White Oak Manor - Tryon

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Feb 4, 2026

  Based on observations, record review, manufacturer recommendations, North Carolina Governor's Executive Order, and staff, Family Member, Medical Director, Civilian, Emergency Medical Services (EMS), and Assistant Fire Chief interviews, the facility failed to supervise a cognitively impaired resident, who had a diagnosis of dementia and wore an elopement alarm device due to exit-seeking behavior, from exiting the facility without staff knowledge for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). On Saturday 01/24/26, Resident #1 exited the facility with her walker, wearing thin, capri pants and a loose-fitting shirt with no jacket in 36-degree Fahrenheit weather. […]

• No harm, potential for more than minimal, patternF550Mar 17, 2023

  Based on record review, observations and staff interviews, the facility failed to treat residents in a dignified manner by standing over them while assisting with eating and/or referring to residents as feeders. This practice affected 5 of 5 residents reviewed for dignity (Residents #206, #21, #31, #16, and #42). The reasonable person concept was applied to this deficiency as individuals have the expectation of being treated with dignity while dining. The findings included: 1. Resident #206 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #206 was moderately cognitively impaired and required extensive assistance with eating. […]

• No harm, potential for more than minimal, isolatedF554Jul 24, 2025

  Based on observations, record review, staff and resident interviews, the facility failed to assess a resident's ability to self-administer medications for 1 of 1 resident reviewed for self-administration (Resident #40).The findings included:Resident #40 was admitted to the facility on [DATE] with multiple diagnoses that included dry eye syndrome and dry mouth.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was cognitively intact and was independent with eating, oral hygiene, and personal hygiene.Review of Resident #40's current and active care plan dated 7/21/25 revealed no goals or interventions for self-administering medications.A review of Resident #40's medical record revealed there was no self-administration assessment or a Physician order for… […]

• No harm, potential for more than minimal, isolatedF583Jul 24, 2025

  Based on observations and staff interviews the facility failed to protect residents' healthcare information by leaving confidential medication information unattended, visible, and accessible to others on the computer screen for 1 of 4 medication carts observed (Medication cart for hall 300).A continuous observation of 300 hall medication cart occurred on 7/21/25 from 1:50pm to 1:52pm. The medication cart was in the hallway unattended, and it was observed to have the computer screen showing resident information such as medications, date of birth , room number, and diagnosis. The medication cart was observed for 2 minutes and during that time 2 staff members and 2 residents walked past the medication cart.Medication Aide (MA) #2 was interviewed at 1:53pm. […]

• No harm, potential for more than minimal, isolatedF602Jul 24, 2025

  Based on observations, record review, staff, and law enforcement officer interviews, the facility failed to protect the resident's right to be free of misappropriation of medication for 1 of 3 residents reviewed for misappropriation (Resident #53).The findings included:Resident #53 was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included hypertension.A physician order dated [DATE] read; Lisinopril 20 milligrams (mg) by mouth every day. Hold for systolic blood pressure less than 100. The order was discontinued on [DATE].A physician order dated [DATE] read; Lisinopril 10 mg by mouth every day. Hold for systolic blood pressure less than 100. […]