Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at White Oak Manor - Newberry during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, hospice services, and a history of major falls was injured when a single hospice CNA was providing bed bath and linen change care despite documentation indicating the resident required a total lift and two staff for turning and repositioning. While the CNA was loosening sheets, the resident rolled off the bed and sustained bilateral distal femur fractures.
Expired and contaminated medications were found stored with current stock in 2 medication carts and 1 medication room. Surveyors observed an expired Povidone-Iodine prep pad, an antiseptic spray with black floating substance, another expired antiseptic spray in a second cart, and expired children's acetaminophen floor stock in the medication room. An LPN confirmed the expired and contaminated items, and the DON stated there should be no expired medications in carts or medication rooms.
Failure to notify the local Ombudsman of a resident discharge. A resident with intact cognition and diagnoses including a healed femur fracture was discharged home with his brother; nursing documented the discharge and medications, and SS arranged home health services and equipment. Facility policy required notice of facility-initiated discharges to be sent to the Ombudsman, but the SSD stated she did not send the discharge information and had not been doing so for resident discharges.
Care Plan Omitted Indwelling Catheter Care: A resident with an indwelling catheter, cognitive impairment, and urinary retention had multiple catheter-related orders in the chart, but the care plan contained no problem, goal, or intervention for catheter care. Observations showed the catheter remained in place, and interviews with the assigned LPN, MDS Coordinator, and DON confirmed the omission and that catheter-related information should have been reflected in the care plan.
Failure to Coordinate Hospice Care Information: A resident with severe cognitive impairment, hospice services, and a history of major falls was being bathed by a hospice CNA when the resident rolled out of bed during a linen change and sustained bilateral femur fractures. Records showed the resident required a total lift and two staff for turning and repositioning, but the hospice CNA believed the resident was a 1-person assist and was not aware of a newly installed pressure-relieving mattress. Interviews showed hospice and facility staff did not have consistent, up-to-date communication about the resident’s assist level and care setup.
Foley Catheter Bag Left on Floor: A resident with an indwelling urinary catheter and diagnoses including vascular dementia and urinary retention was observed in bed with the catheter drainage bag resting on the floor on two occasions. The facility's closed urinary drainage procedure required the bag to be attached to the bed frame below the bladder and not touching the floor. A CNA confirmed the bag was on the floor, and the DON and an LPN stated the bag should be hooked to the bedframe off the floor.
A resident with a history of falls and cognitive impairment experienced an unwitnessed fall, after which the required Head Trauma Protocol was not fully completed. Documentation was missing for several neurological and vital sign checks, and staff interviews revealed lapses in communication and adherence to protocol, with some staff unaware of the need to continue monitoring. The DON acknowledged the oversight and conflicting expectations regarding waking the resident for checks.
Failure to Prevent Resident Fall During Bed Bathing and Linen Change
Penalty
Summary
The facility failed to ensure resident safety and prevent an avoidable accident for one resident who was reviewed for accidents and hazards. The resident was admitted with multiple serious diagnoses, including severe protein-calorie malnutrition, osteoarthritis, bone density disorder, bilateral femur fractures with routine healing, and a pathological fracture of the tibia and fibula. The resident’s annual MDS showed severe cognitive impairment with a BIMS score of 04 out of 15, dependence for all ADLs, and hospice services in place. The resident’s care plan identified a history of falls with major injuries and risk for recurrence related to muscle weakness, cognitive impairment, and the medication regimen. The Safe Resident Handling Data Collection Form indicated the resident required a total lift and two staff members to turn and reposition the resident in bed, with a lift sheet possibly used. Despite this, on the day of the incident, the resident was being bathed and linens were being changed when only one hospice CNA was providing care. The CNA reported that when she walked around the bed to loosen the sheets, the resident began moving and rolled off the bed to the floor, and the CNA was unable to hold the resident to prevent the fall. The fall was witnessed and resulted in injury. Hospital records documented that the resident was brought to the ED after rolling out of bed while being bathed, with concern for lower extremity injury. X-rays showed bilateral distal femur fractures. The resident was nonambulatory, had severe dementia at baseline, and was on hospice care with DNR status. The hospice note documented that the resident had been a one-person assist prior to the fall, but the incident occurred while the resident was being turned and cared for by a single CNA during a linen change and bath.
Expired and Contaminated Medications Found in Carts and Medication Room
Penalty
Summary
Expired medications and contaminated medication stock were found stored with current medications in use for residents in 2 of 5 medication carts and 1 of 3 medication rooms. Review of the facility policy titled, Medication Storage In The Facility, revised September 21, 2022, stated that outdated, contaminated, or deteriorated medications are to be immediately removed from stock and disposed of according to procedure. During an observation on 06/04/2026 at 12:37 PM of medication cart 300C, surveyors found Medichoice Povidone-Iodine Prep Pad expired on 06/15/2025 and a Dermal Wound Cleanser First Aid Antiseptic spray with an expiration date of 07-2028 that contained a black substance floating in the bottle. An interview with LPN2 at approximately 01:40 PM confirmed the medications were expired and contaminated. During an observation on 06/04/2026 at 01:05 PM of medication cart 300A, surveyors found Dermal Wound Cleanser First Aid Antiseptic spray expired 09/2025, and an interview with LPN1 at approximately 02:05 PM confirmed it was expired. During an observation on 06/04/2026 at 01:10 PM of the 300 unit medication room, surveyors found Children's Acetaminophen 160 mg per 5 ml Pain Reliever-Fever Reducer floor stock that expired in October 2025. LPN1 also confirmed this medication was expired. During an interview at approximately 01:15 PM, the DON stated there should be no expired medications on the medication carts or in the medication rooms and said the pharmacist does a monthly audit of the medication carts and medication rooms.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the local ombudsman of a resident’s discharge from the facility. The resident, admitted on 02/20/26 with diagnoses including displaced intertrochanteric fracture of the left femur and gastro-esophageal reflux disease without esophagitis, had a quarterly MDS with a BIMS score of 15 out of 15, indicating intact cognition. Facility records showed the resident was discharged home with his brother, and nursing documented that the brother was informed of the discharge and medications, with belongings paperwork signed by a family member. The facility policy titled Discharge Planning, revised 2/19, states that notice of facility-initiated transfers and discharges are also sent to the local Ombudsman. During interviews, the Social Services Director stated that she and the Social Worker share the workload, that the resident was on her caseload, and that she did not send discharge information for this resident to the Ombudsman. She further stated that she had not been sending residents’ discharge information to the Ombudsman. The Administrator confirmed that Social Services was expected to contact the Ombudsman’s office when residents are discharged and acknowledged being informed that the Ombudsman was not contacted for this resident’s discharge.
Care Plan Omitted Indwelling Catheter Care
Penalty
Summary
The facility failed to ensure Resident 6’s care plan was reviewed and revised to include catheter care related to the resident’s indwelling catheter. Resident 6 was admitted with diagnoses including nontraumatic subarachnoid hemorrhage, vascular dementia, unsteadiness on feet, abnormalities of gait and mobility, and retention of urine. The admission MDS indicated the resident had an indwelling catheter and moderate cognitive impairment, and the medical record contained multiple active catheter-related orders, including catheter bag changes, catheter changes, irrigation as needed for clogging, daily catheter care, output monitoring each shift, and StatLock changes weekly. Review of the care plan showed no problem, goal, approach, or discipline related to the resident’s indwelling catheter or catheter care. During observation, the resident had an indwelling catheter in place with a privacy bag covering the catheter bag. The resident’s husband reported the resident had been admitted with a catheter, had it removed a few days after admission, and had it reinserted in May 2026. A follow-up observation showed the catheter bag remained intact and the resident was sleeping. Interviews confirmed the omission in the care plan. The assigned LPN stated she was aware of the resident’s catheter status and confirmed the care plan did not address it, stating it should be included. The MDS Coordinator reviewed the record and acknowledged the care plan did not contain a catheter-related problem or interventions, calling it an oversight. The DON stated the resident had an indwelling catheter, that it had been reinserted after a trial of voiding, and that catheter-related interventions were not being addressed in the care plan. The Administrator stated her expectation was that care plans be completed accurately and in a timely manner to reflect the resident’s current care and status.
Failure to Coordinate Hospice Care Information
Penalty
Summary
The facility failed to ensure effective coordination of care and communication with the contracted hospice provider for a resident receiving hospice services. The resident was admitted with multiple serious diagnoses, including severe protein-calorie malnutrition, osteoarthritis, bone density disorders, bilateral distal femur fractures with routine healing, and a pathological fracture of the tibia and fibula. The resident’s MDS showed severe cognitive impairment with a BIMS score of 4, dependence for all ADLs, a prognosis of less than six months, and hospice services in place. The resident’s care plan identified a history of falls with major injuries and directed staff to assist with safe transfers per the facility’s safe-handling tool. The safe resident handling form indicated the resident required a total lift and two staff members to turn and reposition in bed. On the day of the incident, the resident was being bathed by a hospice CNA and was turned on her side for a linen change when she rolled or flipped out of bed and fell to the floor. The resident was sent to the hospital with pain and was found to have bilateral distal femur fractures. Interviews and hospice documentation showed conflicting and incomplete communication about the resident’s current care needs. The hospice CNA stated she believed the resident required only one-person assistance and was not aware of a newly installed pressure-relieving mattress. The hospice RN stated the resident had been assessed as a one-person assist and that hospice staff were not made aware of later changes such as the resident becoming a two-person assist. The DON stated the resident required a total two-person assist for transfers and repositioning, and the facility nurse consultant stated communication of updates between the facility and hospice was expected to occur verbally. The hospice clinical note also documented that the resident’s plan of care was changed after the fall to reflect a two-person assist for all ADLs except feeding.
Foley Catheter Bag Left on Floor
Penalty
Summary
The facility failed to ensure proper infection control practices related to an indwelling urinary catheter for a resident admitted with diagnoses including vascular dementia with psychotic disturbance, acute embolism and thrombosis of unspecified deep veins of the lower extremity, neuromuscular dysfunction of the bladder, and hesitancy of micturition. The resident had a physician order for a #16 FR catheter with a 5 ml bulb related to urinary retention. The facility procedure for closed urinary drainage stated that the drainage bag should be attached to the bed frame below the level of the resident's bladder and not touch the floor. During observations, the resident was lying in bed watching television with the bed in low position, and the catheter bag was noted resting on the floor on two separate occasions. A CNA confirmed that the catheter bag was on the floor. The DON stated that staff should always place the foley catheter bag on the bed frame below the bladder and that the catheter bag should never be on the floor. An LPN stated that the DON had just given an in-service and that foley catheter bags should be hooked to the bedframe off the floor, with tubing draped over the resident's legs.
Failure to Complete Head Trauma Protocol After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure completion of the Head Trauma Protocol following an unwitnessed fall for one resident. According to the facility's protocol, staff are required to take baseline vital signs, monitor and record vital signs at specified intervals, complete neurological documentation, and wake the resident every two hours for 24 hours. The resident involved had a history of falls, cognitive impairment, and required supervision with toileting. After the unwitnessed fall, the Head Trauma Protocol form showed missing documentation for neurological and symptom checks at two time points during the night, as well as missing vital signs, neurological, and symptom documentation for a later shift. Interviews with staff revealed that the LPN responsible for the resident at the time of the fall could not recall why the checks were not documented, suggesting the resident may have been sleeping or that the documentation was overlooked. Another LPN who later cared for the resident was not informed of the need to continue the protocol and therefore did not complete the required checks or pass on this information to the next shift. The DON acknowledged missing the review of the Head Trauma Protocol form and stated that, despite the protocol's instructions, staff were not expected to wake a sleeping resident, though she also stated that staff should follow the protocol.
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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 Newberry
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| J F Hawkins Nursing Home | 0.3 mi | ★★★★★ | 3 | 0 |
| Saluda Nursing Center | 10.9 mi | ★★★★★ | 1 | 0 |
| Nhc Healthcare - Clinton | 19.1 mi | ★★★★★ | 2 | 0 |
| Presbyterian Communities Of South Carolina- Clinto | 20.4 mi | ★★★★★ | 0 | 0 |
| The Heritage At Lowman Rehab And Healthcare | 21.7 mi | ★★★★★ | 4 | 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 August 2026) and official state health department websites.