Magnolia Manor - Greenwood
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenwood, South Carolina.
- Location
- 1415 Parkway Drive, Greenwood, South Carolina 29646
- CMS Provider Number
- 425172
- Inspections on file
- 26
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 3 (2 serious)
Citation history
Health deficiencies cited at Magnolia Manor - Greenwood during CMS and state inspections, most recent first.
A resident with severe vascular dementia, a very low BIMS score, and a diagnosis of wandering was observed self-propelling in a wheelchair in the hallway and was later found missing when a nurse attempted to administer medication. The resident, who had been assessed as low elopement risk and did not have a WanderGuard or daily elopement alarm in use, exited the building and crossed the street before being located by staff between nearby medical offices and returned without distress. Staff interviews and record review showed that, although the facility had an elopement policy and a process for assessing and care planning high-risk residents, this resident had not previously been identified as an elopement risk, and adequate supervision and preventive measures were not in place at the time of the elopement, leading to a cited deficiency under F689 for failure to prevent accidents and hazards.
A resident with a history of wandering and cognitive impairment eloped from the facility despite having a wander guard and an active care plan. The resident was last seen by staff in the hallway and later found outside by first responders. Although the door alarm was triggered, a CNA assumed another resident caused it and did not fully investigate, resulting in the resident leaving undetected. Staff only became aware of the elopement after being contacted by police, highlighting a lapse in supervision and monitoring.
A resident with severe cognitive impairment and multiple medical conditions experienced a fall resulting in a fracture. The facility did not update the comprehensive care plan to include new interventions or fall-prevention strategies after the incident, despite policy requiring care plan revisions following significant changes in condition. Staff interviews confirmed the care plan was not revised after the fall.
A resident with nicotine dependence was able to smoke and possess smoking materials on a smoke-free campus without staff awareness, while another resident with mobility and cognitive risks left the facility without proper sign-out or elopement procedures being followed. Staff were unaware of these residents' actions and did not enforce or follow facility policies, resulting in deficiencies in supervision and accident prevention.
Surveyors observed that food items in dry storage, the walk-in cooler, and the freezer were not consistently sealed, labeled, or dated as required by facility policy. Opened items such as corn meal, lasagna noodles, churros, and meatballs were found without proper labeling or with expired dates. Facility leadership confirmed expectations for proper food handling, but acknowledged that mislabeling sometimes occurs.
A resident with impaired decision-making and mobility needs was found missing after being last seen with family outside the facility. Staff searched the premises and attempted to contact the resident and her representative, but were unsuccessful. The incident was reported internally to the DON, but was not reported to the State Survey Agency as required by policy, and no leave of absence documentation was completed.
The facility did not provide required bed-hold notifications to two residents or their representatives during hospitalizations, as confirmed by record reviews and staff interviews. Documentation of bed-hold notifications was missing, and staff were unclear about the process and responsibilities, resulting in residents and their representatives not being informed of their rights and policies related to bed-hold status.
A medication administration error rate of 8 percent was observed when a nurse handled medications with bare hands, failed to follow procedures for missing medications, and did not properly discard a dropped pill. Two residents were directly involved in these incidents, and the nurse did not adhere to established medication management policies.
Surveyors found expired medications, loose unidentified pills, and expired biologicals on two medication carts and one treatment cart. Despite facility policy requiring immediate removal of such items, expired Vitamin D3, Iron, Bisacodyl suppositories, Humalog insulin, Albuterol inhaler, a non-sterile valve, and povidone iodine solution were present. Nursing staff interviews confirmed responsibility for checking carts, but expired and loose items remained.
Staff did not use gowns as required during catheter and wound dressing changes for two residents with wounds and indwelling devices, and EBP signage was not posted outside rooms as per facility policy. The DON indicated that signs were kept inside closets to maintain confidentiality, leading to inconsistent use of required PPE during high-contact care activities.
A resident with a history of falls and requiring substantial assistance was left unattended in the shower by a CNA, resulting in a fall. The resident, who was high risk for falls, was found on the floor with redness to the knees. The incident highlighted a lack of supervision and adherence to care needs, as the resident's care plan did not specify the required assistance level for bathing.
The facility failed to update care plans for three residents after multiple falls, despite recommendations for new interventions. The Care Coordinator was responsible for updating the plans but only did so when instructed, which did not occur. Residents had severe cognitive impairments and experienced falls, some with injuries, but care plans were not revised to include appropriate interventions.
The facility failed to follow its fall management policy by not conducting neurological evaluations and post-fall documentation for 72 hours for three residents who experienced unwitnessed falls. Despite having a policy in place, the facility did not complete necessary evaluations and documentation, as revealed through staff interviews and record reviews. The lack of oversight and accountability among staff, including the use of agency nurses, contributed to this deficiency.
The facility failed to conduct and document fall risk assessments for three residents with severe cognitive impairments and histories of falls, despite multiple incidents. Staff interviews revealed a lack of awareness and responsibility for completing these evaluations, leading to a deficiency in fall management.
The facility failed to notify the physician and responsible party of falls for two residents, despite policy requirements. One resident with severe cognitive impairment experienced multiple falls without physician notification, even when a fall resulted in significant injury. Another resident's fall was not reported to the physician or responsible party, leading to a grievance. Interviews confirmed that the responsibility to notify was not fulfilled by the nursing staff.
A resident with a history of altered mental status and unsteadiness experienced an unwitnessed fall, which was not accurately documented in the MDS assessment. The Care Coordinator failed to review the falls investigation worksheets, leading to the omission of the fall in the quarterly MDS. The facility's policy requires comprehensive assessments, but the oversight was acknowledged during interviews.
Two residents were verbally abused by an LPN who used inappropriate language while instructing one resident to keep his door closed and when another resident requested his medication. The LPN admitted to the behavior, attributing it to lack of sleep and exhaustion. The facility's Administrator took immediate action by suspending and terminating the LPN.
Failure to Adequately Supervise Cognitively Impaired Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent an elopement for a resident with severe cognitive impairment. On the day of the incident, the resident was last observed in his room by a housekeeper at 11:30 a.m. and then seen by a nurse at 11:45 a.m. self-propelling his wheelchair down his hall toward the dining room. At 11:55 a.m., when the nurse went to the resident’s room to administer medication, the resident was noted to be missing. The facility then initiated a Code White at 12:10 p.m. and began an immediate search of the entire building, inside and outside. The resident’s medical record showed diagnoses including vascular dementia (severe), urinary tract infection, wandering, other visual disturbances, and pyogenic arthritis. The most recent Quarterly MDS, with an ARD of 02/19/26, documented a BIMS score of 3/15, indicating severe cognitive impairment. The MDS also indicated the resident had not exhibited wandering behaviors and did not wear a wander/elopement alarm daily. An Elopement Risk Assessment dated 03/27/25 showed no score but indicated the resident was considered low risk for elopement. Prior to the incident, the resident had not been previously identified as an elopement risk and did not have a WanderGuard device in place. During the Code White, staff searched inside and outside the facility. Multiple staff interviews confirmed that CNAs and other staff checked the parking lot and nearby buildings, while the Social Services Director and laundry staff searched the surrounding area by vehicle. A laundry worker ultimately located the resident across the street from the facility, between a cardiologist’s office and a retinal specialist’s office, and pushed the resident back toward the facility in his wheelchair. Staff reported that the resident stated he was going to an address on [NAME] Street, appeared calm, in no distress, and did not resist returning. A subsequent NP progress note documented that the resident did not clearly explain why or how he went outside, reported interest in going outside again, and appeared more altered compared to a prior visit, with concern for altered or worsening mental status. These events and conditions formed the basis for the cited deficiency under 42 CFR 483.25 related to freedom from accidents and hazards. The facility’s elopement policy, last revised on 11/01/17, stated its purpose was to safely and timely redirect patients/residents to a safe environment. The DON reported that elopement risk assessments are conducted on admission, with changes in condition, and when behavioral changes occur, and that residents identified as high risk are care planned and provided with a WanderGuard device, with exit doors equipped with alarms. In this case, the resident, despite severe cognitive impairment and a diagnosis of wandering, had been assessed as low risk and was not on elopement precautions or wearing a WanderGuard at the time he left the building and crossed the street before being found and returned by staff.
Failure to Prevent Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
A deficiency occurred when a resident with a documented history of wandering, psychosis, anxiety disorder, paranoid schizophrenia, schizoaffective disorder, and epilepsy was not adequately supervised to prevent elopement. The resident was identified as being at risk for elopement and wandering, with an active care plan in place that included interventions such as a wander guard device, comfort measures, and environmental modifications. Despite these interventions, the resident was last seen by staff at approximately 5:30 PM and was later found outside the facility by first responders at 6:06 PM, indicating a lapse in supervision and monitoring. The resident's care plan and medical records indicated daily wandering behaviors and cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 9. On the day of the incident, the resident was observed ambulating in the hallway and did not exhibit exit-seeking behaviors at that time. However, the door alarm was activated at approximately 5:15 PM, and a CNA responded but assumed another resident with a wander guard had triggered the alarm. The CNA looked outside but did not see anyone and did not further investigate, resulting in the resident leaving the facility undetected. Staff did not become aware of the resident's absence until contacted by police, at which point a Code White/elopement was initiated. The resident was located approximately 700 feet from the facility and was transported to the hospital for evaluation. Interviews with staff confirmed that the wander guard was functioning, but no alarms were heard by the assigned nurse during the relevant time period. The incident revealed a failure to ensure adequate supervision and response to alarm systems for a resident at high risk of elopement.
Removal Plan
- Resident transported to hospital ER per EMS. Upon reentry, assigned nurse verified resident wander guard bracelet was in place, intact and functioning on right wrist.
- Assigned nurse performed body audit with no injury noted and documented body audit results in resident's medical record.
- Elopement Risk Observation repeated.
- Intervention: Wander guard bracelet to wrist and checked weekly.
- Maintenance Director/Designee performed an audit to ensure facility exits alarms were functioning.
- Wander guard audits completed.
- Residents at risk of elopement identified; placement and function of wander guards verified by DON for each.
- Elopement Risk Observations done in the past 90 days on current residents reviewed by nursing managers for accuracy; residents identified at risk will be reviewed for appropriate interventions.
- Educate facility staff regarding Wander guard System with emphasis on determining cause of alarm if sounding.
- New admissions will be reviewed in morning meeting daily as part of the clinical morning meeting process.
- Elopement Risk Observations will be reviewed for accuracy and interventions validated if indicated.
- Quarterly assessments will be reviewed as part of the MDS/Care planning process.
- The Director of Nursing will randomly audit a minimum of 5 Elopement Risk Observations weekly for 4 weeks then monthly for 2 additional months to validate accuracy.
- The Maintenance Director/designee will inspect facility doors with wander guard system 3 times weekly for 4 weeks then weekly for 2 additional months.
- The Facility Administrator will make rounds weekly for 4 weeks then monthly for 2 additional months with maintenance director to validate that doors are functioning properly.
- Ad hoc QAPI held to discuss the resident elopement and plan for improvement.
- This process will be reviewed in QAPI for a minimum of 3 months.
Failure to Revise Care Plan After Resident Fall with Fracture
Penalty
Summary
The facility failed to ensure that appropriate post-fall interventions were developed and implemented through care plan revision for one resident following a fall that resulted in a fracture. According to the facility's policy, care plans must be updated when a resident experiences a significant change in condition, such as a fall. Review of the resident's electronic medical record and care plan revealed that after the resident experienced a fall with a fracture, there were no updates or revisions made to the care plan to address new or revised interventions, identification of causative or contributing factors, enhanced supervision, environmental modifications, or individualized fall-prevention strategies. The resident involved had multiple diagnoses, including a fracture of the neck of the right femur, encephalopathy, bone density disorders, rhabdomyolysis, dysphagia, and cognitive communication deficit, and was assessed as having severe cognitive impairment. Despite the resident's return from the hospital and a significant change assessment being completed, the care plan was not updated to reflect the fall and subsequent fracture. Interviews with facility staff confirmed that the care plan was not revised as required following the incident.
Failure to Prevent Smoking and Elopement Hazards
Penalty
Summary
A deficiency occurred when a resident with a history of chronic obstructive pulmonary disease, nicotine dependence, and cognitive communication deficit was observed smoking a cigarette in the facility courtyard, despite the facility's policy prohibiting smoking and possession of smoking materials on the premises. The resident had a BIMS score indicating intact cognitive function and was on a nicotine patch, but staff were unaware she was actively smoking. The resident admitted to smoking since admission, keeping cigarettes, a lighter, and a vape in her personal bag, and stated that other residents also smoked without detection. Multiple staff members, including nursing and social work, were unaware of her smoking status or possession of smoking materials, and the facility's policy requiring all smoking materials to be surrendered was not enforced. Another deficiency involved a resident with muscle wasting, atrophy, and an abdominal aortic aneurysm, who required partial to moderate assistance for mobility and was at risk for falls. The resident left the facility without signing out or completing the required leave of absence documentation. Staff did not confirm the resident's whereabouts for several hours, and when the resident was found missing, the response did not follow the facility's elopement policy, which required immediate notification, a prompt search, and contacting authorities if the resident was not located. The resident's ability to make healthcare decisions was not documented, and the required risk assessments and sign-out procedures were not completed. In both cases, the facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents. Staff were not consistently aware of residents' behaviors or risks, and policies regarding smoking and elopement were not effectively implemented or followed, resulting in deficiencies related to resident safety and supervision.
Failure to Properly Label, Date, and Store Food Items
Penalty
Summary
The facility failed to ensure that food items stored in the freezer, refrigerators, and dry food storage areas were properly sealed, labeled, and dated according to facility policy and professional standards. During observations, surveyors found several food items, including a bag of self-rising corn meal and a box of lasagna noodles in dry storage, that were opened but not labeled with an open or use by date, and the noodles were not properly sealed. In the walk-in cooler, a container of dill pickle chips and a container of ham base were found with either expired or illegible dates. In the walk-in freezer, open bags of churros were not properly sealed or labeled, and a bag of meatballs was found with an open date and use by date that had passed. Interviews with the Dietary Manager and Administrator confirmed that it is the facility's expectation that expired foods are discarded and that all opened foods in storage should be dated. However, the Administrator acknowledged that sometimes items are mislabeled with dates that exceed the required timeframe. These findings indicate that the facility did not consistently follow its own policies regarding food safety, labeling, and storage, which had the potential to affect all residents receiving meals from the kitchen.
Failure to Report Resident's Unexplained Absence to State Agency
Penalty
Summary
The facility failed to report to the State Survey Agency an incident involving a newly admitted resident who was no longer present in the facility and whose whereabouts were unknown to staff. According to facility policy, any suspected abuse, neglect, or unexplained absence must be reported immediately or within specified timeframes depending on the severity. The resident, who had diagnoses including muscle wasting, atrophy, and abdominal aortic aneurysm, was assessed as not having safe decision-making capabilities and required assistance for mobility. On the day of the incident, the resident was last seen outside with family, and later could not be located during routine rounds. Staff searched the facility and attempted to contact the resident and her representative without success, and the incident was reported internally to the DON. Despite these actions, there was no documentation that the resident was capable of making her own healthcare decisions, and no completed leave of absence form was found for her. The administrator and staff interviews revealed that the resident did not sign out as required, and there was confusion regarding her cognitive status and risk for elopement. The incident was not reported to the State Survey Agency as required by facility policy, and there was no evidence that external authorities were notified about the resident's unexplained absence.
Failure to Notify Residents or Representatives of Bed-Hold Policies
Penalty
Summary
The facility failed to notify two residents or their resident representatives of bed-hold policies and bed reserve payments when the residents were transferred out of the facility for hospitalizations. According to the facility's policy, residents or their representatives must be provided with a copy of the bed-hold policy before a temporary leave or within 24 hours in the case of emergency hospitalization. Record reviews for both residents did not show evidence of bed-hold notifications, and interviews with staff and a resident representative confirmed that no written or verbal notification was provided regarding bed-hold status. One resident had multiple hospitalizations with bed-hold status, and another had moderate cognitive impairment and was admitted with several medical conditions, including dementia and diabetes. Staff interviews revealed inconsistent practices and a lack of clarity regarding responsibility for bed-hold notifications. The social worker was unaware of the requirement to provide notice, and the business office and nursing staff described informal or incomplete notification processes, with no documentation found in the residents' records.
Medication Administration Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5 percent, as required by policy, resulting in an observed error rate of 8 percent during the survey. Observations revealed that a registered nurse (RN) handled medications with bare hands before placing them in a medication cup, contrary to facility policy, and expressed reluctance to follow the correct procedure, citing inconvenience. Additionally, the RN proceeded with a medication pass despite some prescribed medications being unavailable in the cart, and did not follow the policy for contacting the pharmacy or physician regarding the missing medications. Further observations included the RN offering medication to a resident in the hallway, during which a pill was dropped on the floor. The RN initially suggested the resident could take the dropped pill, only replacing it after surveyor intervention. The RN then discarded the dropped pill in the medication cart's trash can without following the facility's destruction policy and was unsure about the correct procedure for discarding non-opioid medications. These actions were confirmed through interviews with the RN and the Director of Nursing, who stated that the RN was familiar with facility policies.
Failure to Remove Expired and Unidentified Medications from Carts
Penalty
Summary
Surveyors identified that the facility failed to ensure proper storage and removal of expired and unidentified medications and biologicals from medication and treatment carts. During observations, expired medications such as Vitamin D3, Iron, Bisacodyl suppositories, Humalog insulin, and Albuterol inhaler were found on two medication carts. Additionally, several loose, unidentified pills were present in the carts. The facility's policy requires that expired, contaminated, or deteriorated medications be immediately removed from stock and disposed of according to procedures, but these requirements were not followed as evidenced by the presence of expired and loose medications. Further, an open and expired non-sterile valve and expired povidone iodine solution were found on a treatment cart. Interviews with nursing staff revealed that floor nurses, managers, and agency staff are responsible for checking the carts, but expired and loose items were still present. The facility's procedures for checking and removing expired items were not effectively implemented, resulting in the continued storage of expired and unidentified medications and biologicals.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to ensure the use of gowns during high-contact resident care activities, specifically during catheter and wound dressing changes for two residents. According to the facility's own policy on Enhanced Barrier Precautions (EBP), gowns and gloves are required for all residents with wounds or indwelling medical devices during high-contact care activities. Observations revealed that staff performed catheter care and wound dressing changes for two residents without donning gowns, despite both residents having conditions that required EBP. One resident had stage 4 pressure ulcers, and the other had a urethral catheter, both of which meet the criteria for EBP according to facility policy. Further, EBP signage was not posted outside the residents' rooms as required by policy. Instead, the signs were kept inside closet doors with supplies, and staff interviews indicated inconsistent understanding and implementation of gown use and signage requirements. The Director of Nursing stated that signage was not posted on doors to maintain confidentiality, which resulted in staff not being properly reminded of the need for EBP during high-contact care activities. These actions and omissions led to non-compliance with the facility's infection prevention and control program.
Failure to Supervise High-Risk Resident During Shower
Penalty
Summary
The facility failed to adequately supervise a resident, identified as high risk for falls, during a shower. The resident, who had a medical history of chronic obstructive pulmonary disease, unsteadiness on their feet, and repeated falls, was admitted to the facility for rehabilitation. The resident required substantial assistance with daily activities, including bathing, as indicated by their care plan and assessments. However, the care plan did not specify the level of assistance needed for bathing or showers. On the day of the incident, a Certified Nursing Assistant (CNA) left the resident unattended in the shower room to retrieve clothing and linens. During this time, the resident fell from the shower chair, resulting in redness to the knees. The CNA returned to find the resident on the floor and called a Registered Nurse (RN) for assistance. The RN assessed the resident and found no immediate injuries, but the resident was later transferred to the emergency department for further evaluation due to changes in vital signs. Interviews with staff revealed that the resident was left unsupervised in the shower, which was against the facility's expectations for residents at high risk of falls. The Director of Nursing and the Administrator both stated that residents should be afforded safe bathing opportunities based on their capabilities, but the incident demonstrated a lapse in supervision and adherence to the resident's care needs.
Failure to Update Care Plans for Fall Interventions
Penalty
Summary
The facility failed to ensure that resident care plans were updated to include revised appropriate fall interventions for three residents reviewed for falls. The care plans were not updated despite multiple falls and recommendations for interventions. The Care Coordinator (CC) was responsible for updating the care plans but only did so when instructed, which did not occur for the falls experienced by the residents in question. Resident 1 was admitted with multiple diagnoses, including altered mental status and muscle weakness. The resident experienced several falls, some resulting in injury, but the care plan was not updated to reflect new interventions recommended after each fall. The CC stated that interventions were discussed weekly with the interdisciplinary team (IDT), but she was not instructed to update the care plan for the falls that occurred. Resident 2 had severe cognitive impairment and was unable to use the call light or understand others, making some care plan interventions inappropriate. Despite falls and recommendations for increased staff rounds, the care plan was not updated. Resident 3, with severe cognitive impairment and a history of falls, also had a care plan that was not updated after a fall with injury. The Director of Nursing (DON) and the Administrator acknowledged that the CC was responsible for updating care plans, but this was not consistently done.
Failure to Conduct Neurological Evaluations and Post-Fall Documentation
Penalty
Summary
The facility failed to adhere to its fall management policy, specifically in conducting neurological evaluations and post-fall nursing documentation for 72 hours for three residents who experienced falls. The policy required neurological evaluations for unwitnessed falls and post-fall documentation every shift for 72 hours to monitor for late effects or complications. However, the facility did not complete these evaluations and documentation for the residents involved. Resident 1, admitted with multiple diagnoses including dementia and muscle weakness, experienced several unwitnessed falls. The facility's records showed incomplete neurological evaluations and missing post-fall documentation for these incidents. Similarly, Resident 2, who also had cognitive impairments and muscle weakness, had unwitnessed falls without documented neurological evaluations or consistent post-fall documentation. Resident 3, with a history of falls and severe cognitive impairment, also lacked documented neurological evaluations and post-fall documentation after an unwitnessed fall. Interviews with facility staff, including unit managers and the Director of Nursing, revealed a lack of oversight and accountability in ensuring compliance with the fall management policy. The use of agency nurses and unclear responsibilities among staff contributed to the failure in completing necessary evaluations and documentation. The facility's leadership acknowledged the deficiencies but did not have a system in place to audit and ensure compliance with the policy.
Failure to Conduct Fall Risk Assessments
Penalty
Summary
The facility failed to ensure that fall risk assessments were conducted and accurately coded for three residents, leading to a deficiency in fall management. The facility's policy required qualified staff to evaluate residents for fall risk upon admission, quarterly, with significant changes, and post-fall. However, the review revealed that fall risk evaluations were not documented for several falls experienced by the residents, indicating a lapse in adherence to the policy. Resident 1, admitted with multiple diagnoses including severe cognitive impairment and physical impairments, experienced multiple falls between May and July 2024. Despite these incidents, fall risk evaluations were not documented post-fall as required by the facility's policy. Similarly, Resident 2, with severe cognitive impairment and a history of falls, also experienced multiple falls without documented fall risk evaluations. Resident 3, with severe cognitive impairment and a history of falls, had falls in March and June 2024, yet no fall risk evaluations were documented post-fall. Interviews with facility staff, including the Assistant Director of Nursing, Unit Managers, and the Director of Nursing, revealed a lack of awareness and responsibility regarding the completion of fall risk evaluations. The Assistant Director of Nursing acknowledged the difficulty in getting agency nurses to document properly, while the Unit Managers were either unaware of their responsibilities or did not verify the completion of fall risk evaluations. The Director of Nursing confirmed that the evaluations were not completed per policy, attributing the responsibility to the Unit Managers.
Failure to Notify Physician and Responsible Party of Resident Falls
Penalty
Summary
The facility failed to notify the resident's physician and/or responsible party (RP) of falls for two residents, leading to a deficiency in communication and adherence to policy. The facility's policy on Fall Management, revised on 05/05/23, mandates prompt notification of the physician and family following a fall. However, for Resident 1, who was admitted with severe cognitive impairment and multiple physical impairments, there were multiple instances where falls occurred, and the physician was not notified. On 05/25/24, 05/28/24, and 06/02/24, documentation failed to show that the physician was informed, despite the resident experiencing falls, one of which resulted in a large discoloration and pain, prompting a family request for emergency room evaluation. Similarly, Resident 3, also with severe cognitive impairment and a history of falls, experienced an unwitnessed fall on 06/30/24. The documentation did not indicate that the resident's physician or RP was notified. The resident was later sent to the emergency room due to back pain, following a verbal report of the fall from the off-going nurse. The grievance report from the RP highlighted the lack of notification, and interviews confirmed that the nurse on duty did not fulfill the responsibility of notifying the physician or RP, instead passing the task to the next shift, which also failed to act. Interviews with facility staff, including the Director of Nursing (DON), Administrator, Nurse Practitioner (NP), and Medical Director (MD), revealed a reliance on nursing staff to notify providers of falls. The NP and MD expected staff to use the available on-call provider service for such notifications. The Administrator confirmed that it was the duty of the nurse on duty during the fall to notify the physician and RP, which was not done in these cases, leading to the deficiency.
Inaccurate MDS Coding for Resident Fall
Penalty
Summary
The facility failed to ensure the accurate coding of a Minimum Data Set (MDS) for a resident who was reviewed for falls. The facility's policy requires a licensed nurse to conduct or coordinate each assessment with the interdisciplinary team, ensuring a comprehensive and accurate assessment using the Resident Assessment Instrument (RAI) process. The policy also mandates a thorough review of the resident's medical record, including pre-admission activities, current care plans, and various medical notes and records. However, the Care Coordinator did not review the falls investigation worksheets and missed documenting a fall that occurred on 01/06/24 in the quarterly MDS with an Assessment Reference Date (ARD) of 03/17/24. The resident in question was admitted to the facility with diagnoses including altered mental status, muscle wasting and atrophy, dementia, and unsteadiness on feet. An unwitnessed fall occurred on 01/06/24, as noted in the resident's progress notes, but this incident was not reflected in the subsequent MDS assessment. During interviews, the Care Coordinator acknowledged the oversight, stating that she had reviewed the progress notes but failed to include the fall in the MDS. The facility administrator expressed the expectation that MDS assessments should be accurate, highlighting the deficiency in the assessment process for this resident.
Verbal Abuse of Two Residents by LPN
Penalty
Summary
The facility failed to ensure that two residents, R1 and R2, were free from verbal abuse. R1, who had moderate cognitive impairment and was COVID positive, was verbally abused by LPN1 who used inappropriate language while instructing R1 to keep his door closed. This incident was witnessed by two CNAs who heard LPN1 use offensive language towards R1. R2, who is cognitively intact, also experienced verbal abuse from LPN1, who used inappropriate language when R2 requested his medication. R2 expressed his dissatisfaction with the way he was treated to the Social Services Director (SSD) and during an interview with surveyors. LPN1 admitted to speaking inappropriately to both residents and attributed his behavior to lack of sleep and exhaustion. The facility's Administrator was informed of the incident and took immediate action by suspending and subsequently terminating LPN1. The facility's policy on abuse, neglect, exploitation, or mistreatment prohibits all forms of abuse, including verbal abuse, and emphasizes the importance of treating residents with dignity and respect. The failure to adhere to this policy resulted in the verbal abuse of R1 and R2, causing distress to both residents. The facility's leadership is expected to ensure that all staff members comply with the policy and maintain a safe and respectful environment for all residents. The incident highlights the need for ongoing staff training and monitoring to prevent future occurrences of abuse and to ensure the well-being of all residents. The facility must take corrective actions to address the deficiencies identified in the report and to prevent similar incidents from happening in the future.
Latest citations in South Carolina
A cognitively impaired, nonverbal female resident who wandered the unit and required extensive ADL assistance was not protected from sexual contact initiated by a nonverbal male resident with dementia, psychotic and mood disorders, and documented hypersexual and inappropriate behaviors toward staff. Staff had care-planned the male resident’s history of disrobing and genital-focused behaviors, yet he was found naked in bed with the female resident kneeling beside the bed while he guided her hand onto his genital area and attempted to pull her into bed. Multiple CNAs and a UM observed and intervened in the incident, and the SA later cited noncompliance with abuse-prevention requirements under 42 CFR §483.12.
Kitchen staff failed to keep major equipment clean, with the stove, deep fryer, and two ovens observed with heavy grease and food residue and no cleaning schedule for the ovens or deep fryer. Staff also did not consistently wear proper hair or beard restraints, as a male cook with a beard and a female staff member with exposed hair were observed without adequate coverage. Dietary staff also incorrectly calibrated thermometers and handled food with poor hygiene practices while plating and temping meals.
Failure to Provide Recommended OT Services: A resident with spastic hemiplegia, contractures, weakness, and cognitive impairment was assessed by OT as having difficulty with grooming, hygiene, and a right-hand contracture, and continued OT was recommended. The funding request was denied by the Administrator, and the resident later reported worsening hand contracture and pain after therapy stopped.
A resident with severe vascular dementia, a very low BIMS score, and a diagnosis of wandering was observed self-propelling in a wheelchair in the hallway and was later found missing when a nurse attempted to administer medication. The resident, who had been assessed as low elopement risk and did not have a WanderGuard or daily elopement alarm in use, exited the building and crossed the street before being located by staff between nearby medical offices and returned without distress. Staff interviews and record review showed that, although the facility had an elopement policy and a process for assessing and care planning high-risk residents, this resident had not previously been identified as an elopement risk, and adequate supervision and preventive measures were not in place at the time of the elopement, leading to a cited deficiency under F689 for failure to prevent accidents and hazards.
Medication labeling and storage were not maintained according to policy. Surveyors found an opened and undated Tubersol vial in one storage area and multiple expired, opened without dates, or otherwise unlabeled medications in several medication carts, including eye drops, eye ointment, inhalers, and nasal sprays. An LPN, RN, and DON confirmed the findings, and the medications were removed from storage.
Failure to Provide Ordered Medication: A resident with idiopathic pulmonary fibrosis did not receive Nintedanib Esylate 100 mg as ordered on multiple scheduled doses. The MAR showed missed doses, an LPN said the medication had not been given because the facility was waiting for the pharmacy to fill it, and the DON and AP believed it was on hold even though no hold order was documented until later. The pharmacist stated the refill request was not filled due to cost.
An LPN failed to follow infection control practices during medication administration when she dropped a pill into the med cart, picked it up with her bare hands, returned it to a stock medication bottle used for other residents, recapped the bottle, and placed it back in the cart. The LPN confirmed the event and stated she probably should not have done that.
A facility failed to protect residents’ right to voice grievances without fear of retaliation and did not maintain an effective grievance process for all residents reviewed. Residents reported they did not know where to get grievance forms, there was no grievance box, and complaints could be discarded or lead to retaliation. Ongoing Resident Council concerns about evening snacks, delayed call light response, and delays in care were not documented, investigated, tracked, or resolved, and the SSD, DON, CNC, AD, and Administrator confirmed there was no anonymous grievance system despite policy requiring one.
Failure to Date, Label, and Cover Stored Food: Food items in the kitchen were found stored without required dates, labels, or proper covering. An open package of bread in the refrigerator had no date, and multiple frozen items, including waffles, pork ribs, sausage links, and pork chops, were opened and/or exposed without labels or dates. The DS confirmed the findings and stated there was no schedule for checking food dates or expired items.
Failure to Provide Written Transfer/Discharge Notice: The facility did not provide written transfer/discharge documentation to a resident or the resident’s rep after a hospital transfer. The resident had multiple diagnoses including respiratory failure, AFib, dysphagia, vascular dementia, and a stage II heel pressure ulcer, and was transferred for altered mental status and increased confusion before returning to the facility. The required notice, including appeal rights and bed-hold information, was not found in the EMR or the Admissions Coordinator’s file.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired female resident, R3, who lacked capacity to consent, from sexual contact initiated by another resident, R2. R3’s records showed a diagnosis of unspecified dementia with behavioral disturbance and a need for substantial to maximal assistance with ADLs. R3 wandered throughout the facility and required a helmet when out of bed due to multiple falls. R2’s records showed diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and other sexual dysfunction not due to a substance or unknown physiological condition. His MDS indicated he was unable to complete the BIMS interview and required partial to moderate assistance with ADLs. R2’s medical record documented a history of periods of inappropriate behavior and inappropriate gestures toward staff during personal care. His care plan identified a history of pulling at his penis, inappropriate behavior, and inappropriate gestures, with an approach to monitor and record occurrences of hypersexuality toward staff, inappropriate responses to verbal communication, and violence or aggression toward staff or others. Despite this documented pattern, the facility did not prevent an incident in which R2 engaged in sexual contact with R3. On the night of the incident, a CNA walking down the hall observed R2 lying naked on his bed and R3 kneeling beside the bed, with R2’s hand over R3’s hand, placing it on his genital area. The CNAs’ and Unit Manager’s interviews consistently described R2 as unclothed from the waist down and R3 as fully clothed, with R2 using his hand to guide R3’s hand onto his penis and attempting to pull her into the bed. CNA2 initially saw the interaction, left to seek help, and returned with CNA3, who positioned herself between the residents to separate them. When the Unit Manager arrived, she observed R3 on the floor beside the bed and R2 on the bed, and while assessing R3 for injury, noted R3’s hand under R2’s cover with the cover moving. The Administrator confirmed that both residents were nonverbal and unable to have appropriate communication, that R3 wandered throughout the facility, and that R2 usually remained in his room. The State Agency determined that the facility’s noncompliance with 42 CFR §483.12, Freedom from Abuse, Neglect, and Exploitation, resulted in Immediate Jeopardy related to the failure to ensure R3 remained free from sexual abuse.
Kitchen sanitation, hair restraint, and thermometer calibration failures
Penalty
Summary
The facility failed to ensure proper cleaning of kitchen equipment, including the deep fryer, stove, and two ovens. During an initial tour of the main kitchen, the stove, deep fryer, and two ovens were observed with excessive grease and food residue buildup. The Kitchen Manager stated there was a cleaning log for the stove/grill, but no cleaning log or schedule for the ovens or deep fryer, and she did not know when those items had last been cleaned. She stated the ovens and deep fryer would be cleaned that day. The facility also failed to ensure kitchen staff had appropriate hair and facial hair restraints. A male kitchen staff member was observed plating meals with a beard but no beard cover, and he stated he was not required to wear one because he did not have hair. A female kitchen staff member was observed wearing a purple bonnet that did not fully cover approximately 5 inches of her hair, and she stated she believed any covering that touched her hair was sufficient. On another observation, a male cook with a beard was seen prepping meal trays without a beard cover and stated he did not have to wear one because he did not really have a beard. In addition, dietary staff did not correctly demonstrate thermometer calibration when taking food temperatures. One staff member was observed taking food temperatures without calibrating the thermometer and stated calibration was done by turning the thermometer off and on. Another staff member was observed entering the kitchen in a dirty uniform, scratching her face and neck, placing her hands in and out of her pockets, and handling food pans bare handed while only washing her hands once. The Kitchen Manager stated staff were expected to wear clean uniforms, hair restraints, and beard covers, and that thermometers should be calibrated after each food item is temped.
Failure to Provide Recommended OT Services
Penalty
Summary
The facility failed to provide or obtain specialized rehabilitative services for one resident when Occupational Therapy was recommended but not approved. The resident was admitted with multiple diagnoses including spastic hemiplegia affecting the right dominant side, contractures, gait and mobility abnormalities, muscle wasting and atrophy, generalized weakness, and sequelae of cerebral infarction. The resident’s quarterly MDS showed a BIMS score of 8, indicating moderate cognitive impairment, and the care plan identified impaired mobility and ADLs with a need for assistance related to cognitive and functional decline, right-sided hemiplegia, personal care needs, muscle wasting, and weakness. The quarterly Therapy Screening Form documented difficulty performing ADLs, including grooming, along with joint limitations and contractures. The Occupational Therapist noted difficulty completing grooming and hygiene tasks and a right digit contracture, and OT was recommended. A Rehabilitation Therapy Funding Information Form was completed and sent for administrator approval, but the administrator denied the request, documenting that it was not approved at that time. The Director of Rehabilitation stated that the resident was screened quarterly, that the last screening recommended continued OT services based on the resident’s right-hand contracture and decline in grooming and hygiene, and that if the funding form was not approved there was nothing more that could be done to assist with therapy services. During observation, the resident was sitting on the side of the bed looking distressed, with the fingers of the right hand contracted and the pinky finger digging into the palm. The resident stated that therapy had been helping, that the fingers had been straightening out, and that pain had improved, but therapy was stopped because the resident was told services were no longer approved. The Administrator stated he denied the funding form after his own review and said he did not see a reason to continue OT services, later acknowledging that the Therapy Screening Form contained the diagnosis and reason for services, including decline in grooming, hygiene, and right-hand contracture.
Failure to Adequately Supervise Cognitively Impaired Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent an elopement for a resident with severe cognitive impairment. On the day of the incident, the resident was last observed in his room by a housekeeper at 11:30 a.m. and then seen by a nurse at 11:45 a.m. self-propelling his wheelchair down his hall toward the dining room. At 11:55 a.m., when the nurse went to the resident’s room to administer medication, the resident was noted to be missing. The facility then initiated a Code White at 12:10 p.m. and began an immediate search of the entire building, inside and outside. The resident’s medical record showed diagnoses including vascular dementia (severe), urinary tract infection, wandering, other visual disturbances, and pyogenic arthritis. The most recent Quarterly MDS, with an ARD of 02/19/26, documented a BIMS score of 3/15, indicating severe cognitive impairment. The MDS also indicated the resident had not exhibited wandering behaviors and did not wear a wander/elopement alarm daily. An Elopement Risk Assessment dated 03/27/25 showed no score but indicated the resident was considered low risk for elopement. Prior to the incident, the resident had not been previously identified as an elopement risk and did not have a WanderGuard device in place. During the Code White, staff searched inside and outside the facility. Multiple staff interviews confirmed that CNAs and other staff checked the parking lot and nearby buildings, while the Social Services Director and laundry staff searched the surrounding area by vehicle. A laundry worker ultimately located the resident across the street from the facility, between a cardiologist’s office and a retinal specialist’s office, and pushed the resident back toward the facility in his wheelchair. Staff reported that the resident stated he was going to an address on [NAME] Street, appeared calm, in no distress, and did not resist returning. A subsequent NP progress note documented that the resident did not clearly explain why or how he went outside, reported interest in going outside again, and appeared more altered compared to a prior visit, with concern for altered or worsening mental status. These events and conditions formed the basis for the cited deficiency under 42 CFR 483.25 related to freedom from accidents and hazards. The facility’s elopement policy, last revised on 11/01/17, stated its purpose was to safely and timely redirect patients/residents to a safe environment. The DON reported that elopement risk assessments are conducted on admission, with changes in condition, and when behavioral changes occur, and that residents identified as high risk are care planned and provided with a WanderGuard device, with exit doors equipped with alarms. In this case, the resident, despite severe cognitive impairment and a diagnosis of wandering, had been assessed as low risk and was not on elopement precautions or wearing a WanderGuard at the time he left the building and crossed the street before being found and returned by staff.
Medication carts contained expired and undated medications
Penalty
Summary
Medication labeling and storage were not maintained in accordance with facility policy and accepted pharmaceutical practices. Review of the facility policy stated that discontinued, outdated, or deteriorated medications or biologicals are to be handled through the dispensing pharmacy, and that opened multi-dose vials must be dated and discarded within 28 days unless the manufacturer specifies otherwise. The facility also had an undated policy stating that expiration or beyond-use dates must be checked before administration and that the opened date must be recorded when a multi-dose container is opened. During observations and interviews, surveyors found an opened and undated vial of Tubersol in the [NAME] Hall medication storage area. In Medication Cart 1 on Arbor Hall, surveyors found multiple medications that were expired, opened without dates, or otherwise unlabeled, including Brimonidine, Erythromycin eye ointment, Latanoprost eye drops, a Breztri inhaler, Oxymetazoline nasal spray, Nasacort Allergy nasal spray, and three bottles of Fluticasone Propionate nasal spray. In Medication Cart 2 on Arbor Hall, an opened Ipratropium Bromide/Albuterol inhaler was found with an expiration date noted but no valid open date. In the [NAME] House medication cart, an Albuterol inhaler had an opened foil pack with no open date. In the Skilled Unit medication cart, a Wixela inhaler had no open date, and a Fluticasone Propionate/Salmeterol inhalation powder had an open date recorded. Staff confirmed the unlabeled or expired medications and removed them from storage.
Failure to Provide Ordered Medication
Penalty
Summary
The facility failed to ensure Resident 87 received a physician-ordered medication, Nintedanib Esylate 100 mg, as prescribed for idiopathic pulmonary fibrosis. The resident was admitted on 03/30/26 with diagnoses including idiopathic pulmonary fibrosis, and the MAR showed an order to give the medication 1 capsule by mouth twice daily starting 03/31/26. Review of the MAR showed the resident did not receive the medication on 03/30/26 or 03/31/26, and later missed additional scheduled doses on multiple days in April, including missed evening doses and several consecutive days without any doses documented. During observation and interview on 04/15/26, an LPN stated the resident had not been receiving Nintedanib Esylate because the facility was waiting for the pharmacy to fill and send it. The MAR and physician orders showed no order to hold or discontinue the medication until 04/15/26, despite the DON stating the medication had been put on hold. The pharmacist stated the pharmacy had been notified to refill the medication on 04/07/26, but it was not filled due to cost, and the AP stated he thought the medication was on hold and said it had been his intent to put it on hold when the resident was first admitted.
Infection Control During Medication Administration
Penalty
Summary
The facility failed to ensure an LPN followed infection control practices during medication administration. During an observation of the medication pass, the LPN dropped a pill into the medication cart drawer, picked it up with her bare hands, and placed it back into a stock medication bottle intended for use by other residents. She then recapped the bottle and returned it to the medication cart. The facility policy titled, Administering Medications, states that staff follow established infection control procedures, including hand washing, antiseptic technique, gloves, and isolation precautions, as applicable, during medication administration. In interview, the LPN confirmed that she dropped the pill, picked it up with her bare hands, returned it to the bottle, replaced the lid, and put the bottle back in the drawer, and stated she probably should not have done that.
Failure to Maintain an Effective Grievance Process
Penalty
Summary
The facility failed to ensure residents were encouraged to voice grievances without fear of retaliation and failed to establish and maintain an effective grievance process for 89 of 89 residents reviewed. The facility policy stated grievances could be made verbally or during Resident Council meetings, must be documented, investigated, tracked to resolution, and responded to in writing, and residents could file anonymously. However, Resident Council meeting minutes from October 2025 through March 2026 showed repeated resident concerns about inconsistent evening snacks, excessive call light response times, and delays in receiving care, with no documentation that these concerns were treated as grievances, investigated, tracked, or resolved. March 2026 minutes contained no follow-up to the earlier concerns. During interviews, the Social Services Director, identified as the Grievance Official, stated residents were discouraged from filing grievances because of fear of retaliation and that some grievances were resolved the same day without being written down or tracked. She also confirmed Resident Council concerns were not documented as grievances and were not formally investigated or resolved through the grievance process. Residents reported they did not know where to obtain grievance forms, there was no grievance box in the facility, forms had to be requested from Social Services, and one resident stated they could not file a grievance without fear of retaliation. The DON, Corporate Nurse Consultant, Activity Director, Administrator, and SSD all confirmed there was no anonymous grievance submission system in place despite the facility policy allowing anonymous grievances, and that concerns voiced in Resident Council meetings were not consistently processed through the grievance system.
Failure to Date, Label, and Cover Stored Food
Penalty
Summary
Food products stored in the kitchen were not dated, labeled, or covered in accordance with the facility’s policy and professional standards. Review of the facility policy on Date Marking for Food Safety stated that ready-to-eat, time/temperature control for safety foods held more than 24 hours at 41F or less must be labeled and dated, and that opened items should be checked daily for expiration. During observation of the main refrigerator, four slices of white bread were found wrapped in plastic wrap with no date. In the main freezer storage room, waffles were observed in an open bag stored in a cardboard box with no date opened, and two racks of pork ribs were in an opened cardboard box without plastic wrap, leaving the ribs exposed to the freezer. Additional frozen items were also found opened and not labeled. Two plastic bags, one containing 50 frozen pork sausage links and the other containing eight bone-in pork chops, had been opened, resealed with plastic wrap, and had no label. During interview, the Dietitian Supervisor confirmed the observations and stated that bread should be in closed packaging and dated when taken out of the main refrigerator, and that all frozen items once opened should be dated by staff. The Dietitian Supervisor also stated that there had been no schedule for food being checked for dates or expired food.
Failure to Provide Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide written documentation of a hospital transfer to Resident 5 and to the resident’s representative. The facility policy titled, Transfers and Discharges, dated March 2024, required written notification to include the specific reason for the transfer or discharge, the effective date, the specific location, an explanation of the resident’s rights to appeal, bed hold notification, and the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman. Resident 5’s admission record showed diagnoses including acute and chronic respiratory failure, paroxysmal atrial fibrillation, dysphagia, vascular dementia, and a stage II pressure ulcer of the left heel. Nursing progress notes documented that the resident was transferred to the hospital related to altered mental status and increased confusion, and later returned to the facility. There was no documented evidence that a written transfer/discharge notice was provided to the resident or the resident’s representative at the time of transfer or shortly thereafter. During interview, the Administrator stated the notices were generally not scanned into the EMR and were kept in the Admissions Coordinator’s office, but after searching that office, she could not find a discharge/transfer notification for Resident 5.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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