White Oak Manor - Burlington

Inspectors wroteBased on record review and staff interviews, the facility failed to develop a baseline care plan that addressed the resident's immediate needs related to a diagnosis of post-traumatic stress disorder (PTSD) for 1 of 1 resident reviewed for mood and behavior (Resident #125).

Inspectors wroteBased on observation, record review, and staff and resident interviews, the facility failed to follow therapy recommendations to apply a soft hand splint for 1 of 4 sampled residents (Resident #3) reviewed for positioning and mobility.

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain daily nurse staffing sheets for 5 of 62 days reviewed for daily posted nurse staffing information (7/25/25, 7/29/25, 8/3/25, 8/11/25 and 8/15/25).

Inspectors wroteBased on record review, and interviews with staff, Physician, and Nurse Practitioner, the facility failed to ensure the physician was notified when Resident # 3 was initially identified by Nurse Aide # 5 to have discomfort with positioning, swelling, and bruises on his arm and chest with no known cause and while the resident was not receiving an anticoagulant. The physician was not notified until the following shift. When Resident # 3's physician was notified and a complete assessment was conducted, multiple bruises were found on both arms and the resident's chest which was a broader area than had been reported by Nurse Aide # 5 when she identified bruising. The bruising was irregular in shape and included both red and purple bruising. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to implement their abuse policy for employees who worked in the capacity of a licensed nurse by not screening and verifying Employee #1's credentials prior to hiring her as a licensed nurse and allowing her to perform licensed nurse duties for which she had no documented education or nursing license. Employee #1 provided the facility nurse license information for an individual she found online with a name that was similar to her own and she worked at the facility in the role of a licensed nurse from 11/5/24 until her termination on 2/6/25. During this timeframe, Employee #1 had resident assignments and performed licensed nurse responsibilities that she was not qualified to provide. [...]

Inspectors wroteBased on record review, and interviews with staff, physician, and Nurse Practitioner, the facility failed to ensure Resident # 3 was initially assessed by a nurse after Nurse Aide # 5 identified the resident to have discomfort with positioning, swelling, and bruises on his arm and chest with no known cause and while the resident was not receiving an anticoagulant. When Resident # 3's was assessed the following shift by the physician multiple bruises were found on both arms and the resident's chest which was a broader area than had been reported by Nurse Aide # 5. The bruising was irregular in shape and included both red and purple bruising. The bruises continued to spread and two days following the initial identification of the bruises, Resident # 3 was seen in the ED (Emergency Department) where a CT (Computed Tomography) of the chest abdomen and pelvis with contrast was completed. [...]

Inspectors wroteBased on record review and staff and Physician interviews the facility failed to have a system in place to ensure staff who were hired as nurses were trained and competent to perform their job duties. Employee #1, who was not licensed as a nurse and had no documented nursing education, worked at the facility in the role of a licensed nurse from 11/5/24 until her termination on 2/6/25. Her job duties included, but were not limited to: insulin administration, blood sugar monitoring, medication administration, assessments of a resident who sustained falls while on an anticoagulant (blood thinner), and utilizing nursing judgement to make decisions. These job duties required knowledge and education to perform safely. There was no documented competency evaluation completed for Employee #1's job duties or nursing skills. [...]

Inspectors wroteBased on observation, record review, and interview with residents, staff, Physician, and Nurse Practitioner the facility failed to protect Resident #3's right to be free of an injury of unknown source; and abuse/neglect. Resident # 3, who was a cognitively impaired resident, was identified to have significant bruises on his arm and chest which wrapped around his torso on 12/18/24. The bruises were also accompanied by swelling and discomfort with positioning when initially found. Staff reported they had not observed any incident which had caused the bruises. The resident could not provide detailed information about how the bruises occurred, and the extent of the bruising without a known cause indicated a suspicion of neglect or abuse. [...]

Inspectors wroteBased on record review, resident interview, staff interview and Physician Interview the facility failed to complete a thorough investigation related to unexplained swelling, discomfort, and bruising Resident # 3 experienced although there had been no reported accident and the resident was not on an anticoagulant. [...]

Inspectors wroteBased on resident interviews, staff interview and record review, the facility failed to protect a resident's right to be free from abuse for 1 of 5 residents reviewed for physical abuse. Resident #84 was sent to the emergency room for evaluation due an injury. Resident #84 was hit in the mouth resulting in treatment with Dermabond on his upper lip and a referral was sent to the dentist due to missing tooth on the resident's bridge. (Resident # 84).

Inspectors wroteBased on record review and staff interviews, the facility failed to protect the residents' right to be free from misappropriation of a controlled substance medication, oxycodone, which was prescribed for Resident #9 and a combination medication containing oxycodone and acetaminophen prescribed to treat pain which was prescribed for Resident #225. The facility also failed to protect a resident's right to be free from the misappropriation of a bottle of alcohol prescribed for the resident (Resident #42). This occurred for 3 of 3 residents reviewed for misappropriation of property.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to follow their policy on Neglect, Abuse, Mistreatment, Threatened or Alleged Abuse of Residents to maintain documented evidence of a thorough investigation of an allegation of abuse for 1 of 5 residents (Resident #175) reviewed for abuse and of an allegation related to the misappropriation (diversion) of medication for 1 of 3 residents (Resident #225) reviewed for the misappropriation of property. The facility also failed to implement measures to prevent further potential for abuse and maintain documented evidence of the corrective action taken after the misappropriation was verified (including whether more systemic actions were necessary to prevent recurrence of the situation) during these investigations. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to label and date foods brought in by resident's family member and failed to maintain the nourishment refrigerators clean for 3 of 3 Nourishment refrigerators (Nourishment refrigerator #1, Nourishment refrigerator #2 and Nourishment refrigerator #3). The facility failed to maintain the ice scoop clean in 1 of 3 nourishment rooms (C wing Nourishment room). These practices had the potential to affect food served to residents.

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to provide nail care to a resident dependent on staff. This occurred for 1 of 4 residents (Resident #16) reviewed for activities of daily living (ADL) care.

Inspectors wroteBased on record review and interviews with the Responsible Party and facility staff the facility failed to ensure 1 of 1 resident (Resident #76) was transported to a scheduled oncology follow-up appointment.

Inspectors wroteBased on staff and consultant pharmacist interviews and record reviews, the facility failed to: 1) Maintain documentation of the pharmacist's Monthly Medication Reviews (MMRs) within the facility and readily available for review; and 2) Retain documentation of the physician's review and response to the pharmacist's findings / recommendations in the resident's medical record. This occurred for 1 of 5 residents reviewed for Unnecessary Medications (Resident #20).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure staff who performed a job responsibility of a nurse aide (NA) had completed a training and competency evaluation program and was competent to provide nursing and nursing related services when the Maintenance Director assisted NA #2 with transferring Resident #1 from her wheelchair to bed utilizing a mechanical lift on 5/16/24. This deficient practice was for 1 of 7 staff reviewed who performed nursing related services.

Inspectors wroteBased on record review and staff interviews the facility failed to use the service of a registered nurse (RN) for at least 8 consecutive hours (hrs.) a day for 4 of 52 days reviewed (5/6/23, 5/7/23, 5/13/23 and 5/14/23).

Inspectors wroteBased on record review and staff, resident and resident representative interviews, the facility failed to conduct care plan meetings with residents or resident representatives for 2 of 24 sampled residents reviewed for care plans. (Resident #91 and Resident #34)

Inspectors wroteBased on observation, resident and staff interviews and record review, the facility failed to safely transfer a resident from his bed to the wheelchair, failed to immediately notify the nurse of a fall when the resident was lowered to the floor by a staff member during the transfer and failed to investigate the cause of the fall by not interviewing the staff member who was present during the fall. This affected 1 of 11 residents (Resident #60) reviewed for accidents.

Inspectors wroteBased on record review, staff interviews, and family interview, the facility failed to notify a hospice agency when a resident enrolled in hospice had a change in his medical condition and was transferred to the hospital for 1 of 2 residents (Resident #423) reviewed for hospice.

Inspectors wroteBased on resident and staff interviews, interview with the Resident Representative and record reviews, the facility failed to provide the resident and Resident Representative a written notification for the reason for transfer to the hospital for 2 of 3 residents (Resident #60 and Resident #26) reviewed for hospitalization.

Inspectors wroteBased on record review and staff interviews the facility failed to employ a qualified Social Worker on a full-time basis from 1/12/23 to 4/2/23. Review of the daily census report revealed the census was greater than 120 for 56 of the 82 days reviewed.