White Oak Manor Charlotte: Blood Thinner Gap 3 Months - NC
The resident, identified in inspection records only as Resident 1, had been taking Eliquis, a blood thinner used to reduce the risk of dangerous clotting, at a dose of 5 mg twice daily. The medication was stopped in July 2025 before a procedure to place a suprapubic catheter. It was never restarted.
What makes the failure harder to explain is that the medication kept appearing in the resident's chart anyway. Progress notes written by the facility's nurse practitioner on September 24 and again on September 30 listed Eliquis as an active medication. Each note carried a statement saying the writer had reviewed the facility's Medication Administration Record and that readers should refer to it for a complete and current medication list.
The drug wasn't active. It hadn't been given since July.
It wasn't until October 1 that the nurse practitioner's progress note finally reflected the truth: anticoagulation had stopped before the catheter procedure and had not been restarted. That same day, at 2:46 in the afternoon, the NP called in an order to restart the medication, prescribing a loading dose of 10 mg twice daily for seven days before dropping back to the standard 5 mg dose.
When inspectors interviewed the nurse practitioner on October 22, she said the medication lists in the progress notes weren't always reliable because medications carried over automatically from previous notes and didn't necessarily reflect actual changes. She called the failure to restart the Eliquis "an oversight."
The facility's physician said much the same thing. The medication lists in the progress notes were pulled forward from earlier entries, she explained, and she relied on the Medication Administration Record itself for accuracy. She could not explain how the Eliquis had been missed after the urology procedure. She confirmed it should have been restarted.
The administrator and the Director of Nursing, interviewed together on October 23, said they knew the medication lists in the progress notes weren't always accurate. They did not know how those lists were generated or how medications ended up on them. The administrator said the medications should have been reviewed and that the failure to catch the missing Eliquis was something that should not have happened.
What the inspection record shows is a system in which a known flaw, progress notes that automatically carry forward medications regardless of whether those medications are still being given, was accepted as normal. The nurse practitioner knew it. The physician knew it. The administrator and DON knew it. None of them had a process in place to catch the gap it created.
Eliquis belongs to a class of medications prescribed specifically because the consequences of stopping them can be severe. Patients on anticoagulants are typically taking them because their underlying conditions put them at elevated risk for blood clots, stroke, or other complications. The inspection record does not describe what, if any, harm Resident 1 experienced during the three months the medication was withheld.
The inspection was conducted October 27, 2025, following a complaint. Inspectors cited the deficiency at a level of minimal harm or potential for actual harm, affecting few residents.
The administrator said the failure should have been caught. It wasn't, for ninety days, while the progress notes continued to list the medication as active and the resident went without it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for White Oak Manor - Charlotte from 2025-10-27 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
White Oak Manor - Charlotte in Charlotte, NC was cited for violations during a health inspection on October 27, 2025.
The medication was stopped in July 2025 before a procedure to place a suprapubic catheter.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.