White Oak North Grove: Life-Death Code Mix-ups - SC
The same dangerous contradiction existed for multiple residents at White Oak at North Grove, where electronic medical records contradicted signed do-not-resuscitate orders stored in backup binders. Federal inspectors declared an immediate jeopardy to resident safety in May, finding that nurses checking the computer during medical emergencies would receive the wrong instructions about whether to let residents die peacefully.
"I want to be a DNR," Resident 328 told inspectors on May 15. Her family members confirmed they had provided all DNR documentation during the admission process. Yet the resident's electronic banner still showed "Full Code," and there was no physician's order for her actual code status.
The facility's backup binder contained her signed DNR form, but nurses said they primarily relied on the computer system.
Resident 23 faced the opposite problem. The 83-year-old with congestive heart failure had a physician's order for DNR status and a signed South Carolina Emergency Medical Services form stating "no resuscitative efforts including artificial stimulation of the cardiopulmonary system by electrical, mechanical, or manual means be made in the event of cardiopulmonary arrest."
But his paper face sheet in the backup binder was marked "Full Code" right next to a black dot that was supposed to indicate DNR status.
"Then I would have to call the doctor and clarify this with him," Licensed Practical Nurse 4 told inspectors when asked what she would do if she found such conflicting information during an emergency.
The confusion extended throughout the nursing staff. Some nurses said they would check the computer first during a code situation. Others said they would look at physician orders. The backup binder was supposed to be used only when the electronic system was down, but it contained contradictory information that could prove fatal in seconds-count situations.
Social Services Director admitted the dual code statuses would be "confusing for staff and there should not be two different code statuses listed." She watched Resident 328 sign her DNR form but acknowledged that staff following the electronic record would perform unwanted resuscitation if the resident were found unresponsive.
The Administrator claimed the electronic medical record was "the most accurate," while the Director of Nursing called getting advanced directives "a basic process" and said he never expected the code status binder to be inaccurate. The facility had audited the binder just before the inspection began, but staff failed to catch the life-and-death discrepancies that surveyors identified within hours.
Licensed Practical Nurse 2 described the dangerous workflow: if she found conflicting information on a resident's face sheet, she would check the computer for code status. "If a resident coded, she would check the computer first," inspectors noted.
But the computer was wrong.
The immediate jeopardy citation was removed after the facility submitted an acceptable correction plan that included auditing all residents' electronic medical records, verifying DNR orders, and educating licensed personnel on code status processes. Inspectors verified the plan's implementation and downgraded the violation, though it remained a serious deficiency.
Beyond the life-and-death record-keeping failures, inspectors found the facility was not properly administering prescribed oxygen therapy. Resident 23, who required continuous oxygen due to congestive heart failure, was receiving 1.5 liters per minute instead of the prescribed 2 liters per minute for at least two days.
The resident's care plan was supposed to guide staff in providing "O2 at [blank] LPM via [blank], as ordered." But Registered Nurse 4 admitted she had left the oxygen details blank when creating the care plan from a template.
"I was using a template, and I didn't fill in the area," she told inspectors after hastily correcting the care plan during the survey.
Licensed Practical Nurse 3 accompanied inspectors into the resident's room and confirmed the oxygen flow was set incorrectly. She adjusted it to the proper 2 liters per minute, and the resident's oxygen saturation measured 99 percent.
The facility's kitchen presented additional health risks to all 128 residents. Inspectors found food preparation equipment covered in dried food residue, spoiled lettuce that should have been discarded, and improperly stored items throughout refrigeration units.
A drawer containing food scoops was "unclean with dried substances and accumulated food crumbs." Six food preparation pans had dried food stuck to them. A shelf storing cutting boards was covered in "dried and sticky substances."
In the walk-in refrigerator, inspectors discovered undated American cheese and Swiss cheese wrapped in plastic, along with Heritage blend lettuce marked with a handwritten date of April 22 that had turned black with spoilage. The walk-in freezer contained opened boxes of cheddar cheese omelets, beef patties, and biscuits that were "stored opened to air and unprotected from possible contamination."
Dietary Manager confirmed all the cleanliness and food storage violations, acknowledging that "staff should keep drawers and shelves clean" and "spoiled food should be discarded by kitchen staff."
The facility also failed to properly offer pneumonia vaccinations to elderly residents according to CDC guidelines. Resident 14, over 65 years old with diabetes, had received one pneumonia shot in August 2023 but was not offered the additional vaccination recommended by federal health authorities.
Resident 31's family had refused a pneumonia vaccine in 2019, but there was no documentation that the facility had re-offered the vaccination as the resident's health status changed or as updated CDC recommendations emerged.
The Infection Preventionist blamed data entry errors for missing vaccination recommendations, telling inspectors she had "accidentally put in the wrong information" when using CDC mobile applications to track resident immunization needs.
For Resident 31, the Infection Preventionist said she had called the family about pneumonia vaccination but the family wanted to wait until the resident finished antibiotics. When inspectors asked if this conversation was documented in the medical record, she replied, "No."
White Oak at North Grove's policy states the facility will "act affirmatively to preserve the life of all residents" while recognizing that residents have the right to "accept or reject medical treatment." But the inspection revealed a facility where residents' most fundamental healthcare decisions — whether to be resuscitated when dying — were lost in contradictory computer systems and backup binders that nobody seemed to trust completely.
The Director of Nursing summed up the facility's approach to the life-and-death record-keeping: "It was just audited prior to the start of the survey but staff did not catch the discrepancies that were identified by the survey team."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for White Oak At North Grove Inc from 2025-05-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
White Oak At North Grove Inc in Spartanburg, SC was cited for immediate jeopardy violations during a health inspection on May 15, 2025.
"I want to be a DNR," Resident 328 told inspectors on May 15.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.