Whisperwood Nursing & Rehabilitation Center
Whisperwood Nursing & Rehabilitation Center in Lubbock, TX — inspection on August 15, 2025.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 8/15/25 at 8:45 PM, LVN B stated she was unsure of the exact date of the incident that occurred between Resident #1 and Resident #2. LVN B stated that she was in the last room at the end of the hallway assisting another resident.
She stated CNA A heard one of the residents raise their voice.
She stated she asked CNA A which resident raised their voice and was told by CNA A that it was Resident #2 and Resident #1. LVN B stated CNA A told her that Resident #2 was raising her voice at Resident #1. LVN B stated she voiced to Resident #2 that she does not need to raise her voice.
LVN B stated that was it and she left Resident #2 in her room. LVN B stated 5 minutes later both residents could not remember the incident. LVN B stated she does not know what specifically Resident #2 said to Resident #1.
She stated CNA A did not specify what was said but only stated Resident #2 was yelling at Resident #1 because there was piss on the floor. LVN B stated she did not suspect abuse because normally Resident #2 was loud resident and that was the way she talked.
She stated working on the locked unit residents have behaviors and she considered Resident #2 yelling as one of her behaviors and she needed redirection. LVN B stated Resident #1 did not appear afraid to her. LVN B stated Resident #1 went back to her room within an hour of the incident. LVN B stated that CNA A did not report to her or indicate that Resident #1 was afraid. LVN B stated after the incident between Resident #1 and Resident #2 she never had a discussion with Resident #1's family nor did she discuss the incident any further with CNA A. LVN B stated that there had not been any other incidents since the verbal incident between Resident #1 and Resident #2 nor had there been any incidents before. LVN B stated CNA A reported to the Resident #1's family that Resident #1 felt threatened by Resident #2 and that is what caused them to call the ADM. LVN B stated she did not notify the family of the incident but could not give a reason as to why because she could not remember what was going on that day to 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.
675527 08/15/2025
Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416
was raising her voice at Resident #1. LVN B stated she voiced to Resident #2 that she does not need
jeopardy to resident health or minutes later both residents could not remember the incident. LVN B stated she does not know what safety specifically Resident #2 said to Resident #1.
She stated CNA A did not specify what was said but only stated Resident #2 was yelling at Resident #1 because there was piss on the floor. LVN B stated she
talked.
She stated working on the locked unit residents have behaviors and she considered Resident #2 yelling as one of her behaviors and she needed redirection. LVN B stated Resident #1 did not appear afraid to her. LVN B stated Resident #1 went back to her room within an hour of the incident.
LVN B stated that CNA A did not report to her or indicate that Resident #1 was afraid. LVN B stated after the incident between Resident #1 and Resident #2 she never had a discussion with Resident #1's family nor did she discuss the incident any further with CNA A. LVN B stated that had not been any other incidents since the verbal incident between Resident #1 and Resident #2 nor had there been any incidents before. LVN B stated CNA A reported to the Resident #1's family that Resident #1 felt threatened by Resident #2 and that is what caused them to call the ADM.
She stated when they called the ADM, she was instructed to place Resident #2 on 1:1 supervision. LVN B stated she did not report the incident to the abuse coordinator because she felt it was a nursing judgement call to redirect Resident #2. 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.
She stated that protection of the resident(s) involved was a part of following the abuse protocol for the facility.
She stated if she did not see any protection interventions put in place that she would follow up with management and or the abuse coordinator.
LVN B stated Resident #1 and Resident #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]
675527 08/15/2025
Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416
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
675527 08/15/2025
Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416
Form 3614 (Provider Investigation Report), dated 7/17/25, revealed:Incident Date: 7/11/25Person(s)
jeopardy to resident health or the Allegation: Resident #1's roommate cusses at her and tries to make her clean up the bathroom. safety 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
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 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 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
675527 08/15/2025
Whisperwood Nursing & Rehabilitation Center 5502 W 4th St Lubbock, TX 79416
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 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]
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.