White Oak Manor - Charlotte

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 13, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF684Oct 27, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF812Apr 13, 2026

  Based 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. The findings included:a. An initial tour of the main kitchen occurred on 4/6/26 at 10:05 AM with the Dietary Manager. […]

• No harm, potential for more than minimal, patternF812Mar 27, 2025

  Based 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. The findings included: On 03/26/25 at 11:30 AM observations of the lunch meal tray line revealed there were divided plates stacked on a cart to the side of the steam table in preparation for the lunch service. Seven of the divided plates were noted to have dried egg particles on the plates. There were also dried egg particles noted on the plate warmer that contained the regular plates for lunch meal service. […]

• No harm, potential for more than minimal, patternF550Dec 8, 2023

  Based 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. The findings included: 1a. Resident #8 was readmitted to the facility on [DATE]. […]