White Oaks Rehabilitation and Nursing Center

Inspectors wroteBased on observation, interviews and record review during an abbreviated survey conducted on 10/28/2025 for case number 2616775, the facility failed to ensure one (1) (Resident #1) of three (3) residents was free from accidents. Specifically, Certified Nursing Assistant #1 failed to follow the care plan for Resident #1 requiring a two-person assist. On 09/11/2025, Certified Nursing Assistant #1 transferred Resident #1 from their wheelchair to their bed alone resulting in a fractured left humerus (upper arm bone). This resulted in actual harm to Resident #1 that is not Immediate Jeopardy. Resident #1 was admitted on [DATE] with diagnosis that include vascular dementia (a decline in thinking skills caused by conditions that damage blood vessels and reduce or block blood flow to the brain,) cerebral vascular accident (stroke,) and osteoarthritis. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification initiated on 09/02/2025 and completed on 09/08/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen task observation on 09/02/2025 and during the Dining Task on 09/02/2025 at the lunch meal. Specifically, frozen food items (tiramisu, broccoli florets, pizza slices, a tray of diet pudding, regular pudding and peaches, roast beef, Brussel Sprouts) in the walk-in freezer were stored undated and or with opened packaging. Specifically, the facility did not monitor the temperature of cold food items (sandwiches, yogurt, milk) at the time of meal service. [...]

Inspectors wroteBased on observation, interviews, and record review during the Recertification Survey initiated on 09/02/2025 and completed on 09/08/2025, the facility did not ensure each resident had the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident's medical symptoms. This was identified for one (1) (Resident #36) of one (1) resident reviewed for Physical Restraints. Specifically, on 09/02/2025, Resident #36 was observed sleeping in a bed with the bed positioned between another empty bed on the right side and a Geri chair on the left side, thereby blocking the resident from getting out of the bed. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 09/02/2025 and completed on 09/08/2025, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. This was identified for one (Resident #12) of five residents reviewed for Accidents. Specifically, Resident #12 was at risk for elopement and had a physician's order for a Wanderguard (a wearable bracelet for residents at risk for wandering, which causes an alarm when the resident approaches a restricted area). On 08/01/2025, the resident removed the Wanderguard; however, no new interventions were put in place to ensure the resident was appropriately supervised and did not remove the Wanderguard. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey, initiated on 9/2/2025 and completed on 9/8/2025, the facility did not ensure that each resident who required respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. This was identified for one (1) (Resident #129) of three (3) residents reviewed for Respiratory Care. Specifically, Resident #129 did not receive pulse oximetry (oxygen saturation) monitoring (measures the oxygen saturation in blood) as recommended by the Physician in a progress note dated 09/01/2025; however, the Physician did not write an order for their recommendation. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 09/02/2025 and completed on 09/08/2025 the facility did not ensure that it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections for 1) one (Resident #16) of one resident reviewed for Pressure Ulcers and for one (1) (Resident #111) of three (3) residents reviewed for Transmission-Based Precautions. Specifically, 1) during the wound care observation for Resident #16 (bilateral heel wounds) on 09/04/2025, Licensed Practical Nurse #1 did not perform hand hygiene during the various steps of the wound care treatment process, allowed the cleansed heel wounds to come in contact with a dirty surface, and did not re-cleanse the heel wounds. [...]

Inspectors wroteBased on observations, interviews, and record review during the Recertification Survey initiated on 09/02/2025 and completed on 09/08/2025, the facility did not ensure nursing staffing was posted daily and included the actual number of licensed and unlicensed staff working hours per shift. Specifically, the facility's entrance lobby was observed on 09/02/2025 at 09:28 AM with the nursing staffing sheet posted for 08/29/2025. Additionally, the nursing staffing sheets dated 09/02/2025 to 09/03/2025 did not include the actual hours worked by the licensed and unlicensed nursing staff per shift. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 09/02/2025 and completed on 09/08/2025, the facility did not ensure the Facility Assessment determined and indicated specific nursing staffing necessary to care for residents during both day-to-day operation (including night and weekends) and emergencies. This was identified during the Sufficient Nursing Staffing Task. Specifically, the facility stated that nursing staffing, specifically the number of Registered Nurses required for the facility's daily operations, was not accurately documented in the Facility Assessment. [...]

Inspectors wroteBased on observations, record review and interviews conducted during a Recertification Survey initiated on 3/4/2024 and completed on 3/9/2024, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, were reported to the New York State Department of Health. This was identified for one (Resident #119) of eight residents reviewed for Accidents. Specifically, Resident #119, with a diagnosis of Dementia and impaired cognition, sustained the following unwitnessed injuries of unknown origin 1a) a laceration to the right arm which required transfer to the hospital and treatment of 16 staples on 12/6/2023, 1b) ecchymotic (bruise) area to the left buttock on 2/27/2024 and 1c) ecchymotic area to left upper inner forearm and right outer arm on 2/29/2024. [...]

Inspectors wroteBased on observations, record review and interviews conducted during a Recertification Survey initiated on 3/4/2024 and completed on 3/9/2024, the facility did not ensure that all alleged violations were thoroughly investigated in response to allegations of abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown source. This was identified for one (Resident #119) of eight residents reviewed for Accidents. Specifically, Resident #119 with a diagnosis of Dementia and impaired cognition sustained the following unwitnessed injuries of unknown origin 1a) a laceration to the right arm which required transfer to the hospital and treatment of 16 staples on 12/6/2023, 1b) ecchymotic (bruise) area to the left buttock on 2/27/2024 and 1c) ecchymotic area to the left upper inner forearm and the right outer arm on 2/29/2024. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/9/2024 the facility did not ensure that a Baseline Care Plan for each resident was developed that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of admission. This was identified for one (Resident #78) of four residents reviewed for skin conditions. Specifically, Resident #78 was admitted with impaired skin integrity, and a baseline care plan was not developed within 48 hours of the resident's admission. The finding is: The facility's policy titled, Care Planning last revised 1/2022 documented that upon admission the baseline care plan will be initiated and completed within 48 hours as per the Centers for Medicare & Medicaid Services guidelines. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/9/2024 the facility did not ensure each resident's Comprehensive Care Plan was reviewed and revised to reflect the current needs of each resident. This was identified for one (Resident #78) of three residents reviewed for pressure ulcers and one (Resident #171) of two residents reviewed for edema. Specifically, 1) Resident #78's Comprehensive Care Plan was not updated to reflect the resident's use of the heel off-loading medical surgical shoe or offloading the heels; and 2) Resident #171's Comprehensive Care Plan was not updated to reflect the use of lower leg compression wraps to treat bilateral lower leg edema (swelling caused by too much fluid trapped in the body's tissues).

Inspectors wroteBased on observation, record review and staff interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/9/2024, the facility did not ensure that services provided or arranged by the facility outlined by the comprehensive plan of care meet professional standards of care. This was identified for one (Resident #169) of eight residents reviewed for medication administration. Specifically, during a medication pass observation on 3/6/2024 at 6:25 AM for Resident #169, Registered Nurse #4 removed a Levothyroxine (medication used to treat underactive thyroid gland) 50 micrograms tablet from a blister pack that had Resident #49's identification label and then administered the medication to Resident #169. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/9/2024, the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene. This was identified for one (Resident #56) of three residents reviewed for activities of daily living. Specifically, on 3/4/2024 and 3/7/2024 Resident #56 was observed with long fingernails to both hands. The resident's right-hand fingernails were resting on the resident's palm and a brown substance was observed under the nails of the left hand. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/9/2024, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to prevent further decrease in range of motion. This was identified for two (Resident #56 and Resident #36) of three residents reviewed for position/mobility. Specifically, Resident #56 and Resident #36 had a Physician's order for a hand roll to be worn at all times. On multiple occasions, Resident #56 and Resident #36 were observed not wearing the physician-ordered hand rolls.

Inspectors wroteBased on observations, record review and interviews conducted during the Recertification Survey initiated on 3/04/2024 and completed on 3/09/2024, the facility did not ensure that each resident's environment remains as free of accident hazards as possible. This was identified for one (Resident # 167) of three residents reviewed for Accidents. Specifically, Resident #167 was not assessed to safely self-administer medications. During multiple observations on 3/04/2024 at 8:48 AM, 3/04/2024 at 11:13 AM, and again on 3/05/2024 at 8:38 AM. Resident #167 was observed with Physician-ordered medication in their room with no staff member in the vicinity. The finding is: The facility policy titled, Medication Administration dated 11/2023 documented that the Nurse ensures medications are not left unattended and to keep medications secured in a locked area or are visible at all times. [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/9/2024, the facility did not ensure that all nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs. This was identified for one (Resident #20) of two residents reviewed for skin conditions (non-pressure). Specifically, Resident #20 was observed with a bruise on the back of the left hand. Certified Nursing Assistant #10 was aware of the bruise on 3/4/2024; however, did not report the change in skin condition to Registered Nurse #3 until the Surveyor identified the bruise on the resident's left hand. The finding is: [...]

Inspectors wroteBased on observation, record review and interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/9/2024, the facility did not ensure that the procedure that assure the accurate acquiring, receiving, dispensing and administration of all drugs and biologicals to meet the needs of each resident and the facility did not ensure that drug records are in order and that an account of all controlled drugs are maintained and periodically reconciled. This was identified for one (Resident #169) of eight residents reviewed for medication administration and for one (Unit 2 North) of four units reviewed for the Medication Storage task. Specifically, 1) Resident #169 had a Physician's order for Levothyroxine (Synthroid-thyroid medication) 50 microgram to be administered daily at 6:00 AM. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/9/2024 the facility did not provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition services. This was identified for one (Unit 1 North) of four Units observed during the initial tour. Specifically, Resident #107 and Resident #171 were observed eating their breakfast meal served on disposable plates, cups, and bowls. During the Resident Council Meeting held on 3/5/2024 eight of eight residents stated they often received disposable plates, cups, bowls, and utensils for meals on the weekend because of short staffing in the kitchen. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 4/6/2022 and completed on 4/13/2022 the facility did not ensure that the interdisciplinary team had determined that self-administration of medications was clinically appropriate for each resident. This was identified for 1 (Resident # 113) of 8 residents reviewed for Accidents. Specifically, Resident #113 incorrectly self-administered a Physician's prescribed nasal spray medication Fluticasone Propionate (Flonase) during a medication pass observation. The medication was being stored by the resident at their bedside. There was no documented assessment by the interdisciplinary team to determine if the resident could safely self-administer the medication. The finding is: [...]

Inspectors wroteBased on record review, observation, and interviews during the Recertification Survey initiated on 4/6/2022 and completed on 4/13/2022 the facility did not ensure that a comprehensive person-centered care plan was developed to meet each resident's medical and nursing needs. This was identified for 1 (Resident #137) of 2 residents reviewed for use of the Urinary catheter. Specifically, Resident #137 was admitted to the facility with an indwelling Foley catheter; however, there was no Comprehensive Care Plan developed for the Foley catheter use. The finding is: The facility's policy, titled Care Planning, last reviewed 1/2022, documented care, treatment, and services are planned to ensure that they are appropriate to the resident's needs to provide an individualized plan of care for all residents. [...]

Inspectors wroteBased on observation, record review and interviews during the Recertification Survey initiated on 4/6/2022 and completed on 4/13/2022, the facility did not ensure that each resident's environment remained free of accident hazards as is possible. This was identified for 1 (Resident #115) of 8 residents reviewed for Accidents. Specifically, Resident #115 with diagnoses of Dementia and Major Depressive Disorder had an unlocked drawer in their room which contained 2 pairs of scissors, a screwdriver and a medication bottle with Torsemide (diuretic) 20 milligram (mg) Tablets. The facility staff were not knowledgeable of the items in the resident's possession. The finding is: [...]

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey initiated on 4/6/2022 and completed on 4/13/2022, the facility did not ensure a resident who is fed with Enteral means receives the appropriate treatment and services to prevent potential complications of Enteral feeding. This was identified for one (Resident #13) of one resident reviewed for feeding tubes. Specifically, a Certified Nursing Assistant (CNA) was observed providing care to Resident #13 while the resident was lying flat in their bed and the tube feeding was being administered. The finding is: The undated policy and procedure for Enteral tube feedings documented the head of the bed is to remain elevated at 30 to 45 degrees while the feeding is active [running]. Resident #13 was admitted with diagnoses including Cerebral Infarction and Gastrostomy (feeding tube). [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 4/6/2022 and completed on 4/13/2022, the facility did not ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for resident needs for one (Resident #13) of one resident reviewed for tube feeding. Specifically, a Certified Nurse Assistant (CNA) was observed providing care to Resident #13 while the resident was lying flat in their bed and the tube feeding was being administered. The finding is: The undated policy and procedure for Enteral tube feedings documented the head of the bed is to remain elevated at 30 to 45 degrees while the feeding is active [running]. Resident #13 was admitted with diagnoses including Cerebral Infarction and Gastrostomy (feeding tube). [...]