Whisperwood Nursing & Rehabilitation Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

be able to give the investigator accurate information. LVN B stated an incident of the same nature involving Resident #1 and Resident #2 would have been an incident that she would notify family of. LVN B stated she had been trained on the facility's abuse policy recently (within the past 30-60 days) by the ADM, DON and ADON. LVN B stated it was her responsibility to notify family and or responsible party of any significant events involving the residents that resided at the facility.The facility staff (The ADM and Regional Nurse Consultant) did not provide a policy regarding notification to responsible parties. The facility did provide a policy regarding notification to the physician on 08/22/25 at 12:16 PM. A request for notification to the family was requested on 08/22/25 at 2:16 PM. As of 8/29/25 the policy for notification to the family was not provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Whisperwood Nursing & Rehabilitation Center

5502 W 4th St Lubbock, TX 79416

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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

#2 shared the same room after the incident up until she was instructed to place Resident #2 on 1:1 supervision. LVN B stated no other incidents occurred with Resident #1 and Resident #2 after the verbal incident on the unknown date that she was aware of. She stated before the incident that occurred with Resident #1 and Resident #2, she had received training on the facility's ANE policy.During the investigation held on 8/14/25-8/15/25 there were no observation of any interactions between Resident #1 and Resident #2. Resident #1 and Resident #2 were observed in their separate rooms during the visit. Record review of

the facility's Form 3614 (Provider Investigation Report), dated 7/17/25, revealed:Incident Date: 7/11/25Person(s) or Resident(s) involved:Resident #1 Alleged Perpetrator: None listed.Witnesses:CNA ADescription of the Allegation: Resident #1's roommate cusses at her and tries to make her clean up the bathroom. Assessment:7/13/25: Resident has no injuries. Provider Response: Resident #2 was placed on one-to-one monitoring immediately upon receiving report from Resident #1's family. Resident #1 was assessed for any injuries-none noted. Physician notified. Family, physician and psychiatry notified for Resident #2.Investigation Summary: Resident #1's family reported to LVN B, that they had been finding Resident #1 bathroom with bowel and urine on the floor and they had been bringing toilet paper because

she had not had toilet paper and sometimes paper towels. LVN B notified the ADM via phone of the concern. The ADM later received a call from Family Member B stating what family had reported and added that Resident #2 had been yelling and cussing at Resident #1. LVN B was aware that one evening she heard raised voices and sent CNA A to see what was going on but nothing was ever reported to LVN B about cussing or demanding residents to het on her knees and clean up the bathroom. CNA A was suspended pending investigation and will be terminated for failure to report. Both residents lack capacity to m[TRUNCATED]

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Whisperwood Nursing & Rehabilitation Center

5502 W 4th St Lubbock, TX 79416

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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

because CNA A did not report the details of the incident between Resident #1 and Resident #2 to LVN B.

The ADM stated the potential negative outcome for not notifying family was the family would not be aware of issues and they are supposed to be aware of issues concerning their resident. The ADM stated if CNA A would have notified the LVN B then LVN B could have notified Resident #1's family. The ADM stated the reason Resident #1's family was not notified was because CNA A did not report the details of the incident to LVN B. The ADM stated the potential negative outcome for not reporting to the abuse coordinator was

the abuse coordinator would not know. The ADM stated with the abuse coordinator not knowing of an incident then they would not be able to report to HHSC timely to HHSC. The ADM stated the reason the incident was not reported to HHSC timely was because CNA A did not report to the incident to LVN B or to her timely. The ADM stated the potential negative outcome for not reporting to HHSC would be a thorough investigation may not be conducted. The ADM stated the reason that the incident was not reported to HHSC timely was because CNA A did not report the details to LVN B or to her as the abuse coordinator.

The ADM stated the potential negative outcome for not implementing protective measures for a resident

after an incident would be resident safety could be affected. The ADM stated protective measures are put in place to ensure that the resident is safe. The ADM additionally stated that she also ensures that protective measures were put in place by initiating 1:1 supervision until other protective measures can be put in place.

The ADM stated protective measures were not put in place for Resident #1 because CNA A did not report

the incident details to LVN B. During an interview on 8/15/25 at 5:42 PM, the DON stated regarding the failure to prevent abuse that she was familiar with the facility's ANE policy. The DON stated the purpose of pr[TRUN

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Whisperwood Nursing & Rehabilitation Center

5502 W 4th St Lubbock, TX 79416

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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

right now. I'm sick of this shit. LVN B had asked me to go see who she was talking to. I walked to the door and saw Resident #1 standing in front of Resident #2. I motioned for Resident #1 to come out in the hall. I then told LVN B she was talking to Resident #1. LVN B then asked Resident #2 what was going on and Resident #2 stated Resident #1 had peed on the bathroom floor and had done it before, and she wanted her to clean it up. LVN B told Resident #2 that Resident #1 could not do that because she could fall. I had went to get a towel to clean up the urine and Resident #2 stated to me that Resident #1 needed to get on her hands and knees and clean that shit up because she was tired of her doing that. I had advised Resident #2 that Resident #1 was not able to do so. I told Resident #2 if it happened again for her to let me or any aide that is on the hall and we would clean it up. Resident #2 then told me as long as we keep babying her and not making her clean up her mess then she would never stop. I walked out of the room and nothing more was said. Record review of Resident #2's 1:1 monitoring supervision sheet, dated 7/13/25-, revealed:Resident #2 was on 1:1 monitoring from 7/13/25 at 9:49 PM until 7/14/25 at 4:45 AM.Record

review of CNA Record review of staff (LVN BB), undated, witness statements that revealed they had never observed Resident #2 being mean or rude to Resident #1.Record review of staff (CNA Z) written statement, undated, revealed she was not sure of the date, but she heard Resident #2 tell Resident #1 tell Resident #1 to clean up the bathroom, or she would make her and then she would kick her butt. The statement stated Resident #2 told Resident #1 she knew what she was doing. Record review of staff (CNA HH), dated 7/14/25, witness statements that revealed they had never observed Resident #2 being mean or rude to Resident #1.Record review of LVN B's written statement, dated, 7/16/25, revealed she (LVN B) was in the room assisting another resident in the restroom

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Whisperwood Nursing & Rehabilitation Center

5502 W 4th St Lubbock, TX 79416

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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

terminated for failure to report. Both residents lack capacity to make informed decisions. Room changes were done, and Resident #2 remained one to one until the room changes were done. Referral was made to

the behavior center for Resident #2. No issues since Resident #2 does not have a roommate. Facility Investigation Findings: UnconfirmedProvider Action Taken Post-Investigation: Continue to monitor resident and re-education with staff on abuse, neglect and reporting procedures.Record review of CNA A's witness statement, dated 7/14/25, revealed: I was in the room talking to my nurse, LVN B, when I heard Resident #2 yelling and cussing, saying Get your fucking ass in that goddamn bathroom and clean up that mess right now. I'm sick of this shit. LVN B had asked me to go see who she was talking to. I walked to the door and saw Resident #1 standing in front of Resident #2. I motioned for Resident #1 to come out in the hall. I then told LVN B she was talking to Resident #1. LVN B then asked Resident #2 what was going on and Resident #2 stated Resident #1 had peed on the bathroom floor and had done it before, and she wanted her to clean

it up. LVN B told Resident #2 that Resident #1 could not do that because she could fall. I had went to get a towel to clean up the urine and Resident #2 stated to me that Resident #1 needed to get on her hands and knees and clean that shit up because she was tired of her doing that. I had advised Resident #2 that Resident #1 was not able to do so. I told Resident #2 if it happened again for her to let me or any aide that is on the hall and we would clean it up. Resident #2 then told me as long as we keep babying her and not making her clean up her mess then she would never stop. I walked out of the room and nothing more was said. Record review of Resident #2's 1:1 monitoring supervision sheet, dated 7/13/25-, revealed:Resident #2 was on 1:1 monitoring from 7/13/25 at 9:49 PM until 7/14/25 [TRUNCATED]

Event ID:

Facility ID:

If continuation sheet