Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Pines Nursing And Rehab, Llc during CMS and state inspections, most recent first.
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.
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.
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.
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.
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.
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 | ★★★★★ | 2 | 0 |
| Markesan Resident Home | 12.2 mi | ★★★★★ | 4 | 0 |
| Edenbrook Omro | 13 mi | ★★★★★ | 35 | 0 |
| Eden Rehab Suites And Green House Homes | 15.9 mi | ★★★★★ | 5 | 0 |
| Complete Care At Christian Home Llc | 16.3 mi | ★★★★★ | 13 | 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.