Health inspection·May 8, 2025

F 0583 Keep residents' personal and medical records private and confidential. 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 and interview, the facility failed to ensure medication administration bags were secured and resident names and medications were not readily visible in the common trash. This affected three (Residents #15, #27 and #136) of four residents reviewed for privacy. Residents Affected - Few Findings include: Review of Resident #15's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder bipolar type, muscle weakness and difficulty in walking. Review of Resident #15's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #27's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, muscle weakness and heart failure. Review of Resident #27's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #136's medical record revealed the resident was readmitted on [DATE] with diagnoses including cellulitis of the left lower limb with acquired absence of the right leg below the knee and chronic obstructive pulmonary disease. Resident #136's MDS 3.0 assessment dated [DATE] was not completed. Observation on 05/05/25 at 12:47 P.M. with the Director of Nursing (DON) revealed Residents #15, #27 and #136's clear plastic morning medication packages with the resident's name, room number and the names of the medications administered were placed in an open trash receptacle attached to the medication administration cart which was visible when walking by the cart. Interview on 05/05/25 at 12:57 P.M. with the DON revealed staff were to remove the top label part of the medication packaging with the resident names prior to disposing of the bottom half of the plastic packaging with the medications listed. The DON stated if the name was intact, then the staff were to use a black marker and cross out the name of the resident to ensure the privacy of the resident. The DON confirmed Residents #15, #27 and #136's discarded plastic medication bags were intact with the medications listed and the resident's name and room number which was a violation of the resident's privacy. The DON also confirmed the facility did not have a policy on ensuring resident privacy when disposing of medication administration packaging with identifiable resident information intact. Review of the HIPAA Security Measures policy revised 01/01/25 revealed it was the facility policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and/or records that were in the Page 1 of 6 365748 365748 05/08/2025 White Oak Manor 1926 Ridge Avenue Warren, OH 44484

F 0583 electronic format. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Complaint Number OH00165020. Residents Affected - Few 365748 Page 2 of 6 365748 05/08/2025 White Oak Manor 1926 Ridge Avenue Warren, OH 44484

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interviews the facility failed to ensure care planning conferences were completed quarterly. This affected two (Residents #24 and #26) of two residents reviewed for development of care plans. Facility census was 34. Findings include: 1. Review of Resident #24's medical record revealed an admission date of 07/07/23 with diagnoses of severe dementia with other behavioral disturbances, schizophrenia, intermittent explosive disorder, and anxiety. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had moderate cognitive impairment and required supervision for oral hygiene, showers, and personal hygiene. Review of the care planning conferences for Resident #24 from July 2023 to April 2024 revealed conferences were held 11/06/23, 01/17/24, 04/03/24, and 04/24/25. Further review of the care planning conferences revealed the Social Service Designee (SSD) #820 and Assistant Director of Nursing #802 were the members of the interdisciplinary team (IDT) in attendance. Interview on 05/06/25 at 12:12 P.M. with SSD #820 for Resident #24 revealed a care planning conference was held 04/24/25 but prior to that the previous care conference was 07/03/24. SSD #820 confirmed that other members of the IDT including the MDS nurse, floor nurse, dietary, and activities staff were not notified/invited to the care planning conferences. 2. Review of Resident #26's medical record revealed an admission date of 09/25/23 with diagnoses of Alzheimer's disease, leakage of aortic graft, chronic obstructive pulmonary disease, and anemia. Review of the MDS assessment dated [DATE] revealed Resident #26 had severe cognitive impairment and required maximal assistance with toileting, showers, dressing, and transfers and required a wheelchair for locomotion. Review of the care planning conferences revealed Resident #26 had one care planning conference which occurred on 02/25/25. Interview on 05/07/25 at 11:09 A.M. with SSD #820 confirmed no other care conferences were held. Review of the Care Planning-Resident Participation Policy dated 06/01/24 revealed the facility was to discuss the plan of care with the resident and/or representative at regular scheduled care plan conferences, at routine intervals, and after significant changes. 365748 Page 3 of 6 365748 05/08/2025 White Oak Manor 1926 Ridge Avenue Warren, OH 44484

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #1's laboratory bloodwork was completed per the physician orders. This affected one (Resident #1) of two residents reviewed for laboratory services. Residents Affected - Few Findings include: Review of Resident #1's medical record revealed the resident was readmitted on [DATE] with diagnoses including schizoaffective disorder bipolar type, chronic obstructive pulmonary disease and cardiomyopathy. Review of Resident #1's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #1's physician orders revealed an order dated 04/04/25 (discontinued 05/06/25) to obtain a potassium level weekly. Review of Resident #1's laboratory bloodwork revealed the potassium level was obtained on 04/04/25, 04/11/25 and 05/02/25. The potassium bloodwork was not obtained on 04/18/25 and 04/25/25 as ordered. Interview on 05/07/25 at 8:30 A.M. with the Director of Nursing (DON) confirmed Resident #1's potassium bloodwork was not completed as ordered. Review of the Laboratory Services and Reporting policy revised 01/02/25 revealed the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner or clinical nurse specialist in accordance with state law. 365748 Page 4 of 6 365748 05/08/2025 White Oak Manor 1926 Ridge Avenue Warren, OH 44484

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Resident #1's food preferences were followed during meals. This affected one (Resident #1) of four residents reviewed for food and drink. Findings include: Review of Resident #1's medical record revealed the resident was readmitted on [DATE] with diagnoses including schizoaffective disorder bipolar type, chronic obstructive pulmonary disease and difficulty in walking. Review of Resident #1's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #1's nutrition care plans revealed an intervention dated 02/26/16 to provide diet as ordered. Review of Resident #1's physician orders revealed an order dated 11/19/24 for a regular diet, regular texture with a regular-thin consistency. Resident #1's physician orders did not have an order for Boost or chocolate milk. Interview with Resident #1 on 05/05/25 at 8:45 A.M. revealed she was supposed to have Boost on her meal tray and it was not there. Resident #1 stated she never received the Boost. Review of Resident #1's breakfast meal ticket dated 05/05/25 revealed the resident was ordered a regular texture, regular, regular-thin breakfast. Under standing orders on the meal ticket, eight fluid ounces of Boost Very Vanilla was listed. Resident #1 had hand written on the ticket BOOST, WHERE Was Mine? Review of Resident #1's lunch meal ticket dated 05/06/25 revealed the resident was ordered a regular texture, regular, regular-thin lunch. Under notes on the meal ticket, chocolate milk was listed. Interview on 05/06/25 at 12:19 P.M. with Dietary Manager (DM) #845 confirmed Resident #1's preferences were not honored and the resident was not provided the Boost for breakfast on 05/05/25 or the chocolate milk on 05/06/25 for lunch. DM #845 revealed the facility had run out of chocolate milk on 05/06/25 and the resident should have received another Boost until the food truck came in later in the day. Review of the Nutrition Services policy revised March 2017 revealed the facility provided meals for each resident, with preferences accommodated, timely meal services and assistance with eating as needed. Review of the Therapeutic Diets policy revised June 2018 revealed the facility provided therapeutic diets per need and resident preferences. The facility worked with the resident/family, dietitian and physician to balance the medical needs of the resident with their preferences, to have fewer dietary restrictions when possible. 365748 Page 5 of 6 365748 05/08/2025 White Oak Manor 1926 Ridge Avenue Warren, OH 44484

F 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on record review and interview, the facility failed to ensure the infection preventionist (IP) role was conducted by a nurse who worked at least part-time in the facility. This had the potential to affect all 34 residents who resided in the facility. Findings include: Review of the Facility Assessment form dated 06/21/24 revealed the assessment did not designate the amount of hours that were required for the IP to be in the facility to ensure implementation of the infection control programs and activities. Review of the IP Training Plan Proof of Completion form dated 05/30/23 revealed Registered Nurse (RN) Regional #851 was the current IP for the facility. Interview on 05/06/25 at 12:10 P.M. with the Administrator revealed RN Regional #851 was the current IP who was in the building once monthly. Interview on 05/06/25 at 12:25 P.M. with RN Regional #851 confirmed she currently completed the IP role once monthly in the facility. The previous staff member who was the IP no longer worked in the building as of 11/15/24. Review of the Infection Prevention and Control Program revised 01/07/25 revealed the facility had established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 365748 Page 6 of 6