White Oak Manor - Burlington

In the surveyor’s words

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

• Immediate jeopardy, patternF580Mar 31, 2025

  Based 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. […]

• Immediate jeopardy, patternF607Mar 31, 2025

  Based 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. […]

• Immediate jeopardy, patternF684Mar 31, 2025

  Based 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. […]

• Immediate jeopardy, patternF726Mar 31, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF600Mar 31, 2025

  Based 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. […]