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Troubling inspections put White Oak Manor on national watch list

For weeks, Mahoning Matters has reviewed inspection reports on file for the 46 nursing home facilities in Mahoning and Trumbull counties. Today we begin a three-part series detailing our results and providing readers with easy access to look at the reports themselves.
White Oak Manor_LEWIS
White Oak Manor of Warren has a rating of one star. (Photo by William D. Lewis)

[EDITOR'S NOTE: Read all of the Trumbull County inspection reports here. Next, we'll focus on Mahoning County nursing homes.]

WARREN — White Oak Manor Resident No. 10 was asleep at about 8 p.m. on April 20, 2017.

His slumber was interrupted by a loud bang from a neighboring room. When he heard a muffled yell from his neighbor, he immediately put his call light on. 

Then, a voice boomed, “I’ll kill you!”

Resident No. 10 told the nurse aide who responded to check on his neighbor, Resident No. 31.  

The nurse aide found Resident 31 as he was emerging from his room. He had scratches on his neck and bruises on his right shoulder. 

Resident No. 31 told the nurse aide “that [an agency nurse identified as ] LPN No. 7 threw him on the floor and choked him,” according to the Ohio Department of Health report that documented the incident. Earlier in the evening, multiple witnesses said they saw that licensed practical nurse bend Resident No. 31’s arm behind his back to get him into his room. 

Facility staff reported this incident, triggering an investigation.

While nursing homes are routinely inspected every year, additional inspections can result from complaints or facility-reported issues. 

In the past three years, White Oak Manor has been subjected to 20 inspections and cited for 68 deficiencies.

Persistent poor performance in recent years earned White Oak Manor a spot on the national Centers for Medicare and Medicaid Services' Special Focus Facilities list, making it one of the most scrutinized nursing homes in Ohio. 


For weeks, Mahoning Matters has reviewed inspection reports on file for the 46 nursing home facilities in Mahoning and Trumbull counties.

Ohio Department of Health inspectors perform at least one unannounced, on-site inspection at each facility in the state on a 9- to 15-month cycle. Those inspectors may issue citations for deficiencies in service, categorized by residents' freedom from abuse, their quality of life, nutrition and the structure or administration of the facility itself, among others. Inspectors categorize those deficiencies by their scope and severity — whether the deficiency created the risk of harm to residents or placed residents in "immediate jeopardy," and whether the deficiency was isolated or widespread.

The inspections also indicate whether deficiencies were corrected, and when.

The Centers for Medicare and Medicaid Services applies overall quality ratings ranging from one star to five stars to each nursing home, which can be found on the Nursing Home Compare site. The star ratings are based on each facility's health inspections, their level of staffing and the quality of their resident care measures.

Some inspection reports mention an “ombudsman,” a representative from Direction Home of Eastern Ohio’s Long-Term Care Ombudsman Program. The program, which is mandated under the federal Older Americans Act, resolves complaints from nursing home residents and provides the public with information about long-term care facilities.

“The range of complaints could be something like, [the resident] would like their shower in the morning … to situations that may involve abuse or neglect,” said John Saulitis, director of Direction Home’s ombudsman program. 

Though the ratings offer a "snapshot" of the quality of each facility, they aren't a substitute for visiting the facility yourself, according to the centers' website.


When inspectors visited White Oak Manor on Jan. 31, 2019, residents were dressed in hats and coats and covered in blankets in the television common room, which was a chilly 62.4 degrees.

“The only operational shower room of the three shower rooms in the facility was 67.0 degrees F with the door closed, and RA #106 indicated that no residents were receiving showers due to the cold temperature,” the Feb. 1, 2019, report states. 

Mahoning Matters has not yet been able to enter the facility, but inspection reports from last year describe a facility with chipped paint, dirty baseboards, dead bugs in light fixtures and holes in walls. In the previous report, dated Dec. 2, 2018, residents told investigators that there was a raccoon infestation in the ceiling. 

"Resident #8 also stated that they could see the tail of a raccoon hanging down from the ceiling after the raccoon removed the ceiling tile. Resident #8 stated that staff just put the tile back up into the ceiling," the report states. 

A March 1, 2019, report found that a resident overdosed after a medication cart was left unsecured. A July 31, 2019, report described an incident in which a resident in a wheelchair left the facility and was found nearly a mile from the facility wheeling himself down the street in the dark.

The facility's systemic issues culminated in a series of sexual abuse claims over this past summer. Between Aug. 9 and Aug. 11, three residents — Resident Nos. 2, 6 and 10, as identified in an Aug. 28, 2019, report — were sexually abused by Resident No. 9, who was described as having “a documented history of anger and violence issues.”

According to the report, the victims are “cognitively impaired, [have] impaired judgment, and mental illness.” 

During an interview with Resident No. 10, she said, “I think I have gonorrhea. Do you know what that is? That is from him when he had sex with me. Am I going to die? I am scared.”

Although a medical director told the facility to “watch Resident [No. 9] closely,” no plan was in place at White Oak to prevent him from abusing other residents. 


Mahoning Matters requested an interview with the leadership at White Oak Manor including new administrator Rachelle Giering, who was hired in September. Giering scheduled a meeting outside of the facility and showed up with Josh Dubler, regional director at HC Management Consulting, which owns White Oak Manor, to hand-deliver a written statement. 

“Following the state survey issues this past summer, the company made moves to address staffing adjustments and leadership," the statement read. "This change was a needed change and with it brought the [addition] of a new administrator that understands the unique challenges we face with the population we care for."

Administrative changes are “not necessarily a solution,” said Saulitis. “It would depend on the experience of the new administration and what their cultural perspective is of the nursing home world.”

When asked about the priorities and specifics of their improvement plan, Giering and Dubler did not elaborate, beyond Giering  saying, “It's all as a whole. ... Everything is addressed at the same time.” 

Dubler also pointed to the facility’s four-star Medicare rating for “quality measures," which includes metrics such as the percentage of residents who develop a urinary tract infection or suffer a fracture after a fall. 

"We're proud of the fact that the facility is a four-star in those outcomes," said Dubler. 

On the Medicare.gove website, "quality measures" is one of the three star-rating categories. In the other two — "health inspection" and "staffing" — White Oak Manor earned one.

There are other ways to gauge a nursing home facility. U.S. News and World Report’s "Best Nursing Homes" list provides an additional tool for consumers evaluating nursing homes.

This review parallels CMS’s profile of White Oak Manor. On the site, the facility earns an overall rating of one out of five. 

  • Availability of RN staff per resident per day: 7 minutes; Ohio average: 38 minutes
  • Consistent nursing staffing: 54.8 percent; Ohio average: 96 percent
  • Emergency room visits: 27.2 percent; Ohio average: 10.9 percent
  • Flu vaccination of patients: 32.8 percent; Ohio average: 83.3 percent 

Data used in the first three metrics was from April 2018 to March 2019; data for the fourth metric was from January to December 2018. 


The Special Focus Facilities program is an effort of the Centers for Medicare and Medicaid Services to identify the most problematic nursing homes in each state. 

Nursing homes placed on the list exhibit more deficiencies than other nursing homes, have issues of greater severity and a pattern of serious problems that persist over a long period of time, according to the CMS. 

Each state can select between five and 30 facilities from a larger list of candidates. There are four Ohio facilities, including White Oak Manor, on the list. Of the 24 candidate facilities in Ohio, the only other local facility is Oasis Center for Rehabilitation and Healing on Midlothian Boulevard in Youngstown.

Facilities selected for the program are subjected to at least one standard survey every six months. A nursing home can graduate from the program once it has completed two consecutive inspection surveys without deficiency citations at a severity level of “F” or greater.  Facilities that do not graduate from the program are at risk of losing their Medicaid/Medicare license.

Despite the potentially high stakes of the program, many families choosing nursing homes for their loved ones don't know about the SFF list. 

“It’s available,” Saulitis said, “if you know to look for it.”

The updated list can be found on the CMS website.  

In White Oaks' statement, administrators said they believed that "a corner has been turned" and seemed to welcome some aspects that come with inclusion on the SFF list.

"There are certain additional resources available to facilities on this list, and we welcome that added support and direction and are confident that we will be able to graduate this program and be removed from the list,” the statement read. 

From the perspective of Saulitis, it should be harder to get off the list than it currently is. 

“The problem with coming into compliance is you meet the minimum standard, and then you pat yourself on the back and you go back to doing what you were doing before. 

“You don’t see the cultural changes that are necessary,” said Saulitis. 


Saulitis told Mahoning Matters, “What you never want to hear an administrator say is, ‘Well, this is a difficult population.’”

Just days later, the White Oak Manor statement included this: “White Oak Manor has a history of admitting and caring for residents with challenging behaviors, behaviors that most other nursing homes would not take.” 

In response, Saulitis said, "We've known [the residents] for years. They're nice folks. ... The facility should be clean. There shouldn't be holes in the walls. The water should work, regardless of their conditions. It's incumbent on us as a society to ensure there's excellence in quality of care to residents, not some minimum standard." 

In Saulitis' experience, use of language like "challenging behaviors" could signal toleration of lower overall standards.

“The reality is, all people need to be treated with dignity and respect at all times,” said Saulitis. “And once you stop doing that and start blaming the victim for something that happens, then you go down a road of tolerating minor incidents.” 

“If you’re not paying attention to the little details, you’re not paying attention to the big ones either,” Saulitis said.


Important details were overlooked in White Oak's response to the incidents of sexual abuse that occurred in August 2019. Of the eight deficiencies on the Aug. 28, 2019, report, three were related to the facility’s handling of the matter. 

Two incidents of sexual abuse took place on Aug. 9 and 10, but an investigation was not initiated until the third incident was discovered Aug. 11. 

Per facility policy, abuse must be reported to the state agency within 24 hours after the incident is discovered. 

In the first two incidents, nursing aides witnessed the sexual behavior but did not intervene. Each notified a superior, who failed to act. 

"The expectation would be that if they do want to have relations that they're provided a private area by the facility and that the facility is aware that those parties are consenting to that activity," said Theresa Knapik, assistant director of the ombudsman program. "I think the step that was missed at White Oak was that, yes the staff saw the two residents, but they didn't take the time to ensure that both parties were consenting."

In the third incident, which took place during the night shift between Aug. 10 and 11, a licensed practical nurse made aware of the incident reported it to the director of nursing “who then began an investigation which uncovered the previous incidents between Resident [No. 9] and Residents [No. 6] and [No.2].”

“[The director of nursing] said she did not know about Resident #2 and Resident #6 having sexual relations with Resident #9 until after they began investigating the sexual activity between Residents #9 and #10,” the report states.

Because the facility did not initially report the incidents to police, the Ohio Department of Health filed a report on Aug. 15, 2019, nearly a week after the incidents.

The report also notes that a medical director wanted to contact the probate court regarding the victim whose legal guardian gave consent for the victim to engage in sexual activity. According to an interview with the medical director, the facility administrator instructed him not to contact the court. 

In Saulitis' experiences, that was a red flag.

“Once you get in the habit of looking for reasons not to report something, it just cascades out of control,” Saulitis said. 


Closing a facility with persistent, systemic issues may sound justified, but punishing ineffective administrators isn't the goal of resident advocates or programs like the Special Focus Facilities list.

“As bad, as problematic as a particular facility might be, it’s still people’s home,” said Saulitis. 

The goal is to provide excellent care to residents. For facilities with systemic issues, turning a corner involves more than an afternoon of staff training or adjustments to residents' activity schedules; it requires changing a nursing home's culture. 

Facilities on the list should be "required to hire a cardiologist and a theologian," Saulitis said. "You’re not going to really fix a company unless you change the heart and the soul of the corporation into a person-centered care model." 

In a person-centered care model, a facility treats residents as people with preferences. It considers how residents like to be dressed and when they like to shower. In prioritizing things that seem like trivial details, this care model creates a culture and a system that protects residents from harm.

Saulitis summed up the importance of such a model with a question: “How do you select a facility that you can sleep at night knowing your loved one is there?” 

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