White Oak Post Acute Care

In the surveyor’s words

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

• Immediate jeopardy, patternF689May 6, 2026

  Based on observations, interviews, and record reviews, the facility failed to ensure an effective system was in place for staff to identify unsafe smokers and implement interventions including supervision to prevent accident hazards for 2 (#1, #5) of 3 residents reviewed for unsafe smoking. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 on 04/15/2026 when he was observed smoking in another resident's room while oxygen was in use. Resident #1 was a moderately cognitively impaired resident who was deemed an unsafe smoker upon admission to the facility on [DATE]. After 04/15/2026, not all staff were educated. On 05/03/2026, Resident #1 was noted smoking cigarettes in his room with smoking paraphernalia in his possession. […]

• Immediate jeopardy, patternF689Sep 20, 2024

  Based on observations, interviews and record reviews, the facility failed to ensure residents remained free of accident hazards and received adequate supervision and assistance to prevent accidents. The facility failed to ensure: 1. An effective system was in place for nursing staff to identify and implement a resident's assessed transfer needs for 1 (#54) of 4 (#32, #38, #54, and #66) residents reviewed requiring a Hoyer lift for transfers; and 2. An effective system was in place for staff to implement safe smoking interventions for 3 (#49, #75, #87) of 4 (#49, #58, #75, and #87) residents reviewed for smoking. 1. […]

• Immediate jeopardy, patternF726Sep 20, 2024

  Based on observations, interviews and record reviews, the facility failed to ensure nursing staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety, as determined by resident assessments and individual plans of care. The facility failed to ensure: 1. An effective system was in place to ensure licensed nurses and nurse aids were competent to identify and implement a resident's assessed transfer needs for 1 (#54) of 4 (#32, #38, #54, and #66) residents reviewed requiring a Hoyer lift for transfers; and 2. […]

• Immediate jeopardy, patternF835Sep 20, 2024

  Based on observations, interviews, and record reviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain the highest practicable physical, mental, and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place to: 1. Ensure licensed nurses and nurse aids were trained and competent to update, implement, and identify a resident's assessed transfer needs for 1 (#54) of 4 (#32, #38, #54, and #66) residents reviewed requiring a Hoyer lift for transfers; 2. […]

• Immediate jeopardy, isolatedF689Feb 27, 2025

  Based on observations, interviews and record review the facility failed to provide adequate supervision for 1 (#5) of 3 (#5, #6, and #7) residents reviewed for wandering. The facility failed to ensure staff appropriately supervised Resident #5 who was assessed to be a wanderer, unsafe smoker, and a high fall risk. This deficient practice resulted in an immediate jeopardy situation on the weekend of 02/15/2025 through 02/16/2025, when Resident #5, a severely cognitively impaired resident identified as a wanderer, unsafe smoker and high fall risk, entered the smoking patio while no staff were present to provide supervision. Resident #5 self-propel himself in his wheelchair through the gate of the smokers' patio onto the sidewalk along the resident patio exterior doors. […]