White Oak Health Campus

Based on observation, record review, and interview, the facility failed to ensure a resident was assessed to self-administer medications and had Physician's Orders to self-administer medications for 1 of 1 resident reviewed for self-administration of medication. (Resident 43) Finding includes: During an interview on 5/27/26 at 11:55 a.m., Resident 43 indicated she had kept two ointments in a drawer in her room. A tube of tacrolimus ointment (a topical medication used to treat skin conditions) was observed in the drawer. The other ointment she had used was triamcinolone (a corticosteroid used to reduce inflammation) and it had gone missing. A piece of paper posted on the chest of drawers contained instructions for the use of both the tacrolimus and triamcinolone ointments. During the interview, Resident 43 was observed scratching both of her arms.Resident 43's record was reviewed on 5/28/26 at 10:12 a.m.The admission Minimum Data Set assessment, dated 4/28/26, indicated the resident was cognitively intact.A Physician's Order, dated 4/28/26, indicated tacrolimus ointment 0.1%, one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed related to antipsychotic medications for 1 of 16 MDS assessments reviewed. (Resident 40)Finding includes:Resident 40's record was reviewed on 5/29/26 at 12:24 p.m. The admission Minimum Data Set (MDS) assessment, dated 4/26/26, indicated the resident was cognitively intact. In the 7-day look back period, the resident had received an injection, antipsychotic, antianxiety, antidepressant, antibiotic, opioid, antiplatelet, and anticonvulsant medications. The May 2026 Physician's Order Summary indicated promethazine (Phenergan), an antiemetic drug, 25 milligrams every 8 hours as needed for nausea and vomiting. During an interview on 6/1/26 at 3:28 p.m., the MDS Coordinator indicated she had coded an antipsychotic was administered because the resident had received promethazine and that drug required an AIMS assessment along with additional monitoring. During an interview on 6/1/26 at 4:10 p.m., the Nurse Consultant indicated the MDS should not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to Enhanced Barrier Precautions (EBP) and staff not wearing a gown during a peripherally inserted central catheter (PICC) medication administration observation. (Resident 62) Finding includes: During a medication administration observation on 5/28/26 at 12:36 p.m., RN 1 was observed preparing Resident 62's medications, which included antibiotic medication to be administered intravenously through the resident's PICC line. The resident's bathroom door had a sign that indicated EBP was to be used. RN 1 entered the resident's room, used hand sanitizer, and donned gloves. She had not donned a gown. She then proceeded to administer the intravenous medication through the PICC line. At 1:24 p.m. the antibiotic was complete and RN 1 entered the room to disconnect the medication. She used hand sanitizer, donned gloves, disconnected the tubing and flushed the PICC line. She had not donned a gown.During an interview on 5/28/26 at 1:29 p.m., RN 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to keep the kitchen clean and in good repair related to a build up of food debris and grease on the sides of the oven, deep fryer, floor between the oven and deep fryer, and in the bottom front of a closed warming food cart. The facility also failed to have boxes of food not stored up to the ceiling in the walk in freezer. This had the potential to affect 52 of 52 residents who resided in the facility and received food from the kitchen. (Main Kitchen) Findings include: During the Initial Kitchen Sanitation Tour on 3/3/25 at 10:53 a.m., with the Director of Food Services, the following was observed: a. There was a build up of food debris and grease on the sides of the oven. b. There was a build up of food debris and grease on the sides of the deep fryer. c. There was a build up of food debris and grease on the floor between the oven and the deep fryer. d. There was a build up of food debris and grease in the bottom front of a closed warming food cart. e. There were multiple boxes of food stored up to the ceiling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to provide proper feeding tube (gastrostomy tube) (g-tube) care as per professional standards, related to verification of the g-tube placement not completed prior to medication administration for 1 of 1 resident reviewed for feeding tube care. (Resident 29) Finding includes: During an observation of medication pass on 3/5/25 at 12:24 p.m., RN 1 was observed preparing and administering g-tube medications to Resident 29. RN 1 prepared and crushed carbidopa-levodopa (treatment for Parkinson's disease) 25 milligram-100 milligram 2 tablets and glycopyrrolate (treatment for ulcers) 1 milligram tablet in separate medication pouches and then put them into separate medication cups after they were crushed. She washed her hands, donned a gown and gloves, and entered the resident's room. She mixed each medication with approximately 15 milliliters (ml) of water. She flushed the g-tube with 30 ml of water, milked the tubing as the water was not going down by gravity, and then pushed the plunger of the syringe to get the water…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to identify or act on an irregularity in a resident's medication regimen related to a recommended lab not being completed and an accepted recommendation with no follow up for 2 of 5 residents reviewed for unnecessary medications. (Residents 16 and 8) Findings include: 1. Resident 16's record was reviewed on 3/5/25 at 8:45 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, major depression and anemia. The Quarterly Minimum Data Set assessment, dated 1/9/25, indicated the resident had severe cognitive deficits and required substantial assistance for toileting and transfers. A Pharmacy Recommendation, dated 11/19/24, indicated the resident had an order for an iron supplement for over six months and to consider checking serum iron, ferritin, TIBC and percent transferrin saturation (blood tests to determine iron iron levels) to determine if there was a continued need for supplementation. The recommendation was denied per PCP (primary care physician). There was no documentation for why the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure each resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being related to lack of non-pharmacological interventions used prior to giving anti-anxiety medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 252) Finding includes: Resident 252's record was reviewed on 3/4/25 at 3:40 p.m. Diagnoses included, but were not limited to, Parkinson's disease, bipolar disorder, and anxiety disorder. The admission Minimum Data Set (MDS) assessment, dated 3/2/25, was still in progress. A Care Plan, dated 2/25/25, indicated the resident was at risk for adverse consequences related to receiving anxiolytic medications. Interventions included, but were not limited to, attempt non-pharmacological interventions prior to administering as needed (PRN) anxiolytics and administer per orders. The current March 2025 Physician Order Summary indicated clonazepam (anxiolytic) 2 milligrams 1 tablet as needed for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure a medication was kept in a locked medication cart at all times for 1 of 8 residents observed during medication administration. (Resident 29) Finding includes: During an observation of medication pass on 3/5/25 at 12:24 p.m., RN 1 was observed preparing and administering g-tube medications to Resident 29. RN 1 prepared and crushed carbidopa-levodopa (treatment for Parkinson's disease) 25 milligram-100 milligram 2 tablets and glycopyrrolate (treatment for ulcers) 1 milligram tablet in separate medication pouches and then put them into separate medication cups after they were crushed. She washed her hands, donned a gown and gloves, and entered the residents room. She mixed each medication with approximately 15 milliliters (ml) of water. She flushed the g-tube with 30 mls of water, milked the tubing as the water was not going down by gravity, and then pushed the plunger of the syringe to get the water to flow. She did not check for placement of the g-tube prior to administering the water flush. RN 1 then poured…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure a resident's dignity was maintained, related to not placing a dignity bag over a foley (urinary) catheter drainage bag, for 1 of 1 residents reviewed for urinary catheters. (Resident 40) Finding includes: On 2/7/24 at 10:55 a.m., Resident 40 was observed in his room in bed. His catheter drainage bag was observed uncovered and draining yellow urine by gravity. On 2/7/24 at 11:26 a.m., Resident 40's catheter drainage bag was observed uncovered and draining yellow urine by gravity. Resident 40's record was reviewed on 2/7/24 at 10:28 a.m. Diagnoses included, but were not limited to, Parkinson's disease, hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the right dominant side, and obstructive uropathy (obstruction causing a blockage of the flow of urine.) The admission Minimum Data Set (MDS) assessment, dated 1/18/24, indicated the resident was cognitively intact for daily decision making. He had an indwelling urinary catheter. A Physician's Order, dated 1/11/24,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders for self-administration of medication,s and an assessment to self-administer their own medications, for 2 of 2 residents reviewed for self-administration of medication. (Residents 13 and 19) Findings include: 1. On 2/5/24 at 11:11 a.m., a bottle of Tylenol 325 milligram (mg) tablets was noted to be on Resident 13's bedside table. On 2/5/24 at 2:51 p.m., a bottle of Tylenol 325 mg tablets was noted to be on Resident 13's bedside table. The record for Resident 13 was reviewed on 2/7/24 at 12:37 p.m. Diagnoses included, but were not limited to, vascular dementia without behavioral disturbance. The Quarterly Minimum Data Set (MDS) assessment, dated 1/5/24, indicated the resident was moderately impaired for daily decision making. A Physician's Order, dated 5/30/23, indicated acetaminophen tablet 325 milligrams, 2 tablets for fever/pain every 4 hours as needed. There were no orders for self-administration or a self-administration assessment completed for the medication.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure skin odors and discolorations were assessed, monitored, and treated, for 1 of 3 residents reviewed for skin conditions (non-pressure related). (Resident 19) Finding includes: During an interview on 2/5/24 at 11:42 a.m., Resident 19 indicated she had an area of skin underneath her breasts that had a foul odor for a while and was itchy. She was unable to see if it was reddened, and indicated the facility staff were not treating the area. She was observed scratching the area and a foul odor was noted when the resident lifted her breast. The record for Resident 19 was reviewed on 2/7/24 at 2:01 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and chronic bronchitis. The Quarterly Minimum Data Set (MDS) assessment, dated 1/25/24, indicated the resident was cognitively intact for daily decision making. She had no pressure sores or skin conditions. There were no orders for a treatment or any documentation in the record related to the skin area…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.