White Oak Manor: Staff Ignored Infection Control - NC
The violation occurred on April 6 when Nursing Aide #3 and Nursing Aide #4 used a mechanical lift to move Resident #161 from his wheelchair to bed after an outside appointment. Both workers wore gloves but skipped the gowns required by Enhanced Barrier Precautions signage clearly posted on the resident's door.
A plastic holder containing personal protective equipment hung directly beside the warning sign.
When questioned immediately after exiting the room, NA #3 acknowledged he knew the resident was on Enhanced Barrier Precautions due to his gastrostomy tube for feeding. But he insisted gowns were only required "when performing some type of care not when transferring a resident."
Even after inspectors showed him the portion of the sign specifically indicating both gowns and gloves were required for transferring residents, NA #3 maintained his position. He stated transferring was not performing care and he did not consider a transfer to be a high-contact resident care activity.
NA #4 told inspectors she usually worked on a different unit and was unsure what was required on the East unit. April 6 was her first time working with Resident #161, she said.
When asked how she determined Enhanced Barrier Precautions requirements on her regular unit, NA #4 said she followed the signage. She confirmed the sign on Resident #161's door was identical to signs used on her usual unit.
NA #4 admitted she "sometimes used a gown when transferring residents on EBP but not all of the time."
The facility's Infection Preventionist confirmed both nursing assistants should have worn gowns during the mechanical lift transfer, calling it a high-contact resident care activity. He said he rounds daily to verify signage accuracy and ensure protective equipment availability.
Both workers had received comprehensive training on Enhanced Barrier Precautions and personal protective equipment use through multiple channels. The Infection Preventionist had conducted an all-staff infection control training session approximately two weeks before the violation, specifically covering Enhanced Barrier Precautions and protective equipment use.
NA #3 and NA #4 had also received Enhanced Barrier Precautions training during their initial orientation, monthly reviews during staff meetings, and yearly online training modules.
The Director of Nursing stated all staff members should utilize appropriate protective equipment according to infection control signage posted for each resident. She confirmed both nursing assistants should have worn gowns when conducting the mechanical lift transfer.
The Administrator echoed this position, stating he expected staff to wear required protective equipment when providing care to residents on Enhanced Barrier Precautions.
Enhanced Barrier Precautions are infection control measures designed to prevent the spread of multidrug-resistant organisms and other infections in healthcare settings. The protocols require specific personal protective equipment based on the type of resident contact and care activities being performed.
The violation occurred despite the facility's multi-layered training approach and clear visual reminders. The protective equipment was immediately available in the plastic holder mounted beside the warning sign, eliminating any barrier to compliance beyond staff decision-making.
Resident #161 requires tube feeding through his gastrostomy tube, a medical device that creates an opening in the abdominal wall directly into the stomach. The Enhanced Barrier Precautions were implemented specifically due to this feeding tube and associated infection risks.
The inspection found the facility failed to ensure staff followed established infection prevention and control procedures, potentially exposing the resident and others to preventable infections.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for White Oak Manor - Charlotte from 2026-04-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 24, 2026 · Our methodology
White Oak Manor - Charlotte in Charlotte, NC was cited for violations during a health inspection on April 13, 2026.
Both workers wore gloves but skipped the gowns required by Enhanced Barrier Precautions signage clearly posted on the resident's door.
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.