Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Estates during CMS and state inspections, most recent first.
Surveyors found that washer filters were heavily soiled with lint and debris on all observed machines, despite manufacturer instructions and a label on the equipment requiring daily cleaning. The Laundry Supervisor stated that laundry staff did not maintain the filters and that maintenance was responsible, while the Maintenance Supervisor reported the filters were typically cleaned three times per week and that no documentation was kept to verify cleaning in accordance with manufacturer guidelines.
A resident with multiple medical conditions and decreased ability to perform ADLs was found with two white tablets in a medication cup on the bedside table, which the resident identified as Imodium saved from a prior medication pass. Facility policy requires staff to remain with residents until oral medications are swallowed and prohibits leaving medications in a room without a self-administration order. Record review confirmed there was no such order for this resident. An LPN verified that medications had been left at the bedside contrary to policy, and the DON stated that nurses are not to leave medications at the bedside and must observe residents swallowing medications.
The facility failed to properly store medications and biologicals in three medication carts. Observations revealed open and improperly stored items, including a sterile dressing with missing expiration details, a loose colostomy bag, and a non-sterile suture removal kit. The DON acknowledged that nurses are responsible for maintaining the carts, highlighting a lapse in policy adherence.
A hospice resident suffered a fall and minor injuries after a Hospice-Certified Nursing Assistant (HCNA) gave the resident a shower without verifying the resident's care needs. The HCNA, unfamiliar with the resident, did not consult facility staff or review the care plan, which indicated the resident required a bed bath due to weakness. This lack of communication and adherence to facility policies resulted in the resident's legs giving out, causing a fall in the shower.
A resident with moderate cognitive impairment had checks written from her checkbook to a CNA without her consent, amounting to $12,500. The CNA was identified in a bank surveillance video and was suspended and terminated. The facility failed to secure the resident's checkbook, leading to the misappropriation of funds.
Failure to Maintain Washer Filters per Manufacturer Instructions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the maintenance of laundry equipment. Review of the Alliance Laundry Systems washer manufacturer guidelines showed that, as part of end-of-day maintenance, the AC invert drive filter was to be cleaned by removing the external plastic cover, taking out the foam filter, and washing it with warm water and allowing it to air dry, or by vacuuming the filter. During an observation of the laundry area, the filter located on the front of the washing machine was found to be heavily soiled with lint and debris, despite a metal manufacturer label directly beneath the filter stating, "Clean Daily." Three of three washing machines observed had this issue. In an interview conducted at the time of the observation, the Laundry Supervisor acknowledged the condition of the filter and stated that laundry personnel did not maintain the filter, indicating that maintenance staff were responsible for cleaning it. In a subsequent interview, the Maintenance Supervisor reported that maintenance staff usually cleaned the filter about three times a week on Monday, Wednesday, and Friday, rather than daily as directed by the manufacturer. The Maintenance Supervisor also stated there was no log or record maintained to verify that the filter was cleaned as required.
Medications Left at Bedside Without Self-Administration Order
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards when medications were left at the bedside for one resident. The facility’s “Oral Medication Administration Procedure” policy states that staff must administer oral medications in an organized and safe manner, remain with the resident while the medication is swallowed, and never leave medication in a resident’s room without an order for self-administration. Review of the resident’s orders showed there was no order for self-administration of medication. The resident involved had diagnoses including post hemorrhagic anemia, gastrointestinal hemorrhage, irritable bowel syndrome, and osteoarthritis, and had a BIMS score of 15/15, indicating no cognitive impairment. The baseline care plan documented decreased ability to perform ADLs/self-care related to debility/generalized weakness. During observation, two white tablets were found in a medication cup on the resident’s bedside table. An LPN confirmed the medications should not have been left in the room and that the resident did not have an order to self-administer. The resident stated that a nurse had brought the medications the previous night and that she was saving them to use when needed, identifying them as Imodium. The DON stated that nurses are not to leave medications at the bedside and should remain with the resident to ensure medications are swallowed safely, and that anyone could take medications left at the bedside.
Improper Storage of Medications and Biologicals
Penalty
Summary
The facility failed to ensure proper storage of medications and biologicals in three medication carts, as observed during a survey. The facility's policy requires that medications and biologicals be stored safely, securely, and properly, following manufacturer's recommendations. However, during observations, several deficiencies were noted. On Unit 2's Wound Treatment Cart, a sterile Calcium Alginate Dressing was found open with the expiration date and lot number torn off. This was verified and discarded by an LPN. Further observations revealed additional issues on other units. On Unit 1's Wound Treatment Cart, an open 3% Xeroform sterile dressing and a loose colostomy bag not in its original package were found and discarded by another LPN. On Treatment Cart 4, a Suture Removal Kit with open metal forceps, no longer sterile, was discovered. The Director of Nursing acknowledged that it is the responsibility of all nurses to maintain the carts by checking for cleanliness and expiration dates, indicating a lapse in adherence to the facility's medication storage policy.
Failure to Verify Resident's Care Needs Leads to Fall
Penalty
Summary
The facility failed to maintain resident safety for a hospice resident, identified as R38, who was given a shower by a Hospice-Certified Nursing Assistant (HCNA) without verifying the resident's ambulation, transfer status, or Activities of Daily Living (ADL) care. This resulted in a fall where R38 suffered minor injuries. R38 was admitted to the facility with diagnoses including mild cognitive impairment, dementia, essential tremor, peripheral vascular disease, and osteoarthritis. The resident was moderately cognitively impaired and dependent on staff for toileting, showering, and personal hygiene, requiring substantial assistance for mobility and transfers. On the day of the incident, the HCNA, who was unfamiliar with R38, proceeded to give the resident a shower without consulting the facility staff or reviewing the resident's care plan, which indicated that R38 required a bed bath due to weakness. The HCNA did not use any assistive devices or a gait belt, leading to R38's legs giving out, causing the resident to fall in the shower. The fall resulted in skin tears on R38's toes and bruising, with the resident potentially hitting her head, necessitating the initiation of a head trauma protocol. Interviews with facility staff revealed that the HCNA did not follow proper procedures for resident care and failed to communicate effectively with the facility staff. The HCNA assumed the resident could stand and shower independently, despite being informed that R38 required a bed bath. The incident highlighted a lack of communication and adherence to the facility's policies on safe resident handling and fall management, ultimately compromising the safety and well-being of the resident.
Misappropriation of Resident's Funds by CNA
Penalty
Summary
The facility failed to ensure that a resident was free from misappropriation of property. The incident involved a resident with moderate cognitive impairment who had checks written from her checkbook to a Certified Nursing Assistant (CNA) without her consent. The resident's representative discovered the fraudulent checks while reviewing the resident's bank statements and reported the issue to the facility and the police. The checks amounted to $6,500 and $6,000, respectively, and were written for a car and car title. The CNA was identified in a bank surveillance video attempting to cash one of the checks, leading to her suspension and eventual termination. The facility's policy on neglect, abuse, and mistreatment defines misappropriation of resident property as the wrongful use of a resident's belongings or money without consent. Despite this policy, the resident had her checkbook in her possession, and the facility did not initially provide a lockbox for her valuables. The resident's son was adamant about his mother keeping her checkbook, which contributed to the incident. The CNA involved denied any wrongdoing and claimed to be a victim of identity theft, but failed to provide proof when requested by the Administrator. Interviews with various staff members revealed that the CNA had assisted the resident a few times but was not regularly assigned to her. The facility's Director of Nursing and Administrator were able to identify the CNA from the bank's surveillance video, which showed her depositing one of the fraudulent checks. The police were involved, and the CNA was found to have a history of similar accusations at another facility. The facility's failure to secure the resident's checkbook and the CNA's actions led to the misappropriation of the resident's funds.
Removal Plan
- An audit was completed by the Nursing Supervisor of current residents to determine which residents had personal funds in their possession including money, checkbooks and credit cards.
- The immediate action was to offer to lock up the identified residents' monetary possessions in the business office and a lockbox will be purchased by the facility and provided to the identified residents.
- Current residents were also interviewed to ensure no other personal properties or funds were misappropriated.
- The other current residents and RRs will be notified of the availability to secure their monetary possessions, if ever needed, by facility's newsletter.
- Newly admitted residents will be informed of the availability of lockboxes if needed to secure monetary possessions during the Admissions Conference.
- The facility staff were re-educated on the abuse protocol with the emphasis of misappropriation of resident's funds and property.
- The re-education also included to never take, use or ask for resident's property nor accept monetary gifts from the residents and RRs, and abuse including misappropriation of resident's funds is not tolerated by the facility and legal actions will be taken.
- Newly hired staff will receive this education during job specific orientation by the Staff Development Coordinator (SDC).
- The facility Nursing Administration or Social Services Department will monitor current and newly admitted residents by conducting an interview with 5 residents or RRs weekly to ensure monetary possessions are secured and lockboxes are provided as indicated.
- The facility Nursing Administration or Social Services Department will also monitor by interviewing 5 staff members weekly regarding the knowledge of misappropriation of resident's funds, and adhering to the rules of not taking, using or asking for residents' property/funds and not accepting monetary gifts from residents and families.
- Identified trends or issues from the monitoring tools will be discussed during the morning Quality Improvement (QI) meetings, and then discussions with the Quality Assurance (QA) Committee meetings for further recommendations as needed.
- The Administrator, Director of Nursing (DON) and Social Services Director (SSD) are responsible for the ongoing compliance of F602.
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What surveyors actually found near you
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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 Spartanburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Summit Hills Skilled Nursing Facility | 1.5 mi | ★★★★★ | 4 | 0 |
| Spartanburg Hospital For Restorative Care Snf | 3.7 mi | ★★★★★ | 1 | 0 |
| Magnolia Manor - Spartanburg | 3.7 mi | ★★★★★ | 0 | 0 |
| White Oak Manor - Spartanburg | 3.8 mi | ★★★★★ | 4 | 0 |
| White Oak At North Grove Inc | 4.1 mi | ★★★★★ | 1 | 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.