Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Manor - Tryon during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia, identified as an elopement risk and exhibiting exit-seeking behavior, was allowed to leave the facility unsupervised despite having a wander alarm device. The alarm transmitter, which manufacturer guidance specified should be worn on the wrist or ankle, had also been attached to the resident’s walker, and no staff recalled hearing any door alarm or seeing the resident exit. Over the course of the morning, multiple staff observed the resident wandering, confused, and asking to leave, but after she was last seen near the nurses’ station, her whereabouts went unaccounted for until family arrived for a visit and could not locate her, prompting a missing-resident code. During this time, a civilian saw the resident walking along a public road in cold weather and later found her down a steep embankment near a riverbed; EMS and fire personnel rescued her and transported her to the hospital, where she was treated for a forehead contusion.
A resident with multiple diagnoses was left with eye drops and mouth spray at bedside to self-administer without a documented assessment, physician order, or care plan. Staff interviews confirmed that facility policy for self-administration was not followed, and medications were left with the resident on multiple occasions despite the resident being unable to state their purpose or frequency.
A resident with respiratory conditions was not administered oxygen therapy according to physician orders, receiving higher oxygen flow rates at rest than prescribed. Staff interviews and observations confirmed the discrepancy between the ordered and delivered oxygen amounts, resulting in a deficiency related to respiratory care.
A medication cart was left unattended, unlocked, and with a drawer partially open containing resident medications for several minutes. Staff interviews confirmed that the cart should have been locked and all drawers closed when not attended, and that the responsible medication aide had received training on this requirement but failed to follow it due to distraction.
Confidential resident health information was left visible on an unattended medication cart computer screen in a hallway, allowing staff, residents, and visitors to view sensitive data such as medications, date of birth, and diagnoses. The responsible medication aide confirmed she failed to activate the privacy screen or lock the computer before leaving the cart, despite annual training and established facility protocols.
A deficiency was cited when the facility did not protect a resident from the wrongful use of their belongings or money. The report notes a failure to safeguard personal property or financial resources, but does not provide further details about the incident or those involved.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft, as evidenced by gaps in staff training, inconsistent reporting, and unclear guidance for identifying and responding to such incidents. This left residents vulnerable due to insufficient preventive measures.
The facility did not provide RN coverage for at least 8 consecutive hours on one day due to a scheduling oversight when the regular weekend RN was on vacation. The DON, responsible for reviewing staffing sheets, was unaware of the gap, and the Scheduler was unable to secure contract RN coverage, resulting in a lapse in required RN presence.
The facility did not consistently complete or accurately post daily nurse staffing sheets, with missing or incomplete documentation of nurse and nurse aide hours on several days, and one day with no staffing sheet present. The DON was responsible for oversight but was unaware of the omissions and errors, and the Administrator could not account for the discrepancies.
A facility failed to request a Level II PASRR for a resident diagnosed with a new mental health disorder, despite a change in treatment. The Social Service Director was unaware of the requirement for a Level II PASRR for new diagnoses, focusing only on schizophrenia and Huntington's disease. The Administrator expected compliance with PASRR requirements, but this was not met.
Failure to Prevent Elopement of Cognitively Impaired Resident Resulting in Off-Site Fall
Penalty
Summary
The deficiency involves the facility’s failure to adequately supervise a cognitively impaired resident at known risk for elopement, resulting in the resident exiting the building without staff knowledge. The resident had dementia with moderate cognitive impairment (BIMS score 10/15), was resistive to nursing home placement, expressed a desire to leave or go home, and had poor decision-making skills. An elopement risk assessment identified the resident as at risk for elopement, and an elopement alarm bracelet was ordered verbally per the Medical Director and applied on 01/22/26, initially to the resident’s wrist and then additionally to her walker and cane when she repeatedly removed the device from her person. However, there was no corresponding physician order documented for the elopement alarm device in the physician orders at that time, and the alarm bracelet placement on equipment was contrary to manufacturer instructions, which specified that transmitters should be worn on the ankle or wrist and not directly attached to equipment. On the morning of the elopement, multiple staff observed the resident wandering, confused, and exit-seeking over several hours. The Weekend RN Supervisor reported seeing the resident frequently between 7:30 AM and 9:30 AM, during which the resident was asking to leave, wanting to go outside, and attempting to open exit doors that remained locked and would not open for her. The Weekend RN Supervisor redirected the resident multiple times and had her sit in a chair near the 200 Hall medication cart, but after seeing the resident walk toward another hall around 9:30 AM, she did not see her again. A nurse aide assigned to the resident noted that the resident was walking around the hall and refused breakfast between approximately 8:30 AM and 9:00 AM, removed the breakfast tray, and then had no further contact with the resident that morning. Another nurse observed the resident at about 9:40 AM wandering on a different hall looking for turtles, walked her to a courtyard door to show where the turtles were, and then saw her walk back toward the nurses’ station near the front lobby; this was the last confirmed sighting of the resident inside the facility. Despite the resident’s known elopement risk, active exit-seeking behavior that morning, and the presence of an elopement alarm system, no staff reported hearing an elopement alarm sound, and no one observed the resident leaving the building. The DON stated she last saw the resident standing by the nurses’ station approximately 15–20 minutes before being asked about her whereabouts by the Weekend RN Supervisor, and a facility-wide search (Code [NAME]) was not initiated until the resident’s family arrived for a visit and reported they could not find her. During the period when the resident’s whereabouts were unaccounted for, a civilian observed her walking along a public two-lane road without sidewalks in cold weather, and later found her down a steep embankment near a riverbed after seeing her walker abandoned by the roadside. EMS and fire personnel documented that the resident had fallen approximately 17 feet down the embankment, required rescue with a stokes basket and ladder, and was transported to the hospital, where she was found to have a right frontal forehead contusion but no acute intracranial injury. EMS personnel and the civilian both reported that no elopement alarm bracelet was observed on the resident at the scene, while the facility later confirmed that an alarm bracelet remained attached to the resident’s walker and that the device functioned when tested at the front door, indicating that the resident had been able to leave the facility without effective alarm activation or staff intervention.
Removal Plan
- Conduct staff interviews with nursing, dietary and housekeeping staff who were present and working during the time of the elopement.
- Initiate the missing person protocol and conduct a head count of all current residents, documenting that residents are present and accounted for.
- Contact the on-call physician and notify the Medical Director.
- Complete a full skin assessment upon the resident's return from the hospital and document findings.
- Check and test the wander management system and door alarms, including testing the bracelet through the front door, and have maintenance check alarm doors for faults.
- Determine the likely exit route and confirm other doors are locked and require a code.
- Reapply an alarm bracelet to the resident's person and maintain a wander alarm bracelet on the rollator walker.
- Update the resident's plan of care for elopement risk after readmission.
- Ensure the physician order for the wander alarm bracelet is entered into the electronic medical record.
- Update the elopement board and binders with the resident's picture and room number.
- Implement 1-on-1 supervision for the resident using licensed nurses, nursing assistants and dietary staff.
- Transition the resident to 15-minute checks as a trial with continued monitoring for further incidents.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications, as required, for a resident with multiple diagnoses including dry eye syndrome and dry mouth. The resident was cognitively intact and independent with personal care, but there was no documented assessment, physician order, or care plan addressing self-administration of medications. Observations revealed that the resident had bottles of eye drops and mouth spray left at her bedside on multiple occasions, with faded or partially removed labels, and the resident was unable to state the purpose or frequency of the medications beyond general use for her eyes and mouth. The resident reported that nursing staff left the medications with her to self-administer and would later retrieve them. Interviews with staff confirmed that there was no order or assessment for the resident to self-administer medications, and that the facility's policy required such steps before allowing self-administration. A medication aide admitted to leaving the medications in the resident's room due to a stressful shift and forgetting to retrieve them, while the nurse and DON both acknowledged that medications should not be left with a resident without proper authorization and assessment. The administrator also confirmed that the required procedures for self-administration had not been followed in this case.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to administer oxygen therapy as prescribed for a resident with a history of pneumonia, heart failure, sleep apnea, and acute/chronic respiratory failure. The resident was admitted with physician orders specifying oxygen at 4 liters per minute (LPM) via nasal cannula while walking and 1 LPM while sitting or resting. However, multiple observations revealed that the resident was receiving oxygen at 2 or 3 LPM while at rest, rather than the ordered 1 LPM. The resident was cognitively intact, reported no shortness of breath, and stated that staff managed his oxygen settings. Nursing staff interviews confirmed that the resident was routinely placed on 2 LPM at rest and 4 LPM with exertion, with therapy staff having recently titrated the oxygen during therapy sessions. Upon review of the resident's orders, a nurse realized the prescribed amount at rest was 1 LPM, not 2 LPM as previously administered. The DON stated that nurses are responsible for ensuring the correct oxygen dose is delivered after reviewing orders each shift. The discrepancy between the physician's order and the oxygen administered at rest led to the deficiency.
Unattended and Unlocked Medication Cart with Open Drawer
Penalty
Summary
A medication cart on hall 300 was observed to be left unattended, unlocked, and with a drawer partially open containing resident medications for a period of two minutes. During this time, two staff members walked past the cart, but no residents were observed near it. The medication aide assigned to the cart confirmed that she had walked away from the cart without locking it or closing the drawer, stating she was in a hurry and forgot to secure the cart. Interviews with the medication aide, a nurse, the Director of Nursing, and the Administrator all confirmed that facility policy and training require medication carts to be locked and drawers closed when unattended. The staff involved acknowledged awareness of this requirement and confirmed that the medication aide had received annual training on this policy. The incident was attributed to the aide becoming distracted and failing to follow established procedures for securing medications.
Failure to Protect Resident Health Information on Unattended Medication Cart
Penalty
Summary
The facility failed to protect residents' healthcare information by leaving confidential medication information visible and accessible on an unattended computer screen attached to a medication cart. On two separate occasions, the medication cart in the 300 hall was observed left in the hallway with the computer screen displaying sensitive resident information, including medications, date of birth, room number, allergies, and diagnosis. During these periods, multiple staff members, residents, and visitors walked past the unattended cart, making the information accessible to unauthorized individuals. Interviews with the Medication Aide responsible for the cart confirmed that the computer screen was left open to resident information when she walked away to care for another resident. The aide acknowledged she was in a hurry and forgot to activate the privacy screen or lock the computer. Both the nurse and the Director of Nursing confirmed that staff are trained annually to ensure computer screens are locked or set to privacy mode when unattended, and that the aide was aware of this requirement.
Failure to Protect Residents from Wrongful Use of Belongings or Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report documents that the facility failed to ensure that residents were safeguarded against unauthorized or improper use of their personal property or financial resources. Specific actions or omissions by staff or facility management that led to this deficiency are not detailed in the report. No information is provided about the residents involved, their medical history, or their condition at the time of the incident.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these forms of mistreatment. This deficiency was observed through a review of facility documentation and staff interviews, which revealed gaps in staff training, inconsistent reporting mechanisms, and a lack of clear guidance on how to identify and respond to incidents of abuse, neglect, or theft. As a result, residents were left vulnerable due to the absence of adequate preventive measures.
Failure to Provide Required RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least 8 consecutive hours on one of the 82 days reviewed for staffing. On the date in question, review of the daily posted nurse staffing sheets confirmed there was no RN coverage. The Director of Nursing (DON) stated she was responsible for checking the daily posted staffing sheets Monday through Friday and would review weekend sheets on Monday. The DON was unaware that the RN coverage needed to be for 8 consecutive hours and explained that the regular weekend RN was on vacation during the relevant period. Although coverage was arranged for one day, the DON realized upon reviewing the schedule that there was no RN present on the other day in question. The Scheduler, who had recently started in her position, confirmed she was aware of the 8-hour RN requirement and attempted to find contract staff to fill the need but was unable to secure RN coverage for the day in question. She stated she had informed the DON of the lack of coverage. The DON was uncertain if she had been told about the absence of RN coverage and stated that if she had known, she would have tried to find an RN. The Administrator confirmed that the DON was responsible for checking staffing sheets and was aware of the RN coverage requirement but was not aware that there was no RN present on the day in question.
Incomplete and Missing Daily Nurse Staffing Sheets
Penalty
Summary
The facility failed to ensure that daily posted nurse staffing sheets were completed accurately and consistently for 6 out of 61 days reviewed. Specifically, on several dates, the staffing sheets were missing required information such as the number of hours worked by nurse aides and nurses, and in one instance, the staffing sheet was missing entirely. Additionally, there was an instance where the recorded RN hours did not reflect the required 8 consecutive hours, and another where the number of RNs on duty was incorrectly documented as hours worked. These deficiencies were identified through record review and staff interviews. The Director of Nursing (DON) acknowledged responsibility for ensuring the accuracy and presence of the daily posted nurse staffing sheets but was unaware of the missing or incomplete entries on the specified dates. The DON also indicated a lack of awareness regarding the requirement for documenting 8 consecutive RN hours. The Administrator confirmed that the DON was responsible for the staffing sheets and was unable to explain the errors found. No information about residents' medical history or condition was provided in relation to this deficiency.
Failure to Request Level II PASRR for New Mental Health Diagnosis
Penalty
Summary
The facility failed to submit a request for a re-evaluation for Preadmission Screening and Resident Review (PASRR) determination for a resident diagnosed with a new mental health disorder. The resident, who had a Level I PASRR effective since 2016, was admitted with a mood disorder and later diagnosed with a delusional disorder. Despite this new diagnosis and a change in treatment involving antipsychotic medication, no Level II PASRR evaluation was requested or completed. The Social Service Director was unaware that a new mental health diagnosis required a Level II PASRR request, focusing only on schizophrenia and Huntington's disease. The Administrator expected all residents to have a current PASRR at the appropriate level for their diagnosis, but this was not met for the resident in question. The oversight was identified through record reviews and staff interviews, highlighting a gap in the facility's compliance with PASRR requirements.
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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 Tryon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willowbrooke Court Sc Ctr At Tryon Estates | 2.7 mi | ★★★★★ | 0 | 0 |
| Autumn Care Of Saluda | 6.6 mi | ★★★★★ | 3 | 0 |
| Hendersonville Health And Rehabilitation | 12 mi | ★★★★★ | 0 | 0 |
| Golden Age Operations | 13.5 mi | ★★★★★ | 0 | 0 |
| Inman Healthcare | 13.7 mi | ★★★★★ | 0 | 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.