Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at White Oak Health Campus during CMS and state inspections, most recent first.
A resident kept topical meds in a drawer and had written instructions posted at the bedside, but the chart had no self-administration assessment and no MD order allowing self-administration. The resident was cognitively intact and was observed scratching both arms, while RN and the DON stated the resident was not permitted to keep meds at the bedside and that family had continued bringing in meds despite prior education.
Inaccurate MDS Coding for Antipsychotic Medication: A resident’s MDS was incorrectly coded for antipsychotic use after promethazine was treated as an antipsychotic. The MDS Coordinator stated the drug was coded that way because it required AIMS monitoring, but the Nurse Consultant later confirmed the MDS should not have been marked for antipsychotic meds because promethazine is an antiemetic, not an antipsychotic.
EBP was not followed during IV medication administration for a resident with a PICC line. An RN used hand sanitizer and gloves but did not don a gown when administering an IV antibiotic and later disconnecting the tubing and flushing the PICC line, even though the resident’s door indicated EBP was required. The RN stated a gown should have been worn, and the IP confirmed EBP applies to residents with PICC lines.
The facility's kitchen had significant cleanliness and storage issues, affecting all 52 residents receiving food from this area. Observations revealed a buildup of food debris and grease on kitchen appliances and floors, and improper storage of food boxes up to the ceiling in the walk-in freezer. The Director of Food Services acknowledged these issues, and the facility lacked policies to address them.
A facility failed to verify the placement of a gastrostomy tube (g-tube) before administering medications to a resident, as observed during a medication pass. The nurse administered medications without checking the tube's placement, contrary to the facility's policy requiring verification before each administration. The Director of Nursing confirmed the policy, highlighting a deficiency in the care provided to the resident with a feeding tube.
The facility failed to address medication regimen irregularities for two residents. A resident's iron supplement use was not evaluated with recommended lab tests, as the physician denied the recommendation without documented rationale. Another resident's accepted recommendation for a gradual dose reduction of sertraline was not implemented, with unclear reasons for the acceptance and lack of family consultation.
A facility failed to manage a resident's medication regimen effectively by not attempting non-pharmacological interventions before administering PRN clonazepam for anxiety. The resident, with Parkinson's disease, bipolar disorder, and anxiety disorder, received multiple doses of the medication without documented attempts of alternative interventions, despite a care plan indicating the need for such measures. The DON had no additional information during an interview.
A nurse failed to keep medications secure during administration for a resident with a g-tube. The nurse left the medications unattended on the bedside table while retrieving a spoon, which was acknowledged as inappropriate by both the nurse and the DON. Additionally, the nurse did not check the g-tube placement before flushing it with water.
Failure to Assess and Order Self-Administration of Topical Medications
Penalty
Summary
The facility failed to ensure a resident was assessed for self-administration of medications and did not have a physician's order permitting self-administration of medications. Resident 43 was cognitively intact per the admission MDS dated 4/28/26. During an interview, the resident stated she kept two ointments in a drawer in her room, and a tube of tacrolimus ointment was observed there. The resident also reported using triamcinolone ointment, which had gone missing. A paper with instructions for both ointments was posted on the chest of drawers, and the resident was observed scratching both arms during the interview. Record review showed physician's orders for tacrolimus ointment 0.1% every 12 hours as needed and triamcinolone acetonide cream 0.1% every 12 hours as needed, but there was no self-administration assessment and no physician's order for the resident to self-administer her own medications. RN 2 stated the resident was not permitted to keep medications at the bedside, and the tacrolimus tube found in the drawer had a worn-off pharmacy label and blue tape marked "face." The DON stated the family had previously brought medications into the facility and continued to do so even after being educated that nursing staff needed to be notified of any new skin issues or itching so the resident could be properly assessed.
Inaccurate MDS Coding for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure an accurate MDS comprehensive assessment for one resident by incorrectly coding antipsychotic medication use. The resident’s admission MDS indicated the resident was cognitively intact, and the 7-day look-back period showed receipt of multiple medications, including an injection, antipsychotic, antianxiety, antidepressant, antibiotic, opioid, antiplatelet, and anticonvulsant medications. However, the May 2026 physician order summary listed promethazine (Phenergan) 25 mg every 8 hours as needed for nausea and vomiting, which the MDS Coordinator said had been coded as an antipsychotic because the resident received promethazine and that it required an AIMS assessment and additional monitoring. The Nurse Consultant later stated the MDS should not have been marked for antipsychotic medications, and after speaking with the Consultant Pharmacist, explained that promethazine is an antiemetic and not truly classified as an antipsychotic medication.
EBP Not Followed During PICC Line Medication Administration
Penalty
Summary
The facility failed to ensure infection control practices were in place and implemented related to Enhanced Barrier Precautions (EBP) during intravenous medication administration through a PICC line for Resident 62. During a medication administration observation, RN 1 prepared the resident’s medications, including an antibiotic to be administered intravenously through the resident’s PICC line. The resident’s bathroom door had a sign indicating EBP was to be used, and RN 1 entered the room, used hand sanitizer, and donned gloves, but did not don a gown before administering the medication through the PICC line. At the completion of the antibiotic, RN 1 returned to the room to disconnect the tubing and flush the PICC line. She again used hand sanitizer and donned gloves, but did not don a gown. During interview, RN 1 stated she should have worn a gown when administering intravenous medication through a PICC line. The Infection Preventionist stated EBP should be implemented for residents with a PICC line. The facility policy indicated residents with indwelling medical devices, including central lines, are to have EBP in place during high contact care activities and that staff shall wear gloves and gowns.
Kitchen Cleanliness and Storage Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper storage in the kitchen, which had the potential to affect all 52 residents receiving food from this area. During an inspection, a significant buildup of food debris and grease was observed on the sides of the oven, deep fryer, and the floor between these appliances, as well as in the bottom front of a closed warming food cart. Additionally, boxes of food were improperly stored up to the ceiling in the walk-in freezer. The Director of Food Services acknowledged these issues, indicating that the boxes should not be stored up to the ceiling and that the appliances and floors required more frequent cleaning to prevent buildup. The facility's cleaning list specified that kitchen staff were responsible for daily sweeping and mopping of floors and weekly cleaning of utility carts, but no facility policies were provided to address these concerns.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to provide proper care for a resident with a gastrostomy tube (g-tube) by not verifying the placement of the g-tube prior to medication administration. During an observation, RN 1 was seen administering medications to a resident with a g-tube without checking the tube's placement. The nurse prepared and crushed medications, mixed them with water, and flushed the g-tube with water without verifying the tube's placement, which is against the facility's policy. The nurse indicated that she checked for placement once per shift, which contradicted the facility's policy requiring verification before each medication administration. The Director of Nursing confirmed that the nursing staff should check for g-tube placement before every medication administration. The facility's policy on administering gastric/jejunostomy tube medications outlines the need for pre-administration assessments, including verifying tube placement through various methods such as checking gastric residual volume and observing changes in the external length of the tubing. The failure to adhere to these procedures resulted in a deficiency related to the care of the resident with a feeding tube.
Failure to Act on Medication Regimen Irregularities
Penalty
Summary
The facility failed to identify or act on irregularities in the medication regimens of two residents. For Resident 16, a pharmacy recommendation suggested checking serum iron levels due to prolonged use of an iron supplement. This recommendation was denied by the primary care physician without documented rationale, as the Director of Nursing (DON) later explained that the physician did not want to stress the resident with a blood draw. However, this rationale was not documented in the resident's medical record. For Resident 8, the facility did not implement a pharmacist's accepted recommendation for a gradual dose reduction (GDR) of sertraline, an antidepressant medication. Although the recommendation was marked as accepted, the GDR was not carried out. The DON indicated that the resident was doing well and that the facility staff had not yet met with the family to discuss the plan of care. Additionally, the hospice company was not in agreement with the GDR, but the reason for the acceptance of the recommendation remained unclear.
Failure to Implement Non-Pharmacological Interventions Before PRN Anxiolytics
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. This deficiency was related to the lack of non-pharmacological interventions used prior to administering anti-anxiety medication to a resident diagnosed with Parkinson's disease, bipolar disorder, and anxiety disorder. The resident's care plan, dated 2/25/25, indicated a risk for adverse consequences from anxiolytic medications and included interventions to attempt non-pharmacological methods before administering PRN anxiolytics. However, the Medication Administration Record for February and March 2025 showed multiple instances where PRN clonazepam was administered without documentation of attempted non-pharmacological interventions. During an interview, the Director of Nursing had no further information to provide.
Medication Security Deficiency During Administration
Penalty
Summary
The facility failed to ensure that medications were kept secure during administration for one of the residents observed. During a medication pass, RN 1 prepared and crushed medications for a resident with a g-tube, including carbidopa-levodopa and glycopyrrolate. After preparing the medications, RN 1 entered the resident's room, mixed the medications with water, and began administering them through the g-tube. However, RN 1 did not check the placement of the g-tube before flushing it with water, which is a necessary step to ensure proper administration. Furthermore, RN 1 left the medications unattended on the resident's bedside table while she exited the room to retrieve a spoon to mix the remaining medication. This action was acknowledged as inappropriate by both RN 1 and the Director of Nursing during interviews. The failure to keep the medication secure at all times during administration constitutes a deficiency in the facility's medication management practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Monticello
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monticello Healthcare | 1 mi | ★★★★★ | 0 | 0 |
| St Elizabeth Healthcare Center | 12.8 mi | ★★★★★ | 8 | 0 |
| Parkview Haven | 17.8 mi | ★★★★★ | 0 | 0 |
| Indiana Veterans Home | 19.6 mi | ★★★★★ | 4 | 0 |
| Heritage Healthcare | 20.3 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.