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 (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 6 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 05/08/2025 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)