Inspection·December 7, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review the facility did not ensure Resident #11 had a physician order and/ or care plan for the use of ankle foot orthosis (AFO) to the bilateral lower extremities per therapy recommendation. This affected one resident (Resident #11) of one resident (Resident #11) reviewed for a splinting device. This had the potential to affect two residents (Residents #10 and #11) with recommendations for a splinting device. Findings include: Review of the medical record for Resident #11 revealed an admission date of 07/27/20 with diagnoses including osteoarthritis, difficulty walking, muscle wasting with atrophy, split foot (birth defect that consists of missing toes), and major depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had impaired cognition. He was independent with bed mobility, transfers, and locomotion. He required limited assist of one staff with dressing. He was unable to ambulate. Review of the November 2022 physician orders revealed there was no physician order for Resident #11 to have AFO's to his bilateral extremities. Review of undated comprehensive care plan for Resident #11 revealed there was nothing in the care plan regarding the use of AFO's. Review of the Occupational Therapy Discharge summary dated [DATE] and completed by Occupational Therapist (OT) #642 revealed Resident #11 was discharged from therapy because he was at his highest practical level. The summary revealed Resident #11 completed his lower extremity dressing with minimal assist including the use of bilateral AFO's. Review of the [NAME] Report dated 11/28/22 revealed under the dressing section Resident #11 was independent with dressing. The [NAME] revealed there was nothing in regard to the use of AFO's to the bilateral lower extremities. Observation on 12/04/22 at 9:24 A.M. revealed Resident #11 was sitting in his wheelchair and placed his right lower leg up onto his bed as he was trying to apply his AFO. Observation revealed he had difficulty applying the AFO especially with fitting the Velcro strap through the hole. Resident #11's roommate, Resident #7, observed Resident #11 having difficulty and Resident #7 revealed he usually had to help him in the morning apply his brace as he had a hard time putting it on. Resident #7 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 8 Event ID: 365748 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365748 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White Oak Manor 1926 Ridge Avenue Warren, OH 44484 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)