F-F578: Request/Refuse/Discontinue; Formulate Advance Directives. The Administrator was notified on [DATE REDACTED] at 5:56 PM of the Immediate Jeopardy.
The facility provided an acceptable removal plan on [DATE REDACTED] at 10:28 AM. The removal plan included auditing all residents' electronic medical record code status, including DNR order verification and appropriate face sheet labeling; auditing of all records in the facility code status binder, and educating all licensed personnel
on the facility's processes regarding resident code status. Through interviews with facility staff, review of electronic medical records and the facility code status binder, and review of staff education records, the survey team verified all elements of the facility's IJ Removal Plan and removed the IJ, effective [DATE REDACTED] at 6:22 PM, and the S/S was lowered to a D, isolated with no actual harm with potential for more than minimal harm.
Findings include:
Review of the facility's undated policy titled, Advanced Directives revealed, It is the policy of [NAME] Oak Management, Inc. and its member facilities to act affirmatively to preserve the life of all residents. However, [NAME] Oak Management, Inc. recognizes that in certain cases, medical treatment or resuscitative efforts, such as cardiopulmonary resuscitation, may be medically contraindicated inappropriate or inconsistent with a resident's expressed wishes. [NAME] Oak Management, Inc. recognizes the rights of competent residents to accept or reject medical treatment. It is the policy of [NAME] Oak Management, Inc. to honor advance directives which are properly executed in accordance with State law. Such advance directives will be honored consistent with the procedures outlined in the Policy and Procedure manual for Advance Directives.
1. Review of Resident R328's Face Sheet, located in resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE REDACTED] and was listed as Full code.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 12 425408 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425408 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
White Oak at North Grove Inc 290 N Grove Medical Park Drive Spartanburg, SC 29303
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578 Review of Resident R328's banner, listed on the face sheet of the EMR, revealed the resident was listed as Full Code.
Level of Harm - Immediate Review of Resident R328's Physician Orders, located in the resident's EMR under the Orders tab, revealed no order jeopardy to resident health or for code status. safety
Review of the code status binder located at the N1 unit wing nurses' station revealed a signed DNR form for Residents Affected - Few Resident R328, dated [DATE REDACTED], located behind Resident R328's face sheet.
During an interview on [DATE REDACTED] at 11:35 AM, Family member (FM)1 and (FM)2 stated that Resident R328 wanted to be
a DNR, and the facility was provided with all that information during the admission process.
During an interview on [DATE REDACTED] at 3:10 PM, Resident R328 stated, I want to be a DNR, not resuscitated.
Review of the Code Status Nursing report, dated [DATE REDACTED] at 3:19 PM and provided by the facility, revealed Resident R328's code status was listed as full code.
2. Review of Resident R82's Face Sheet, located in resident's EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE REDACTED] and was listed as DNR and attempt CPR.
Review of Resident R82's banner, listed on the face sheet of the EMR, revealed the resident was listed as DNR.
Review of Resident R82's Physician Orders, located in the resident's EMR under the Orders tab, revealed an order for DNR.
Review of the code status binder located at the N1 unit wing nurses station revealed full code and a black dot which indicated DNR, with a signed DNR, dated [DATE REDACTED], behind Resident R82's face sheet.
3. Review of Resident R23's Face Sheet, located under the Resident tab in the EMR indicated Resident R23 was readmitted to
the facility on [DATE REDACTED] with diagnoses that included congestive heart failure.
Review of Resident R23's admission Minimum Data Set (MDS), located under the RAI (Resident Assessment Instrument) tab in the EMR and with an Assessment Reference Date (ARD) of [DATE REDACTED], indicated Resident R23 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated Resident R23 was moderately cognitively impaired.
Review of Resident R23's Medical Condition Certification, located under the Resident Documents in the EMR and dated [DATE REDACTED], indicated, . This resident DOES [sic] possess decisional capacity to make healthcare decisions for self .
Review of Resident R23's Physician's Orders, located under the Orders tab in the EMR, revealed an order dated [DATE REDACTED] for Code Status - DNR.
Review of Resident R23's Care Plan, located under the RAI tab in the EMR, revealed the code status of DNR was not reflected in the resident's care plan.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 12 425408 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425408 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
White Oak at North Grove Inc 290 N Grove Medical Park Drive Spartanburg, SC 29303
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578 Review of Resident R23's Face Sheet, located in the N3 Notebook at the Nurses' Station ,d+[DATE REDACTED] revealed a dot at
the top of the Face Sheet and beside the resident's name it was recorded, Full Code. Level of Harm - Immediate jeopardy to resident health or Review of Resident R23's South Carolina Emergency Medical Services, located under the Resident Document tab in safety the EMR, revealed a Do Not Resuscitate Order, signed by Resident R23 and dated [DATE REDACTED], which indicated, . This notice is to inform all emergency medical personnel who may be called to render assistance to [name of Residents Affected - Few Resident R23] that he/she has a terminal condition which has been diagnosed by me and has specifically requested . that no resuscitative efforts including artificial stimulation of the cardiopulmonary system by electrical, mechanical, or manual means be made in the event of cardiopulmonary arrest .
During an interview on [DATE REDACTED] at 3:15 PM, Resident R23 stated, I want to be a DNR.
During an interview on [DATE REDACTED] at 11:43 AM, Licensed Practical Nurse (LPN)1 stated when a resident was found unresponsive, they would look at the banner in the EMR or at the physician's order. She stated they could look in the code status binder. She stated they can also look at the resident's face sheet.
During an interview on [DATE REDACTED] at 11:45 AM, LPN3 was asked where she would go to check a resident's code status. She stated, I will go in the computer to check the code status of a resident.
During an interview on [DATE REDACTED] at 12:55 PM, LPN4 was asked where she would go to check a resident's code status. She stated, I will go into the computer to check the code status. When asked where she would look to determine a resident's code status if the computer was not working, LPN4 stated, I would look in the binder at the nurses' desk. When asked what she would do if there was a dot at the top of the Face Sheet in the binder, which indicated DNR, and beside of the resident's name it was written Full Code, LPN4 stated, Then I would have to call the doctor and clarify this with him.
During an interview on [DATE REDACTED] at 1:20 PM, the Social Services Director (SSD) stated after a resident was admitted , their code status would come up in the EMR under the advanced directives tab. She stated the binder would come into play as a backup if the EMR system went down. The SSD stated she was unsure if
the binders were audited to catch discrepancies. She stated staff would look at the order for code status, but if there was no order, they would have to look in the binder. The SSD stated a DNR was indicated in the binder by a black dot on the face sheet. She stated if the face sheet indicated both full code and had a dot, staff should know the dot meant DNR, but she agreed that it would be confusing for staff and there should not be two different code statuses listed. The SSD stated Resident R328 was currently a DNR because she watched her sign the DNR. She looked at the resident's EMR and stated R328was listed as a full code and that staff would follow that if she were to be found unresponsive. The SSD stated she was unsure why the EMR had not been updated to reflect the DNR status or why there was no order for code status.
During an interview on [DATE REDACTED] at 1:23 PM, the Administrator stated the binder was only used as a backup when staff were unable to access the EMR. He stated the code status listed in the EMR was the most accurate.
During an interview on [DATE REDACTED] at 2:25 PM, LPN 2 (a nurse on 400 hallway) stated if a resident's face sheet had a black dot and also recorded that the resident was a full code, she would then check the computer for
the resident's code status LPN2 stated if a resident coded, she would check the computer first for the code status.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 12 425408 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425408 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
White Oak at North Grove Inc 290 N Grove Medical Park Drive Spartanburg, SC 29303
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578 During an interview on [DATE REDACTED] at 4:47 PM, the Director of Nursing (DON) stated getting advanced orders and code status in place was a basic process. The DON stated the Social Worker (SW) spoke with the family Level of Harm - Immediate and the resident and would get an order from the physician. He stated the order should have been updated jeopardy to resident health or in the medical record to reflect the correct code status based on the resident and family's wishes. The DON safety stated the code status binder was the last thing he ever expected to be inaccurate. He stated it was just audited prior to the start of the survey but staff did not catch the discrepancies that were identified by the Residents Affected - Few survey team.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 12 425408 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425408 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
White Oak at North Grove Inc 290 N Grove Medical Park Drive Spartanburg, SC 29303
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695 Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28306 potential for actual harm Based on observation, interview, record review and policy review, the facility failed to administer oxygen as Residents Affected - Few ordered by the physician for one of two residents (Resident (R) 23) out of a total sample of 32. This failure had the potential for Resident R23 to experience adverse reactions by not receiving the prescribed oxygen concentration.
Findings include:
Review of the facility's undated policy titled, Oxygen Therapy indicated, . To administer oxygen in conditions
in which insufficient oxygen is carried by the blood stream . The policy did not indicate to administer the oxygen by physician's orders.
Review of the facility's policy Comprehensive Team Care Planning, dated 01/09/12, indicated . Specific, individualized steps or approaches that staff will take to assist the resident to achieve the goals. These approaches serve as instructions for resident care and provide for continuity of care by all staff .
Review of Resident R23's Face Sheet, located under the Resident tab in the electronic medical record (EMR), indicated Resident R23 was readmitted to the facility on [DATE REDACTED] with diagnoses that included congestive heart failure and dependence on supplemental oxygen.
Review of Resident R23's admission Minimum Data Set (MDS), located under the RAI (Resident Assessment Instrument) tab in the EMR and with an Assessment Reference Date (ARD) of 04/24/25, indicated Resident R23 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated Resident R23 was moderately cognitively impaired. Resident R23 was also coded as requiring continuous oxygen on admission to the facility.
Review of Resident R23's Care Plan, located under the RAI tab in the EMR and dated 04/18/25 revealed a Problem for Dependence on oxygen r/t [related to] CHF [congestive heart failure]. Interventions were O2 [oxygen] @ [at] [blank]LPM [liters per minute] via [by] [blank], as ordered. Further review of Resident R23's entire care plan revealed no documented evident that Resident R23 refused to wear oxygen as ordered or had the behavior of adjusting the oxygen flow meter on the oxygen concentrator.
Review of Resident R23's Physician's Orders, located under the Orders tab in the EMR and dated 04/18/25, revealed, . Oxygen at 2L/min [sic] [liters/minute] via nasal cannula as ordered .
Observations were made on 05/13/25 at 10:49 AM and again on 05/14/25 at 8:30 AM of Resident R23's oxygen flow meter setting on 1.5L/min via nasal cannula.
On 05/14/25 at 10:45 AM, Licensed Practical Nurse (LPN) 3 accompanied the surveyor into Resident R23's room and LPN3 confirmed the oxygen was at 1.5L/min via nasal cannula. LPN3 adjusted the oxygen flow meter so that 2 L/min would be given to the resident as the physician ordered. Resident R23's oxygen saturation was checked, and
it was 99%.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 12 425408 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425408 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
White Oak at North Grove Inc 290 N Grove Medical Park Drive Spartanburg, SC 29303
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695 During an interview on 05/14/25 at 12:37 PM, Registered Nurse (RN) 4 was asked to review the care plan for Resident R23. RN4 was asked what the interventions were for Resident R23. RN4 stated, O2 [oxygen] as ordered per the Level of Harm - Minimal harm or provider. RN4 was notified that when the care plan was reviewed by the surveyor earlier on 05/14/25 the O2 potential for actual harm was blank. RN4 stated, I went in and fixed this one this morning. RN4 confirmed that the intervention for O2 was blank prior to doing the revision of the care plan. RN4 also stated, I was using a template, and I didn't fill Residents Affected - Few in the area.
During an interview on 05/15/25 at 9:19 AM, the Assistant Director of Nursing stated, The oxygen should be administered at whatever the doctor ordered it to be.
During an interview on 05/15/25 at 5:57 PM, the Director of Nursing (DON) was asked what the purpose of
the resident's care plan was. The DON stated, It provides guidelines for resident care.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 12 425408 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425408 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
White Oak at North Grove Inc 290 N Grove Medical Park Drive Spartanburg, SC 29303
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food
in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 06401
Residents Affected - Many Based on observation, interview, and facility policy review, the facility failed to keep food scoops, food preparation and service pans, a kitchen drawer, and a kitchen shelf clean. The facility also failed to discard lettuce that had signs of spoilage and failed to cover or date food that was stored in the kitchen's refrigeration and freezer units. These failures had the potential to create an environment for food-borne illnesses which could affect 128 residents who consumed food prepared from the facility's kitchen.
Findings include:
Review of the facility's policy titled, Sanitation/Infection Control, dated 08/2010, specified, . Policy: Clean equipment and utensils will be handled in a manner to prevent contamination . 2. Cleaned and sanitized equipment and utensils shall be stored in a clean, dry location in a manner to protect them from splashes or dust .
Review of the facility's policy titled, Storage of Food and Supplies, dated 08/2010, specified, Purpose: To ensure foods and supplies are stored appropriately to maintain wholesomeness and meet regulatory requirements . 5. Staple, frozen, and refrigerated foods are stored with the new product to the back of the older products. Foods removed from the original packaging will be labeled with the received date, either individually or as a unit . 7. All opened items are securely wrapped or stored in a secure storage container and labeled to identify the product (if not readily identifiable) as well as the date opened or a use-by date no greater than 72 hours after opening (unless documentation for a longer shelf life is available) .
1. Observation during the initial kitchen inspection on 05/13/25 from 8:40 AM to 9:05 AM, with the Dietary Manager (DM) present, revealed the following unclean food preparation and service equipment that was stored and ready for use: a drawer that contained numerous food preparation scoops was unclean with dried substances and accumulated food crumbs; four food scoops were unclean with dried food on them; a shelf, which had cutting boards stored on it, was unclean with dried and sticky substances; and six food preparation and service pans were unclean with dried food on them.
During an interview on 05/13/25 at 9:10 AM, the DM confirmed the kitchen's drawer which contained numerous food scoops, the four food scoops, the shelf with cutting boards stored on it, and the six-food preparation and service pans were not clean. The DM stated staff should keep drawers and shelves clean and food scoops and food preparation and service pans should be cleaned by staff prior to being stored for use.
2. Observation during the initial kitchen inspection on 05/13/25 from 8:40 AM to 9:05 AM, with the DM present, revealed the following concerns with food storage:
a. Observation of food stored in the kitchen's walk-in refrigerator revealed undated American cheese slices that were wrapped in plastic wrap; undated Swiss cheese slices that were wrapped in plastic wrap; an opened package of Heritage blend lettuce that was wrapped in plastic wrap, with a handwritten date of 04/22/25 on it, with lettuce that was black in color.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 12 425408 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425408 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
White Oak at North Grove Inc 290 N Grove Medical Park Drive Spartanburg, SC 29303
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812 b. Observation of food stored in the kitchen's walk-in freezer revealed a box of cheddar cheese omelets, a box of beef patties, and a box of biscuits that were stored opened to air and unprotected from possible Level of Harm - Minimal harm or contamination. potential for actual harm c. Observation of food stored in the kitchen's reach-in refrigerator revealed undated American cheese slices Residents Affected - Many that were wrapped in plastic wrap and a box of bacon slices that was stored opened to air and unprotected from possible contamination.
During an interview on 05/13/25 at 9:10 AM, the DM confirmed the spoiled lettuce and undated and uncovered food that was observed stored in the kitchen's refrigerator units and walk-in freezer. The DM stated food should be dated and closed when stored and spoiled food should be discarded by kitchen staff.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 425408 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425408 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
White Oak at North Grove Inc 290 N Grove Medical Park Drive Spartanburg, SC 29303
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28306 potential for actual harm Based on interview, record review, policy review, and review of the Centers for Disease Control and Residents Affected - Few Prevention (CDC) guidelines, the facility failed to offer pneumococcal vaccinations per CDC recommendations for two of five residents (Residents (R)14 and Resident R31) reviewed for immunizations out of a total sample of 32. This failure had the potential to place the residents at increased risk of pneumonia.
Findings include:
Review of CDC website titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html, last reviewed 09/12/24, indicated . CDC recommends pneumococcal vaccination for all adults [AGE] years or older. The tables below provide detailed information . For adults [AGE] years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give one dose of PCV20 [pneumococcal conjugate vaccines] or PCV21 . If PCV15 is used, this should be followed by a dose of PPSV23 [pneumococcal polysaccharide vaccine] at least one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak . If PCV20 or PCV21 is used, Give a dose of PCV15 at least one year later . For adults [AGE] years or older who have only received a PPSV23, CDC recommends you . May give one dose of PCV20 or PCV21 . The PCV20 or PCV15 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults [AGE] years or older who have only received PCV13, CDC recommends you . Give PPSV23 as previously recommended. For adults who have received PCV13, Give one dose of PCV20 or PCV21 or PPSV23 to be administered at least a year later . If PCV20 and PCV21 are used, their pneumococcal vaccinations are complete .
Review of the facility's policy titled, Influenza and Pneumonia Vaccination Policy and Procedure, dated 04/23/25, revealed, . Frequency of Administering Vaccines . Pneumonia .Per CDC guidelines or specific order of physician, based on individual's overall health .
1. Review of Resident R14's Face Sheet, located under the Resident tab in the electronic medical record (EMR), indicated Resident R14 was admitted to the facility on [DATE REDACTED] with diagnoses that included diabetes mellitus. Resident R14 was over [AGE] years old.
Review of Resident R14's Immunizations, located under the Preventive Health Care tab in the EMR, revealed Resident R14 was given a PPSV23 on 08/30/23. There was no documentation Resident R14 received or refused any further pneumococcal immunizations.
2. Review of Resident R31's Face Sheet, located under the Resident tab in the EMR, indicated Resident R31 was admitted to
the facility on [DATE REDACTED] with diagnoses that included diabetes mellitus. Resident R31 was over [AGE] years old.
Review of Resident R31's Immunizations, located under the Preventive Health Care tab in the EMR, indicated Resident R3's RR had refused the pneumococcal vaccine on 09/20/19. There was no further documentation regarding pneumococcal vaccinations in the resident's clinical record.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 425408 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425408 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
White Oak at North Grove Inc 290 N Grove Medical Park Drive Spartanburg, SC 29303
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0883 During an interview on 05/15/25 at 5:30 PM, the Infection Preventionist (IP) stated, When I was putting the information into the PneumoRecs VaxAdvisor (mobile application from the CDC), I accidentally put in the Level of Harm - Minimal harm or wrong information in. The IP stated the recommendation that came up recorded that Resident R14 needed another potential for actual harm pneumococcal vaccine in five years. The IP stated that for Resident R31, she had called the family member and asked if she wanted Resident R31 to have the pneumococcal vaccine. The IP stated the family member had informed her Residents Affected - Few that she wanted to wait until Resident R31 was off of antibiotics. The IP was asked if this was documented in the EMR, and the IP replied, No.
During an interview on 05/15/25 at 7:05 PM, the Director of Nursing was asked the expectations of the IP nurse in regard to administering vaccinations. The DON stated, They will be given as recommended.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 425408