White Oak Manor

In the surveyor’s words

From the most serious findings on record at White Oak Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 1, 2025

  Based on observation, record review, review of a facility self-reported incident (SRI) investigation, review of police reports, review of the Emergency Medical Services (EMS) run report, review of hospital documentation, review of facility policy, and interviews, the facility failed to provide adequate supervision to prevent Resident #16, who was cognitively impaired, aphasic and at risk for elopement (with use of a WanderGuard device) from eloping. This resulted in Immediate Jeopardy and the potential for Actual Harm, serious physical injury or death on [DATE] when 911 dispatch for the local police department received a 911 call from a passerby in the community with concerns for an unattended individual. […]

• Immediate jeopardy, isolatedF689Dec 8, 2021

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure care and services were provided, physician orders were followed, and care planned interventions were implemented to ensure one resident (Resident #6) did not elope from the facility. This affected one resident (Resident #6) out of three residents reviewed for elopement. On 12/02/21 at 2:51 P.M. the Administrator, Vice President of Operations #805, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 11/30/21 at 7:15 P.M. when Resident #6 was unable to be located in the facility or on the facility grounds. Licensed Practical Nurse (LPN) #305 entered Resident #6's room at 7:15 P.M. […]

• No harm, potential for more than minimal, widespreadF921Apr 22, 2026

  Based on observation, staff interview, and policy review, the facility failed to maintain a comfortable homelike environment in good repair. This had the potential to affect all 32 residents residing in the facility. The census was 32. Findings include:1. Observation on 04/21/26 at 10:45 A.M. revealed three burnt out ceiling hallway lights from room [ROOM NUMBER] until the end of the 300-hallway. The end of the hallway was darker than the rest of the hallway. Interview with Licensed Practical Nurse (LPN) #447 and Maintenance Director #417 at the time of the observation confirmed the three burnt out ceiling lights starting outside room [ROOM NUMBER] and extending to the end of hallway 300, making the end of the hallway darker than the rest of the hallway. 2. […]

• No harm, potential for more than minimal, widespreadF882May 8, 2025

  Based on record review and interview, the facility failed to ensure the infection preventionist (IP) role was conducted by a nurse who worked at least part-time in the facility. This had the potential to affect all 34 residents who resided in the facility. Findings include: Review of the Facility Assessment form dated 06/21/24 revealed the assessment did not designate the amount of hours that were required for the IP to be in the facility to ensure implementation of the infection control programs and activities. Review of the IP Training Plan Proof of Completion form dated 05/30/23 revealed Registered Nurse (RN) Regional #851 was the current IP for the facility. Interview on 05/06/25 at 12:10 P.M. […]

• No harm, potential for more than minimal, widespreadF921Mar 8, 2022

  Based on observation and interview the facility failed to ensure a clean and well maintained physical environment. This affected all residents. The facility census was 37. Findings include: Observations of the facility on 03/02/22 between 8:30 A.M. and 11:35 A.M. revealed the following. - Pervasive odor of urine on the 100 and 200 halls. - Floors in Resident #37's, Resident #6's, Resident #21's, Resident #11's, Resident #12's, Resident #16's, Resident #8's, Resident #19's rooms had multiple scuffs, dried liquid stains, worn waxed surfaces with dirt and grime ground in to the wax, the edges/corners of the rooms had build-up dirt and grime, bathroom floors had cracks, tears in the flooring with build-up of dirt and grime along the edges and corners of the floors. […]