White Oak Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at White Oak Rehabilitation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF603Apr 29, 2025

  Based on record review, observation, and interview with residents and staff, and other pertinent documents it was determined that the facility subjected residents to involuntary seclusion by restricting their ability to move freely. This was evident for 4 (Resident #17, #30, #102, #108) out of 15 residents residing in the locked area of the Med Bridge unit. Additionally, due to the restriction, Resident #108 experienced distress resulting in self-inflicted physical harm in an attempt to exit the locked unit. As a result of the non-compliance an IJ (Immediate Jeopardy) was determined on 4/25/2025 at 3:30 PM. An IJ summary tool was provided to the facility on 4/25/25. The facility submitted a draft of their plan to remove the immediacy on 4/25/25 at 6:40pm, and it was not accepted. […]

• Immediate jeopardy, isolatedF689Apr 29, 2025

  4a. Record review of Resident #23's medical record on 4/16/25 at 10:15 AM revealed a smoking care plan was initiated on 7/27/22 and revised on 2/5/25. It indicated the resident was a dependent smoker with the goal to monitor any issues or complications and assist the resident during smoking times. Additionally, on 5/22/23 a focus area was added to the care plan that the resident was non-compliant with wearing the recommended smoking vest and following the facility smoking policy; however, the goals and/or interventions did not address the resident's noncompliance. During observation rounds 4/16/25 at 9am resident #23 was observed reclining back in the wheelchair in the courtyard located on the first floor. […]

• Immediate jeopardy, isolatedF689Dec 19, 2022

  Based on observations, record review and interviews, it was determined that the facility failed to prevent a cognitively impaired resident with exit seeking behaviors from leaving the facility. This was evident for 1 (Resident#1) out of 1 resident reviewed for accidents. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy, and the facility was notified verbally and in writing of this determination at 7:15 PM on 01/26/2023. The facility provided a plan to remove the immediacy while the surveyors were onsite. […]

• Immediate jeopardy, isolatedF689Dec 19, 2022

  Based on observations, record review and interviews, it was determined that the facility failed to prevent a cognitively impaired resident with exit seeking behaviors from leaving the facility. This was evident for 1 (Resident#1) out of 1 resident reviewed for accidents. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy, and the facility was notified verbally and in writing of this determination at 7:15 PM on 01/26/2023. The facility provided a plan to remove the immediacy while the surveyors were onsite. […]

• Actual harm, isolatedF550Jan 26, 2021

  Based on record review, observation and interview, it was determined the facility staff failed to allow a competent resident (#6) their right to leave the facility. The facility physically stopped Resident #6 from leaving through the exit door and, as with their previous requests to depart, was told he/she had to wait 4 more days to leave. This failure to allow Resident #6 to leave resulted in actual psychosocial harm that was manifested in a mental state causing him/her to take desperate action on a cold winter night to break a window lock and escape through a ground floor window on foot. This desperate action reflected Resident #6's mental state that they had no other recourse but to break out. […]