Magnolia Manor - Greenwood

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure that Resident (R)1 had adequate supervision to prevent a successful elopement on 04/05/2026. On 04/20/26 at 4:25 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 04/05/26. The IJ was related to 42 CFR 483.25 - Freedom from Accidents and Hazards. On 04/20/26 the facility provided an acceptable IJ Removal Plan. On 04/20/26 the survey team, validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The SA is considering this IJ at Past Noncompliance as of 04/07/26. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care.

Inspectors wroteBased on review of facility policy, record review, and staff interviews, the facility failed to ensure that Resident (R)1 was adequately supervised to prevent elopement. R1 was noted to have eloped on 12/13/2025. R1 was last seen by facility staff in the facility at approximately 5:30 PM. Facility was made aware that R1 was found outside the facility at 6:06 PM by first responders. According to weather.com, the weather in [NAME], SC on 12/13/25 was a high of 65 degrees Fahrenheit (F) and a low of 49F with sunset at 5:19 PM.As a result of Complaint #2697173, on 12/30/2025 at 2:40 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations could cause psychosocial harm. [...]

Inspectors wroteBased on review of the facility policy, record review, and interviews, the facility failed to ensure appropriate post-fall interventions were developed and implemented through care plan revision for 1 of 3 residents reviewed for falls Resident (R)2. This failure had the potential to place the resident at risk for additional falls and injury.

Inspectors wrote(2.) Based on review of the facility policy, observations, record reviews and interviews, the facility failed to ensure R131 was free from potential accidents, related to smoking on facility grounds for 1 of 4 residents identified for smoking. R131 being observed smoking unsafely, on the property of a smoke-free facility on 06/13/2025. On 06/13/2025 at 1:31 PM, the SA presented the Administrator with an IJ template related to this incident. On 06/13/2025 at 5:00 PM, the facility presented an acceptable IJ removal plan. Verification of the plan revealed the facility implemented their removal plan as of 06/16/25 at 6:30 PM. The facility remained out of compliance at a lower scope/severity level of D.

Inspectors wroteBased on review of the facility policy, observations, and interviews, the facility failed to ensure foods that were stored in the freezer, refrigerators and dry food storage were appropriately sealed, labeled, dated with a use by date, and/or discarded after the manufacturer's expiration date. This had the potential to affect all residents who received meal trays from the kitchen.

Inspectors wroteBased on a review of the facility policy, record reviews, and interviews, the facility failed to report to the State Survey Agency an incident that occurred on 03/23/2025. The facility neglected to identify R78 was no longer in the facility, or was her whereabouts known to facility staff.

Inspectors wroteBased on review of the facility policy, observations, record reviews and interviews, the facility failed to notify Resident (R)7 and R78 or their resident representative (RR) of bedholds, including bed reserve payments 2 of 2 residents.

Inspectors wroteBased on review of the facility policy, observations, record review and interviews, the facility failed to ensure a medication administration error rate of less than 5 percent. The medication administration error rate was 8 percent for 2 out of 25 opportunities observed for error.

Inspectors wroteBased on review of the facility policy, observations and interviews, the facility failed to ensure expired medication and biologicals, and 4 loose unidentified pills were removed from 2 of 2 medication carts. The facility further failed to remove open and expired items from 1 of 2 treatment carts.

Inspectors wroteBased on review of facility policy, observations, and interviews, the facility failed to ensure the useof gowns during catheter and wound dressing changes 2 of 2 residents reviewed, Resident (R)35and R57.

Inspectors wroteBased on interview, record review, observation and facility policy review, the facility failed to supervise 1 (Resident (R)6) of 3 sampled residents reviewed for accidents. Specifically, the facility failed to supervise R6, who the facility determined was high risk for falls and required staff assistance with showers/bathing, during a shower on 10/06/24. R6 fell from a shower chair when staff left the resident in the shower room unattended and the resident sustained redness to the knees.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure resident care plans were updated to include revised appropriate fall interventions for 3 (Residents (R)1, R2, and R3) of 3 sampled residents reviewed for falls.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure staff followed the facility policy for fall management and conducted neurological evaluations and post fall nursing documentation for 72 hours for 3 (Residents (R)1, R2, and R3) of 3 sampled residents reviewed for falls.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure staff conducted fall risk assessments and accurately coded fall risk assessments for 3 (Residents (R)1, R2, and R3) of 3 sampled residents reviewed for falls.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure staff notified the resident's physician and/or the resident's responsible party (RP) of a fall for 2 (Resident (R)1 and R3) of 3 sampled residents reviewed for falls.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure staff accurately coded a Minimum Data Set (MDS) for 1 (Resident (R)2) of 3 sampled residents reviewed for falls.

Inspectors wroteBased in record review, interviews, and review of facility policy, the facility failed to ensure Residents (R)1 and R2 were free from verbal abuse for 2 of 2 residents reviewed.

Inspectors wroteBased on review of facility policy, interview and record review, the facility failed ensure the dignity and resident rights of 1 of 3 residents. Specifically, on 11/22/23, Certified Nursing Aide (CNA)1 posted a video of Resident (R)1 to TikTok (a social media platform).

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to ensure all glasses were allowed to be air dried before stacked, all equipment was clean after washing, and items in dry storage were dated. These failures had the potential to affect all 76 residents in the facility who consumed food from the kitchen.

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to revise their pneumococcal vaccine policy to reflect current pneumococcal vaccination guidelines. This failure increased the risk for residents to not be vaccinated per current guidelines.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Level I Pre-admission Screening Resident Review (PASSAR) was accurate for 1 of 24 residents, Resident (R)31. This failure had the potential for residents with mental disorders not to receive identified specialized services.

Inspectors wroteBased on review of the facility policy, record review, and interviews, the facility failed to honor a resident's wishes related to medication refusals for 1 of 1 resident. Specifically, Resident (R)1 did not want to take an ordered medication for stool softer, however Registered Nurse (RN)1 attempted to force R1 to take the medication.

Inspectors wroteBased on record review, interviews and review of facility policy, the facility failed to ensure the physician's medication orders were accurately documented for 1 of 1 resident, Resident (R)1.

Inspectors wroteBased on observations, interviews, record review, and review of the facility's policy, the facility failed to provide activities of daily living to a resident who was unable to carry out activities of grooming and personal hygiene. Resident #42's nails were long and curled under. One (1) of two (2) residents reviewed for activities of daily living.

Inspectors wroteBased on observation, interviews, record review, and review of the facility policy, the facility failed to ensure the medication error rate was not five (5) percent or greater. The facility had a medication error rate of 12%. This deficient practice affected one of seven residents observed for medication administration.