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Inspection visit

Inspection

WHITNEY NURSING AND REHABILITATION CENTERCMS #6760745 citations on this visit
5 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0641 Ensure each resident receives an accurate assessment. 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 the comprehensive assessment accurately reflected the resident's status for 11 of 18 Residents (Resident # 20, Resident # 38, Resident #47, Resident #16, Resident #3, Resident #1, Resident #10, Resident #9, Resident #28, Resident #17, and Resident #4) reviewed for accuracy of assessments, in that: Residents Affected - Some 1. Resident #20's MDS dated [DATE] reflected COVID, when the resident had not had COVID since 01/2022. 2. Resident #38's MDS date 05/13/2022 reflected sepsis, when the resident had not had sepsis since 03/2021. 3. Resident #47's MDS date 05/26/2022 reflected pneumonia and sepsis, when the resident had not had pneumonia or sepsis since 11/2021. 4. Resident #16's MDS date 04/04/2022 reflected sepsis, when the resident had not had sepsis since 04/2021. 5. Resident #3's MDS date 03/08/2022 reflected pneumonia, when the resident had not had pneumonia since 08/2020. 6. Resident #1's MDS date 06/05/2022 reflected pneumonia, when the resident had not had pneumonia since 10/2018. 7. (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 9 Event ID: 676074 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 676074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitney Nursing and Rehabilitation Center 101 San Marcus Whitney, TX 76692 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 0641 Resident #10's MDS date 03/19/2022 reflected pneumonia and sepsis, when the resident had not had pneumonia or sepsis since 12/2021. Level of Harm - Minimal harm or potential for actual harm 8. Residents Affected - Some Resident #9's MDS dated [DATE] reflected COVID, when the resident had not had COVID since 01/2022. 9. Resident #28's MDS date 03/28/2022 reflected pneumonia, when the resident had not had pneumonia since 09/2021. 10. Resident #17's MDS dated [DATE] reflected COVID and Pneumonia, when the resident had not had COVID since 12/2021 or Pneumonia since 08/2019. 11. Resident #4's MDS dated [DATE] reflected COVID, when the resident had not had COVID since 11/2020 This failure could place residents at risk of inaccurate assessments and not receiving appropriate care according to their current status. Findings include: Resident #20 Record review of the electronic face sheet on 06/09/2022 for Resident #20 revealed an admission date of 08/18/2018. Resident was a [AGE] years old male with diagnoses to include: Dementia, blood pressure, and muscle weakness. Record review of MDS dated [DATE] for Resident #20 reveals a BIMS score of 8 indicating moderately impaired cognitive skills for daily decision making. Further review of MDS Section I Active Diagnoses revealed COVID 19. Record review of electronic physician's orders dated 02/01/2022 to 06/09/2022 for Resident #20 revealed no orders for treatment of COVID. Record review of electronic progress notes from 02/01/2022 to 06/09/2022 for Resident #20 revealed no documentation of COVID and no signs and symptoms of COVID. Record review of lab results from 02/01/2022 to 06/09/2022 for Resident #20 revealed no lab work to diagnosis COVID. Record review of diagnostics test from 02/01/2022 to 06/09/2022 for Resident #20 revealed no test to diagnosis COVID. Record review of active care plan for Resident #20 revealed resident had been diagnosed with COVID (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676074 If continuation sheet Page 2 of 9 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 676074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitney Nursing and Rehabilitation Center 101 San Marcus Whitney, TX 76692 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 0641 on 01/13/2022 and recovered 01/20/2022. Level of Harm - Minimal harm or potential for actual harm Resident #38 Residents Affected - Some Record review of the electronic face sheet on 06/09/2022 for Resident #38 revealed an admission date of 03/02/2021. Resident was an [AGE] year-old female with diagnoses to include: Dementia, stomach bleed, Sepsis (major infection), and low potassium. Record review of MDS date 05/13/2022 for Resident #38 reveals a BIMS score of 09 indicating moderately impaired cognitive skills for daily decision making. Further review of MDS Section I Active Diagnoses revealed Sepsis. Record review of the electronic physician's orders from 01/01/2022 to 06/09/2022 for Resident #38 revealed no orders to test for or to treat sepsis. Record review of electronic progress notes from 01/01/2022 to 06/09/2022 for Resident #38 revealed no documentation of sepsis and signs and symptoms of sepsis. Record review of lab results from 01/01/2022 to 06/09/2022 for Resident #38 revealed no lab work to diagnosis sepsis. Record review of diagnostics test from 01/01/2022 to 06/09/2022 for Resident #38 revealed no test to diagnosis sepsis. Record review of active care plan for Resident #38 revealed no documentation of sepsis or interventions to treat or prevent sepsis. Resident #47 Record review of the electronic face sheet on 06/09/2022 for Resident # 47 revealed an admission date of 11/16/2021. Resident was an [AGE] years old male with diagnoses to include: Pneumonia, Sepsis, Lung disease, and heart failure. Record review of MDS date 05/26/2022 for Resident #47 reveals a BIMS score of 99 indicating severely impaired cognitive skills for daily decision making. Further review of MDS Section I Active Diagnoses revealed Sepsis and Pneumonia. Record review of the electronic physician's orders from 01/01/2022 to 06/09/2022 for Resident #47 revealed no orders to test for or to treat sepsis or pneumonia. Record review of electronic progress notes from 01/01/2022 to 06/09/2022 for Resident #47 revealed no documentation of sepsis or pneumonia and no signs and symptoms of sepsis or pneumonia. Record review of lab results from 01/01/2022 to 06/09/2022 for Resident #47 revealed no lab work to diagnosis sepsis or pneumonia. Record review of diagnostics test from 01/01/2022 to 06/09/2022 for Resident #47 revealed no test to diagnosis sepsis or pneumonia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676074 If continuation sheet Page 3 of 9 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 676074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitney Nursing and Rehabilitation Center 101 San Marcus Whitney, TX 76692 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of active care plan for Resident #47 revealed no documentation of sepsis or pneumonia or interventions to treat or prevent sepsis or pneumonia. Resident #16 Record review of the electronic face sheet on 06/09/2022 for Resident #16 revealed an admission date of 04/12/2021. Resident was a [AGE] years old female with diagnoses to include: Alzheimer's, Respiratory Failure, and fractur of sacrum. Record review of MDS date 04/04/2022 for Resident #16 reveals a BIMS score of 04 indicating severely impaired cognitive skills for daily decision making. Further review of MDS Section I Active Diagnoses revealed Sepsis. Record review of the electronic physician's orders from 01/01/2022 to 06/09/2022 for Resident #16 revealed no orders to test for or to treat sepsis. Record review of electronic progress notes from 01/01/2022 to 06/09/2022 for Resident #16 revealed no documentation of sepsis and no signs and symptoms of sepsis. Record review of lab results from 01/01/2022 to 06/09/2022 for Resident #16 revealed no lab work to diagnosis sepsis. Record review of diagnostics test from 01/01/2022 to 06/09/2022 for Resident #16 revealed no test to diagnosis sepsis. Record review of active care plan for Resident #16 revealed no documentation of sepsis or interventions to treat or prevent sepsis. Resident #3 Record review of the electronic face sheet on 06/09/2022 for Resident #3 revealed an admission date of 06/09/2018. Resident was a [AGE] year-old female with diagnoses to include: heart failure, kidney failure, and diabetes. Record review of MDS date 04/08/2022 for Resident #3 reveals a BIMS score of 12 indicating moderate impaired cognitive skills for daily decision making. Further review of MDS Section I Active Diagnoses revealed Pneumonia. Record review of the electronic physician's orders from 01/01/2022 to 06/09/2022 for Resident #3 revealed no orders to test for or to treat pneumonia. Record review of electronic progress notes from 01/01/2022 to 06/09/2022 for Resident #3 revealed no documentation of pneumonia and no signs and symptoms of pneumonia. Record review of lab results from 01/01/2022 to 06/09/2022 for Resident #3 revealed no lab work to diagnosis pneumonia. Record review of diagnostics test from 01/01/2022 to 06/09/2022 for Resident #3 revealed no test to diagnosis pneumonia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676074 If continuation sheet Page 4 of 9 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 676074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitney Nursing and Rehabilitation Center 101 San Marcus Whitney, TX 76692 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of active care plan for Resident #3 revealed no documentation of pneumonia or interventions to treat or prevent pneumonia. Resident #1 Record review of the electronic face sheet on 06/09/2022 for Resident #1 revealed an admission date of 03/30/2015. Resident was a [AGE] year-old female with diagnoses to include: Dementia, fractured femur, High blood pressure, and depression. Record review of MDS date 06/05/2022 for Resident #1 reveals a BIMS score of 03 indicating severely impaired cognitive skills for daily decision making. Further review of MDS Section I Active Diagnoses revealed Pneumonia. Record review of the electronic physician's orders from 01/01/2022 to 06/09/2022 for Resident #1 revealed no orders to test for or to treat pneumonia. Record review of electronic progress notes from 01/01/2022 to 06/09/2022 for Resident #1 revealed no documentation of pneumonia and no signs and symptoms of pneumonia. Record review of lab results from 01/01/2022 to 06/09/2022 for Resident #1 revealed no lab work to diagnosis pneumonia. Record review of diagnostics test from 01/01/2022 to 06/09/2022 for Resident #1 revealed no test to diagnosis pneumonia. Record review of active care plan for Resident #1 revealed no documentation of pneumonia or interventions to treat or prevent pneumonia. Resident #10 Record review of the electronic face sheet on 06/09/2022 for Resident # 10 revealed admission date 10/02/2019. Resident was a [AGE] year-old female with diagnoses to include: Dementia, difficulty swallowing, left eye vison loss, and heartburn. Record review of MDS date 05/19/2022 for Resident #10 reveals a BIMS score of 02 indicating severely impaired cognitive skills for daily decision making. Further review of MDS Section I Active Diagnoses revealed Sepsis and Pneumonia. Record review of the electronic physician's orders from 01/01/2022 to 06/09/2022 for Resident #10 revealed no orders to test for or to treat sepsis or pneumonia. Record review of electronic progress notes from 01/01/2022 to 06/09/2022 for Resident #10 revealed no documentation of sepsis or pneumonia and no signs and symptoms of sepsis or pneumonia. Record review of lab results from 01/01/2022 to 06/09/2022 for Resident #10 revealed no lab work to diagnosis sepsis or pneumonia. Record review of diagnostics test from 01/01/2022 to 06/09/2022 for Resident #10 revealed no test to diagnosis sepsis or pneumonia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676074 If continuation sheet Page 5 of 9 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 676074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitney Nursing and Rehabilitation Center 101 San Marcus Whitney, TX 76692 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of active care plan for Resident #10 revealed no documentation of sepsis or pneumonia or interventions to treat or prevent sepsis or pneumonia. Resident #9 Record review of the electronic face sheet on 06/09/2022 for Resident #9 reveled admission date 01/02/2021. Resident was a [AGE] years old female with diagnoses to include: Dementia, chest pain, diabetes, and high blood pressure. Record review of MDS dated [DATE] for Resident #9 reveals a BIMS score of 03 indicating severely impaired cognitive skills for daily decision making. Further review of MDS Section I Active Diagnoses reveled COVID 19. Record review of electronic physician's orders dated 02/01/2022 to 06/09/2022 for Resident #9 revealed no orders for treatment of COVID. Record review of electronic progress notes from 02/01/2022 to 06/09/2022 for Resident #9 revealed no documentation of COVID and no signs and symptoms of COVID. Record review of lab results from 02/01/2022 to 06/09/2022 for Resident #9 revealed no lab work to diagnosis COVID. Record review of diagnostics test from 02/01/2022 to 06/09/2022 for Resident #9 revealed no test to diagnosis COVID. Record review of active care plan for Resident #9 revealed resident had been diagnosed with COVID on 01/21/2022 and recovered 02/01/2022. Resident #28 Record review of the electronic face sheet on 06/09/2022 for Resident #28 revealed admission date 09/07/2021. Resident was a [AGE] year-old male with diagnoses to include: low heart rate, pacemaker, lung disease, and heart failure. Record review of MDS date 05/28/2022 for Resident #28 reveals a BIMS score of 12 indicating no impaired cognitive skills for daily decision making. Further review of MDS Section I Active Diagnoses revealed Pneumonia. Record review of the electronic physician's orders from 01/01/2022 to 06/09/2022 for Resident #28 revealed no orders to test for or to treat pneumonia. Record review of electronic progress notes from 01/01/2022 to 06/09/2022 for Resident #28 revealed no documentation of pneumonia and no signs and symptoms of pneumonia. Record review of lab results from 01/01/2022 to 06/09/2022 for Resident #28 revealed no lab work to diagnosis pneumonia. Record review of diagnostics test from 01/01/2022 to 06/09/2022 for Resident #28 revealed no test to diagnosis pneumonia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676074 If continuation sheet Page 6 of 9 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 676074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitney Nursing and Rehabilitation Center 101 San Marcus Whitney, TX 76692 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of active care plan for Resident #28 revealed no documentation of pneumonia or interventions to treat or prevent pneumonia. Resident #17 Record review of the electronic face sheet on 06/09/2022 for Resident #17 revealed admission date 08/21/2019. Resident was a [AGE] year-old male with diagnoses to include: Dementia, Diabetes, depression, and high blood pressure. Record review of MDS date 06/05/2022 for Resident #17 reveals a BIMS score of 99 indicating severely impaired cognitive skills for daily decision making. Further review of MDS Section I Active Diagnoses revealed Pneumonia and COVID. Record review of the electronic physician's orders from 01/01/2022 to 06/09/2022 for Resident #17 revealed no orders to test for or to treat pneumonia or COVID. Record review of electronic progress notes from 01/01/2022 to 06/09/2022 for Resident #17 revealed no documentation of pneumonia or COVID and no signs and symptoms of pneumonia or COVID. Record review of lab results from 01/01/2022 to 06/09/2022 for Resident #17 revealed no lab work to diagnosis pneumonia or COVID. Record review of diagnostics test from 01/01/2022 to 06/09/2022 for Resident #17 revealed no test to diagnosis pneumonia or COVID. Record review of active care plan for Resident #17 revealed no documentation of pneumonia or COVID or interventions to treat or prevent pneumonia or COVID. Resident #4 Record review of the electronic face sheet on 06/09/2022 for Resident #4 revealed admission date 01/13/2018. Resident was a [AGE] years old male with diagnoses to include: Dementia, COVID, blockage of the bladder, and high blood pressure. Record review of MDS date 03/09/2022 for Resident #4 reveals a BIMS score of 13 indicating no impaired cognitive skills for daily decision making. Further review of MDS Section I Active Diagnoses revealed COVID. Record review of the electronic physician's orders from 01/01/2022 to 06/09/2022 for Resident #4 revealed no orders to test for or to treat COVID. Record review of electronic progress notes from 01/01/2022 to 06/09/2022 for Resident #4 revealed no documentation of pneumonia or COVID and no signs and symptoms of COVID. Record review of lab results from 01/01/2022 to 06/09/2022 for Resident #4 revealed no lab work to diagnosis COVID. Record review of diagnostics test from 01/01/2022 to 06/09/2022 for Resident #4 revealed no test to diagnosis COVID. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676074 If continuation sheet Page 7 of 9 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 676074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitney Nursing and Rehabilitation Center 101 San Marcus Whitney, TX 76692 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of active care plan for Resident #4 revealed no documentation of COVID or interventions to treat or prevent COVID. During an interview on 06/08/22 at 08:30 AM the MDS Coordinator stated she just copied what carried over each quarter from the computer on to the MDS. She stated all diagnosis carried over. She stated the diagnoses should have been removed every quarter and updated. She stated she did not realize they were not being removed. During a follow up interview on 06/08/22 at 03:00 PM the MDS Coordinator stated MDS are done to submit to Medicare to receive payments. She stated they are done every 90 days to capture new diagnosis and treatments to received proper payment. She stated she gets all of her information for MDS from the computer and the diagnosis are carried over and she reviewed the nurses notes and new orders for any changes. She stated that the importance of the MDS is to get the most amount of money. She stated not removing nonactive diagnosis does not cause any problems and she never has removed them. She stated this has no actual negative impact on residents. She stated it is not a problem if old information is not removed and that it's only a problem if they do not capture new information. During an interview on 06/08/22 at 04:12 PM the DON stated she stated she does not do MDS and does not know much about the process. She stated they are done quarterly to capture any new diagnosis or treatments to get payment for them. She stated that when doing an MDS only current information should be on them. She stated her MDS nurse does not know how to remove old data, she just adds the new data. She stated she was not aware the old diagnoses were not being removed and the MDS Coordinator would learn how. She stated that claiming major infections and inaccurate diagnosis is not a problem because it does not reflect the RUG payment. Record review of the facilities policy titled, Senior Care Centers Operational/Resident Care Policies, with no date, read in part . Accuracy of Assessments: The assessment must accurately reflect the resident's status. Each resident's comprehensive assessment is conducted or coordinated by a registered nurse with the appropriate participation of health professionals. The registered nurse who conducts or coordinates each assessment shall sign and certify the completion of the assessment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676074 If continuation sheet Page 8 of 9 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 676074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitney Nursing and Rehabilitation Center 101 San Marcus Whitney, TX 76692 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to post the daily nurse staffing information at the beginning of each shift in a prominent place, readily accessible to residents and visitors that included the facility name; the total number of hours worked per shift by the registered nurses, the licensed vocational nurses, and the certified nurse aides directly responsible for resident care for the facility for 1 of 1 days reviewed for nursing staff information posting. Residents Affected - Few The facility failed to post the required staffing with hours worked daily for the public and residents. This failure could place the residents, families, and visitors at risk of not knowing the daily nurse staffing information. Findings included: During an observation on 06/08/22 at 3:35 PM no daily nursing staff information was posted in the lobby, halls to resident's rooms, or at the nurse station with the facility name, number of staff for each category or actual hours worked by RNs, LVNs and CNAs, or the facility's current census. During an observation and interview on 06/08/22 at 3:40 PM, the DON stated the ADON had the daily nurse staffing information on her door. The DON pulled a nursing schedule in a wall pocket on the outside of the ADON's office door. During an interview on 06/08/22 at 3:40 pm, the ADON stated she printed the nursing schedule daily and made it accessible to the staff by putting it in the wall pocket on the office door. Observation on 06/08/22 at 3:40 pm of ADON's door showed nursing staffing schedule did not include the CNAs. During an interview on 06/08/22 at 5:00 pm, the Medical Records Director stated she was told by state surveyors during the past 3 surveys that it was not necessary to post the information. The Medical Records Director was not able to recall the name of the person who made the statement. The Medical Records Director stated state just looked at time clock records. During an interview on 06/09/22 at 9:43 AM a request for a policy on daily nursing staff posting was made to the Administrator. She stated the facility did not have a written policy on posting nurse staffing daily. During an interview on 06/09/22 at 11:25 AM the DON stated during the relicensure/recertification survey in January 2019 the facility administration, responsible for ensuring regulations were being followed, was told that since the facility was reporting direct care staffing and census information electronically every quarter to the government as required, posting staff information daily was not necessary. During an interview on 06/09/22 at 12:13 PM with the DON, ADON, SW, and Admin, the DON stated if anyone wanted to know staffing information, she could access the information online. The SW stated not posting the information may lead to resident families wondering if there was enough staff to care for all the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676074 If continuation sheet Page 9 of 9

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Citations

5 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.

  • 0641GeneralS&S Epotential for harm

    F641 - Accuracy of Assessments

    Ensure each resident receives an accurate assessment.

  • 0732GeneralS&S Dpotential for harm

    F732 - Nurse Staffing Information

    Post nurse staffing information every day.

  • 0211GeneralS&S Dpotential for harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

  • 0700GeneralS&S Fpotential for harm

    F700 - Bed Rails

    Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.

  • 0741GeneralS&S Fpotential for harm

    F741 - The facility must have sufficient staff who provide direct services to

    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

FAQ · About this visit

Common questions about this visit

What happened during the June 9, 2022 survey of WHITNEY NURSING AND REHABILITATION CENTER?

This was a inspection survey of WHITNEY NURSING AND REHABILITATION CENTER on June 9, 2022. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at WHITNEY NURSING AND REHABILITATION CENTER on June 9, 2022?

Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure each resident receives an accurate assessment."

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.

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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.