Magnolia Manor - Greenwood

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings include:Review of the facility's policy titled, Care Plan Process, Person Centered Care with a revision date of 05/05/23 revealed, Policy: The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards and quality care. The facility will coordinate the development of the person-centered care plan within the required timeframes. Procedures:

1. 9. Thru ongoing assessment, the facility will initiate person-centered care plans when the resident's clinical

status or change of condition dictates the need such as but not limited to falls and pressure ulcer development.Review of Resident R2's Electronic Medical Record (EMR) Face sheet revealed Resident R2 was admitted to the facility on [DATE REDACTED] with diagnoses including, but not limited to, fracture of the neck of the right femur, encephalopathy, other disorders of bone density and structure, rhabdomyolysis, dysphagia and cognitive communication deficit. Review of Resident R2's significant change Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident R2 has severe cognitive impairment and scored a 06 on the Brief Interview for Mental Status (BIMS) assessment, indicating Resident R2 was not cognitively intact.Review of the facility's incident documentation indicated that Resident R2 experienced a fall on 08/27/25 at approximately 06:00 PM in his room. Post-fall documentation indicated that the resident was assessed, and no serious injury was identified.Review of Resident R2's EMR comprehensive Care Plan revealed the care plan was not updated to include new or revised interventions related to the fall, identification of causative or contributing factors, enhanced supervision or environmental modifications, or any evidence of individualized fall-prevention strategies implemented following the resident's fall with fracture on 08/27/25. During an interview on 12/30/25 at 11:26 AM with the Registered Nurse (RN)/MDS Coordinator, revealed, The resident has had two fractures. We may have resolved the one for August. Let me look. The MDS Coordinator revealed,I ran the history from 09/01/25 until today,12/30/25, but I don't see the care plan for the fracture in August 2025. There is nothing in August because he went out to the hospital on [DATE REDACTED] and returned on 09/02/25. We did a significant change on 09/07/25. That should have alerted us to update the care plan, but I do not see any care plan updates for August or September 2025.During an interview on 12/30/25 at 12:20 PM with the Director of Nursing revealed, My expectation is that the care plans are updated with a significant change in a resident. Upon readmission to the facility from the hospital, the care plan should be updated.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Manor - Greenwood

1415 Parkway Drive Greenwood, SC 29646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

by nursing managers for accuracy. Residents identified at risk will be reviewed for appropriate interventions.

Educate facility staff regarding Wander guard System with emphasis on determining cause of alarm if sounding. Any member of target audience not receiving this by this date will receive prior to next scheduled New admissions will be reviewed in morning meeting daily Monday thru Friday as part of the clinical morning meeting process. Elopement Risk Observations will be reviewed for accuracy and interventions validated if indicated. Quarterly assessments will be reviewed as part of the MDS/Care planning process.

New admission documentation reviewed from 12/23/25 to 12/30/2025 reveals facility had 2 new admissions, assessment reveals both residents did not exhibit any exit behaviors, no further interventions required as no risk noted. The Director of Nursing will randomly audit a minimum of 5 Elopement Risk

Observations weekly for 4 weeks then monthly for 2 additional months to validate accuracy. Review of facility document titled, Wander Guard Monitoring, on 12/13/2025, 12/17/25 and 12/24/25 by DON reviewed. 9 Residents identified with wander guard, no concerns noted. The Maintenance Director/designee will inspect facility doors with wander guard system 3 times weekly for 4 weeks then weekly for 2 additional months. Review of maintenance director calendar log reveals wander guard audits were completed on 12/18/25, 12/22/25, 12/23/25, 12/24/25, 12/29/25 and 12/30/25. Audit completed with LNHA for each date. Observation of maintenance director on 12/30/2025 between 1-3 PM reveals maintenance director completing wander guard audit by placing spare wander guard within proximity of exit doors. No concerns noted. The Facility Administrator will make rounds weekly for 4 weeks then monthly for 2 additional months with maintenance director to validate that doors are functioning properly. Review of maintenance director calendar log reveals wander guard audits were completed on 12/18/25, 12/22/25, 12/23/25, 12/24/25, 12/29/25 and 12/30/25. Audit completed with LNHA for each date. Ad hoc QAPI held on 12-15-25. Review of ADHOC QAPI on 12/15/25 reveals meeting was attended by Medical director, LNHA, DON, ADON, SDC, IP, Housekeeping supervisor, Activities Director, Maintenance supervisor, Social services, Nurse assessments coordinator, Dietary Manager, Medical Records, and other staff members.

Subject discussed involved the resident elopement. Medical Director was notified of the incident and plan for improvement on 12-13-25 ( MD1) and 12-18-25(MD2). 12/13/2025 06:45 PM [Recorded as Late Entry

on 12/14/2025 04:20 PM] 12/13/2025 at 621pm-Received pc from Administrator that resident had left the facility without staff supervision. During transit to facility, received call from Administrator, at 627pm that resident had been located and was safe. Upon arrival at facility, at 645pm, ADM present and report received from staff that the CODE WHITE process had been initiated. Resident had been transported by EMS to SRHC ER for eval and treatment. Attempted to notify RP with no answer and could not leave VM r/t had not been set up per automated response. MD1 notified of events. This process will be reviewed in QAPI for a minimum of 3 months. Only been 2 weeks since last QAPI meeting, interventions will be discussed on

the next QAPI meeting in January. Observation of exit doors completed with DON on 12/30/25 at 5:30PM.

Alarms are functioning and send off loud alarms when in proximity of a wander guard. Doors are locked.

Event ID:

Facility ID:

If continuation sheet