Health inspection·March 7, 2024

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cerebral infarction, hypertension, difficulty walking, schizoaffective disorder, anemia, major depressive disorder, dysphagia, gastro esophageal reflux, restlessness and agitation, tobacco use, angina, insomnia. Review of Resident #15's MDS 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. Resident #15 was independent for bed mobility, transfers and dressing. Resident #15 was independent to walk ten feet. Review of the Plan of Care dated 01/16/24 revealed Resident #15 had mood problems such as agitation, depression, schizophrenia. Interventions included administering medication as ordered, encouraging resident to express feelings. Invite or assist resident in activities of choice. Observe acute episodes of feelings of sadness, loss of pleasure of doing things. Notify physician as needed. Psych counseling services as needed. Staff to provide one on one as needed. Review of a nurse progress note dated 02/09/24 at 10:08 P.M. written by LPN # 149 revealed staff observed resident in a physical altercation (no specific details were provided) with another resident in the bedroom. Staff separated the residents, and left resident (#15) in her current room and placed the other resident (#5) in a separate room. No redness, swelling or injuries were noted to the resident and Resident #15 did not complain of any pain. The note indicated the DON was notified. Review of a nurse note dated 02/12/24 at 12:32 P.M. written by the DON revealed the DON spoke with Resident #15's daughter to update her on residents refusal to take medications, and physical and verbal behaviors. The daughter was made aware Resident #5 was moved to a private room per resident request because of complaints she did not like her current roommate. The daughter gave recommendations to see if any medication could be discontinued or any given intra muscular. The DON informed the daughter she would notify the resident's primary care physician and the psych nurse practitioner for a medication review. Observation conducted on 03/07/24 of the resident room in which the documented incident occurred revealed it was a large room with three bed capacity. The room revealed only two residents resided in this room which were Resident #13 and Resident #5. Observation within the rest of the facility revealed Resident #15's room was on an entirely different unit which was separated from Resident #15's unit by a large, common area room closed off by doors. Interview on 03/07/24 at 1:28 P.M. with the DON revealed a thorough and timely investigation was not conducted to determine if abuse had occurred because LPN #149 never notified her of the physical altercation on 02/09/24 despite the documentation she was notified. The DON was not able to investigate the incident immediately to identify staff responsible for interventions, identify and interview all involved persons, including alleged victims and/or perpetrator and other witnesses who might have knowledge of the altercation. No incident report was started. The DON stated she educated LPN # 149 and documented the education that the DON was to be notified immediately. The DON also stated because she was not notified immediately after the incident occurred, the incorrect resident (Resident #5) was placed in a separate bedroom. The DON said it would have been more appropriate for Resident #15 to be moved into a room by herself since she was having some verbal and physical behaviors directed towards others which were addressed with her care providers. Interview on 03/07/24 at 3:00 P.M. with the DON verified LPN #149 documented the physical altercation in the progress note but no incident report was filed on 02/09/24 and therefore the plan of care was not updated for Resident #5 or Resident #15. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365748 If continuation sheet Page 2 of 3 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 03/07/2024 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)

F 0610 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Abuse, Neglect, and Exploitation dated 10/01/22 revealed abuse was defined as the willful infliction of injury and physical abuse including slapping. Investigation of alleged abuse would include an immediate investigation when suspicion of abuse occurred. The facility was to provide complete and thorough documentation of the investigation. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00151164. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365748 If continuation sheet Page 3 of 3