Inspection Reports for White Oak Manor Columbia
3001 BEECHAVEN RD, COLUMBIA, SC, 29204-2701
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% better than South Carolina average
South Carolina average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Annual Inspection
Deficiencies: 2
Nov 20, 2025
Visit Reason
The inspection was conducted as a routine annual survey of White Oak Manor - Columbia to assess compliance with regulatory standards related to resident safety, medication administration, and kitchen sanitation.
Findings
The facility was found deficient in providing adequate supervision during medication administration, resulting in a resident pocketing medications. Additionally, the kitchen was found to have multiple sanitation and cleanliness issues, including improper labeling and storage of food items, dirty equipment, and poor maintenance of kitchen facilities.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide appropriate supervision during medication administration, resulting in a resident not swallowing medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to procure food from approved sources and maintain proper sanitation and cleanliness in the kitchen, including improper labeling and dating of food items and dirty kitchen equipment. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication administration time: 8.16
Observation time: 10.4
Observation date: Sep 23, 2025
Medication dosage: 500
Medication dosage: 100
Food item date: Sep 22, 2022
Food item open dates: 71625
Food item open dates: 91225
Food item open dates: 92125
Food item quantity: 20
Food item quantity: 25
Food item quantity: 25
Food item quantity: 15
Food item quantity: 25
Food item weight: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | LPN | Administered medications to Resident 4 and observed pocketing of pills |
| Licensed Practical Nurse 2 | Unit Manager | Discussed documentation and expectations for medication administration related to Resident 4 |
| Director of Nursing | DON | Provided information on medication administration procedures and follow-up plans for Resident 4 |
| Dietary Manager | DM | Oversaw kitchen operations and acknowledged kitchen sanitation deficiencies |
| Certified Dietary Manager | CDM, Dietetic Technician Registered | Responsible for clinical portion of dietary services and commented on kitchen conditions |
| Facility Administrator | FA | Provided information on kitchen staffing, cleaning responsibilities, and recent mock survey |
Inspection Report
Complaint Investigation
Deficiencies: 2
Apr 18, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide adequate supervision to prevent falls and to properly update resident care plans with appropriate interventions, specifically related to Resident 3 (R3) who sustained multiple falls resulting in injury.
Findings
The facility failed to adequately supervise R3 to prevent falls, failed to consider all causal factors related to the falls, and did not update the resident-centered care plan with appropriate interventions after multiple falls. The facility also failed to ensure proper transfer techniques following a fall, resulting in injury. Several interventions were either not implemented or not updated despite repeated falls.
Complaint Details
The investigation was complaint-driven, focusing on multiple falls sustained by Resident 3 between 08/18/2024 and 02/23/2025, including a fall on 02/07/2025 that resulted in a right humeral neck fracture. The complaint included concerns about inadequate fall prevention interventions and improper transfer techniques.
Severity Breakdown
Level of Harm - Actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide adequate supervision to prevent falls and failed to update care plan with appropriate interventions for Resident 3 after multiple falls. | Level of Harm - Actual harm |
| Failed to ensure staff performed an appropriate transfer from the floor to the bed following the fall on 02/07/2025. | Level of Harm - Actual harm |
Report Facts
Falls sustained by Resident 3: 5
BIMS score: 6
BIMS score: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN11 | Licensed Practical Nurse | Assigned to care for Resident 3 on 01/16/2025 and 02/07/2025; assessed resident after falls and assisted with transfers. |
| CNA12 | Certified Nursing Assistant | Assisted with Resident 3's transfer from floor to bed on 02/07/2025; fell into bed during transfer. |
| CNA16 | Certified Nursing Assistant | Assisted with Resident 3's transfer from floor to bed on 02/07/2025. |
| Director of Nursing | Director of Nursing (DON) | Oversaw fall investigations and provided statements regarding fall interventions and transfer procedures. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Handled fall investigations, described investigation process, and provided statements on interventions and transfer methods. |
| Therapy Director | Therapy Director | Observed wheelchair, confirmed no slip-resistant material, and stated Resident 3 was on therapy caseload. |
| Medical Director | Medical Director (MD) | Provided medical opinions on fall prevention and transfer risks. |
Inspection Report
Routine
Deficiencies: 4
Aug 22, 2024
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding resident care, medication management, respiratory care, food safety, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to timely complete PASARR Level II screening for a resident with intellectual disabilities, improper administration of oxygen therapy at prescribed settings, failure to remove expired medications and properly label opened insulin pens, and inadequate labeling and discarding of expired food items in the kitchen.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure Resident (R)79 was screened timely for a PASARR Level II with recommendations for further evaluation based on intellectual disabilities indicators. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer oxygen therapy at the physician's prescribed setting for Resident (R)78; oxygen was observed at 5L/min instead of ordered 2L/min. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to remove/dispose of expired medication from medication carts, date/label open insulin pens, and remove expired biological from treatment carts. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to label and date open food items and discard expired food items in the kitchen, risking food poisoning and bacterial growth. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Deficiencies cited: 4
Oxygen flow rate ordered: 2
Oxygen flow rate observed: 5
Medication expiration dates: Jul 31, 2022
Treatment pad expiration date: Jul 28, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Interviewed regarding oxygen therapy orders and medication cart observations |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding order verification and medication management |
| Wound Nurse | Wound Nurse | Interviewed regarding oxygen therapy printout and observations |
| LPN5 | Licensed Practical Nurse | Interviewed regarding medication and treatment cart checks |
| LPN4 | Licensed Practical Nurse | Interviewed regarding medication cart and discontinued medications |
| LPN2 | Licensed Practical Nurse | Interviewed regarding medication cart maintenance and standards |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding medication cart responsibilities and insulin pen labeling |
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Interviewed regarding food labeling, expiration checks, and storage practices |
| Dietary Aide | Dietary Aide | Interviewed regarding food labeling and expiration procedures |
| Dietary Technician | Dietary Technician | Interviewed regarding food labeling and expiration checks |
| Dietician | Dietician | Interviewed regarding food labeling and discard policies |
| Social Service Worker | Social Service Worker | Interviewed regarding PASARR Level II screening for Resident R79 |
Inspection Report
Routine
Deficiencies: 2
Jul 26, 2022
Visit Reason
The inspection was conducted to evaluate compliance with medication storage requirements and infection prevention and control protocols, including COVID-19 precautions, at White Oak Manor - Columbia.
Findings
The facility failed to monitor medication refrigerator temperatures in two medication refrigerators, potentially compromising medication efficacy for residents. Additionally, the facility failed to ensure proper use of personal protective equipment (PPE) by staff and proper isolation of residents under droplet precautions for COVID-19.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to monitor medication refrigerator temperatures in 2 of 2 medication refrigerators, risking decreased efficacy of medications for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure two Certified Nursing Assistants donned proper PPE prior to providing care to a resident under droplet precautions for COVID-19 and failure to properly isolate two residents under droplet precautions. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents with insulin stored: 19
Residents under droplet precautions for COVID-19: 17
Temperature readings: 50
Temperature readings: 56
Temperature readings: 0
Temperature readings: 49
Start date of droplet precautions: 2022
Duration of droplet precautions: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN2 | Licensed Practical Nurse | Interviewed regarding medication refrigerator temperature monitoring and confirmed lack of temperature logs. |
| IDON | Interim Director of Nursing | Interviewed regarding medication refrigerator temperature monitoring and facility policies. |
| MD | Maintenance Director | Interviewed regarding replacement of medication refrigerator on the second floor. |
| CP | Consultant Pharmacist | Interviewed regarding medication storage temperature expectations and refrigerator condition. |
| CNA1 | Certified Nursing Assistant | Observed and interviewed regarding failure to don full PPE and improper handling of contaminated items. |
| CNA2 | Certified Nursing Assistant | Observed and interviewed regarding failure to don full PPE while providing care to COVID-19 positive resident. |
| RN | Registered Nurse | Interviewed regarding PPE requirements for staff caring for residents on droplet precautions. |
| Administrator | Interviewed regarding COVID-19 positive residents and PPE expectations for staff. | |
| Corporate Nurse Consultant | Interviewed regarding PPE requirements for staff caring for COVID-19 positive residents. |
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