White Oak Manor - Charlotte

Inspectors wroteBased on observations, record review, and interviews with the Nurse Practitioner (NP) and staff, the facility failed to prevent a resident with severe cognitive impairment, wandering and exit seeking behavior and at high risk for falls, from exiting the facility unsupervised without staff's knowledge. On two consecutive nights Resident #89 exited the facility through an unlocked emergency exit door near the back of the facility that was in working order, but the door had been manually unlocked, and the door alarm had been turned off with a key and therefore did not alarm. On 6/28/25 at an undetermined time early in the morning (it was still dark outside) Nurse #1 noticed Resident #89 was not walking in the hallway and was not in his room. [...]

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to label and date leftover food items stored for use, keep a food preparation area clean and orderly and store a scoop without the potential for cross-contamination. These practices occurred in 1 of 2 walk-in coolers, 1 of 1 food preparation areas, and 3 of 3 Nourishment rooms (Nourishment room [ROOM NUMBER], Nourishment room [ROOM NUMBER], Nourishment room [ROOM NUMBER]). These practices had the potential to affect food served to residents.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to maintain a resident's dignity when Nurse Aide (NA) #6 quickly pulled Resident #67 backward down the hall approximately 30 feet from the day room to her room while reclined in a geriatric chair for 1 of 3 sampled residents reviewed for dignity (Resident #67). A reasonable person would have expected to be treated with dignity and would have wanted to be wheeled forward in their geriatric chair.

Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility failed to provide hair washing services for 1 of 3 dependent residents reviewed for activities of daily living (ADL) (Resident #144).

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to follow their infection control policies and procedures for Enhanced Barrier Precautions (EBP) when Nurse #5 did not wear a gown while providing catheter care for Resident #132 and Nurse Aide (NA) #3 and NA #4 failed to wear a gown while conducting a mechanical lift transfer of Resident #161 who had a feeding tube. The deficient practice occurred for 3 of 10 staff members observed for infection control practices (Nurse #5, NA #3, and NA #4).

Inspectors wroteBased on record review, and staff and Medical Director interviews, the facility failed to correctly transcribe a verbal physician's order for twice daily blood sugar checks resulting in no blood sugar checks being performed during a resident's admission. This affected 1 of 3 residents reviewed for services provided meet professional standards (Resident #3).

Inspectors wroteBased on observations, and resident, staff, Family Member #1, and Pest Control Representative interviews, the facility failed to effectively manage pests in 1 of 3 resident rooms (Resident #1) reviewed for pest control and for 1 of 1 observation for pest control in the conference room.

Inspectors wroteBased on record review and interviews with the Family Member, facility staff, Nurse Practitioner, and Medical Director, the facility failed to resume Eliquis, an anticoagulant commonly known as blood thinner, for Resident #1. Upon admission in March 2025, Resident #1 was prescribed Eliquis due to a history of deep vein thrombosis and pulmonary embolus. The medication was temporarily discontinued on 7/2/2025, in preparation for a scheduled medical procedure performed on 7/7/2025. However, the facility did not restart Eliquis until 10/1/2025, nearly three months later, after the resident began exhibiting symptoms including shortness of breath, bilateral lower extremity (BLE) edema, and a need for supplemental oxygen. [...]

Inspectors wroteBased on record review, and staff, Nurse Practitioner, and Physician interviews, the medical providers failed to review the total plan of care and ensure the medication list on the Nurse Practitioner and Physician progress notes were accurate for 1 of 3 residents reviewed to ensure the facility is free of medication errors (Resident #1).

Inspectors wroteBased on record review and interviews with the Consultant Pharmacist, Nurse Practitioner, Medical Director and Director of Nursing, the facility's Consultant Pharmacist failed to identify a significant lapse in anticoagulant therapy. Specifically, Eliquis (an anticoagulant, also known as a blood thinner) was discontinued on 7/2/25 for a surgical procedure and was not resumed until 10/1/25. This interruption in therapy was not addressed in the drug regimen reviews following the procedure, thereby failing to ensure the continuation of chronic anticoagulant treatment for Resident #1. This deficient practice was identified in 1 of 3 residents reviewed for unnecessary medications (Resident #1).

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure dishware (divided plates and bowls) were clean for use for 1 of 1 meal service observation and failed to ensure the plate warmer was free of food debris. This practice had the potential to affect food served to residents.

Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to provide a safe transfer for 1 of 6 residents reviewed for accidents (Resident #51).

Inspectors wroteBased on observations, record reviews, resident, staff, and Physician Assistant (PA) interviews, the facility failed to ensure oxygen was delivered at the prescribed rate (Resident #41 & Resident #101). These deficient practices occurred for 2 of 2 residents reviewed for respiratory care and services.

Inspectors wroteBased on record reviews, observations and staff interviews, the facility failed to discard expired medications in 1 of 2 medication rooms (South Hall Medication Room) and failed to store a lidded container of prescription topical medicated cream that treats fungal infections in a secure locked storage area for 1 of 1 resident observed with medicated cream at the bedside (Resident #126).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to follow their Hand Hygiene policy when the Treatment Nurse did not perform hand hygiene before each donning of clean gloves while providing wound care to Resident #63. This deficient practice occurred for 1 of 5 staff members observed for infection control practices (Treatment Nurse).

Inspectors wroteBased on observations, resident, family and staff interviews and record review, the facility failed to provide a dignified dining experience when Nurse Aide (NA) #4 fed Resident #10 while 5 residents who were seated at the same table did not have their lunch. This failure occurred for 5 of 5 residents sampled for dignity (Residents #8, #39, #119, #70 and #100). The reasonable person concept was applied as individuals have the expectation of dining in a dignified environment.

Inspectors wroteBased on record review, policy review, resident and staff interviews, the facility failed to provide a written decision/resolution regarding a grievance related to missing bras belonging to Resident #52 and failed to submit a grievance per the facility's grievance policy for 3 of 3 residents (Resident #52's missing supply of salad dressing, Resident #446's missing property and Resident #141's concerns related to a disrespectful staff).

Inspectors wroteBased on record review, resident/ family and staff interviews, the facility failed to schedule, invite residents/representatives, and hold care plan meetings for 3 of 3 residents (#52, #28, #4) reviewed for care planning.

Inspectors wroteBased on record review interviews with the Hospital Case Manager, Veterans Affairs (VA) Case Manager and staff, the facility failed to allow a resident to return the facility after a facility-initiated transfer to the hospital for 1 of 1 (Resident #445) resident reviewed for readmission from the hospital.

Inspectors wroteBased on observations, resident and staff interviews and record review, the facility failed to honor food preferences for 2 of 2 residents reviewed for food preferences (Resident #19 and #52).

Inspectors wroteBased on observations, resident and staff interviews and record review, the facility failed to provide Resident #95 a renal diet per physician order for 1 of 1 sampled resident reviewed for therapeutic diets.