombudsman regarding the transfers and discharges of five residents. These residents included one who was discharged home after an exacerbation of congestive heart failure, another discharged following hospitalization for sepsis, and three others who were transferred to the hospital for various medical conditions such as a positive blood culture, evaluation of a foot wound, and other health issues. The facility did not notify the Ombudsman of these transfers and discharges at the time they occurred. The surveyor's review of the facility's records revealed that the notifications were only sent to the Ombudsman on January 13, 2025, well after the events took place. The Social Worker responsible for sending these notifications was on leave during the fall, and the Nursing Home Administrator was supposed to send them in their absence. However, there was no evidence that this was done. The Ombudsman confirmed receiving the notifications late and emphasized the importance of facilities maintaining proof of sent documents.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically misappropriation of property, as required by section 1150B of the Act. A resident, identified as R22, reported to staff that a staff member had stolen soda from their personal supply. Despite the report, the facility did not notify the State Agency or local law enforcement about the allegation of misappropriation. The facility's policy mandates that any suspicion of misappropriation must be reported immediately to the Administrator and then to the State Agency within 24 hours. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Nursing Home Administrator (NHA) confirmed that the allegation was discussed among them, but no documentation was provided to the surveyor, and the allegation was not reported to the appropriate authorities. R22, who had moderate cognitive impairment, had reported the missing soda to ADON-D, who did not find the report credible and failed to take further action. This inaction led to a deficiency in the facility's compliance with federal reporting requirements.
Failure to Investigate Allegation of Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation involving a resident, identified as R22, who reported that a staff member stole soda from their personal supply. R22, who has moderate cognitive impairment and was admitted with diagnoses including depression and surgical wound complications, noticed the soda missing after returning from an activity. R22 reported the incident to the Assistant Director of Nursing (ADON), who informed the resident that the allegation was addressed with the accused staff. However, the ADON, along with the Nursing Home Administrator (NHA) and Director of Nursing (DON), did not find the report credible and did not conduct a thorough investigation. Interviews with the ADON, DON, and NHA revealed that they discussed the allegation but did not document any investigation or take further action because they did not believe the allegation was credible. The ADON and DON planned to monitor the resident's soda supply but did not provide any documentation related to the allegation. The NHA confirmed that an investigation was only initiated after the surveyor's inquiry, indicating a delay in addressing the resident's report of missing soda.
Failure to Provide Proper Wound Care for Resident with BKA
Penalty
Summary
The facility failed to provide proper surgical wound treatment for a resident with a right below-the-knee amputation (BKA). The resident's wound dressing was not changed according to the physician's order, which specified changes every other day. The Treatment Administration Record (TAR) indicated that the dressing change was not completed on one of the scheduled days. The Licensed Practical Nurse (LPN) on duty confirmed that the dressing was not changed because the resident was not present due to dialysis, and the task was not completed later in the day. Additionally, the facility did not conduct a weekly in-house wound assessment for the resident's surgical wound, as required by the facility's policy. The Assistant Director of Nursing (ADON), who is also the wound nurse, confirmed that no assessment had been completed since the resident's admission. The ADON acknowledged that an assessment should have been conducted within 24-48 hours of admission to establish a baseline for the wound, but this was not done.
Inadequate Infection Control Practices in PPE Usage
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper use of personal protective equipment (PPE) for two residents on contact and enhanced barrier precautions. Resident R283, who was on contact precautions due to chronic Clostridium difficile infection, was observed multiple times with staff entering the room without donning the appropriate PPE, such as gowns and gloves, despite clear signage indicating the need for such precautions. The Director of Therapy and other staff members were noted to have entered the room without PPE and failed to disinfect equipment after use, contrary to the facility's policy. Resident R131, who was on enhanced barrier precautions due to a right below-the-knee amputation and dependence on dialysis, was also subject to improper PPE use. Staff members assisting with high-contact activities, such as toileting, did not wear gowns as required by the facility's policy. Despite having received training, staff misunderstood the requirements for gown use during high-contact activities, leading to non-compliance with the enhanced barrier precautions. Interviews with the Assistant Director of Nursing revealed a lack of understanding and adherence to the facility's infection control policies. The ADON acknowledged that contact precautions were not being followed correctly for R283 and that high-contact activities for R131 required PPE, including gowns, which were not consistently used. This deficiency highlights a significant gap in the facility's infection control practices, particularly in the proper use of PPE to prevent the transmission of infections.
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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 Ripon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Juliette Manor | 10 mi | ★★★★★ | 5 | 0 |
| Markesan Resident Home | 12.2 mi | ★★★★★ | 4 | 0 |
| Edenbrook Omro | 13 mi | ★★★★★ | 1 | 0 |
| Eden Rehab Suites And Green House Homes | 15.9 mi | ★★★★★ | 5 | 0 |
| Complete Care At Christian Home Llc | 16.3 mi | ★★★★★ | 9 | 0 |
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