Whitney Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the resident's right to a dignified existence for 1 of 4 residents (Residents #1) reviewed for dignity. 1. The facility failed on 01/20/2026 to promote Resident #1's dignity by dressing him with 2 diaper briefs, leading to urine leakage over his clothes when he was not changed timely. 2. The facility failed on 01/20/2026 to provide Resident #1 with a change of clothes or extra toiletries when he had to be out of the facility all day for appointments.This failure placed residents at risk of embarrassment and a loss of dignity. Findings included:Review of Resident 1's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old male admitted to the facility on [DATE]. He had the following diagnoses: neurogenic bladder (loss of bladder control due to nerve problems), high cholesterol, paraplegia (paralysis of the legs and lower body), psychotic disorder (severe mental disorder characterized by a dissociation from reality), schizophrenia…

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 observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1of 1 Medication storage room reviewed for drug storage. The facility failed to ensure 1 expired 70/30 Mix Insulin Aspart, and 2 expired Central Line Dressing Trays were removed from the medication storage room. This failure could place residents at risk for receiving medications that are not at therapeutic levels. Findings include: Observation on 12/3/25 at 2:50 PM of the Medication Storage room revealed: 2 Central Line Dressing Change Trays expired 11/30/25. 1 Bottle of 70/30 Mix Insulin Aspart opened on 9/20/25 (Discard date 10/20/25) In an interview on 12/4/25 at 11:54 AM REG stated, the facility does not have a policy for medication storage or destruction of expired medications. She stated it is just a standard expectation that expired items are discarded. In an interview on 12/4/25 at 2:21 PM MA-A stated, the facility policy on expired medications and supplies was to dispose of them in the expired medication bin and it was…

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, interviews, and record reviews the facility failed to review the risks and benefits of bed rails and enabler/grab bars (smaller 1/8 size bars affixed to the bed frame used by the person in bed to reposition themselves), with the resident or resident representative and obtain informed consent prior to installation for six (Residents #7, #11, #26, #29, #41, and #143) of six resident rooms observed and reviewed for bed rails/grab bars. The facility failed to have evidence of informed consent, assessment of the resident for risk of entrapment, and care planning for the quarter bed rails/enabler bars for Residents #7, #11, #26, #29, #41, and #143. This failure could affect residents who used bed rails/enabler bars at risk of the resident/responsible party not being aware of the risks, informed consent not being obtained from the resident or responsible party, physician not being aware of use of the enabler/grab bars, and care plan not being properly documented. Findings included: Resident #7:…

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, facility failed to ensure the medication error rate was not 5 percent (5%) or greater for 2 of 31 opportunities resulting in a 6.14 % medication error rate for two of nine residents observed for medication pass (Resident #24 and Resident #96). 1. The facility failed to ensure Resident #24's insulin was administered according to the sliding scale as physician ordered by LVN B 2. The facility failed to ensure Resident #96's blood pressure medication Metoprolol was held and not administered by MA D as physician had order for blood pressure reading of 105/65. These failures could place residents at risk for significant medication errors and jeopardize the resident health and safety. Finding included: 1.Resident #24 Review of Resident #24's face sheet, dated [DATE], reflected she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included respiratory failure with hypoxia (the body not receiving enough oxygen), unspecified convulsions…

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, interviews, and record review, the facility failed to in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for one of two nurse medication carts (Cart A) and one of two med aide medications cart (Cart B) that were reviewed for security and storage of drugs and biologicals. The facility failed to ensure nurse medication Cart A had dated insulin and unexpired insulin in it for Resident # 24, and Resident #25 per manufactueres recommendation to be used in 28 days after opening the insulin. The facility failed to ensure MA D locked and secured medication Cart B when it was unattended and out of view while inside Resident # 96's room. This failure could place residents at risk of having access to unauthorized medications, drug diversions, and could lead to possible harm. Findings included: Resident #24 Review of Resident #24's face sheet, dated [DATE],…

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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for four of ten residents (Residents #1, #6, #17, and #143) reviewed for infection control. 1.The facility failed to ensure MA D sanitized blood pressure cuff in-between residents use on Residents # 1, #6, and Resident #17. 2.The facility failed to ensure LVN A wore PPE for EBP, cleaned bedside table, and performed hand hygiene during catheter care for Resident #143. These failures could place residents at risk of infectious diseases and cross contamination. Findings included: 1. Resident #1 Record review of Resident #1's face sheet dated [DATE], revealed a [AGE] year-old male that was admitted to the facility on [DATE]. His diagnoses included Epilepsy (is a seizure disorder), hypertension (high blood pressure), idiopathic…

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 each resident received an accurate assessment, reflective of the resident's status for two (Residents #24 and #32) of 24 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #24's and Resident #32's most recent comprehensive assessments did not inaccurately reflect the residents each having a urinary catheter (a tube inserted into the body to allow urine to drain). This failure could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Findings included: Review of Resident #24's admission Record, dated 09/19/24, reflected she was an [AGE] year-old female, admitted on [DATE], with diagnoses of respiratory failure with hypoxia (the body not receiving enough oxygen), unspecified convulsions, dementia, and diabetes. Review of Resident #24's MDS, dated [DATE], reflected she was usually able to understand…

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, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #24) of 8 residents reviewed for pharmacy services. The facility failed to ensure Resident #24's insulin was used within 28 days of opening date [DATE] prior to LVN B administering it. These failures could place residents at risk for medication errors, ineffective relief from pain medication, and drug diversion of controlled substances. Findings included: 1.Resident #24 Review of Resident #24's face sheet, dated [DATE], reflected she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included respiratory failure with hypoxia (the body not receiving enough oxygen), unspecified convulsions (seizure like activity), dementia (this is a brain disease that alters brain function causes cognitive decline), and…

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 ensure each resident had the right to be free from misappropriation of property for 2 of 6 residents (Resident #1 and #2) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #1's morphine sulfate (concentrate) solution 30 mg/ml, a medication to help with pain. This failure placed residents at risk for not receiving prescribed medications. Findings included: Record review of Resident #1's AR, dated 5/6/2024, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. She was diagnosed with Chronic Obstructive Pulmonary Disease (COPD, which was a respiratory condition characterized by persistent breathlessness and cough,) Alzheimer's Disease (which was a progressive disease having had caused mild memory loss, ability to carry on conversations, or the ability to respond to the environment,) and Heart Failure (which occurred when the heart muscle did not pump blood as well as it…

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 the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Resident #22, Resident #27, Resident #39) of 16 residents reviewed for ADLs (Activities of Daily Living). The facility failed to ensure Resident #22, Resident #27, and Resident #39 had their fingernails and toenails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings include: A record review of Resident #22's face sheet dated 07/27/2023 reveled: Resident #22 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of: Hypertension, Peripheral vascular disease, depression, dementia (a progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change,…

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 maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of five (CNAs B, CNA D, and LVN K) staff observed for infection control. CNAs (Certified Nursing Assistance) B, and D failed to change gloves, and perform hand hygiene during incontinence care for Resident #18. LVN (licensed Vocational Nurse) K failed to change gloves, and perform hand hygiene during blood sugar check for Resident #38 These failures could place residents at risk for infection through cross-contamination. Findings included: Review of Resident #18's face sheet, dated 07/28/2023, reflected she was a [AGE] year-old female admitted to facility 08/18/2018. Her diagnoses included Heart failure, diabetes mellitus, dementia (a progressive loss of intellectual functioning, especially with impairment of memory and…

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.