Woodruff Manor: Wrong Medication Given to Resident - SC
The licensed practical nurse, identified in the inspection report as LPN1, described what happened in her own words during an interview with inspectors on September 2, 2025. "I looked at Point Click Care and told myself I was going to look at [Resident 1]," she said. "I pulled the medications and popped them out of the container. When I went in the room, we started talking. I usually give the other resident her medications first, but I didn't. I ended up giving [Resident 2's] medication to [Resident 1]."
She caught the error herself. After returning to the electronic medical record system, she realized what she had done and reported the incident to her supervisor. Together they checked the resident's allergy list. The resident had a documented statin allergy. The known reaction was muscle cramps.
"We immediately called the NP," LPN1 said. "I monitored her all night. It was a big mix-up."
The nurse practitioner, a palliative NP, remembered the call. "I do remember that, and I remember telling them to call the pharmacy," she told inspectors. "When someone calls us we rely on what they say. I instructed them to call the practitioner."
The pharmacist director did not find out until inspectors arrived.
"No one mentioned this incident to me as the pharmacist director until today," the pharmacist said during an interview at 1:50 PM on the day of inspection. The pharmacy operates around the clock. The pharmacist said the call was likely routed to the main office rather than to him directly. He added that the pharmacists who had been working that shift were no longer employed there.
The Director of Nursing said she was called when the error occurred. The supervisor had already reached the provider and the pharmacist on call and received instructions on what signs and symptoms to watch for. The DON said she conducted one-on-one education with LPN1 afterward.
The administrator confirmed the facility recognized it as a medication error. "We looked to see if it would have any side effects, and we did one-to-one education with that nurse," the administrator said. "The night shift supervisor is good about going around and monitoring the nurses."
LPN1 said the facility went over the six rights of medication administration with her and that a supervisor watched her pull medications afterward to verify she was doing it correctly.
The resident who received the wrong medication told inspectors she had not noticed any problems. "I take a lot of medications," she said. "I haven't had any problems with those pills."
Federal inspectors cited the facility under F0689, which covers the obligation to protect residents from accidents and foreseeable harm. The violation was tagged at the level of minimal harm or potential for actual harm, affecting a small number of residents.
The error traced back to a single decision at the medication cart. LPN1 said she normally gave the other resident her medications first. That night, she didn't. She pulled Resident 2's medications, walked into Resident 1's room, and administered them before checking the record again. By the time she confirmed the mistake, the pills were already taken.
The resident did not experience the muscle cramps her allergy history flagged as the expected reaction. Whether that was luck or a matter of dose and timing, the inspection report does not say. The pharmacist who would have been best positioned to assess the risk learned about it from a federal inspector, months after the fact.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodruff Manor from 2025-09-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 30, 2026 · Our methodology
Woodruff Manor in Woodruff, SC was cited for violations during a health inspection on September 2, 2025.
"I looked at Point Click Care and told myself I was going to look at [Resident 1]," she said.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.