White Oak Manor - York

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 2, 2026

  Based on record review, observation, interview, staff interview, and review of facility policy, the facility failed to provide supervision consistent with the assessed needs of one of one resident reviewed for accidents (Resident (R) 111). Specifically, the facility failed to supervise R111 by leaving her unattended in the dayroom. This failure resulted in an unwitnessed fall and a right distal humerus fracture requiring emergency department evaluation and immobilization.Findings include:Record review of the facility's Fall Management Policy revealed newly admitted residents were to be evaluated for fall risk based on fall history, physical and cognitive status, symptoms, and medication regimen. […]

• Actual harm, isolatedF658Oct 8, 2021

  Based on facility policy, record review and interview, the facility failed to follow the care plan for one (1) resident (Resident #57) reviewed for accidents/hazards. Care plan interventions included maintain environment free of clutter and safety hazards. Due to the failure of following the care plan, on 10/4/21, the resident was found on the floor by the bathroom in his/her room, which resulted in a skin tear to the lower spine and bruising to the right hand and forearm, resulting in harm to the resident. The resident's wheelchair was stored in the bathroom, which caused the resident to fall. […]

• Actual harm, isolatedF689Oct 8, 2021

  Based on observation, record reviews, interviews, and review of facility policy, it was determined for one (1) of 26 sampled residents (Resident #57) the facility failed to ensure that the resident's environment remained free of accidents and hazards as possible, and that the resident received adequate supervision as well as assistance to prevent accidents. The facility failed to ensure resident's safety by not ensuring the wheelchair was properly stored (located in resident's bathroom) by staff resulting in the resident falling in the doorway of bathroom and hitting his/her back on the wheelchair causing a skin tear to lower back and bruising to the right hand and forearm, resulting in harm to the resident. […]

• No harm, potential for more than minimal, widespreadF812Jul 2, 2026

  Based on observation, interview and policy review, the facility failed to store, prepare and serve food under accepted sanitary conditions due to failure to separate dented cans from the for-use supply and failure to remove expired items from the food supply. The deficient practice had the potential to affect the 92 of 97 residents receiving oral diets. The findings include: Review of facility policy titled Storage of Food and Supplies, revised 12/5/2017, revealed PURPOSE: To ensure foods and supplies are stored appropriately to maintain wholesomeness and to meet regulatory guidelines. POLICY: Food and supplies are received, stored and monitored according to federal, state, and legal guidelines. […]

• No harm, potential for more than minimal, patternF582Oct 6, 2023

  Based on record review and interview the facility failed to ensure Center for Medicare/Medicaid Services (CMS)-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) was completed correctly by the responsible parties for Resident #198 and Resident #52. This affected two (2) of three (3) residents reviewed for notification of changes in Medicare Part A coverage. The findings include: Review of an undated facility policy, titled, Advance Beneficiary Notice of Non-Coverage (ABN) CMS-R-131 revealed: The Business Office is to initiate, and deliver, the ABN CMS-R-131 form when a Medicare beneficiary is, or will be, receiving a service that Medicare is not likely to provide coverage in a specific case under Part B items or services. […]