Deficiencies (last 3 years)
Deficiencies (over 3 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Nov 18, 2025
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with healthcare regulations and standards at White Oak Manor - Charlotte.
Findings
The facility was found deficient in two main areas: failure to correctly transcribe a physician's verbal order for blood sugar checks resulting in no blood sugar monitoring for a diabetic resident, and failure to effectively manage pest control leading to flies and gnats in resident rooms and the conference room.
Deficiencies (2)
Failed to correctly transcribe a verbal physician's order for twice daily blood sugar checks, resulting in no blood sugar checks being performed during a resident's admission.
Failed to effectively manage pests in resident rooms and the conference room, with observations of flies and gnats despite pest control efforts.
Report Facts
Residents affected: 1
Residents affected: 1
Frequency of hemodialysis: 3
Dates of verbal order: Sep 5, 2025
Dates of care plan: Sep 10, 2025
Dates of hospital admission: Aug 23, 2025
Dates of hospital return: Sep 12, 2025
Dates of observation: Sep 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #2 | Entered verbal order incorrectly for blood sugar checks | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding transcription error and pest control observations |
| Medical Director | Medical Director | Provided verbal order for blood sugar checks and interviewed about transcription |
| Administrator | Administrator | Interviewed about physician orders and pest control issues |
| Wound Nurse | Wound Nurse | Interviewed regarding Resident #1's wound care and pest observations |
| Nurse Aide #1 | Nurse Aide | Observed flies and gnats in Resident #1's room |
| Nurse Aide #2 | Nurse Aide | Observed flies and gnats and insect trap in Resident #1's room |
| Maintenance Director | Maintenance Director | Interviewed about pest control measures and spraying |
| Director of Housekeeping | Director of Housekeeping | Interviewed about cleaning and pest control in Resident #1's room |
| Pest Control Representative | Pest Control Representative | Interviewed about pest control visits and reports |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 27, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to resume anticoagulant therapy (Eliquis) for Resident #1 after a surgical procedure, leading to serious health complications.
Complaint Details
The complaint investigation found that Resident #1's Eliquis was discontinued on 7/2/25 for a procedure and was not restarted until 10/1/25, leading to pulmonary emboli and hospitalization. Immediate jeopardy was identified beginning 7/7/25 and removed on 10/26/25 after corrective actions. The investigation included interviews with family, staff, NP, Medical Director, and pharmacist, and review of medical records and medication administration records.
Findings
The facility failed to restart Eliquis for Resident #1 after it was discontinued for a suprapubic catheter placement procedure, resulting in bilateral pulmonary emboli and hospitalization. Additional findings included inaccurate medication lists in provider progress notes and failure of the consultant pharmacist to identify the medication lapse during monthly drug regimen reviews.
Deficiencies (3)
Failure to resume Eliquis anticoagulant therapy after surgical procedure, resulting in immediate jeopardy to resident health.
Failure of resident's doctor to review care and accurately document medication lists in progress notes at required visits.
Failure of licensed pharmacist to perform effective monthly drug regimen review, missing significant lapse in anticoagulant therapy.
Report Facts
Days Eliquis was discontinued: 85
Resident sample size: 3
Eliquis dosage: 5
Eliquis loading dose: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner | Nurse Practitioner | Responsible for discontinuing and failing to restart Eliquis after procedure; interviewed regarding oversight. |
| Medical Director | Medical Director | Reviewed resident care, acknowledged medication error, and ordered follow-up labs and treatment. |
| Assistant Director of Nursing | Assistant Director of Nursing | Notified family of blood clot, identified medication discontinuation, and communicated with NP. |
| Director of Nursing | Director of Nursing | Conducted audits of anticoagulant therapy, interviewed regarding medication oversight. |
| Consultant Pharmacist | Consultant Pharmacist | Failed to identify lapse in Eliquis therapy during monthly drug regimen reviews. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 27, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide a safe transfer for Resident #51, who required assistance with transfers.
Complaint Details
The complaint investigation found that Nurse Aide #3 assisted Resident #51 with a stand and pivot transfer instead of using the required sit-to-stand lift, resulting in a fall onto the bed. Resident #51 was not injured. The incident was substantiated by interviews with staff and the Director of Nursing.
Findings
The facility failed to provide a safe transfer for Resident #51, who required 2-person assistance using a sit-to-stand lift. Nurse Aide #3 assisted Resident #51 with a stand and pivot transfer against care plan instructions, resulting in both falling onto the bed without injury. Interviews confirmed the transfer was unsafe and the sit-to-stand lift should have been used.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, specifically failing to provide a safe transfer for Resident #51.
Report Facts
Residents reviewed for accidents: 6
Residents affected: 1
Date of incident: Jan 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #3 | Nurse Aide | Assisted Resident #51 with unsafe stand and pivot transfer. |
| Nurse #4 | Nurse | Responded to incident, assessed Resident #51, found no injuries. |
| Director of Nursing | Director of Nursing | Acknowledged the unsafe transfer and confirmed sit-to-stand lift should have been used. |
| Administrator | Administrator | Confirmed Resident #51 required 2-person assistance and sit-to-stand lift; noted NA #3 should have used the lift. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Mar 27, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident safety, respiratory care, medication management, food service, and infection control.
Findings
The facility was found deficient in several areas including unsafe resident transfer practices, incorrect oxygen delivery rates, improper medication storage and labeling, unclean dishware and equipment, and failure to follow hand hygiene protocols during wound care.
Deficiencies (5)
Failed to provide a safe transfer for a resident requiring 2-person assistance with a sit-to-stand lift, resulting in a fall without injury.
Failed to ensure oxygen was delivered at the prescribed flow rate for two residents, with observations showing oxygen concentrators set higher or lower than ordered.
Failed to store a lidded container of prescription topical medicated cream in a secure locked area and failed to discard expired medications in the medication room.
Failed to ensure dishware and plate warmer were clean prior to meal service, with dried food particles observed on plates and bowls.
Failed to follow hand hygiene policy during wound care when the Treatment Nurse did not sanitize hands between glove changes.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Expired medication expiration date: 202401
Expired medication expiration date: Jul 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #3 | Nurse Aide | Assisted Resident #51 with unsafe stand and pivot transfer |
| Nurse #4 | Nurse | Responded to Resident #51 after fall and assessed no injury |
| Nurse #2 | Nurse | Assigned nurse for Resident #41, confirmed oxygen order and flow rate |
| Nurse #3 | Nurse | Assigned nurse for Resident #101, did not check oxygen flow rate |
| Nurse #1 | Nurse | Assigned nurse for Resident #126, unaware of medicated cream at bedside |
| Unit Manager #1 | Unit Manager | Observed medicated cream at Resident #126's bedside and removed it |
| Treatment Nurse | Nurse | Observed failing to sanitize hands between glove changes during wound care for Resident #63 |
| Director of Nursing | Director of Nursing | Provided interviews regarding multiple deficiencies and expectations |
| Administrator | Administrator | Provided interviews regarding multiple deficiencies and expectations |
| Physician Assistant | Physician Assistant | Provided interview regarding oxygen orders and nursing staff responsibilities |
| Medical Director | Medical Director | Provided interview regarding medication management and resident assessment |
| Infection Preventionist | Infection Preventionist | Provided interview regarding wound care hand hygiene expectations |
| Dietary Manager | Dietary Manager | Provided interview regarding dishware cleanliness procedures |
| Regional Dietary Manager | Regional Dietary Manager | Provided interview regarding dishware cleanliness procedures |
Inspection Report
Routine
Deficiencies: 5
Date: Dec 8, 2023
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, grievance policies, readmission procedures, food preferences, and therapeutic diet orders at White Oak Manor - Charlotte.
Findings
The facility failed to provide a dignified dining experience by serving meals to some residents while others waited, failed to properly resolve grievances related to missing personal items and disrespectful staff, did not allow a resident to return after hospital transfer due to financial authorization issues, failed to honor food preferences including allergies and dietary restrictions, and failed to provide a renal diet as ordered for a resident.
Deficiencies (5)
Failed to provide a dignified dining experience when some residents were fed while others waited for their meal trays.
Failed to provide a written decision/resolution regarding grievances related to missing personal items and failed to submit grievances per policy for multiple residents.
Failed to allow a resident to return to the facility after hospital transfer due to financial authorization issues despite VA authorization.
Failed to honor food preferences for residents including serving disliked foods and not regularly offering plant-based options.
Failed to provide a resident with a renal diet per physician order, including serving foods high in potassium and phosphorus.
Report Facts
Residents affected: 5
Missing bras: 5
VA veteran limit: 30
VA veteran census: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #4 | Nurse Aide / Restorative Aide | Fed Resident #10 while other residents waited for meals |
| NA #5 | Nurse Aide / Scheduler | Noticed Resident #8 did not have lunch meal and retrieved it from kitchen |
| NA #6 | Nurse Aide | Described meal tray delivery process and feeding order |
| Nurse #4 | Nurse | Observed feeding and meal tray delivery issues, trained on dignity |
| Dietary Manager | Dietary Manager | Responsible for meal preferences and tray card system |
| Assistant Director of Nursing | ADON | Re-educated staff on dignified dining and described grievance process |
| Administrator | Facility Administrator | Expected residents to be served meals together and grievances to be resolved |
| Laundry Supervisor | Laundry Supervisor | Managed laundry department and missing bras issue |
| Social Service Director #1 | Social Service Director | Grievance official for missing bras and other grievances |
| Social Service Director #2 | Social Service Director | Involved in grievance and packing belongings of Resident #446 |
| Nurse #2 | Nurse | Received complaint of disrespect from Resident #141 |
| Nurse Supervisor | Nurse Supervisor | Shift supervisor who would handle grievances if informed |
| Registered Dietitian #1 | Registered Dietitian | Diet order for Resident #95 |
| Registered Dietitian #2 | Registered Dietitian | Dialysis facility dietitian for Resident #95 |
| Corporate Business Office Consultant | Business Office Consultant | Confirmed VA contract and authorization for Resident #445 |
| VA Case Manager | VA Case Manager | Explained VA authorization and veteran admission limits |
| Hospital Case Manager | Hospital Case Manager | Coordinated hospital discharge and readmission for Resident #445 |
| Business Office Manager | Business Office Manager | Handled VA authorization paperwork |
Inspection Report
Deficiencies: 3
Date: Apr 28, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident safety, accurate assessments, and food safety in the facility.
Findings
The facility was found deficient in maintaining residents' wheelchairs in good repair, accurately coding the Minimum Data Set (MDS) assessment for a restorative nursing program, and removing expired or spoiled food items from storage. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (3)
Failed to maintain residents' wheelchairs in good repair for 2 of 2 sampled residents, with torn and frayed arm rests causing potential skin irritation.
Failed to accurately code the Minimum Data Set (MDS) assessment for a restorative nursing program for 1 of 2 residents reviewed, due to incorrect recording of days splints were applied.
Failed to remove expired milk, spoiled potatoes, green bell peppers, and salad mix from refrigerator storage areas, posing potential risk to residents.
Report Facts
Expired milk cartons: 16
Spoiled potatoes: 42
Spoiled green bell peppers: 4
Restorative nursing splinting days: 1
Restorative nursing splinting days recorded incorrectly: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #5 | Stated arm rests for Residents #43 and #94 needed replacement and described notification process | |
| Maintenance Manager | Maintenance Manager | Admitted oversight in missing wheelchair repairs during routine checks |
| Director of Nursing | Director of Nursing | Expected direct care staff to be attentive to health equipment repair needs |
| Administrator | Administrator | Expected all health equipment to be in good repair and all expired food to be discarded |
| MDS Nurse #1 | Explained incorrect coding of restorative nursing splinting days in MDS assessment | |
| Dietary Manager | Dietary Manager | Acknowledged expired and spoiled food items in walk-in cooler and described staff training and oversight |
| Corporate Dietician | Corporate Dietician | Commented on Dietary Manager's recent hire and oversight regarding expired food |
Report
Dec 8, 2023
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