Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**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 reside and receive
services in the facility with reasonable accommodation of resident needs and preferences for 1 of 10
residents (Resident #1) reviewed for reasonable accommodations.
Residents Affected - Few
The facility failed to ensure Resident #1 was allowed to use his personal motorized wheelchair during his
stay at the facility.
This failure could place residents at risk for a loss of independence, decreased quality of life, self-worth,
and dignity.
Findings included:
Record review of Resident #1's face sheet, dated 04/15/25, indicated he was a [AGE] year-old male,
admitted to the facility on [DATE], and discharged on 02/24/25. His diagnoses included spastic quadriplegic
cerebral palsy (a severe form of cerebral palsy that affects all four limbs, leading to paralysis and muscle
stiffness), and chronic kidney disease (a long-term condition where the kidneys are damaged and can't
filter blood as effectively, leading to a buildup of waste and fluids in the body).
Record review of Resident #1's MDS assessment, dated 02/21/25, indicated he had a BIMS score of 15,
which indicated intact cognition. The assessment indicated he used a motorized wheelchair prior to his
admission. He had impairment of one of his upper extremities, and both of his lower extremities.
During an interview on 04/15/25 at 1:05 PM, the ADON said the facility did not allow the residents to use
motorized wheelchairs in the facility. She said this had been in effect since before the current corporate
entity took over. She said it has always been this way.
During an interview on 04/15/25 at 1:18 PM, the
ADON said Resident #1 had Cerebral Palsy. She said when he admitted to the facility, he used a
wheelchair for mobility. She said he had poor trunk control. She said she did not think he was able to move
the wheelchair on his own and had to be propelled when he wanted to be moved. She said he required
substantial to maximal assistance with mobility. She said a previous administrator disallowed the motorized
wheelchairs because of a previous resident that was unsafe with the motorized wheelchair. She said from
then on they would allow the residents to use a motorized wheelchair, provided that they were assessed to
be safe to use the motorized wheelchair.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
675386
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675386
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Whispering Pines Lodge
2131 Alpine Rd
Longview, TX 75601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0558
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 04/15/25 at 2:00 PM, Resident #1 said the facility did not let him use his motorized
wheelchair. He said when he arrived, he told the facility that his motorized wheelchair was on the way, and
the facility staff did not allow him to use his motorized wheelchair. He said he did not have the strength to
move his facility provided wheelchair. He said he did not like having to wait on staff to help him. He said he
was used to being independent. He said it felt like they were taking away his independence. He said he was
in the facility for about a week. He said he was frustrated about it while he was in the facility. He did not
recall who specifically did not allow him to use his motorized wheelchair.
During an interview on 04/16/25 at 9:43 AM, the ADON said the risk to not allowing residents to use
motorized wheelchairs was that residents would have to depend on staff for care and could lose their sense
of independence
During an interview on 04/16/25 at 9:56 AM, RNC A said she expected the facility to allow the resident to
use his motorized wheelchair. She said they required a safety assessment with therapy, and the motorized
wheelchair should be in working condition. She said the facility was under the impression they did not allow
wheelchairs from an administrator about 4 administrators ago. She said not allowing a resident to use their
motorized wheelchair could affect their dignity and diminish their sense of independence.
During an interview on 04/16/25 at 10:14 AM, the Administrator said she was not working in the facility
during Resident #1's stay. She said she expected the staff to allow the motorized wheelchair as long as
they are assessed by the therapy department, and were found to be safe. She said the risk was that it was
possible the resident could feel isolated from the building, socialization, and activities if they were not
allowed to use their motorized wheelchair.
Record review of the facility's undated policy, Resident Rights, stated:
The resident has a right to a dignified existence, self-determination, and communication with and access to
persons and services inside and outside the facility, including those specified in this policy.
A facility must treat each resident with respect and dignity and care for each resident in a manner and in an
environment that promotes maintenance or enhancement of his or her quality of life, recognizing each
resident's individuality. The facility must protect and promote the rights of the resident .
.Respect and dignity - The resident has a right to be treated with respect and dignity, including: .
.2. The right to retain and use personal possessions, including furnishings, and clothing, as space permits,
unless to do so would infringe upon the rights or health and safety of other residents.
3. The right to reside and receive services in the facility with reasonable accommodation of resident needs
and preferences except when to do so would endanger the health or safety of the resident or other
residents .
Record review of the facility's policy, Electric or Motorized Wheelchair, last revised 02/27/15, stated:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675386
If continuation sheet
Page 2 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675386
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Whispering Pines Lodge
2131 Alpine Rd
Longview, TX 75601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0558
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
.A Medicaid and Medicare certified [Nursing Facility] must not discriminate on the basis of disability. A
nursing facility that denies access and service to a potential resident may be found in noncompliance with
state rules and federal regulations.
It is out policy to ensure, to the best of our ability, the safety of residents who own and use an electric
wheelchair, as well as the safety of all other resident's, staff and visitors in the facility. Therefore, resident's
owning/using an electric wheelchair will be assessed on admission, quarterly and upon a significant
change of condition for their ability to guide/drive the wheelchair .
.The facility should allow a resident to store the power mobility device in the resident's room if there are no
Life Safety Codes concerns, such as blocking or limiting egress .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675386
If continuation sheet
Page 3 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675386
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Whispering Pines Lodge
2131 Alpine Rd
Longview, TX 75601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure that the resident environment remains
as free of accident hazards as is possible and each resident receives adequate supervision and assistance
devices to prevent accidents for 1 of 10 residents (Resident #2) reviewed for accidents and supervision.
The facility failed to ensure an oxygen cylinder found in Resident #2's room was properly stored.
This deficient practice could place residents at risk of injury.
Findings included:
Record review of Resident #2's face sheet, dated 04/14/25, indicated he was an [AGE] year-old male,
admitted to the facility on [DATE]. His diagnoses included pleural effusion (a condition where excessive fluid
builds up in the space between the lungs and chest wall), heart failure (occurs when the heart can't pump
enough blood to meet the body's needs), and end stage renal disease (the most severe stage of chronic
kidney disease where the kidneys can no longer adequately filter waste from the blood).
Record review of Resident #2's admission MDS assessment, dated 04/11/25, indicated he had a BIMS
score of 13, which indicated intact cognition.
During an observation and interview on 04/14/25 at 2:25 PM, Resident #2 was lying in bed in his room.
There was an oxygen tank upright on the floor in this room. The oxygen tank was not in a caddy. Resident
#2 said he was not sure how long the tank had been in his room on the floor.
During an observation on 04/14/25 at 3:10PM, the oxygen tank was still in Resident #2's room on the floor.
It was not in a caddy.
During an observation and interview on 04/14/25 at 3:26 PM, this surveyor observed LVN B carry the
oxygen tank out of Resident #2's room. She said the oxygen tank should have been stored in a caddy while
it was in the resident's room. She said it should have been in a caddy while she moved it down the hallway.
She said the tank could hurt someone if it fell down or was knocked over.
During an interview on 04/16/25 at 8:37 AM, the Maintenance Supervisor said the oxygen tanks should be
stored in a carrier or in the storage room. He said they should never be stored directly on the floor. He said
the risk was a potential explosion.
During an interview on 04/16/25 at 9:43 AM, the ADON said she expected the oxygen tanks to be stored in
the oxygen room or in a caddy. She said the tank could hurt someone or cause damage if it was knocked
over.
During an interview on 04/16/25 at 9:56 AM, RNC A said she expected the storage tanks to be secured so
they do not fall over. She said the risk was that the tank could potentially hurt someone.
During an interview on 04/16/25 at 10:14 AM, the Administrator said the oxygen tanks should be
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675386
If continuation sheet
Page 4 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675386
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Whispering Pines Lodge
2131 Alpine Rd
Longview, TX 75601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
stored properly and kept on a cart. She stated they should never be out on the floor. The Administrator
stated they could also be stored in a caddy. She said the tank could be knocked over and a resident could
potentially get hurt.
Record review of the Facility's policy, Safe Handling Of Compressed Gases, last revised 12/10/15, stated:
Residents Affected - Few
.11 . When tanks are stored, all tanks and cylinders should be stored in a cylinder cart or securely
chained in a secure storage area. Never leave cylinders free-standing. All cylinders must be
individually secured .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675386
If continuation sheet
Page 5 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675386
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Whispering Pines Lodge
2131 Alpine Rd
Longview, TX 75601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0919
Make sure that a working call system is available in each resident's bathroom and bathing area.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure residents could call for staff assistance
through a communication system which relays the call directly to a staff member or to a centralized staff
work area from each resident's bedside for 1 of 10 residents (Resident #4) reviewed for the ability to call for
staff assistance.
Residents Affected - Few
The facility failed to ensure Resident #4 had a call light that was functional. Resident #4's call light did not
turn on when the button was pressed.
This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth,
and dignity.
Findings included:
Record review of Resident #3's face sheet, dated 04/15/25, indicated she was a [AGE] year-old female,
admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a
condition caused by damage to the airways or other parts of the lung).
Record review of Resident #3's admission MDS assessment, dated 04/11/25, indicated she had a BIMS
score of 15, which indicated intact cognition.
Record review of Resident #4's face sheet, dated 04/15/25, indicated she was a [AGE] year-old female,
admitted to the facility on [DATE]. Her diagnoses included dementia (loss of brain function, including
memory, thinking, language, judgment, or behavior, that interferes with daily life), heart failure (occurs when
the heart can't pump enough blood to meet the body's needs), and major depressive disorder (a serious
mental illness that involves persistent feelings of sadness and loss of interest in activities).
Record review of Resident #4's quarterly MDS assessment, dated 03/05/25, indicated she had a BIMS
score of 7, which indicated severe cognitive impairment. She had impairment of all four extremities. She
was completely dependent on staff for toileting, bathing, lower body dressing, personal hygiene, and
bed-to-chair transfers. She required maximal assistance with upper body dressing, roll left and right, sit to
lying, and lying to sitting on side of bed. She was always incontinent of both bowel and bladder.
Record review of Resident #4's care plan, dated 04/01/25, indicated a focus of the resident was dependent
on staff for activities, cognitive stimulation, social interaction related to cognitive deficits, disease process,
and physical limitations. Interventions included ensure that adaptive equipment that the resident needs is
provided and is present and functional.
During an interview 04/15/25 at 10:17AM, Resident #3 was sitting up in bed watching TV. She said her
roommate Resident #4's call light had not been working for around 2 weeks. She said while she was in the
room, if Resident #4 needed anything, then she would press her own call light for Resident #4.
During an observation and interview on 04/15/25 at 10:22AM, Resident #4 was lying in bed resting. She
asked this surveyor if she could be changed. This surveyor pressed her call light to call for a
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675386
If continuation sheet
Page 6 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675386
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Whispering Pines Lodge
2131 Alpine Rd
Longview, TX 75601
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0919
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
staff member. The light did not turn on. This surveyor asked her roommate Resident #3 to press her light
and it then came on.
During an observation and interview on 04/15/25 at 10:27AM, CNA C came into Resident #3 and Resident
#4's room and answered the call light. She attempted to press the call light on Resident #4's side and it did
not come on. She said she would notify the maintenance department. She said the risk to the resident was
that she would be unable to call for help if she needed something or if she fell and needed help.
During an interview on 04/16/25 at 8:37AM, the Maintenance Supervisor said he checked the call lights in
at least 5 rooms each week. He said he checks the call light panel at the nurse's station daily. He said if he
notices an issue, then he checks on the lights right away. He said he was not aware of the light not working
in Resident #4's room before this surveyor noticed it was not working. He said he replaced the call light
cord in Resident #4's room and it was functional at that time. He said the risk to the resident was they could
fall and get hurt and be unable to call for help. He said someone could have a nursing related issue and be
unable to call for help. He said he had worked in the facility since the end of February. He said he was
unaware of the last time the call light was checked because it would have been before he started working
there. He said they use a maintenance request program to request the maintenance director to check
things. He said he had not received a request for the call light in Resident #4's room.
During an interview on 04/16/25 at 9:43AM, the ADON said she was not aware of the call light in Resident
#4's room not working before this surveyor pointed it out. She said it was replaced and was working. She
said the cable was bad and not working. She said the risk was that the resident could miss care she wanted
due to not being able to turn on the light. She said it was possible the resident could fall and not be able to
call for help.
During an interview on 04/16/25 at 9:56AM, RNC A said she expected the call light to be functional. She
said she expected the call light, if it was not working, to be communicated to the maintenance director to be
addressed immediately. She said the risk was that the resident's needs could not be met timely. She said it
was possible the resident could fall and not be able to call for help.
During an interview on 04/16/25 at 10:14AM, the Administrator said she expected the call lights to be
functional at all times. She said if it was not working, then staff should notify maintenance immediately. She
said the risk was that the resident could need assistance and the staff would not know to come help her.
She said it was possible the resident could fall and be unable to get help.
Record review of the facility's undated Life Safety Binder stated:
.Call Lights - Check 2 rooms a hall weekly and 100% before full book .
Record review of a sheet titled Call Lights Check, dated 03/03/25 through 04/15/25, indicated Resident #3
and Resident #4's room call lights were checked on 04/15/25. There were no other dates for Resident #3
and Resident #4's room.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675386
If continuation sheet
Page 7 of 7
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F919 - Resident Call System
Make sure that a working call system is available in each resident's bathroom and bathing area.
FAQ · About this visit
Common questions about this visit
What happened during the April 16, 2025 survey of Whispering Pines Lodge?
This was a inspection survey of Whispering Pines Lodge on April 16, 2025. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Whispering Pines Lodge on April 16, 2025?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.