Inspection Reports for White Oak Manor Rock Hill
1915 EBENEZER RD, ROCK HILL, SC, 29732-1097
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
91% worse than South Carolina average
South Carolina average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Mar 13, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, treatment and care according to physician orders, and accommodation of resident allergies and preferences.
Findings
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents, failed to provide treatment according to physician orders for one resident, and failed to accommodate food allergies and preferences for another resident. These deficiencies posed risks of unmet care needs, inappropriate care, and potential health complications.
Deficiencies (3)
Failed to ensure accuracy of Minimum Data Set (MDS) assessments for three residents, including cognitive patterns, mood, indwelling urinary catheter use, and fall history.
Failed to provide appropriate treatment and care according to physician orders; medication administered without a physician's order.
Failed to serve alternate food for dessert containing eggs and served cheese to a resident with known allergies to eggs and milk.
Report Facts
Residents in sample: 35
Residents affected: 3
Residents observed during medication pass: 4
Residents reviewed for food allergies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Confirmed failure to assess cognitive patterns and mood for R52 and confirmed inaccurate MDS for R73 |
| Director of Nursing | Director of Nursing (DON) | Confirmed medication administered without physician's order for R20 |
| Licensed Practical Nurse 2 | Licensed Practical Nurse (LPN)2 | Observed administering medication without physician's order to R20 |
| Administrator | Administrator | Confirmed inaccurate MDS regarding fall history for R131 |
| Dietary Director | Dietary Director (DD) | Confirmed failure to serve alternate dessert and confirmed serving cheese to allergic resident R180 |
Inspection Report
Deficiencies: 5
Date: Dec 12, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to catheter care, dialysis care, dental services, food storage and labeling, infection prevention and control, and laundry sanitation at White Oak Manor - Rock Hill.
Findings
The facility was found deficient in providing appropriate catheter care to prevent infections, maintaining communication with the dialysis center, providing routine dental services, ensuring proper food storage and labeling, following infection control standards during meal tray service, and sanitizing laundry carts and machines. These deficiencies had the potential to affect resident care and safety.
Deficiencies (5)
Failed to provide catheter care to prevent and/or decrease the spread of infections for 1 of 4 residents reviewed for catheter care.
Failed to maintain ongoing communication and collaboration with the dialysis center for 1 of 1 resident reviewed for dialysis.
Failed to provide dental services for routine maintenance of dentures to prevent loss for 1 of 1 resident reviewed for dental services.
Failed to ensure proper storage and labeling of foods in 1 of 1 main kitchen.
Failed to follow proper infection control standards to prevent or decrease the spread of infections when passing out meal trays and failed to properly sanitize laundry carts and laundry machines.
Report Facts
Deficiencies cited: 5
Dates of missing dialysis communication forms: 8
Dates of dialysis communication forms without physician signature: 3
Date of catheter care observation: Dec 12, 2023
Date of lunch dining observation: Dec 11, 2023
Date of laundry services observation: Dec 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA1 | Certified Nursing Assistant | Observed failing to perform proper catheter care and hand hygiene during meal tray service. |
| CNA2 | Certified Nursing Assistant | Observed failing to properly secure catheter tubing during catheter care. |
| Director of Nursing | Director of Nursing | Provided statements regarding expectations for catheter care, dialysis communication, and infection control. |
| Administrator | Administrator | Provided statements regarding expectations for catheter care, dialysis communication, dental services, and infection control. |
| Kitchen Manager | Kitchen Manager | Provided statements regarding food labeling and tray service responsibilities. |
| Laundry Worker 1 | Laundry Worker | Observed failing to sanitize laundry cart and washer properly. |
| Director of Laundry Services | Director of Laundry Services | Confirmed expectations for sanitizing laundry equipment and carts. |
| Social Services Director | Social Services Director | Provided information regarding resident dentures. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 14, 2023
Visit Reason
The inspection was conducted due to a complaint investigation following a resident's successful elopement from the facility on 09/11/2023 at approximately 9:00 PM.
Complaint Details
The complaint investigation found that Resident 5 eloped from the facility on 09/11/23 at approximately 9:00 PM. The facility was found non-compliant with federal regulations related to accidents and supervision, resulting in Immediate Jeopardy status which was removed after corrective actions were implemented.
Findings
The facility failed to ensure adequate supervision to prevent the elopement of Resident 5, who was found outside in the parking lot. The facility was initially cited with Immediate Jeopardy which was removed after the facility implemented corrective actions including one-on-one observation, electronic monitoring, staff reeducation, and enhanced security measures.
Deficiencies (1)
Failure to ensure adequate supervision to prevent Resident 5's successful elopement from the facility.
Report Facts
Date of elopement: Sep 11, 2023
Date of survey completion: Sep 14, 2023
BIMS score: 5
Assessment Reference Date: Sep 3, 2023
Audit monitoring period: 12
Time of last observation before elopement: 1845
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Interviewed regarding the elopement incident and supervision details. |
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Interviewed about observations and resident supervision on the night of the elopement. |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Observed resident outside during lunch break and assisted in returning resident inside. |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Assigned to resident on the night of elopement and assisted in returning resident inside. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 27, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged verbal abuse between residents R11 and R8 at White Oak Manor - Rock Hill.
Complaint Details
The complaint involved verbal abuse by Resident R11 towards Resident R8. The abuse was substantiated based on medical records and staff interviews. The facility failed to report the incident to the state agency within the required 2-hour timeframe.
Findings
The facility failed to ensure Resident R8 was free from verbal abuse by Resident R11 and failed to timely report the resident-to-resident verbal abuse incident to the state agency within the required 2-hour timeframe. Interviews and medical record reviews confirmed the verbal abuse and threats, and that the incident was not reported promptly.
Deficiencies (2)
Failed to protect Resident R8 from verbal abuse by Resident R11.
Failed to timely report the resident-to-resident verbal abuse incident to the state agency within 2 hours.
Report Facts
Residents reviewed for Abuse: 4
Residents Affected: 1
Reporting timeframe: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Witness to the verbal abuse incident and nurse taking care of both residents |
| CNA1 | Certified Nursing Assistant | Intercepted the verbal abuse incident and assisted with remote control |
| Administrator | Administrator | Interviewed regarding the incident and reporting failure |
| Director of Nursing | Director of Nursing | Interviewed regarding the incident and reporting failure |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Sep 29, 2021
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain a urine odor-free environment in the 100 hallway, failure to provide timely written notification of hospital transfers and bed hold rights to residents and their representatives, incomplete and outdated care plans for multiple residents, inadequate fall prevention interventions, lack of physician orders for an indwelling catheter, failure to limit PRN psychotropic medication orders to 14 days, and failure to maintain refrigerator temperature logs for resident food storage.
Deficiencies (9)
Failed to ensure one of four hallways (100 hallway) and rooms were free of urine odor affecting 37 residents.
Failed to provide written notice of hospital transfer to resident R115 and their representative.
Failed to provide written notice with bed hold rights including reserved payment information to residents R66, R108, R113, and R115.
Failed to develop and implement comprehensive care plans addressing communication, psychotropic medication use, and falls for residents R82, R11, R36, and R76.
Failed to revise care plans based on changing needs and failed to invite resident R24 to care plan meetings.
Failed to ensure interventions to reduce hazards and fall risks were implemented for residents R36 and R76.
Failed to have a physician's order for an indwelling catheter for resident R264.
Failed to ensure PRN anti-anxiety medication orders had a 14-day discontinue date for resident R112.
Failed to maintain temperature logs for refrigerators storing resident food on multiple units.
Report Facts
Residents affected: 37
Residents reviewed: 25
Residents affected: 4
Residents affected: 4
Residents affected: 6
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 9 | Licensed Nurse | Confirmed urine odor in 100 hallway and notified housekeeping |
| Maintenance Supervisor | Confirmed urine odor persisted despite maintenance efforts | |
| Environmental Services Director | Environmental Services Director | Confirmed urine odor persisted despite cleaning efforts |
| Business Manager | Provided verbal notification of hospital transfer but not written notice | |
| Director of Social Services | Director of Social Services | Confirmed failure to provide written hospital transfer and bed hold notices |
| Licensed Practical Nurse 11 | Licensed Practical Nurse | Confirmed lack of care plans for communication and medication needs |
| Resident Assessment Coordinator 1 | Confirmed care plans were not updated or reviewed as required | |
| Licensed Nurse 12 | Licensed Nurse | Confirmed fall prevention interventions were not implemented |
| Restorative Aide 4 | Restorative Aide | Confirmed fall prevention equipment (hipsters) not present for resident |
| Director of Nursing | Director of Nursing | Confirmed lack of physician order for indwelling catheter and PRN medication order issues |
| Corporate Nursing Consultant | Confirmed no policy for physician orders for indwelling catheters | |
| Licensed Nurse 11 | Licensed Nurse | Confirmed PRN anti-anxiety medication order practices |
| Dietary Manager | Confirmed lack of refrigerator temperature logs |
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