Woodruff Manor: Wrong Medication Given to Allergic Resident - SC
The nurse, identified in inspection records only as LPN1, described what happened in an interview with inspectors on September 2. She had pulled medications for two residents, intending to give one patient her medications first. She changed her routine. "I usually give the other resident her medications first, but I didn't," she told inspectors. "I ended up giving R2's medication to R1."
She caught the error only after returning to the electronic medical records system. By then, the wrong medications had already been swallowed.
The resident had a documented allergy to statins. The specific reaction on record: muscle cramps. LPN1 said she and her supervisor immediately reviewed the allergy, called the nurse practitioner, and were told what to watch for. "I monitored her all night," LPN1 said. "It was a big mix-up."
The Director of Nursing confirmed she was notified the same night. "They had already called the provider and the pharmacist and were instructed on what to do and the signs and symptoms to look for," she said. She conducted one-on-one retraining with the nurse afterward. The administrator said staff also reviewed what she called "the six rights of education," and the night supervisor began directly observing LPN1 pulling medications.
The facility's pharmacy director said he learned about the incident only when inspectors arrived. "No one mentioned this incident to me as the pharmacist director until today," he said during his interview. He noted that the pharmacists on duty during the shift when the error occurred no longer work there.
The inspection was conducted as a complaint investigation. CMS rated the harm level as minimal, with few residents affected. Whether the resident experienced muscle cramps that night, the records reviewed by inspectors do not say.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Woodruff Manor in Woodruff, SC was cited for violations during a health inspection on September 2, 2025.
The nurse, identified in inspection records only as LPN1, described what happened in an interview with inspectors on September 2.
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.