Inspection Reports for White Oak Post Acute Care
2828 Westfork, Baton Rouge, LA 70816, LA, 70816
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 3, 2025, identified deficiencies related to medication administration, resident assessments, consent for bed rails, food storage, and medical record accuracy. Earlier inspections showed a pattern of issues with medication management, care planning, documentation, staffing, and resident safety, including substantiated complaints about falls, abuse, and supervision lapses. Inspectors frequently cited failures to ensure timely medication administration, accurate assessments, adequate supervision, and proper infection control, with some immediate jeopardy findings related to resident safety and care plan implementation. Complaint investigations were mostly substantiated, including a notable case of resident-to-resident physical abuse and multiple medication errors. While deficiencies persist, the facility has taken steps to address some concerns, but the overall trend indicates ongoing challenges in maintaining consistent compliance.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
29.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
643% worse than Louisiana average
Louisiana average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
92 residents
Based on a December 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 3, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure nursing staff observed and ensured a resident consumed medication as prescribed.
Complaint Details
The complaint investigation found that nursing staff left Resident #10's medication at the bedside without ensuring consumption, confirmed by interviews with the resident, nurse S7LPN, and the Director of Nursing (S3DON).
Findings
The facility failed to ensure services met professional standards of quality by nursing staff not observing Resident #10 consume their medication, Lasix, which was left at the bedside and not taken by the resident.
Deficiencies (1)
Nursing staff failed to observe and ensure Resident #10 consumed medication as prescribed; medication was left at bedside and not taken.
Report Facts
Residents reviewed for medication administration: 7
Resident ID: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S7LPN | Nurse who left medication at bedside and confirmed failure to observe medication consumption | |
| S3DON | Director of Nursing who confirmed nurses should witness medication consumption and medications should not be left at bedside |
Inspection Report
Annual Inspection
Census: 92
Deficiencies: 7
Date: Dec 3, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including accurate resident assessments, coordination with PASRR Level II, medication administration, consent for bed rails, drug storage, food safety, and medical record maintenance.
Findings
The facility failed to ensure accurate coding of residents' MDS assessments, coordination with PASRR Level II recommendations, proper medication administration and documentation, valid informed consent for bed rails, proper labeling and storage of insulin pens, safe food storage practices, and accurate medical record documentation for medication administration and colostomy care.
Deficiencies (7)
Failure to ensure accurate MDS assessment coding for 5 residents (#4, #7, #13, #21, #43).
Failure to coordinate assessments with PASRR Level II recommendations for Resident #98.
Failure to ensure nursing staff observed and ensured Resident #10 consumed medication as ordered.
Failure to obtain valid informed consent prior to installation of bed rails/grab bars for Resident #13.
Failure to label insulin pens with opened dates on 2 medication carts.
Failure to properly label, date, and seal food items in the kitchen.
Failure to maintain accurate medication administration records for Residents #10 and #95, and failure to document colostomy changes for Resident #79.
Report Facts
Residents affected: 5
Current census: 92
Residents reviewed for PASRR: 4
Residents affected by PASRR coordination deficiency: 1
Residents reviewed for medication administration: 7
Residents in sample: 19
Medication carts with unlabeled insulin pens: 2
Residents affected by medication record inaccuracies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3DON | Director of Nursing | Confirmed inaccuracies in MDS coding, medication administration, and consent validity |
| S8MDS | Confirmed inaccurate MDS coding for Residents #7, #43, #4, and #21 | |
| S9MDS | Confirmed inaccurate MDS coding for Resident #13 and restraint coding for Residents #4 and #21 | |
| S1ADM | Administrator | Confirmed failure to implement PASRR Level II recommendations and food safety issues |
| S7LPN | Licensed Practical Nurse | Left medication at bedside without observing consumption for Resident #10 and confirmed unlabeled insulin pen |
| S6LPN | Licensed Practical Nurse | Confirmed unlabeled insulin pen for Resident #92 |
| S5DM | Dietary Manager | Confirmed unlabeled, undated, and unsealed food items in kitchen |
| S4ADON | Assistant Director of Nursing | Confirmed no documentation of colostomy changes for Resident #79 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 26, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to maintain accurate documentation of pressure ulcer interventions for Resident #2.
Complaint Details
The visit was complaint-related, focusing on documentation deficiencies for pressure ulcer care for Resident #2. The complaint was substantiated as the facility confirmed the documentation was incomplete despite care being provided.
Findings
The facility failed to ensure nursing staff accurately documented pressure ulcer interventions for Resident #2, who had multiple unhealed pressure ulcers. Documentation was missing for turning and repositioning the resident every two hours and floating her heels as ordered, despite staff interviews confirming care was provided but not documented.
Deficiencies (1)
Failure to maintain accurate records and ensure nursing staff accurately documented Resident #2's pressure ulcer interventions.
Report Facts
Residents reviewed for pressure ulcers: 3
Residents affected: Few
Dates with missing documentation: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (S2CNA) | Interviewed and confirmed care was provided but not documented | |
| Certified Nursing Assistant (S3CNA) | Attempted contact but unable to reach | |
| Director of Nursing (S1DON) | Interviewed and confirmed documentation deficiencies and responsibility of CNAs |
Inspection Report
Routine
Deficiencies: 1
Date: Apr 3, 2025
Visit Reason
The inspection was conducted to assess whether the nursing facility met professional standards of quality, specifically focusing on the safe and timely administration of medications.
Findings
The facility failed to ensure medications were administered safely and timely by leaving medications at the bedside for one resident (Resident #3) without physician orders for self-administration. Interviews confirmed the nurse left medications at bedside contrary to policy and physician orders.
Deficiencies (1)
Medications were left at the bedside for Resident #3 without physician orders for self-administration, posing a risk to safe and timely medication administration.
Report Facts
Number of residents observed with medication issue: 1
Number of pills observed at bedside: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3LPN | Nurse who left medications at Resident #3's bedside and confirmed no physician orders for self-administration | |
| S2DON | Director of Nursing who confirmed Resident #3 did not have physician orders for self-administration and medications should not have been left at bedside |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Feb 27, 2025
Visit Reason
The inspection was conducted due to complaints and concerns regarding failure to notify physician and family of a resident's fall, untimely completion of Minimum Data Set (MDS) assessments, failure to implement fall interventions, incomplete care plans, inadequate supervision of a high-risk wandering resident, and inaccurate documentation of census checks.
Complaint Details
The complaint investigation revealed substantiated findings of failure to notify physician and family of a resident's fall, untimely MDS assessments, failure to implement fall interventions, incomplete care plans, inadequate supervision of a wandering resident leading to an unwitnessed fall on the smoking patio, and failure to document census checks as ordered.
Findings
The facility failed to notify the physician and family of a resident's fall, complete MDS assessments timely, implement fall interventions as per care plans, develop comprehensive care plans within required timeframes, provide adequate supervision to a cognitively impaired resident who wandered and fell on the smoking patio, and accurately document census checks for residents at risk of wandering and elopement. An immediate jeopardy was identified due to inadequate supervision leading to a resident fall outside the facility.
Deficiencies (6)
Failure to notify the physician and family of a resident's fall during the weekend of 02/15/2025 through 02/16/2025.
Failure to complete a resident's comprehensive Minimum Data Set (MDS) admission assessment within the required 14-day timeframe.
Failure to implement fall interventions, such as use of a fall mat, as identified on the care plan for a resident at risk for falls.
Failure to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for a resident.
Failure to provide adequate supervision for a cognitively impaired resident who was a wanderer, unsafe smoker, and high fall risk, resulting in an unwitnessed fall on the smoking patio and immediate jeopardy to resident health or safety.
Failure to accurately document census checks every 30 minutes or every hour as ordered for residents at risk of elopement and wandering.
Report Facts
Residents reviewed for falls: 3
Residents reviewed for comprehensive assessments: 8
Residents reviewed for care plans: 7
Residents reviewed for wandering: 3
Residents affected by inadequate supervision: 1
Residents affected by inaccurate census checks: 2
Fall risk assessments for Resident #5: 2
Frequency of census checks ordered for Resident #5: 30
Frequency of census checks ordered for Resident #6: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S16RN | Day shift charge nurse | Named in failure to notify physician and family of resident's fall and inadequate supervision findings |
| S11LPN | Licensed Practical Nurse | Named in failure to notify physician and family of resident's fall finding |
| S8ADON | Assistant Director of Nursing | Named in failure to notify physician and family of resident's fall and inadequate supervision findings |
| S1DON | Director of Nursing | Named in failure to notify physician and family of resident's fall, care plan, and inadequate supervision findings |
| S3LPN | Licensed Practical Nurse | Named in failure to implement fall interventions finding |
| S5CNA | Certified Nursing Assistant | Named in failure to implement fall interventions finding |
| S2MDS | MDS Coordinator | Named in untimely MDS assessment and care plan findings |
| S13CNA | Certified Nursing Assistant | Named in inadequate supervision and smoking aide findings |
| S14WC | Ward Clerk | Named in inadequate supervision and fall reporting findings |
| S15CNA | Certified Nursing Assistant | Named in inadequate supervision and fall reporting findings |
| S9LPN | Licensed Practical Nurse | Named in inadequate supervision findings |
| S10CNA | Certified Nursing Assistant | Named in inadequate supervision findings |
| S12CNA | Certified Nursing Assistant | Named in inadequate supervision findings |
| S17WC | Smoking Aide Scheduler | Named in inadequate supervision findings |
Inspection Report
Routine
Census: 76
Deficiencies: 5
Date: Jan 27, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident transfers, care planning, activities of daily living, staffing, and documentation.
Findings
The facility was found deficient in timely notification to the Ombudsman of emergency resident transfers, development and implementation of comprehensive care plans for certain residents, adherence to ordered care protocols such as every 30-minute checks, provision of necessary assistance for activities of daily living, sufficient nursing staff coverage, and accurate documentation of care provided.
Deficiencies (5)
Failed to notify the Ombudsman of facility-initiated emergency resident transfers for 2 of 3 residents reviewed.
Failed to develop and implement a comprehensive person-centered care plan meeting the needs of 3 of 5 residents reviewed, including failure to complete PT evaluation, address wandering behaviors, and perform ordered every 30-minute checks.
Failed to provide necessary care and assistance for activities of daily living to maintain good personal hygiene for 1 of 4 residents reviewed.
Failed to have sufficient certified nursing assistant staff to provide nursing and related services to meet resident needs.
Failed to ensure accurate documentation of activities of daily living care for 2 of 3 residents reviewed.
Report Facts
Residents affected: 76
Falls since admission: 2
Staffing ratio: 8
Staffing ratio: 4
Staffing ratio: 3
BIMS score: 9
BIMS score: 5
BIMS score: 3
BIMS score: 14
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3SSD | Social Services Director or designee | Responsible for documenting resident transfers and submitting Ombudsman Emergency Transfer Log |
| S11PTD | Physical Therapist Director | Interviewed regarding therapy screening after falls |
| S12PTA | Physical Therapist Assistant | Interviewed regarding therapy screening after falls |
| S4MDS | MDS Coordinator | Interviewed regarding care plans and assessments |
| S2DON | Director of Nursing | Interviewed regarding care plan oversight and staff awareness |
| S13CNA | Certified Nursing Assistant | Interviewed regarding resident wandering behavior |
| S14LPN | Licensed Practical Nurse | Interviewed regarding resident wandering behavior |
| S15CNA | Certified Nursing Assistant | Interviewed regarding resident wandering behavior |
| S16CNA | Certified Nursing Assistant | Interviewed regarding resident wandering behavior and incontinent care |
| S8CNA | Certified Nursing Assistant | Interviewed regarding rounds frequency for Resident #5 |
| S7CNA | Certified Nursing Assistant | Interviewed regarding rounds frequency for Resident #5 |
| S6LPN | Licensed Practical Nurse | Interviewed regarding rounds frequency for Resident #5 |
| S5CNA | Certified Nursing Assistant | Interviewed regarding rounds frequency for Resident #5 and staffing levels |
| S1ADM | Administrator | Interviewed regarding staffing requirements and actual staffing |
| S9CNA | Certified Nursing Assistant | Interviewed regarding staffing levels |
| S10CNA | Certified Nursing Assistant | Interviewed regarding staffing levels |
| S21CNA | Certified Nursing Assistant | Interviewed regarding incontinent care for Random Resident 1 |
| S22ADON | Assistant Director of Nursing | Interviewed regarding incontinent care and staff assignments |
| S17LPN | Licensed Practical Nurse | Interviewed regarding documentation of bed baths |
| S20CRN | Clinical Registered Nurse | Interviewed regarding missing documentation of bed baths |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 14, 2024
Visit Reason
The inspection was conducted due to a complaint or allegation regarding the facility's failure to provide pharmaceutical services to meet the needs of residents, specifically related to medication administration for behavioral health services.
Complaint Details
The complaint investigation found that Resident #1 was not administered Ativan as ordered on 10/13/2024. The nurse confirmed not administering the medication because the resident calmed down and did not contact the physician to discontinue the order. The Director of Nursing stated staff are expected to follow physician's orders and to call the physician if medication is not administered.
Findings
The facility failed to ensure that a licensed nurse administered Ativan to Resident #1 as ordered by the physician. The nurse did not administer the medication because the resident had calmed down and did not obtain a discontinuation order from the physician, violating the facility's medication administration policy.
Deficiencies (1)
Failed to provide pharmaceutical services to meet the needs of Resident #1 by not administering Ativan as ordered.
Report Facts
Residents reviewed: 3
Residents affected: 1
Date of order: Oct 13, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2RN | Staff Nurse | Named in medication administration deficiency for not administering Ativan |
| S1DON | Director of Nursing | Interviewed regarding expectations for following physician's orders |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 15
Date: Sep 20, 2024
Visit Reason
The inspection was conducted based on complaints and allegations including failure to respond to call lights timely, environmental concerns, abuse reporting, inaccurate resident assessments, incomplete care plans, missed physician appointments, inadequate assistance with activities of daily living, unsafe transfer practices, unsafe smoking practices, medication storage issues, and infection control deficiencies.
Complaint Details
The complaint investigation included allegations of failure to respond to call lights timely, environmental concerns, abuse reporting failures, inaccurate assessments, incomplete care plans, missed physician appointments, inadequate ADL assistance, unsafe transfers, unsafe smoking practices, medication storage issues, and infection control deficiencies. Immediate jeopardy was identified related to unsafe transfers and smoking practices.
Findings
The facility was found deficient in multiple areas including failure to respond timely to call lights, unsafe and unsanitary environment, failure to timely report abuse allegations, inaccurate resident assessments and care plans, missed physician appointments, inadequate assistance with ADLs, unsafe resident transfers resulting in injury, unsafe smoking practices without proper supervision, medication storage violations, lack of staff competency documentation, failure to post nurse staffing data, improper food storage, failure to administer feeding tube nutrition as ordered, and failure to implement an effective infection prevention and control program.
Deficiencies (15)
Failure to respond to call lights in a timely manner for 1 of 5 residents reviewed.
Unsafe, unclean, and uncomfortable environment observed in multiple rooms and halls affecting 88 residents.
Failure to timely report allegations of physical abuse and misappropriation of resident property for 1 of 27 residents reviewed.
Inaccurate coding of PASRR Level II and hospice status in resident assessments for 2 residents.
Failure to refer residents with mental health diagnoses for PASRR Level II evaluation for 4 residents.
Failure to develop and implement comprehensive person-centered care plans for 5 residents including hospice status, ostomy care, physician appointment attendance, transfer status, and smoking status.
Failure to provide necessary assistance with activities of daily living including bathing for 1 of 3 residents reviewed.
Immediate jeopardy due to failure to identify and implement assessed transfer needs for 1 resident resulting in a fall with injury; failure to implement safe smoking interventions for 3 residents.
Failure to provide ordered enteral feeding for 1 resident; feeding tube not running for several hours.
Failure to post nurse staffing data daily in a prominent location accessible to residents and visitors.
Medication carts contained loose pills and expired medications; medication refrigerator temperature out of range.
Dietary staff not trained on how to test chemical dishwasher for chlorine.
Failure to ensure residents understood binding arbitration agreements signed on admission for 2 residents.
Failure to implement an infection prevention and control program including proper PPE use for residents on enhanced barrier precautions and removal of urine soiled laundry from resident rooms.
Failure to develop and implement effective quality assurance and performance improvement plans to address ongoing deficiencies including therapeutic diets, food storage, abuse reporting, and enhanced barrier precautions.
Report Facts
Residents affected: 88
Residents reviewed for abuse: 27
Residents reviewed for PASRR: 6
Residents reviewed for nutrition: 4
Residents reviewed for ADL: 3
Residents reviewed for transfer needs: 4
Residents reviewed for smoking: 4
Dietary staff: 5
Medication carts reviewed: 2
Medication refrigerator temperature: 29
QAPI meeting date: Aug 28, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4CNA | Certified Nursing Assistant | Named in transfer injury incident for Resident #54 |
| S6CAC | Admissions Coordinator | Responsible for explaining admissions and arbitration agreements |
| S12LPN | Licensed Practical Nurse | Administered medications without gown on Enhanced Barrier Precautions resident |
| S15LPN | Licensed Practical Nurse | Observed medication cart issues and feeding tube not running |
| S29MDS | MDS Nurse | Responsible for smoking assessments and updating resident care plans |
| S34LPN | Licensed Practical Nurse | Nurse assigned during Resident #54 fall, unaware of transfer needs |
| S38CNA | Certified Nursing Assistant | Interviewed about transfer status communication |
| S40CNA | Certified Nursing Assistant | Trainer of new CNAs, no competency checkoffs performed |
| S43LPN | Licensed Practical Nurse | Aware of resident smoking but unaware of responsibilities |
| S1ADM | Administrator | Interviewed about facility processes and immediate jeopardy |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 6
Date: Sep 20, 2024
Visit Reason
The inspection was conducted based on complaints regarding call light response times, environmental concerns, allegations of abuse and misappropriation, unsafe resident transfers, smoking safety, and feeding tube care.
Complaint Details
The complaint investigation included issues related to call light response delays, environmental deficiencies, abuse and misappropriation allegations, unsafe resident transfers, smoking safety violations, and feeding tube care concerns.
Findings
The facility failed to respond timely to call lights for one resident, maintain a safe and homelike environment in multiple areas, timely report abuse allegations, ensure safe resident transfers, implement effective smoking safety interventions, and provide continuous enteral feeding as ordered.
Deficiencies (6)
Failure to respond to call lights in an appropriate time frame for 1 of 5 residents reviewed.
Failure to maintain a safe, clean, comfortable, and homelike environment in 9 observed areas affecting 88 residents.
Failure to timely report allegations of physical abuse and misappropriation of resident property for 1 of 27 residents reviewed.
Failure to ensure safe resident transfers resulting in a fall with injury for 1 of 4 residents requiring a Hoyer lift.
Failure to implement effective smoking safety interventions for 3 of 4 residents reviewed, resulting in unsafe smoking behaviors.
Failure to provide continuous enteral feeding as ordered for 1 of 1 resident reviewed for tube feeding.
Report Facts
Residents affected by environmental concerns: 88
Residents reviewed for call light response: 5
Residents reviewed for abuse: 27
Residents requiring Hoyer lift for transfers: 4
Residents reviewed for smoking safety: 4
Duration feeding tube was not running: 7.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S42LPN | Licensed Practical Nurse | Involved in abuse allegation reporting and feeding tube observation. |
| S46CNA | Certified Nursing Assistant | Reported abuse allegation and assisted with feeding tube observation. |
| S4CNA | Certified Nursing Assistant | Involved in resident fall during transfer without Hoyer lift. |
| S1ADM | Administrator | Interviewed regarding abuse reporting, transfer safety, and smoking safety. |
| S29MDS | MDS Nurse | Interviewed regarding transfer status documentation and smoking assessments. |
| S36LPN | Licensed Practical Nurse | Interviewed regarding transfer status documentation and smoking assessments. |
| S33LPN | Licensed Practical Nurse | Interviewed regarding smoking safety. |
| S16CON | Director of Nursing | Interviewed regarding transfer status and smoking safety. |
| S12LPN | Licensed Practical Nurse | Interviewed regarding unsafe smoker Resident #49. |
| S20SW | Social Worker | Interviewed regarding abuse allegations and smoking safety. |
Inspection Report
Routine
Deficiencies: 5
Date: Jul 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, hygiene, pressure ulcer prevention, diabetes management, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to timely honor a resident's request to get out of bed, delayed incontinence care, inadequate pressure ulcer prevention resulting in actual harm, inaccurate medication administration records for insulin, and failure to maintain proper infection prevention and control practices including improper use of personal protective equipment and hand hygiene.
Deficiencies (5)
Failed to ensure Resident #3's request to get out of bed was honored in a timely fashion.
Failed to ensure Resident #3 received incontinence care timely.
Failed to provide necessary treatment and services to promote healing and prevent new pressure ulcers by failing to ensure Resident #2's heels were floated as ordered, resulting in actual harm.
Failed to maintain accurate medical records for Resident #R3 regarding insulin administration, documenting insulin given when it was not administered.
Failed to maintain an infection prevention and control program by not ensuring staff wore proper personal protective equipment, did not hang urinary drainage bag above bladder level, and failed to perform proper hand hygiene for residents on Enhanced Barrier Precautions.
Report Facts
Residents sampled: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Deep Tissue Injury size: 3.5
Deep Tissue Injury size: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S18CNA | Certified Nursing Assistant | Named in delayed transfer and incontinence care findings for Resident #3. |
| S2ADON | Assistant Director of Nursing | Interviewed and confirmed unacceptable delays and infection control expectations. |
| S1DON | Director of Nursing | Interviewed and confirmed expectations for timely care and infection control compliance. |
| S4LPN | Licensed Practical Nurse | Named in insulin administration documentation error for Resident #R3. |
| S3LPN | Licensed Practical Nurse | Named in insulin administration documentation error for Resident #R3. |
| S6TN | Wound Care Nurse | Observed pressure ulcer care deficiencies and infection control lapses. |
| S8CNA | Certified Nursing Assistant | Named in pressure ulcer prevention and infection control deficiencies. |
| S10LPN | Licensed Practical Nurse | Named in infection control and hand hygiene deficiencies during Resident #R1 care. |
| S11CNA | Certified Nursing Assistant | Named in infection control and hand hygiene deficiencies during Resident #R1 care. |
| S12CNA | Certified Nursing Assistant | Named in infection control and hand hygiene deficiencies during Resident #R1 care. |
Inspection Report
Complaint Investigation
Deficiencies: 13
Date: Jun 10, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding resident elopement, care plan implementation, treatment and care for indwelling devices, medication errors, and facility administration.
Complaint Details
The complaint investigation was triggered by concerns about a resident elopement, care plan implementation, medication errors, and facility administration issues. The investigation confirmed multiple deficiencies including an Immediate Jeopardy related to indwelling device care and resident elopement supervision.
Findings
The facility failed to timely report a resident elopement, ensure proper care plan implementation for diet and indwelling devices, prevent medication errors including missed doses and improper PRN orders, maintain effective QAPI meetings and documentation, ensure proper food storage and menu adherence, and provide mandatory staff training on effective communication.
Deficiencies (13)
Failed to timely report a resident elopement to the State Survey Agency as required.
Failed to implement a resident's comprehensive care plan for diet as ordered by the physician.
Failed to ensure treatment and care in accordance with professional standards by not obtaining and clarifying device site care orders for indwelling devices, resulting in an Immediate Jeopardy situation.
Failed to ensure adequate supervision to prevent unsafe wandering and elopement for a cognitively impaired resident with exit-seeking behaviors, resulting in an Immediate Jeopardy situation.
Failed to limit PRN orders for psychotropic medications to 14 days and indicate duration for such orders.
Failed to ensure residents were free from significant medication errors, including missed doses of seizure medication due to unavailability.
Failed to meet nutritional needs by not following approved menus and not recording menu substitutions.
Failed to store food in accordance with professional standards, evidenced by moldy sprouted red beans in dry storage.
Failed to ensure all admission orders were obtained, clarified, and entered into the resident's electronic medical record, specifically for PEG and nephrostomy site care.
Failed to ensure the administrator reported to and was accountable to the governing body and failed to maintain the facility's QAPI program.
Failed to complete a facility-wide assessment to determine necessary resources to care for residents competently during day-to-day operations and emergencies.
Failed to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program focused on outcomes of care and quality of life.
Failed to provide effective communication training as mandatory training for all direct care staff.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 77
Residents affected: 87
Residents affected: 84
Staff affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2DON | Director of Nursing | Confirmed multiple deficiencies including failure to report elopement, care plan issues, and QAPI program responsibility |
| S1ADM | Administrator | Confirmed failure to report elopement, lack of QAPI involvement, and lack of notification to governing body |
| S16UM | Unit Manager/Nurse | Provided interviews confirming care plan and supervision failures |
| S15ADON | Assistant Director of Nursing | Responsible for admission orders, failed to obtain nephrostomy tube dressing orders |
| S22DM | Dietary Manager | Confirmed menu substitutions and food storage issues |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 16, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to care planning, medical record accuracy, and infection prevention and control at White Oak Post Acute Care.
Findings
The facility failed to implement a comprehensive care plan reflecting a resident's frequent bath refusals, maintain accurate wound care documentation for two residents, and ensure staff compliance with infection prevention protocols, specifically proper use of personal protective equipment during care of residents on Enhanced Barrier Precautions.
Deficiencies (3)
Failed to develop and implement a complete care plan that meets all the resident's needs, specifically for Resident #1's frequent bath refusals.
Failed to maintain accurate medical records and documentation of wound care for Residents #1 and #3.
Failed to maintain an infection prevention and control program ensuring staff wore proper Personal Protective Equipment while providing care for Resident #2 on Enhanced Barrier Precautions.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Dates wound care not documented: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2WC | Nurse | Failed to properly input verbal/telephone wound care orders into the computer |
| S8NP | Nurse Practitioner | Gave wound care orders to S2WC |
| S1DON | Director of Nursing | Expected nurses to input telephone/verbal orders immediately and document wound care tasks; was unsure about appropriate PPE for Enhanced Barrier Precautions |
| S4CNA | Certified Nursing Assistant | Performed incontinent care for Resident #2 without wearing a gown as required |
| S5CNA | Certified Nursing Assistant | Reported Resident #1 frequently refused baths |
| S6CNA | Certified Nursing Assistant | Reported Resident #1 frequently refused baths |
| S3LPN | Licensed Practical Nurse | Reported Resident #1 frequently refused baths |
| S7MDS | MDS Coordinator | Responsible for updating care plans; confirmed care plan should have included Resident #1's bath refusals |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 14, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding physical abuse of Resident #1 by Resident #2 at the facility.
Complaint Details
The complaint investigation substantiated that Resident #2 physically abused Resident #1 by burning him with a cigarette and punching him multiple times on 12/01/2023. The facility confirmed the abuse, placed Resident #2 on 1:1 supervision, notified police, and sent Resident #2 for behavioral evaluation.
Findings
The facility failed to protect Resident #1 from physical abuse by Resident #2, who burned Resident #1 with a cigarette and punched him multiple times. The facility responded by placing Resident #2 on 1:1 supervision, notifying authorities, and sending Resident #2 for behavioral assessment. Staff abuse training was incomplete at the time of the incident.
Deficiencies (1)
Failure to protect residents from physical abuse by another resident, including cigarette burns and physical assault.
Report Facts
Residents reviewed for abuse: 6
Residents affected: 1
Punches reported: 4
Date of incident: Dec 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S7LPN | Licensed Practical Nurse | Reported Resident #1's statements and observations of abuse |
| S8RA | Resident Assistant | Reported Resident #1's injury and abuse to nursing staff |
| S3ADON | Assistant Director of Nursing | Assessed Resident #1's injuries and placed Resident #2 on supervision |
| S2DON | Director of Nursing | Confirmed abuse and supervised Resident #2's placement and assessment |
| S1ADM | Administrator | Notified of incident, coordinated response, and conducted staff abuse training |
Inspection Report
Deficiencies: 1
Date: Nov 29, 2023
Visit Reason
The inspection was conducted to assess compliance with staff education requirements on dementia care and abuse, neglect, and exploitation reporting.
Findings
The facility failed to provide required abuse, neglect, and exploitation training for one staff member (S6CNA) who was rehired on 10/02/2023, with no documented evidence of completion of this training after rehire.
Deficiencies (1)
Failure to provide abuse, neglect, and exploitation training for one staff member (S6CNA) after rehire.
Report Facts
Personnel records reviewed: 6
Personnel records with deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1HR | Interviewed and confirmed lack of documented training for S6CNA |
Inspection Report
Routine
Census: 78
Deficiencies: 11
Date: Aug 17, 2023
Visit Reason
The inspection was conducted to evaluate compliance with healthcare facility regulations, including medication administration, resident care, staffing, safety, and quality assurance.
Findings
The facility failed to ensure proper medication administration, secure medication storage, adequate staffing levels, effective quality assurance, and proper implementation of policies including hospice care, water management, antibiotic stewardship, kitchen safety, emergency preparedness, and workplace violence prevention. Multiple residents experienced missed or undocumented medication doses, expired medications were found on medication carts, and the emergency medication kit was not securely stored. Staffing shortages impacted resident care and response times. The facility lacked an accurate and complete facility assessment tool.
Deficiencies (11)
Failed to protect residents from misappropriation of property related to narcotic medication by a licensed practical nurse who tested positive for oxycodone without a valid prescription.
Failed to ensure residents received scheduled medications as ordered, including documentation errors and missed doses for multiple residents.
Failed to provide assistance with activities of daily living, resulting in a resident not receiving scheduled baths for over 10 days.
Failed to provide appropriate respiratory care by not changing oxygen tubing and humidification bottles weekly as ordered.
Failed to provide sufficient nursing staff to meet resident needs, resulting in staffing shortages and delayed resident care.
Failed to ensure medications were available for administration as ordered, resulting in multiple residents missing doses of prescribed and over-the-counter medications.
Failed to ensure medication error rate was less than 5%, with a medication error rate of 13.04% observed during medication administration.
Failed to ensure safe and secure storage of medications, including emergency kit not permanently affixed and containing Schedule II medications not in single unit packaging, medication refrigerator temperature logs incomplete, and expired medications found on medication cart.
Failed to conduct and document an accurate facility-wide assessment to determine resources necessary to care for residents competently during day-to-day operations and emergencies.
Failed to administer the facility in a manner that enabled effective and efficient use of resources, including inadequate staffing, ineffective medication availability and administration policies, ineffective hospice program, water management, antibiotic stewardship, kitchen and dietary services, emergency preparedness, workplace violence prevention, and QA/QAPI program.
Failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to narcotic medication discrepancies and monitoring.
Report Facts
Medication error rate: 13.04
Staffing hours short: 25.05
Staffing hours short: 21.85
Staffing hours short: 22
Staffing hours short: 11.5
Facility census: 78
Facility census: 73
Facility census: 76
Facility census: 75
Emergency kit weight: 16.8
Medication cart expired medications: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S23LPN | Licensed Practical Nurse | Named in narcotic medication misappropriation and positive drug screen incident |
| S44LPN | Licensed Practical Nurse | Named in narcotic medication discrepancy report |
| S2DON | Director of Nursing | Involved in multiple interviews and findings related to medication administration, staffing, and QA/QAPI |
| S14UM | Utilization Manager | Involved in narcotic log audits and medication refill process |
| S9LPN | Licensed Practical Nurse | Named in medication administration observation and staffing interviews |
| S11LPN | Licensed Practical Nurse | Named in medication administration and medication availability interviews |
| S12LPN | Licensed Practical Nurse | Named in medication administration and refill interviews |
| S10LPN | Licensed Practical Nurse | Named in medication administration and medication cart inspection |
| S1ADM | Administrator | Named in staffing, QA/QAPI, and facility assessment interviews |
| S4MS | Maintenance Staff | Named in water management and emergency kit box inspection |
| S22LPN | Licensed Practical Nurse | Named in medication availability interviews |
| S16CRN | Consultant Registered Nurse | Named in medication availability interviews |
| S3COO | Chief Operating Officer | Named in workplace violence prevention plan interview |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 12
Date: Aug 17, 2023
Visit Reason
The inspection was conducted based on complaints and concerns related to medication administration errors, misappropriation of resident property, inadequate nursing staffing, medication availability, hospice care coordination, infection control, food safety, and overall facility administration.
Complaint Details
The complaint investigation was triggered by allegations of medication administration errors, narcotic misappropriation, inadequate staffing, and failure to provide appropriate hospice and infection control services.
Findings
The facility failed to ensure residents were free from misappropriation of property, failed to administer medications as ordered, had inadequate staffing levels, failed to maintain medication availability and storage standards, failed to coordinate hospice care properly, lacked an effective water management and antibiotic stewardship program, failed to maintain sanitary food storage and preparation, and did not have an accurate facility-wide assessment or effective QA/QAPI system.
Deficiencies (12)
Failed to protect residents from misappropriation of property related to narcotic medication by a licensed practical nurse who tested positive for oxycodone without a valid prescription.
Failed to ensure residents received scheduled medications as ordered, including missed doses and undocumented administration for multiple residents.
Failed to provide adequate nursing and certified nursing assistant staffing to meet resident needs, resulting in delayed care and unmet needs.
Failed to ensure medications were available for administration as ordered, resulting in missed doses for multiple residents.
Failed to ensure safe and secure storage of medications, including unsecured emergency kit containing controlled substances and expired medications on medication carts.
Failed to store and prepare food under sanitary conditions, including uncovered, unlabeled, undated, and expired food items in kitchen storage areas.
Failed to maintain daily temperature logs for unit refrigerators and freezers.
Failed to conduct and document an accurate facility-wide assessment to determine resources necessary to care for residents competently during day-to-day operations and emergencies.
Failed to coordinate hospice care services, including updating hospice binders with current orders and care plans, and implementing new orders for hospice residents.
Failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to narcotic medication discrepancies and monitoring.
Failed to implement an infection prevention and control program, specifically lacking a water management program to prevent Legionella and other waterborne pathogens.
Failed to implement an antibiotic stewardship program to monitor and trend antibiotic use and infections.
Report Facts
Medication error rate: 13.04
Staffing hours short: 25.05
Staffing hours short: 21.85
Staffing hours short: 22
Staffing hours short: 11.5
Facility census: 75
Medication count: 56
Medication count: 8
Weight: 16.8
Medication errors: 6
Medication opportunities: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S23LPN | Licensed Practical Nurse | Named in narcotic misappropriation and disciplinary action related to medication discrepancies and positive drug screen. |
| S2DON | Director of Nursing | Interviewed regarding multiple findings including narcotic discrepancies, staffing, medication availability, hospice coordination, infection control, and QA/QAPI. |
| S14UM | Utilization Manager | Interviewed regarding narcotic discrepancies, medication availability, hospice coordination, and QA/QAPI. |
| S1ADM | Administrator | Interviewed regarding staffing, facility assessment, QA/QAPI, and overall facility administration. |
| S11LPN | Licensed Practical Nurse | Interviewed and observed during medication pass; confirmed missed medication doses and lack of notification. |
| S10LPN | Licensed Practical Nurse | Interviewed regarding expired medications on medication carts. |
| S4MS | Maintenance Staff | Interviewed regarding water management program and emergency kit box weight. |
| S1ADM | Administrator | Confirmed lack of effective QA/QAPI and incomplete facility assessment. |
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