White Oak Rehabilitation and Nursing Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely staff response to Resident #6's repeated verbal calls for assistance. Resident #6 called out for help for 29 minutes without staff intervention. This failure affected 1 of 1 resident reviewed for timely response to resident needs and placed the resident-who has extensive neurological, cognitive, swallowing, behavioral, and mobility related diagnoses-at risk for unmet care needs, avoidable decline, and compromised safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed infection prevention and control practices during feeding tube care for 1 of 1 residents reviewed for enteral feeding (Resident #18). Staff failed to perform hand hygiene, failed to change gloves after environmental contact, placed supplies on unclean surfaces, did not follow Enhanced Barrier Precautions, and did not check gastric residuals as ordered. These failures increased the risk of contamination and infection for a resident dependent on a gastrostomy tube.

Inspectors wroteBased on record review, observation, and interview with residents and staff, and other pertinent documents it was determined that the facility subjected residents to involuntary seclusion by restricting their ability to move freely. This was evident for 4 (Resident #17, #30, #102, #108) out of 15 residents residing in the locked area of the Med Bridge unit. Additionally, due to the restriction, Resident #108 experienced distress resulting in self-inflicted physical harm in an attempt to exit the locked unit. As a result of the non-compliance an IJ (Immediate Jeopardy) was determined on 4/25/2025 at 3:30 PM. An IJ summary tool was provided to the facility on 4/25/25. The facility submitted a draft of their plan to remove the immediacy on 4/25/25 at 6:40pm, and it was not accepted. [...]

Inspectors wrote4a. Record review of Resident #23's medical record on 4/16/25 at 10:15 AM revealed a smoking care plan was initiated on 7/27/22 and revised on 2/5/25. It indicated the resident was a dependent smoker with the goal to monitor any issues or complications and assist the resident during smoking times. Additionally, on 5/22/23 a focus area was added to the care plan that the resident was non-compliant with wearing the recommended smoking vest and following the facility smoking policy; however, the goals and/or interventions did not address the resident's noncompliance. During observation rounds 4/16/25 at 9am resident #23 was observed reclining back in the wheelchair in the courtyard located on the first floor. The resident was observed with a lit cigarette hanging from his/her mouth and was unsupervised. [...]

Inspectors wroteBased on record review and an interview, it was determined that the facility failed to ensure a Resident was offered information for an Advance Directive. This was evident for 4 (Residents #85, #108, #109, #135) out of 6 residents reviewed for Advance Directives.

Inspectors wroteDuring observation rounds on 04/16/2025 the following concerns were found: 3. At 8:09 AM room [ROOM NUMBER]: The resident bathroom sink was found to be loosely hanging from the wall and the base of the toilet, where the toilet meets the floor, was brown in color with no seal leaving a hole between the base of the toilet and the floor. 4. At 8:20 AM room [ROOM NUMBER]: The resident bathroom floor was noted to have several areas of a brown in color substance that had a strong foul odor and the base of the toilet, where the toilet meets the floor, was brown in color with no seal. The bathroom wallpaper was ripped from the wall in several places. 5. At 8:28 AM room [ROOM NUMBER]: The door frame of the bathroom and the connected wall were separated, not allowing for the bathroom door to be safely used. 6. At 8:35 AM room [ROOM NUMBER]: [...]

Inspectors wrote2. On 4/16/25 at 9am while speaking with Resident #39, s/he stated, I was seen by the dentist and would like these teeth pulled. I can only eat soft foods. On 4/16/25 at 9:30am the unit manager (staff #18) was made aware of the resident request. She stated the resident was seen by the dentist and she would follow up on it. Review of Resident #39's medical record on 4/22/25 at 11am revealed a dental consult dated 4/2/25 from a Prosthodontist, which read please evaluate and treat for full mouth rehabilitation; resident strongly wants implants. A Prosthodontist is a dental specialist who focuses on tooth restoration and replacement, including the design and fitting of prosthetics. They are trained in areas like dental implants, crowns bridges and dentures. The referral indicated Resident #39 needed several teeth surgically extracted. [...]

Inspectors wroteBased on observations, interviews and facility policy review, it was determined that the facility failed to store food in accordance with professional standards for food service safety.

Inspectors wroteBased on observation and interview, it was determined that the facility staff failed to provide an environment that promotes dignity and respect for a resident (#16) while proving am care. This is evident for 1 of 15 residents reviewed during the survey.

Inspectors wrote3. During an interview on 04/16/2025 at 12:00 PM Resident #50 stated that he/she reported to the facility that $20.00 was stolen from his/her room last year and no one had followed up with him/her as to what happened. During an interview on 04/16/2025 at 1:00 PM staff #1 was made aware, by surveyor, that Resident #50 reported that there was money stolen from his/her room. During an interview and review of facility documentation on 04/16/25 at 3:00 PM staff #1 submitted the Facility Reported Incident Initial Report Form (FRI) regarding Resident #50's missing money to surveyor. The (FRI) revealed that the facility documented having been aware of Resident #50 money missing on 10/03/24 but did not report it to the Office of Health Care Quality or other appropriate agencies within 24 hours of the time the money was reported missing. [...]

Inspectors wroteBased on observation, record review and interviews with staff, it was determined that the facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (Resident #105) out of 33 residents reviewed during the investigative portion of the survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to ensure residents were offered the opportunity to participate in their care planning process by holding timely care plan meetings. This was evident for 1 (Resident #8) out of 4 residents reviewed for care planning during the survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to meet professional standards of care by ensuring a resident's cardiology follow up appointment was scheduled as ordered by physician. This was evident for 1 (Resident #303) out of 33 facility residents reviewed during the investigative phase of the survey.

Inspectors wroteBased on medical record review, observation, and staff interview it was determined the facility failed to administer medication to a resident as ordered by the physician. This was evident for 1 resident #106 out of 7 residents reviewed for orders during the survey.

Inspectors wroteBased on medical record review, observation and staff interview, it was determined that the facility failed to perform accurate reconciliation of resident controlled substance medications. This was evident for 1 resident (#106) out of 7 residents reviewed for medications during survey.

Inspectors wroteBased on observation and interviews it was determined that the facility staff failed to ensure a resident received dental care. This deficient practice was evidenced in 1 (#39) of 2 residents assessed for dental care during the survey.

Inspectors wrote3. A Brief Interview for Mental Status (BIMS) is a standardized cognitive screening tool used in long-term care facilities to quickly assess a resident's cognitive function. The score ranges from 0 to 15, and different ranges suggest varying levels of cognitive impairment. A score of 13-15 generally indicates intact cognition, 8-12 suggests moderate impairment, and 0-7 indicates severe impairment. A smoking screen and/or assessments in long-term care facilities focus on evaluating residents' ability to safely smoke without posing a risk to themselves or others. These assessments typically consider cognitive ability, judgement, manual dexterity, mobility, and physical diagnoses that could impact smoking safety. [...]

Inspectors wroteBased on observation and interview with staff, it was determined that the facility failed to ensure a resident's tracheostomy extension tubing and drainage bag were not touching the floor. This was evident for 1 (Resident #88) out of 2 residents observed with tracheostomy's during the survey.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to maintain a safe, comfortable environment for residents. This was evident for 2 resident bathrooms observed during the survey.

Inspectors wroteBased on observation and interviews, it was determined that the facility failed to post the required staffing information in a prominent and readily accessible location for all residents and visitors. This was evident for 17 out of 32 residents on the Med Bridge unit.

Inspectors wroteBased on staff interviews and review of facility records, it was determined that the facility failed to disseminate mail delivered to the facility for the residents. This was evident for 1 (Residents #167) out of 4 residents reviewed during the survey.

Inspectors wroteBased on resident interviews and staff interviews and review of facility documentation, it was determined that the facility failed to protect the resident's property from loss. This was evident for 2 (Resident #161 and #203) out of 6 residents reviewed during the survey.

Inspectors wroteBased on medical record review and staff interviews, it was determined the facility failed to ensure that resident or resident's representative received in writing the facility bed-hold policy before a resident was transferred to the hospital. This was evident for 1 resident (#156) out of 6 residents, reviewed during the survey.

Inspectors wroteBased on observation and staff interview, it was determined that the facility nursing staff failed to ensure that all medications were stored in a locked compartment or room. This was observed during a tour of the facility.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to 1) complete the daily assessments and documentation accurately, 2) have dental consults readily available on the chart, and 3) address a documented 41-pound weight gain discrepancy in one month, and 4) accurately document a resident observed skin assessment after admission. This was evident during the review of 4 of 55 (Residents #8, #45, #36 and #55) residents reviewed during a complaint survey.

Inspectors wroteBased on complaint and observation, it was determined that the facility failed to maintain all patient care equipment in proper working function by 1) not having enough batteries available for resident lifts, 2) not having enough battery charging receptacles available for the resident lifts, and 3) the rest room fan in room [ROOM NUMBER] is in disrepair by making loud grinding noises. This was observed on the Terrace and [NAME] nursing units during an observation tour of the facility.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to maintain the resident call system in working order. This was evident for 1 of 4 nursing units observed during a revisit survey.

Inspectors wroteBased on complaint, reviews of an active and closed medical record, and staff interviews, it was determined that the facility failed to 1) to report an allegation of sexual abuse (Resident # 18), 2) create a facility reported incident for a resident (Resident # 19) who fell outside on the facility grounds, and 3) report an injury of unknown source to the State survey agency. This was evident for 3 (Residents #18, #19, #30) of 55 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility failed to thoroughly investigate allegation of resident abuse (resident #5 and #18). This was evident in 2 of 18 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility failed to provide written notice to the resident or resident representative of bed hold policy. (Resident # 18). This was evident in 1 of 18 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility failed to complete the discharge process when the resident (Resident # 18) failed to reside in the facility for more than 30 days. This was evident in 1 of 18 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to 1. update care plans based on medication use, and 2. initiate identified concerns for a resident after they were sent to the hospital for an extended admission, 3) initiate a care plan for a resident with a history of opiod disorder. This was evident for 3 of 4 residents (#14, #39 and # 41) reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined that that facility failed to hold care plan meetings every quarter and include the resident and or the representative. This was evident for 1 of 3 reviewed (Resident #1) for care plan meetings during the complaint process.

Inspectors wroteBased on medical record review, interview with Director of Nursing and review of the GNA [NAME], it was determined that resident # 12 did not receive toileting care on the following dates. This was evident for 1 out of 5 residents reviewed for toileting.

Inspectors wroteBased on complaint, reviews of a closed medical record, and staff interview, it was determined that the facility nursing staff failed to administer an intravenous antibiotic timely. This was evident for 1 (Resident #30) of 55 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility failed to provide psychiatric evaluation for a resident (resident #26) who had a history of Post Traumatic Stress Disorder (PTSD) and Schizophrenia. This is evident in 1 of 18 residents reviewed during a complaint survey.

Inspectors wroteBased on record review and staff interview, it was determined that facility staff failed to offer and provide the influenza vaccine to a resident (resident #3) during his/her stay. This deficient practice was evident for 1 of 18 residents reviewed during a complaint survey.

Inspectors wroteBased on observation and interview with laundry staff and the Director of housekeeping and laundry, the facility failed to replace, fix, or have another system in place for 1 out of 2 washing machines that were not in working order. This has affected all residents who have their laundry done by the facility.

Inspectors wroteBased on review of facility and resident records and interview with staff it was determined the facility failed to thoroughly investigate and report the investigation findings to the Office of Health Care Quality (OHCQ). This was evident for 2 (#433, #28) of 43 residents reviewed for Abuse.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 4 (#53,430, 431, 432 ) of 5 residents reviewed for hospitalization.

Inspectors wrote3) The facility staff failed to ensure the (MDS) assessments were accurately coded for (#39). Review of Resident #39's medical record on 5/20/2021 at 11:40 AM revealed a quarterly assessment MDS from 9/20/2021 which documented in Section I, Active Diagnoses, that the resident had no Multi-drug Resistant Organism (MDRO) infections. Further review of Resident #39's medical record revealed an order for Contact precautions every shift for MDRO of unknown organism with KPC gene starting 8/22/2019 and ending 10/22/2019 when the resident was discharged . 4) The facility staff failed to ensure the (MDS) assessments were accurately coded for Resident #116. [...]

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to have a system in place to complete an interim care plan and to provide a written summary of the interim plan of care to the resident or responsible party. This was found to be evident for 1 out of 16 residents (Resident #4) reviewed for care planning during the annual survey.

Inspectors wroteBased on a medical record review and staff interview, it was determined that facility staff failed to initiate a care plan for a resident receiving anticoagulant therapy. This was evident for two residents out of 56 selected for review during the annual survey, residents (#4, 98).

Inspectors wroteBased on observation and interview with residents and facility staff, it was determined that the facility failed to 1) provide sufficient supervision of residents' smoking as evidenced by failing to follow their smoking policy and failing to complete smoking assessments accurately and 2) failed to protect a resident, who was dependent on staff for turning and positioning, from falling out of bed during care. This was evident of 2 (Resident #116, #113)) of 3 residents reviewed for smoking.

Inspectors wroteBased on reviews of staff competencies conducted on 5/24/21 at 1:14 PM, the facility failed to provide competency training services for 4 out of 5 staff members.

Inspectors wroteBased on medical record review and interviews, it was determined the Nurse Practitioner and Resident #4's primary physician failed to develop a comprehensive plan to manage Heparin therapy, including monitoring for increased risk of bleeding and making dosage adjustments in one (Resident #4) of 16 residents reviewed during the annual survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to; 1) accurately reflect what was in Resident's #4 medical record; 2.) ensure that documentation of Residents' #97'showers was accurate. 3.) respond to Resident #8's medication regimen review in a timely manner.

Inspectors wroteBased on observation, it was determined that the facility failed to ensure that residents outside of their rooms wore masks and that hand sanitizer dispensers were available and kept from going empty. Failure to apply resident masks was evident for 1 of 9 days the survey took place. Failure to keep hand sanitizer readily accessible at the check-in station was evident for 2 of 9 days the survey took place. Failure to keep hand sanitizer dispensers filled was evident for 3 of 13 sampled hallway dispensers and 5 of 20 sampled room dispensers.

Inspectors wroteBased on observations, medical record reviews, and interviews during a tour of the facility, it was determined that the facility failed to maintain and enhance the dignity of the residents: 1) by failing to provide privacy and rendering care to resident (#4) , 2) failed to provide clean clothes and or linen for resident (#37) due to broken equipment and, 3 ) failed to provide proper bedding for resident (#99). This occurred in three of three sampled residents for dignity.

Inspectors wroteBased on observations and interviews it was determined the facility failed to: 1) ensure that Resident (#68) was provided proper storage for personal belongings, and 2) ensure that (residents #69, #114, #116) have access to the facility's communication system (call bell). This was found to be evident for 4 out of 56 residents reviewed during the annual survey.

Inspectors wroteBased on discussions with the residents during the Resident Council Meeting held on 5/25/21 at 1 PM, the facility staff do not respond to all the concerns the residents had. This was evident for all residents who attended the resident council meetings.

Inspectors wroteBased on observations and staff interviews it was determined the facility failed to: 1) provide housekeeping and maintenance services to keep the resident's environment clean and in good repair on the first floor nursing unit, and . 2) failed to ensure that equipment involved in a resident's artificial feeding was maintained in a clean, sanitary, and homelike manner for Resident #84.

Inspectors wroteBased on review of facility staff records and interview with the administrator, the facility failed to present background checks for employees that have been employed by the facility prior to March 2020. This was evident for 2 out of 5 staff checked for background checks (Staff # 16 and 17).

Inspectors wroteBased on medical record review, review of facility statements, and interviews, it was determined the facility staff failed to report an incident to the Office of Health Care Quality (OHCQ) and local law enforcement as required in a timely manner. This was evident for 2 (Resident #433 and #8 ) out of 43 residents reviewed during a complaint survey.

Inspectors wroteBased on review of Minimum Data Set (MDS) Assessment material and interview with facility staff, it was determined that the facility failed to transmit MDS assessments within 14 days of completion of the assessment. This was evident for 1 (Resident #1) of 2 residents reviewed for resident assessment.

Inspectors wroteBased on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure that a resident whose stay at the facility exceeded 30 days had a new Preadmission Screening and Resident Review (PASARR) Level 1 screening completed within 40 days of admission. This was evident for 1 (Resident #116) of 4 residents reviewed for PASARR.

Inspectors wroteBased on review of resident medical records and interview with facility staff, it was determined that the facility failed to hold care plan meetings of the interdisciplinary team for residents at the time of the quarterly revision of their care plan. This was evident for 1 (Resident #116) of 4 residents reviewed for Bladder and Bowel Incontinence.

Inspectors wroteBased on medical record review, it was determined that the facility staff failed to provide a resident with a completed discharge summary. This was evident for 1 (Resident #432) of 43 residents reviewed during an annual recertification survey.

Inspectors wroteBased on medical record review and staff interview it was determined that the facility failed to provide treatment and care in accordance with professional standards of practice. This was evident for 2 (#432, #430) of 43 residents reviewed during the survey

Inspectors wroteBased on the record review on 5/19/21 at 11:54 AM, resident interview on 5/18/21 at 9:16 AM, and complaint # MD00160765, staff failed to put hearing aids in Resident # 98's ears on a routine basis. This was evident for 1 out of 3 residents with hearing loss.

Inspectors wroteBased on medical record review and interviews, it was determined the Nurse Practitioner and Resident #4's primary physician failed to supervise Resident #4's care as evidenced by their failure to develop a comprehensive plan to manage heparin therapy, including monitoring for increased risk of bleeding and making dosage adjustments. This was evident for one (Resident #4) of 16 residents reviewed during the annual survey.

Inspectors wroteBased on medical record review and staff interview it was determined that what the Nurse Practitioner documented in the resident's progress notes, did not accurately reflect what was in the resident's medical records. This was evident for 1 (#4) of 16 residents.

Inspectors wroteBased on resident interviews during the resident council meeting, the facility failed to answer the call lights in a timely manner. This had the potential to affect all residents at the facility.

Inspectors wroteBased on review of staff hire documents and training programs, 1out of 1 staff members did not have 12 hours of documented dementia training in their records.

Inspectors wroteBased on observation and interview with residents and facility staff, it was determined that the facility failed to ensure that posted nursing staff information was accurate. This was true for 1 of 4 units in the facility.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure that medication carts were locked. This was evident for 2 out of the 8 medication carts.

Inspectors wroteBased on resident interview, staff interview and record review it was determined that the facility failed to provide a meal that met a resident's special dietary needs and preferences. This was evident for 1 (Resident #97) of 43 residents reviewed during the survey.

Inspectors wroteBased on observation, it was determined that the facility failed to ensure that the facility stored food in accordance with professional standards for food service safety. This was evident for 1 of 2 observaitons of the kitchen.

Inspectors wroteBased on observation it was determined the facility staff failed to dispose of garbage and refuse properly.

Inspectors wroteBased on record review and staff interview it was determined the facility failed to provide specialized rehabilitative services. This was evident for 1 (Resident #435) of 43 residents in the final sample.

Inspectors wroteBased on a review of the Quality Assurance Program and interview, the Quality Assurance Committee failed to identify issues related to quality assessment activities, failed to recognize gaps in systems or processes, monitor and ensure implementation of plans of action to correct deficiencies.

Inspectors wroteBased on a review of the Quality Assurance (QA) attendance records and staff interviews it was revealed that the required facility staff is not attending the QA meetings.

Inspectors wroteBased on observation and interview, the facility failed to ensure that handrails were secure to provide a safe environment. This was evident for 1 out of 15 handrails observed during the annual survey.

Inspectors wroteBased on medication cart observations and staff interviews it was determined that facility staff failed to ensure that the medical record was kept in a confidential manner. This was evident in 1 out of 8 medication carts with Informed Consent /Declination Forms involving Resident's #48 and Resident #363.

Inspectors wroteBased on observation and staff interview it was determined the facility failed to ensure a staff restroom was kept locked or was included in the resident call system. This was evident for 1 of 3 staff restrooms observed during the survey.