Inspection·July 7, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review the facility failed to ensure Resident #3's left lower leg (LLE) surgical wound dressing was completed per the physician order and failed to ensure the medical record accurately reflected Resident #3's LLE surgical wound care. This finding affected one resident (#3) of three residents reviewed for wounds. Residents Affected - Few Findings include: Review of Resident #3's medical record revealed she was admitted on [DATE], discharged out to the hospital on [DATE], and returned to the facility on [DATE] with diagnoses including displaced bicondylar fracture of the left tibia, unspecified fall, and unspecified fracture of the left patella. Review of Resident #3's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited intact cognition. Review of Resident #3's physician orders revealed an order dated 06/29/23 to change the dressing to the left lower leg (LLE) every other day and as needed. Keep the knee straight for four weeks with a brace. Review of Resident #3's treatment administration record (TAR) dated 06/29/23 revealed Licensed Practical Nurse (LPN) #814 documented she had completed the LLE surgical wound care. Review of Resident #3's TAR dated 07/01/23 revealed LPN #815 documented she had completed the LLE surgical wound care. Review of Resident #3's progress note dated 07/02/23 at 12:46 A.M. revealed the resident refused the leg treatment because she was sleeping. Review of Resident #3's TAR dated 07/03/23 revealed LPN #815 documented she had completed the LLE surgical wound care. Observation on 07/06/23 at 3:52 P.M. with LPN #809 and the Director of Nursing (DON) of Resident #3's LLE surgical wound care revealed the DON held up the LLE while LPN #809 unwrapped the ace wrap and cast type dressing from the leg, removed her gloves, washed her hands, replaced her gloves, and placed abdominal pads and Kerlix gauze around the sutures to Resident #3's LLE. Interview on 07/06/23 at 4:05 P.M. with LPN #809 revealed the facility did not have the cast type dressing which she had removed from Resident #3's LLE during the surgical wound care dressing change, (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 2 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 07/07/2023 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)