Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
80% worse than South Carolina average
South Carolina average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Dec 30, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #2697173 regarding the facility's failure to adequately supervise a resident to prevent elopement and failure to update care plans after a resident fall.
Findings
The facility failed to update the care plan for a resident after a fall, potentially placing the resident at risk for further injury. Additionally, the facility failed to adequately supervise a resident who eloped from the facility, resulting in immediate jeopardy to resident health and safety. The facility implemented corrective actions and the immediate jeopardy was removed as of 12/14/2025.
Complaint Details
Complaint #2697173 triggered the investigation. The State Agency determined the facility's non-compliance could cause psychosocial harm. Immediate Jeopardy (IJ) was identified related to inadequate supervision and accident hazards. The facility provided an acceptable IJ Removal Plan and the IJ was removed as of 12/14/2025.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure appropriate post-fall interventions were developed and implemented through care plan revision for 1 of 3 residents reviewed for falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents, resulting in resident elopement. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents affected: 1
Residents affected: 1
Distance eloped: 700
Duration eloped: 30
BIMS score: 6
BIMS score: 9
Temperature high: 65
Temperature low: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Notified about missing resident and involved in elopement incident documentation |
| Director of Nursing | Director of Nursing | Provided expectations on care plan updates and involved in elopement incident response |
| Administrator | Facility Administrator | Notified and involved in elopement incident response and corrective actions |
| MDS Coordinator | Registered Nurse / MDS Coordinator | Interviewed regarding care plan updates after resident fall |
Inspection Report
Complaint Investigation
Deficiencies: 8
Jun 16, 2025
Visit Reason
The inspection was conducted due to complaints and concerns regarding failure to report an elopement incident, failure to notify residents or representatives of bed-hold policies, unsafe smoking practices, medication administration errors, expired medications, food safety violations, and infection control issues.
Findings
The facility failed to report an elopement incident involving Resident R78, failed to notify residents or representatives about bed-hold policies, allowed unsafe smoking on premises, had a medication administration error rate of 8%, stored expired and unlabeled medications and food items, and failed to ensure proper use of gowns during catheter and wound care.
Complaint Details
The complaint investigation was substantiated with findings including failure to report an elopement incident, failure to notify residents or representatives of bed-hold policies, unsafe smoking practices, medication errors, expired medications, food safety violations, and infection control deficiencies.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Level of Harm - Immediate jeopardy to resident health or safety: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities related to Resident R78's elopement on 03/23/2025. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide required documentation or notification related to residents' needs, appeal rights, or bed-hold policies for Residents R7 and R78. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure Resident R131 was free from potential accident hazards related to smoking on facility grounds, resulting in Immediate Jeopardy. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to ensure adequate supervision and accident hazard prevention related to Resident R78's elopement on 03/23/2025. | Level of Harm - Immediate jeopardy to resident health or safety |
| Medication administration error rate of 8 percent observed, including improper handling of medications and failure to replace unavailable medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to remove expired medication and biologicals, and loose unidentified pills from medication carts and treatment carts. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure foods stored in freezer, refrigerators, and dry food storage were appropriately sealed, labeled, dated, and discarded after expiration. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure use of gowns during catheter and wound dressing changes for Residents R35 and R57, and failure to post appropriate Enhanced Barrier Precautions signage. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication administration error rate: 8
Residents identified as smokers: 4
Elopement search time: 30
BIMS score: 14
BIMS score: 9
BIMS score: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN2 | Licensed Practical Nurse | Provided account of incident involving Resident R78 elopement |
| Administrator | Provided statements regarding Resident R78 elopement, smoking policy, and facility plans | |
| Medical Director | Interviewed regarding awareness of Resident R78 leaving against medical advice | |
| RN3 | Registered Nurse | Observed medication administration errors and handling |
| Director of Nursing | Director of Nursing | Provided statements on medication policies, smoking policy, and infection control |
| CNA1 | Certified Nursing Assistant | Provided information on Resident R78 care on day of elopement |
| RN2 | Registered Nurse | Observed not using gown during wound dressing change for Resident R35 |
| CNA3 | Certified Nursing Assistant | Interviewed about use of gowns and EBP signage |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 8, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to adequately supervise a high fall-risk resident (R6) during a shower, which resulted in the resident falling from a shower chair on 10/06/24.
Findings
The facility failed to supervise Resident R6, who was identified as high risk for falls and required assistance with showers, leading to a fall and minor injury. The investigation included review of policies, resident records, therapy evaluations, progress notes, and interviews with staff. The resident was found on the shower floor with reddened knees but no serious injury. The facility reeducated staff on shower room safety following the incident.
Complaint Details
The complaint investigation substantiated that the facility failed to supervise Resident R6, who was high risk for falls and required assistance with showers. The resident fell on 10/06/24 when left unattended in the shower room, sustaining redness to the knees. The resident was transferred to the emergency department with no fractures or intracranial injury found. The facility reeducated the assigned CNA regarding shower room safety.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to supervise a high fall-risk resident during shower resulting in a fall from a shower chair and minor injury. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Date of fall: Oct 6, 2024
Blood pressure: 162
Blood pressure: 74
Pulse rate: 79
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN9 | Registered Nurse | Documented fall incident, assessed resident, notified Nurse Practitioner and Responsible Party |
| CNA8 | Certified Nursing Assistant | Provided shower to resident, left resident unattended, reeducated on shower room safety |
| Director of Nursing | Director of Nursing | Interviewed regarding resident's capability and safety in shower |
| Administrator | Administrator | Interviewed regarding expectations for safe bathing of residents |
Inspection Report
Complaint Investigation
Deficiencies: 5
Jul 27, 2024
Visit Reason
The inspection was conducted to investigate complaints related to failure to notify physicians and responsible parties of resident falls, inaccurate Minimum Data Set (MDS) coding, failure to update care plans with fall interventions, incomplete neurological evaluations and post-fall nursing documentation, and failure to conduct and document fall risk assessments.
Findings
The facility failed to notify physicians and responsible parties of resident falls for 2 of 3 sampled residents, inaccurately coded MDS for 1 resident, failed to update care plans with fall interventions for all 3 sampled residents, did not complete neurological evaluations and post-fall documentation for 72 hours for all 3 residents, and failed to conduct and document fall risk assessments after falls and quarterly for all 3 residents. Interviews with staff confirmed these deficiencies and lack of oversight.
Complaint Details
The complaint investigation revealed failures in fall notification to physicians and responsible parties, inaccurate MDS coding, incomplete care plan updates, lack of neurological evaluations and post-fall documentation, and missing fall risk assessments for residents R1, R2, and R3.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to notify resident's physician and/or responsible party of falls for 2 of 3 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately code Minimum Data Set (MDS) for 1 resident regarding falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to update resident care plans to include revised fall interventions for 3 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct neurological evaluations and post-fall nursing documentation for 72 hours for 3 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct fall risk assessments and accurately code fall risk assessments for 3 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Falls: 7
BIMS score: 3
BIMS score: 0
MDS Assessment Reference Date: Jul 5, 2024
MDS Assessment Reference Date: Mar 17, 2024
MDS Assessment Reference Date: Jun 21, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN3 | Licensed Practical Nurse | Documented fall progress notes for Resident R1 and interviewed regarding fall notification |
| RN4 | Registered Nurse | Nurse on duty during Resident R3's fall who failed to notify resident's representative or physician |
| DON | Director of Nursing | Reviewed falls and confirmed staff failed to notify physicians and responsible parties; stated responsibility of Unit Managers |
| CC | Care Coordinator | Responsible for updating care plans; interviewed about MDS coding and care plan updates |
| CNA5 | Certified Nursing Assistant | Provided information about resident R2's care and fall interventions |
| UM1 | Unit Manager | Responsible for completing Falls Investigation Worksheet; unaware of responsibility for fall risk evaluations |
| UM2 | Unit Manager | New to position; responsible for reviewing fall packets but unaware of responsibility for fall risk evaluations |
| ADON | Assistant Director of Nursing | Stated responsibility of Unit Managers to ensure nurses complete neurological evaluations and fall risk assessments |
| NP | Nurse Practitioner | Expected nurses to complete neurological evaluations per policy |
| Administrator | Stated expectations for notification of falls and responsibility of Unit Managers for follow-up | |
| Medical Director | Stated expectation that staff notify provider when resident had a fall |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 8, 2024
Visit Reason
The inspection was conducted following a complaint investigation regarding verbal abuse allegations involving two residents at Magnolia Manor - Greenwood.
Findings
The facility failed to ensure that two residents were free from verbal abuse by a Licensed Practical Nurse (LPN1), who admitted to using inappropriate language and was subsequently suspended and terminated. Interviews and record reviews confirmed the verbal abuse incidents and the facility's zero-tolerance policy for abuse.
Complaint Details
The complaint investigation substantiated verbal abuse by LPN1 towards Residents R1 and R2. R2 reported staff talking to him meanly and offensively. LPN1 admitted to inappropriate language and was suspended and terminated. The Administrator confirmed zero tolerance for abuse.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect residents from verbal abuse by staff, including use of inappropriate language and disrespectful behavior. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Named in verbal abuse findings and admitted to inappropriate language. |
| CNA1 | Certified Nursing Assistant | Witnessed LPN1's verbal abuse and confirmed resident presence. |
| CNA2 | Certified Nursing Assistant | Witnessed LPN1's verbal abuse and reported incident context. |
| RN1 | Registered Nurse | Present during verbal abuse incident and involved in removing LPN1 from resident's room. |
| Administrator | Administrator | Reported suspension and termination of LPN1 and stated zero tolerance for abuse. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 27, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a Certified Nursing Aide (CNA) posting a video of a resident on TikTok, potentially violating resident rights and privacy.
Findings
The facility substantiated the mental abuse of one resident when CNA1 posted a video of the resident on TikTok without consent, violating facility policy and resident rights. The CNA was terminated following the incident.
Complaint Details
The complaint was substantiated. CNA1 posted a video of Resident 1 to TikTok without consent, violating resident rights and facility policy. The facility terminated CNA1. The Social Services Director and other staff confirmed the incident.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the dignity and resident rights of 1 of 3 residents by posting a video of the resident on social media without consent. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA1 | Certified Nursing Aide | Named in mental abuse finding for posting resident video on TikTok |
| CNA2 | Certified Nursing Aide | Discovered the video on TikTok and notified Social Services Director |
Inspection Report
Annual Inspection
Deficiencies: 3
Dec 1, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including PASARR screening accuracy, food safety standards, and vaccination policy adherence at Magnolia Manor - Greenwood.
Findings
The facility failed to ensure accurate PASARR Level I screening for one resident, maintain proper food safety practices in the kitchen, and update pneumococcal vaccination policies according to current CDC guidelines. These deficiencies posed potential risks to residents' specialized service needs, food safety, and vaccination protection.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure a Level I Pre-admission Screening Resident Review (PASSAR) was accurate for 1 of 24 residents, potentially affecting specialized services for residents with mental disorders. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure all glasses were air dried before stacking, equipment was clean after washing, and dry storage items were dated, potentially affecting all 76 residents consuming food from the kitchen. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise pneumococcal vaccine policy to reflect current CDC vaccination guidelines, increasing risk for residents not being vaccinated per current standards. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 76
Residents affected: Residents potentially affected by vaccination policy deficiency
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Interviewed regarding PASSAR screening responsibility and errors |
| Administrator | Administrator | Interviewed regarding expectations for PASSAR and kitchen sanitation |
| Dietary Manager | Dietary Manager | Verified kitchen observations and interviewed about food safety expectations |
| Kitchen Supervisor | Kitchen Supervisor | Verified kitchen observations |
| Director of Nursing | Director of Nursing | Interviewed regarding pneumococcal vaccination policy awareness |
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 24, 2023
Visit Reason
The inspection was conducted following a complaint regarding a nurse allegedly forcing a resident to take medication against her wishes.
Findings
The facility failed to honor a resident's right to refuse medication when a nurse attempted to force medication administration despite the resident's refusal. The nurse was suspended and later terminated for improper documentation and failure to report the incident. The resident was cognitively intact and no physical harm was found.
Complaint Details
The complaint involved allegations that a nurse (RN1) forced Resident 1 to take medication despite refusal. Interviews with the resident, roommate, and staff confirmed the resident's refusal and the nurse's insistence. The nurse was suspended and terminated after investigation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to honor a resident's right to refuse medication; nurse attempted to force medication administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physician's medication orders were accurately documented for the resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication administration time: 6
BIMS score: 13
BIMS score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Nurse who allegedly forced medication administration and was terminated |
| RN2 | Registered Nurse | First shift nurse familiar with the incident and interviewed during investigation |
| Administrator | Administrator and Director of Nursing | Conducted interviews, suspended and terminated RN1, and provided statements on expectations |
Inspection Report
Deficiencies: 2
Dec 10, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including activities of daily living and medication administration.
Findings
The facility failed to provide adequate nail care to a resident requiring total assistance with personal hygiene, resulting in long, overgrown nails curling under and indenting the skin. Additionally, the facility had a medication error rate of 12%, exceeding the acceptable threshold of 5%, with a medication administration error observed involving incorrect dosages.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide care and assistance to perform activities of daily living for a resident unable to do so, specifically nail care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication error rates were below 5 percent; medication error rate was 12%. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 12
Residents observed for medication administration: 7
Residents affected: 1
Residents reviewed for activities of daily living: 2
Residents affected by nail care deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Verified resident's nails were long, overgrown, and curling under |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Put a cloth under resident's nails to prevent skin indenting |
| CNA #1 | Certified Nursing Assistant | Provided showers and bed baths but did not cut resident's nails |
| Director of Nursing | Director of Nursing | Verified nail care deficiency and medication errors; stated expectations for care |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Administered wrong medication dosage to resident |
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