Health inspection·May 8, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to implement their abuse policy regarding thoroughly investigating and failing to submit a self-reported incident (SRI) to the state agency of an allegation of staff-to-resident verbal abuse for Resident #2. This affected one resident (#2) of three residents reviewed for abuse. The facility census was 34. Residents Affected - Few Findings include: Review of the medical record revealed Resident#2 was admitted to the facility on [DATE] with diagnoses including depression, anxiety, morbid obesity, and a need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was cognitively intact. Review of the care plan dated 03/25/24 revealed Resident #2 had an activity of daily living (ADL) deficit and required the assistance of one to two staff to complete bathing, toileting and grooming. The care plan also revealed Resident #2 can display accusatory and paranoid behaviors and refused for certain staff to be in her room. Interventions included allow resident to discuss feelings, approach and speak to resident in a calm voice. On 05/07/02 at 10:26 A.M. an interview with Long Term Care Ombudsman (LTCOs) # 98 and #99 revealed they were at the facility on 04/23/24. They interviewed Resident #2 during their visit, and Resident #2 told them State Tested Nurse Aide (STNA) #63 had called her a [expletive]. LTCOs #98 and #99 stated they told the facility Administrator immediately after the interview with Resident #2. LTCOs #98 and #99 stated they called the facility for follow-up on 04/26/24 and were informed by the Administrator a care conference was held with Resident #2, and the allegation of staff-to-resident abuse did not need to be thoroughly investigated. On 05/07/24 at 1:00 P.M.an interview with the Administrator and the Director of Nursing (DON) revealed they did not implement their abuse policy and investigated the allegation of staff-to-resident verbal abuse for Resident #2. Both stated they had a care conference with Resident #2, and her son and Resident #2 did not feel abused or mistreated. Both stated State Tested Nursing Assistant (STNA) #63, the alleged perpetrator, was removed from being assigned to Resident #2 but was not removed from schedule. Both verified there were no staff witness statements for the day of the occurrence nor were there resident interviews regarding the incident. In addition, the facility did not submit an (SRI) to the state agency. A review of the policy titled, Abuse, Neglect and Exploitation dated 10/01/22, revealed on page (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 4 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 05/08/2024 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)