White Oaks Rehabilitation and Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF689Nov 20, 2025

  Based on observation, interviews and record review during an abbreviated survey conducted on 10/28/2025 for case number 2616775, the facility failed to ensure one (1) (Resident #1) of three (3) residents was free from accidents. Specifically, Certified Nursing Assistant #1 failed to follow the care plan for Resident #1 requiring a two-person assist. On 09/11/2025, Certified Nursing Assistant #1 transferred Resident #1 from their wheelchair to their bed alone resulting in a fractured left humerus (upper arm bone). […]

• No harm, potential for more than minimal, widespreadF812Sep 8, 2025

  Based on observation, record review, and interviews during the recertification initiated on 09/02/2025 and completed on 09/08/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen task observation on 09/02/2025 and during the Dining Task on 09/02/2025 at the lunch meal. Specifically, frozen food items (tiramisu, broccoli florets, pizza slices, a tray of diet pudding, regular pudding and peaches, roast beef, Brussel Sprouts) in the walk-in freezer were stored undated and or with opened packaging. Specifically, the facility did not monitor the temperature of cold food items (sandwiches, yogurt, milk) at the time of meal service. […]

• No harm, potential for more than minimal, isolatedF604Sep 8, 2025

  Based on observation, interviews, and record review during the Recertification Survey initiated on 09/02/2025 and completed on 09/08/2025, the facility did not ensure each resident had the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident's medical symptoms. This was identified for one (1) (Resident #36) of one (1) resident reviewed for Physical Restraints. Specifically, on 09/02/2025, Resident #36 was observed sleeping in a bed with the bed positioned between another empty bed on the right side and a Geri chair on the left side, thereby blocking the resident from getting out of the bed. […]

• No harm, potential for more than minimal, isolatedF689Sep 8, 2025

  Based on observation, record review, and interviews during the Recertification Survey initiated on 09/02/2025 and completed on 09/08/2025, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. This was identified for one (Resident #12) of five residents reviewed for Accidents. Specifically, Resident #12 was at risk for elopement and had a physician's order for a Wanderguard (a wearable bracelet for residents at risk for wandering, which causes an alarm when the resident approaches a restricted area). On 08/01/2025, the resident removed the Wanderguard; however, no new interventions were put in place to ensure the resident was appropriately supervised and did not remove the Wanderguard. […]

• No harm, potential for more than minimal, isolatedF695Sep 8, 2025

  Based on observation, record review, and interviews during the Recertification Survey, initiated on 9/2/2025 and completed on 9/8/2025, the facility did not ensure that each resident who required respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. This was identified for one (1) (Resident #129) of three (3) residents reviewed for Respiratory Care. Specifically, Resident #129 did not receive pulse oximetry (oxygen saturation) monitoring (measures the oxygen saturation in blood) as recommended by the Physician in a progress note dated 09/01/2025; however, the Physician did not write an order for their recommendation. […]