Above 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 Manor - Spartanburg during CMS and state inspections, most recent first.
Oxygen Not Administered as Ordered: A resident with COPD, CHF, and respiratory failure with hypoxia had a physician order for continuous O2 at 2 L/min via nasal cannula, but was observed receiving 1.5 L/min on multiple occasions. An RN confirmed the resident was not receiving the ordered rate, an LPN verified the MAR showed the 2 L/min order, and the DON stated she was aware of the discrepancy.
Medication administration error rate exceeded 5% when an LPN crushed and administered a resident's enteric-coated aspirin 81 mg and tamsulosin capsule in applesauce, despite orders and reference material indicating both medications should not be crushed. Surveyors observed 2 errors in 27 opportunities, resulting in a 7.41% error rate; the DON confirmed neither medication should have been crushed, and the LPN stated it was done because it was easier for the resident to take them that way.
The facility failed to keep an oxygen concentrator clean and free of debris for a resident with respiratory failure and CHF. Staff observed the concentrator in use with a brown substance and other debris on the top, front, and sides, and the DON stated it should not look like that and should be clean. The facility also reported no policy for cleaning and maintenance of oxygen concentrators and no documentation of outside servicing.
The facility failed to provide the CMS Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to two residents receiving Medicare A therapy services. The business office did not issue the SNF ABN, Form CMS-10055, as required by policy, which mandates delivery no later than two days before Medicare coverage ends. This oversight was confirmed by the facility administrator.
The facility failed to follow infection control practices during wound care and medication administration. An IP changed gloves without hand hygiene, and an LPN donned gloves without sanitizing hands, reused a glove, and touched a sanitizer dispenser with contaminated hands. These actions were acknowledged by the staff involved.
Oxygen Not Administered at Ordered Rate
Penalty
Summary
The facility failed to administer oxygen as ordered for one resident who was reviewed for respiratory care. The resident had diagnoses including COPD, CHF, and acute and chronic respiratory failure with hypoxia, and the physician’s order directed oxygen at 2 liters per minute via nasal cannula continuously as tolerated every shift for shortness of breath. The resident’s care plan also directed nursing staff to administer oxygen therapy as ordered, and the facility policy required oxygen therapy to be recorded on the TAR or in the EMR, including the rate of flow. During observations, the resident was seen receiving oxygen from a concentrator via nasal cannula at 1.5 liters per minute on multiple occasions. An RN later confirmed the resident was not receiving oxygen at the prescribed rate after checking the EMR and finding the current order for 2 liters per minute. An LPN also reviewed the MAR and stated it showed the resident was to receive oxygen at 2 liters per minute, with the order initiated on 03/08/26. The DON stated she was aware the resident had been observed not receiving oxygen at 2 liters per minute as ordered and stated she expected oxygen to be administered at the physician-ordered rate.
Medication Administration Error Rate Exceeded
Penalty
Summary
Medication administration error rate exceeded 5 percent when surveyors observed two medication errors out of 27 opportunities, resulting in a 7.41% error rate. Review of the facility policy stated that medications not otherwise indicated may be crushed, but if a medication order says do not crush and the resident needs medication crushed, pharmacy should be consulted. Review of reference material identified that tamsulosin capsules should not be crushed, chewed, or opened, and that enteric-coated/delayed release aspirin 81 mg should not be crushed. Resident R39 was admitted with diagnoses including non-ischemic myocardial injury and retention of urine. Physician orders included aspirin delayed release/enteric coated 81 mg daily and tamsulosin 0.4 mg after breakfast with instructions not to crush. During medication administration observation, LPN1 crushed the delayed release aspirin tablet, mixed it with applesauce, and administered it to R39. LPN1 also crushed the tamsulosin capsule, mixed it with applesauce, and administered it to R39. The DON stated that neither medication should be crushed, and LPN1 stated the medications were crushed because it was easier to get the resident to take them that way.
Dirty Oxygen Concentrator in Use for a Resident
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when it did not ensure that oxygen concentrators were maintained in a clean condition and free of debris for 1 of 6 concentrators in use for R31. R31 was admitted with diagnoses including respiratory failure and congestive heart failure. During observations in R31's room, the oxygen concentrator had a brown unidentified substance down the front and other debris on the top and down the front and sides while it was in use delivering oxygen at 2 liters by nasal cannula. The facility reported there was no policy on the cleaning and maintenance of oxygen concentrators and no documentation that an outside company had serviced the concentrators. During a later observation and interview, the DON and ADON/IP observed the same concentrator with a brown substance running down the front and sides and other debris, and the DON stated that it should not look like that and should be clean.
Failure to Provide SNF ABN to Residents
Penalty
Summary
The facility failed to provide the Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to two residents, identified as R22 and R32, who were receiving Medicare A therapy services. This oversight occurred because the business office did not issue the SNF ABN, Form CMS-10055, as required by the facility's policy. The policy mandates that the SNF ABN should be delivered no later than two days before the resident's Medicare coverage ends, to inform them of the remaining days under Medicare A coverage. Resident R22 was admitted for long-term care and was receiving skilled therapy services starting on November 27, 2024. The SNF Beneficiary Notice Form indicated that R22's last day of Part A service was February 6, 2025, but the SNF ABN was not provided due to a mistake by the business office. Similarly, Resident R32, admitted for long-term care and receiving skilled therapy services from October 8, 2024, had their last day of Part A service on November 15, 2024, without receiving the SNF ABN due to the same error. The facility administrator confirmed during an interview that the residents did not receive the required notices.
Infection Control Lapses During Wound Care and Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care and medication administration, as observed in two separate incidents. In the first incident, during wound care for a resident, the Infection Preventionist (IP) was observed changing gloves without performing hand hygiene between glove changes. This was acknowledged by the IP during an interview, indicating a lapse in following the facility's hand hygiene policy, which requires hand hygiene after removing gloves and before donning new ones. In the second incident, during medication administration for another resident, an LPN entered the resident's room and donned gloves without performing hand hygiene first. The LPN then removed one glove, placed it on a bedside table, and put the same glove back on without sanitizing hands. After applying a lidocaine patch, the LPN removed the gloves and touched the wall hand sanitizer dispenser with contaminated hands before applying sanitizer. This sequence of actions was acknowledged by the LPN during an interview, highlighting a failure to follow the facility's infection control policy, which emphasizes hand hygiene before and after glove use.
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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) |
|---|---|---|---|---|
| Magnolia Manor - Spartanburg | 0.3 mi | ★★★★★ | 0 | 0 |
| Spartanburg Hospital For Restorative Care Snf | 0.3 mi | ★★★★★ | 1 | 0 |
| White Oak At North Grove Inc | 1.2 mi | ★★★★★ | 1 | 0 |
| Physical Rehabilitation And Wellness Center Of Spa | 2 mi | ★★★★★ | 7 | 2 |
| Summit Hills Skilled Nursing Facility | 2.9 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 July 2026) and official state health department websites.