Federal inspectors cited Magnolia Manor-Greenwood for immediate jeopardy to resident health and safety following the incident. The facility's administrator called the medical director at 6:21 PM to report the resident had left. Six minutes later, at 6:27 PM, the administrator called back to confirm the resident had been located.
Staff initiated a CODE WHITE emergency response. The resident was transported by ambulance to Self Regional Healthcare's emergency room for evaluation and treatment.
The medical director arrived at the facility at 6:45 PM and received reports from staff about the emergency procedures. Attempts to notify the resident's responsible party failed because voicemail had not been set up on their phone.
Inspectors found the facility had wander guard systems installed on exit doors, designed to sound alarms when residents wearing monitoring devices approach. Nine residents were identified as needing wander guard monitoring, according to facility documents reviewed by the director of nursing on December 13, 17, and 24.
The maintenance director had been conducting wander guard system checks three times weekly, testing doors by placing spare monitoring devices near exits. Inspection logs showed audits completed on December 18, 22, 23, 24, 29, and 30, each reviewed with the licensed nursing home administrator.
During the December 30 inspection, investigators observed the maintenance director completing a wander guard audit between 1 PM and 3 PM. Exit door alarms functioned properly and produced loud sounds when monitoring devices came within proximity. All doors remained locked.
The facility held an emergency quality assurance meeting on December 15 to review the incident, attended by the medical director, administrators, nursing supervisors, and department heads.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Magnolia Manor - Greenwood from 2025-12-30 including all violations, facility responses, and corrective action plans.