White Oak Manor - Charlotte

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

concerns regarding the Resident's anticoagulant being held for 85 days. Formal apology provided on behalf of the facility. Official grievance was completed and resolved with spouse. Spouse agreed to allow the Resident to return to the facility. On 10/16/25, Resident readmitted to the facility with an order for anticoagulant (Eliquis 5mg, 1 tablet, every 12 hours). An audit of current residents in the month of October

on anticoagulant therapy was completed by running current orders for anticoagulants and reviewing the orders for accuracy to determine whether any changes or adjustments with the anticoagulant were made, and verifying the appropriate administering or discontinuing of the medication as ordered. The audit was completed by the DON on 10/13/25. The DON ensured residents had their anticoagulant ordered and administered as required, and verified that the medication was available in the medication cart. No further concerns were identified. Another audit of current residents on anticoagulant therapy and residents that had discontinued anticoagulant orders for the month of October 2025 was completed on 10/23/25 by the DON and the Assistant Director of Nursing (ADON). There were no other concerns identified. A further audit will be completed by reviewing the Healthcare Practitioner's progress notes and provider's consultations for the month of October 2025 to identify any other medication that have been discontinued specifically focused on anticoagulant medications and have not been restarted. The audit will be completed on 10/24/25 by the DON, ADON and the Pharmacy Consultant. If any further concerns are identified from the audit, the Healthcare Practitioner will be notified, and the resident will be evaluated. Current and newly admitted residents on anticoagulants, residents with newly ordered for anticoagulants and anticoagulant that have been discontinued have the potential to be affected. The facility will ensure the residents' medications will be administered, discontinued and restarted appropriately.Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The Licensed Nurses were originally re-educated on the importance of ensuring a resident's medication, such as an anticoagulant, that is temporarily discontinued due to a procedure, treatment or hospitalization, has been restarted. The Licensed Nurse must verify that the medication that

the resident was taking prior to being discontinued has been reentered, verified and activated, if still deemed medical necessary. If the medication is held for a certain number of days, the Licensed Nurse is to [TRUNCATED]

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

White Oak Manor - Charlotte

4009 Craig Avenue Charlotte, NC 28211

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)

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

10/22/25 which read that the patient was not taking Eliquis on the date of the progress note. Resident #1's NP progress note dated 9/17/25 included Eliquis 5 mg oral every 12 hours on the medication list. The medication list had a statement which read ‘I have reviewed the resident's medications in the facility chart (MAR) (Medication Administration Record). Refer to the facility's Mediation Administration Record (MAR) for

a complete and up to date list of active medications.' Resident #1's NP progress note dated 9/24/25 included Eliquis 5 mg oral every 12 hours on the medication list. The medication list had a statement which read ‘I have reviewed the resident's medications in the facility chart (MAR) (Medication Administration Record). Refer to the facility's Mediation Administration Record (MAR) for a complete and up to date list of active medications.' Resident #1's NP progress note dated 9/30/25 included Eliquis 5 mg oral every 12 hours on the medication list. The medication list had a statement which read ‘I have reviewed the resident's medications in the facility chart (MAR) (Medication Administration Record). Refer to the facility's Mediation Administration Record (MAR) for a complete and up to date list of active medications.' Resident #1's NP progress note dated 10/01/25 read that the patient's chronic anticoagulation stopped in July 2025 prior to procedure to have suprapubic catheter place. Anticoagulation was not restarted. Will reinitiate Eliquis with loading dose. An order to restart the Eliquis was given by telephone from the NP on 10/01/25 at 2:46 PM.

The order was for Eliquis 5 mg 2 tabs (total 10 mg) oral every 12 hours for 7 days, then 5 mg oral every 12 hours with no stop date. An interview on 10/22/25 at 3:51 PM with the NP revealed the progress notes medication list indicated that Eliquis was an active medication for Resident #1. She stated that the medications carried over from the previous note may not always be accurate or reflect medication changes.

She stated the failure to restart the Eliquis was an oversight. An interview on 10/22/25 at 3:52 PM with the MD revealed Resident #1's Eliquis should have been restarted after the suprapubic catheter insertion procedure. The medication list on the progress notes were active medications and were carried over from previous progress notes. The MD stated she reviewed the facility Medication Administration Record for an accurate resident medication list. The MD was unable to explain how the Eliquis medication was missed and had not been restarted after the urology procedure. An interview on 10/23/25 at 4:18 PM with the Administrator and the Director of Nursing (DON) revealed they were aware the MD and NP progress note medication lists were not always accurate but were unaware of the specific process of how the medication list got on the progress note. The Administrator stated that the medications should have been reviewed and

the failure to restart the Eliquis should have been caught.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

White Oak Manor - Charlotte

4009 Craig Avenue Charlotte, NC 28211

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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and interviews with the Consultant Pharmacist, Nurse Practitioner, Medical Director and Director of Nursing, the facility's Consultant Pharmacist failed to identify a significant lapse in anticoagulant therapy. Specifically, Eliquis (an anticoagulant, also known as a blood thinner) was discontinued on 7/2/25 for a surgical procedure and was not resumed until 10/1/25. This interruption in therapy was not addressed

in the drug regimen reviews following the procedure, thereby failing to ensure the continuation of chronic anticoagulant treatment for Resident #1. This deficient practice was identified in 1 of 3 residents reviewed for unnecessary medications (Resident #1).Findings included:Resident #1 was admitted to the facility on [DATE REDACTED] with diagnoses which included atrial fibrillation, type 2 diabetes, and a history of pulmonary embolus. On 3/19/25, the physician ordered Eliquis 5 milligrams (mg) by mouth every 12 hours. Resident #1's physician orders for July 2025 revealed Eliquis 5 mg by mouth every 12 hours was discontinued on 7/2/25. The Consultant Pharmacist review of Resident #1 dated 7/30/25, 8/25/25, and 9/24/25 revealed no recommendations for restarting the Eliquis medication.On 10/1/25 a physician's order was written for 2 Eliquis 5 mg tablet and to administer every 12 hours for total 10 mg.The Consultant Pharmacist was interviewed via phone on 10/23/25 at 9:07 AM. He stated a pharmacy review for Resident #1 was completed on 7/30/25, 8/25/25 and on 9/24/25. The Consultant Pharmacist stated he did review NP and Medical Director's notes along with labs and it was an oversight that the Eliquis was not included on his July 2025 pharmacy review. The Consultant Pharmacist stated Eliquis was not on Resident #1's medication list for August 2025 and September 2025 because he knew Eliquis had been stopped by the physician. The pharmacist stated the Eliquis might have been stopped because of bleeding after the procedure or other reasons, but he did not remember specifics. The Medical Director was interviewed on 10/23/25 at 12:10 PM and stated the monthly pharmacy reviews should have caught the Eliquis was not restarted and brought it to her attention. An interview on 10/23/25 at 4:18 PM with the Administrator and DON revealed the Eliquis medication should have been reviewed and captured on the pharmacy reviews for Resident #1.

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