Whispering Oaks

Based on observation, staff interview, and record review, the facility failed to ensure 1. One of one walk in freezer unit was maintained in a manner to prevent frosting and heavy ice build up on shelving and packaged food items and 2. Failed to ensure one of one dish washing machine was operating within wash and rinse water temperature specification requirements. Findings included: 1. On 8/21/2023 at 9:15 a.m., an interview was conducted with Staff B, Dietary Manager and Staff C, Registered Dietician. Staff B said he had only been working at the facility for a couple of weeks. Staff C said she too was new to the facility and was only a Traveling Dietician. Staff B and Staff C confirmed there was a full time Dietician for the facility that was currently in the hiring process. An initial kitchen tour was conducted with Staff B and Staff C. During the tour, they said the dish machine did not normally operate until 10:00 a.m. as the facility is very large and each meal service took some time to complete. On 8/21/2023 at 10:18 a.m., a second kitchen tour was conducted with Staff B.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of allegations of abuse, neglect, exploitation, or mistreatment for one (Resident #113) of three sampled residents. Findings included: On 08/21/2023 at 9:00 a.m., Resident #113 was observed laying in bed holding his arm, with his covers halfway on his body. Resident # 113's arm was observed with a laceration. On 08/22/2023 at 11:00 a.m., Resident #113 was observed laying in bed with his covers on top of him. Resident # 113 arm was observed with an dirty bandage on his arm, next to the open laceration. A review of the admission record showed Resident # 113 was admitted to the facility on [DATE], with diagnoses to include but not limited to Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites, Metabolic Encephalopathy, Other Toxic Encephalopathy, Malignant Neoplasm of Peritoneum, and Uncomplicated, Chronic Kidney Disease, Stage 3A. A review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interview, the facility failed to confirm the accuracy of a Pre-admission Screening and Resident Review (PASRR) and to correct the document for seven (Residents #172, #205, #28, #81, #82, #110 and #130) of forty residents sampled when mental illness or suspected mental illness diagnoses were identified and added to the resident's medical diagnoses . Findings included: 1. Review of Resident #172's admission Record identified an original admission date of 8/27/21 and a recent admit date of 8/9/22. The review of Resident #172's Pre-admission Screening and Resident Review (PASRR), dated 8/25/21, showed the diagnoses of bipolar disorder, psychotic disorder, and substance abuse. The PASRR revealed the resident had had the following characteristics of difficulty of interpersonal functioning, concentration, persistence, and pace, and adaptation to change, recent treatment for mental illness, and exhibited actions or behaviors that may make them a danger to themselves or others.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services to prevent further decrease in range of motion for one (Resident #3) of three sampled residents. Findings included: On 8/21/2023 at 10:12 a.m., 11:45 a.m., 12:50 p.m., and 1:55 p.m., Resident #3 was observed in her room, lying flat in bed and with her head on a pillow. One quarter bed rails on both sides of the bed were up. Resident #3 had eyes closed and with the bed linen over her and covering the lower part of her body. She was not presenting with any behaviors, pain or discomfort during all observed times. Further observations revealed both of her upper extremities (hands) were contracted. Her hands were positioned and leaning on bed rails in a manner that appeared uncomfortable. Resident #3 was not interviewable. The resident was observed not wearing any splints or braces on either of her hands. On 8/22/2023 at 7:06 a.m. and 8:20 a.m., the resident was observed in bed in a flat position with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to follow physician orders related to side effect monitoring for psychotropic medications for one (Resident #161) out of five sampled residents. Findings included: The admission Record showed Resident #161 was initially admitted on [DATE] with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression, generalized anxiety disorder, and altered mental status. Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] revealed Resident #161 was rarely/never understood. Section N Medications indicated the resident took antianxiety and antidepressants for 7 days. The Order Summary Report with active orders as of 08/24/23 revealed the following orders: side effect monitoring; Ativan oral tablet 0.5 MG- Give 1 tablet by mouth (po) at bedtime for anxiety; buspirone HCL oral tablet 10 MG- Give 1 tablet po three times a day related to generalized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed and two errors were identified for two (#87 and #106) of six residents observed. These errors constituted a 8% medication error rate. Findings included: 1. On 8/22/23 at 8:55 a.m., an observation of medication administration with Staff H, Licensed Practical Nurse (LPN), was conducted with Resident #87. The staff member dispensed the following medications: - Acidophilus Probiotic 1 billion over-the-counter (OTC) capsule - Retrieved from medication refrigerator. - Amlodipine Besylate 2.5 milligram (mg) tablet - Baclofen 20 mg tablet - Vitamin D 25 microgram (mcg) - 2 tablets OTC - Loratadine 10 mg tablet OTC - Vitamin B-12 1000 mcg - 2 tablets OTC - Praxada 150 mg capsule - Potassium chloride Extended Release 20 milliequivalent (meq) - Furosemide 20 mg tablet - Gabapentin 100 mg - 2 capsules - Tamsulosin 0.4 mg capsule - Lubiprostone 24 mcg capsule - Metformin 500 mg tablet Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure 1. one (secured 400-hall) out of five treatment carts were locked while unattended by authorized personnel on two separate occasions, 2. a tube of medicated topical ointment prescribed for a resident was not left on the dresser in a room that the resident did not reside, and 3. one (2-High) out of eight medication carts did not contain an unopened vial of Insulin Lispro. Findings included: 1. On 8/21/23 at 9:28 a.m., an observation was conducted on the secured behavioral 400-hall of a treatment cart parked behind the nursing desk next to a dining/common area. The area did not have a latched gate or door and was accessible to residents, unauthorized personnel, and visitors. The observation revealed the first drawer of the treatment cart held 2 bottles of Thick Hand Sanitizer, a box that indicated it contained a tube of Hydrocortisone cream, multiple packages of denture cleanser, and a bottle of a reddish-brown liquid. The second…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that one (Resident #37) of one resident reviewed for dental services was provided with dental follow-up for missing dentures. Findings included: An interview with Resident #37 on 08/21/23 at 10:17 a.m. revealed he had broken upper and lower teeth. The resident said he had dentures and lost them. He said he thought someone was working on getting new ones, but he was not sure who was working on it. Review of the annual Minimum Data Set (MDS) dated [DATE] indicated the following: -No broken or loose fitting dentures -No cavity or broken natural teeth Review of the Nutrition Evaluation dated 6/28/23 indicated the following: -chewing problems -dysphagia A review of Resident #37's care plan showed has potential oral/dental problem dated 9/26/18. The care plan, including the interventions, had no mention of the use of dentures. A review of the dental vendor Patient Progress report dated 4/19/23 showed that Patient presents for evaluation.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure all residents/representatives was appropriately informed and provided consent for Pneumococcal and influenza vaccinations for four (Resident #59, #81, #82, #141) of five residents reviewed for immunizations. Findings included: 1. Review of Resident #59's record showed a form titled Pneumococcal & Influenza Vaccination Information & Request was present in the file. The form showed the resident requested the Pneumococcal vaccination and the annual influenza. Further review of the form indicated the form was signed by a facility representative on 10/14/22. There was no signature present from the resident or responsible party. 2. Review of Resident #81's record showed a form titled Pneumococcal & Influenza Vaccination Information & Request was present in the file. The form showed the resident declined the Pneumococcal vaccination and the annual influenza. Further review of the form showed the form was signed by a facility representative on 6/19/23. There was no signature present from the resident or responsible party.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure two (Residents #26 and #215) of 59 residents received treatment and care in accordance with professional standards of practice related to not obtaining orders for the use of a skin cream and accurately completing skin assessments for Resident #26 and not following hospital discharge orders related to a catheter and wound vac for Resident #215. Findings included: On 08/22/23 at 11:07 a.m., Resident #26 was observed in bed. A red rash was observed around her nose and on her forehead. Resident #26 stated the rash itched and staff was putting cream on it. On 08/23/23 at 9:25 a.m., Resident #26 was observed in the hallway, dressed for the day, and wearing shoes. A red rash was observed around her nose and on her forehead. Staff U, Registered Nurse (RN), was observed at the medication cart. She stated Resident #26 had dermatitis and she had a cream for it. A review of the admission Record showed Resident #26 was initially admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide enteral nutrition for one (Resident #150) out of six residents sampled for tube feeding as evidence by staff stopping the nutrition prior to the prescribed amount being infused. Findings included: On 8/21/23 at 12:50 p.m., Resident #150 was observed lying in bed with a enteral pump on an infusion pole next to the bed. The observation showed that no nutrition bottle was hanging on the pole and the pump was not running. On 8/22/23 at 11:04 a.m., Resident #150 was observed without a bottle of nutrition hanging from the infusion pole and the nutrition pump was not running. (Photographic Evidence Obtained) Review of Resident #150's admission Record revealed the resident had been admitted on [DATE] with diagnoses that included but not limited to oropharyngeal phase dysphagia, unspecified protein-calorie malnutrition, and gastrostomy status. Review of Resident #150's physician orders, completed on 8/22/23 at 1:48 p.m., revealed an order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to honor resident's rights related to their choice of food preferences for five (Residents #37, #122, #160, #171, #193) of 59 sampled residents. Findings included An interview on 8/13/21 at 12:48 p.m., with Resident #160 revealed that she was on a regular diet and loved hot dogs and missed eating hot dogs. She reported that she did not know why she could not have a hot dog. She reported that the facility said that it was a safety hazard. She said, her mother brought her some hotdogs thinking that the facility would cook them but they would not, she was told that she could buy ready cooked hotdogs from outside the facility. Review of Resident #160's record revealed that she was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE], revealed that she had a Brief Interview for Mental Status (BIMS) score of 13 (Cognitively intact), did not require her food to be mechanically altered, and had no difficulty chewing. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure that two (#36 and #68) out of five residents on one of the two secured units who required extensive assistance with eating were identified in a dignified manner. Findings included: On 8/10/2021 at 12:11 p.m., Staff Member G, 300-unit Registered Nurse/Unit Manager (RN/UM), was observed removing trays from the meal cart on the 300-secured unit and passing them to staff members who were assisting residents with the set up of their lunch meal. The RN/UM removed one tray from the cart, while an aide waited for her to pass the tray, then placed it back on the cart while identifying that Resident #36 is a feeder. The Unit Manager was observed delivering a tray into room [ROOM NUMBER], returning with the tray and stated that Resident #68 is a feeder. Staff Member G stated, on 8/10/21 at 12:26 p.m., that both Resident #36 and Resident #68 required 1:1 assistance with eating. She confirmed that she did call Resident #36 and Resident #68…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to ensure that each resident was afforded the right to personal privacy for one (Resident #168) of 59 sampled residents. Findings include: Observations of Resident #168's room on 8/10/21 at 11:28 a.m., revealed the resident lived in a 4 bed room and occupied the bed next to the window. It was noted that there were multiple broken and bent blinds at the window not allowing for privacy. Observations on 8/11/21 at 10:18 a.m., revealed that the window blinds next to Resident #168 bed were bent, broken, and not allowing for privacy. Observations on 8/12/21 at 9:27 a.m., revealed that Resident #168 was asleep in her bed and the window blinds on the window next to her bed were bent, broken, and not allowing for privacy Observations on 8/13/21 at 7:47 a.m., revealed Resident #168 lying in bed sleeping in her bed next to the window. The window blinds were bent, broken, and not allowing for privacy. Review of Resident #168's quarterly Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide a complete written notification of a Transfer & Discharge notice to the Resident representative and the Ombudsman for one (Resident #81) of five residents sampled for discharge. Findings included: Resident #81 was admitted to the facility on [DATE] according to the admission Record. On 8/11/21 at 10:11 a.m., Resident #81 was observed lying in bed. The resident was unable to speak or answer any questions related to care and was bed bound. A review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) was unable to be conducted due to Resident #81 being rarely/never understood. A review of the progress notes, dated 6/1/21 at 11:15 a.m., revealed Resident #81 had episodes of vomiting projectile coffee ground emesis times 4. The physician was notified, and the Advanced Registered Nurse Practitioner (ARNP) ordered the nurse to send the resident to the emergency room for evaluation and treatment. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to provide written notification of the facility Bed Hold Policy to the Resident representative for one (Resident #81) of five residents sampled for discharge. Findings included: A review of the facility bed hold policy (dated 6/1/21) revealed a stamp on the document stating a copy was sent with Resident #1 and a copy was mailed to the patient representative. Unable to sign was written on the document and dated by nursing on 6/1/21. A review of the policy entitled Bed hold and in-house transfer- Florida with a revised dated of February 2021, revealed the following: Policy: The facility provides the resident/resident representative notice of bed-hold in advance of transfer. An additional notice, which specifies the duration of the bed-hold, will be provided upon transfer to the hospital or prior to the therapeutic leave. The bed hold form provided at the time of discharge or therapeutic leave will be written and shall specify the duration for the bed-hold.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that resident assessments reflected the resident's status accurately for two (#29, #32) of 59 sampled residents. Findings included: 1. Observations on 8/10/21 at 11:55 a.m., revealed that Resident #29 was noted with his lower mouth sunken in. The resident opened his mouth to show his upper dentures in place and reported that his lower dentures were in the night stand top draw and that staff assist him in putting it in daily but no one had done it today. Observations of Resident #29 on 8/11/21 at 12:15 p.m., revealed the resident with his midday meal. It was noted that he did not have in his lower dentures. Observations on 8/12/21 at 9:24 a.m., revealed Resident #29 seated in the hallway by a window looking out. He reported that he had his breakfast already but that his dentures were still in his room in the drawer. He reported that he did not get any assistance with getting his dentures put in for his meal. Review of the quarterly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to revise the care plan for one (#153) out of fifty-nine sampled residents in related to the implementation of positioning devices while the resident was in bed. Findings included: Resident #153 was observed, on 8/11/21 at 9:25 a.m., lying in bed with the head of the bed raised and bilateral floor mats. During the observation, the mattress appeared to have bilateral bolsters on each side of the resident. On 8/12/21 at 4:10 p.m., the resident was observed lying in bed with bilateral mattress bolsters and no side rails were attached to the bed frame. On 8/12/21 at 5:28 p.m., an observation of Resident #153 was conducted with the Director of Nursing (DON) and the Assistant DON (ADON). The DON confirmed that the blue wedge on the left-side of the bed was removable from the mattress and not attached to the bed frames and that the rectangular bolster on the right-side of the bed was not attached to either the mattress or bed frame. On 8/13/21 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide prompt dental service when a residents dentures do not fit appropriately for one (Resident #29) of 59 sampled residents. Findings included: Observations on 8/10/21 at 11:55 a.m., revealed that Resident #29 was noted with his lower mouth sunken in. The resident opened his mouth to show his upper dentures in place and reported that his lower dentures were in the night stand top draw and that staff assist him in putting it in daily but no one had done it today. Observations of Resident #29 on 8/11/21 at 12:15 p.m., revealed the resident with his midday meal. It was noted that he did not have in his lower dentures. Observations on 8/12/21 at 9:24 a.m., revealed Resident #29 seated in the hallway by a window looking out. He reported that he had his breakfast already but that his dentures were still in his room in the drawer. He reported that he did not get any assistance with getting his dentures put in for his meal. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.