Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Magnolia Manor - Spartanburg during CMS and state inspections, most recent first.
A facility failed to notify the provider of a dehisced wound for two days, leading to a resident's hospital return. The resident, with a history of an above-knee amputation and diabetes, had an open, draining incision that was not promptly reported to the NP or MD. Despite staff observations of the worsening condition, the weekend staff did not contact the on-call provider. The NP later assessed the wound as infected, necessitating hospital evaluation.
A resident with a history of falls and cognitive intactness did not have ordered fall prevention devices in place, including an anti-roll back device on the wheelchair and non-skid strips by the bedside. The resident fell while attempting to turn on the lights, resulting in hip pain and a trip to the emergency department. Staff interviews revealed a lack of awareness and implementation of the necessary safety measures.
A resident with moderate cognitive impairment reported alleged physical abuse by a CNA over the weekend, but the incident was not reported to the administration until days later. The delay was due to an LPN's failure to follow the facility's policy requiring immediate reporting of abuse allegations.
A resident was discharged from a facility without a physician's order and proper arrangements, leading to him being left without shelter. Despite having multiple health issues and lacking decisional capacity, the resident was transported to a housing authority that could not accommodate him due to financial issues. The facility staff failed to communicate effectively and ensure a safe discharge process.
A nurse failed to follow physician orders and manufacturer's guidelines when administering Trelegy Ellipta to a resident with multiple health conditions. The nurse did not instruct the resident to exhale before inhaling the medication and failed to ensure the resident rinsed and spit after use, as required. The nurse admitted to not seeing the instructions on the medication label and electronic record.
A resident with acute respiratory failure and chronic heart failure was observed receiving oxygen at 1L/min instead of the ordered 2L/min. This discrepancy was confirmed by an LPN and adjusted accordingly. The DON stated that nurses are expected to ensure accuracy of oxygen flow rates, but this was not adhered to, indicating a deficiency in following prescribed respiratory care protocols.
A resident requiring dialysis services experienced poor communication between the LTC facility and the dialysis center. The facility failed to provide necessary communication forms, including vital signs and medication lists, as outlined in their Dialysis Contract. Interviews with staff and the DON revealed inconsistencies in preparing residents for dialysis, and the Facility Administrator acknowledged the issue, unable to explain the staff's failure to maintain proper documentation.
A facility failed to provide necessary competency training for CNAs and LPNs in colostomy care, leading to CNAs performing tasks beyond their scope of practice. A resident with a colostomy and cognitive impairment was affected, as CNAs were observed changing colostomy wafers and bags, a task meant for licensed nursing staff. The DON was unaware of this practice, indicating a lack of oversight and adherence to scope of practice policies.
A facility failed to ensure proper PPE use during colostomy care for a resident with MRSA. A CNA entered the resident's room without sanitizing hands or donning required PPE, despite signage indicating Enhanced Barrier Precautions. The CNA acknowledged the oversight, and the DON and Administrator confirmed the expectation for staff to use proper PPE and hand hygiene.
A resident with a history of diabetes and other conditions had a critical blood sugar level over 500, but the facility failed to notify the on-call provider in a timely manner. Despite staff claims of monitoring and reporting, there was no documentation to support these actions, leading to inadequate care and the resident's eventual passing.
Failure to Notify Provider of Dehisced Wound
Penalty
Summary
The facility failed to notify the provider of a dehisced wound for two days, resulting in a resident's return to the hospital. The resident, who had a history of an above-knee amputation, peripheral vascular angioplasty, and Type 2 diabetes mellitus, was admitted to the facility with a surgical incision that required monitoring. Despite the facility's policy requiring clinicians to follow specific physician orders for wound treatment, the resident's dehisced wound was not promptly reported to the provider. On December 28th, a progress note indicated that the resident's incision was open and draining blood, causing pain. The Director of Nursing (DON) was informed, and a temporary dressing was applied, but the Nurse Practitioner (NP) or Medical Doctor (MD) was not notified. Over the weekend, multiple staff members, including CNAs and LPNs, observed the wound's condition worsening, with reports of bleeding and drainage. However, there was a lack of communication and action to address the issue, as the weekend staff did not contact the on-call provider. By December 30th, the NP assessed the wound, which appeared infected and required hospital evaluation. The resident was sent to the emergency room, where the wound dehiscence and infection were confirmed. Interviews with staff revealed a breakdown in communication and adherence to protocol, as the wound was not monitored according to the facility's policy, and there were no specific orders for the surgical site upon the resident's return from the hospital.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to ensure that ordered fall prevention devices were in place for a resident identified as being at risk for falls. The resident, who was cognitively intact, had a history of a displaced intertrochanteric fracture of the right femur and hemiplegia following a cerebral infarction. Despite having physician orders for an anti-roll back device on the wheelchair and non-skid strips by the bedside, these safety measures were not implemented. The resident reported falling when attempting to turn the lights back on, which resulted in pain in the right hip, and was subsequently sent to the emergency department for evaluation. Observations and interviews revealed that the resident's wheelchair did not have the required anti-roll back device, and non-skid strips were absent at the bedside. A CNA was unaware of the resident's fall risk and the necessary safety measures, while an LPN acknowledged the absence of the anti-roll back device and suggested a mix-up with the roommate's wheelchair. The DON confirmed that all ordered safety measures should have been in place for the resident.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident within the required timeframe. The resident, who had moderate impaired cognition, reported to a social worker that a certified nursing assistant (CNA) had physically abused him over the weekend. The resident was unable to recall the exact day of the incident but identified the staff member involved. Despite the facility's policy requiring immediate reporting of such allegations, the incident was not reported to the administration until several days later. Interviews revealed that the resident had informed a Licensed Practical Nurse (LPN) over the weekend about the alleged abuse, but the LPN did not report it to the Director of Nursing (DON) or the Administrator immediately. The DON and Administrator only became aware of the incident on a subsequent weekday, prompting an investigation. The delay in reporting was attributed to the LPN's failure to follow the facility's policy, which mandates immediate notification to the administration of any suspected or reported abuse.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident, identified as R60, who was transported and discharged to a housing authority 62 miles away without proper arrangements. The housing authority was unable to receive the resident due to financial issues, and the facility did not obtain a physician's order for the discharge. This oversight led to the resident being left without a place to stay, resulting in him spending the night in a motel and seeking shelter the following day. R60 was admitted to the facility with multiple diagnoses, including schizophrenia, chronic obstructive pulmonary disease, and congestive heart failure. Despite having a Brief Interview for Mental Status (BIMS) score indicating cognitive intactness, a Decisional Capacity Form revealed that R60 did not meet the criteria for making healthcare decisions independently. The discharge summary inaccurately stated that R60 was set to go home with family care, and the resident signed his own discharge without a physician's order. Interviews with facility staff and the housing authority representative revealed a lack of communication and coordination regarding the discharge. The social services staff was unaware of R60's lack of decisional capacity and relied on the BIMS score. The transport driver was not provided with a specific address and left the resident at a location he identified, without ensuring he had access to the building. The facility's administrator and director of nursing were not aware of the decisional capacity form and confirmed the absence of a discharge order.
Removal Plan
- Residents who have been discharged in the past 30 days have been reviewed to validate safe, orderly discharge including living arrangements by the Director of Social Services or designee.
- The Administrator, Director of Nursing, and Interdisciplinary Team including the Social Worker will be reeducated by the Clinical Consultant on discharge planning including: Obtaining an order for discharge from the resident's physician, Validating community resources that are identified by the interdisciplinary team, resident, and/or family have been arranged, Providing written discharge instructions for care, Notifying the resident's legal representative, if any, or an interested family member regarding the upcoming discharge.
- Licensed Nurses will be reeducated by the Director of Nursing/Designee on the discharge process which includes: Obtaining an order for discharge from the resident's physician, Providing written discharge instructions for care, Notifying the resident's legal representative, if any or an interested family member regarding the discharge.
- Licensed Nurses not receiving this reeducation will receive prior to their next scheduled shift.
- Anticipated discharges will be reviewed in the Clinical Morning Meeting by the Interdisciplinary Team to validate preparation for a safe discharge is in place including living arrangements, family and/or responsible party notification, and physician order for discharge.
Improper Administration of Inhaled Corticosteroid
Penalty
Summary
The facility failed to ensure that a nurse followed physician orders and manufacturer's guidelines for administering an inhaled corticosteroid, Trelegy Ellipta, to a resident. The facility's policy requires that medications be administered according to accepted standards of practice and in compliance with regulatory requirements. However, during an observation, a registered nurse administered the inhaler without instructing the resident to exhale prior to inhaling the medication. Additionally, the resident did not rinse and spit after using the inhaler as per the physician's order and manufacturer's guidelines. The resident involved was admitted with multiple diagnoses, including multiple sclerosis, insomnia, hypertension, chronic respiratory failure with hypoxia, anemia, dependence on supplemental oxygen, and chronic kidney disease. The resident had a Brief Interview for Mental Status score indicating no cognitive impairment. Despite the clear instructions on the prescription order and the electronic medication administration record, the nurse admitted to not seeing the instructions, leading to the improper administration of the medication.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to follow physician orders for oxygen administration for a resident, identified as R41, who was reviewed for respiratory care. R41 was admitted with multiple diagnoses, including acute respiratory failure with hypoxia and chronic systolic heart failure. The resident's care plan included maintaining oxygen saturation at or above 95% and applying oxygen as ordered. However, during observations, it was noted that R41 was receiving oxygen at 1 liter per minute via nasal cannula, contrary to the physician's order of 2 liters per minute. This discrepancy was confirmed during interviews with the resident and a Licensed Practical Nurse (LPN), who acknowledged the incorrect flow rate and adjusted it to match the order. The Director of Nursing (DON) stated that nursing staff are expected to ensure the accuracy of oxygen flow rates at the bedside by reviewing and visualizing the orders during each shift. Despite these expectations, the oxygen flow rate for R41 was not maintained as per the physician's order, indicating a lapse in following the facility's respiratory care procedures. The failure to administer the correct oxygen flow rate as ordered by the physician was observed and verified by the surveyor, highlighting a deficiency in the facility's adherence to prescribed respiratory care protocols.
Failure in Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure proper communication with the dialysis center for a resident requiring dialysis services. The facility's Dialysis Contract outlined specific obligations, including providing the dialysis center with necessary medical and administrative information about the resident. However, the facility did not consistently fulfill these obligations, as evidenced by the lack of communication forms in the resident's dialysis communication book. The resident, who was cognitively intact and dependent on hemodialysis, reported poor communication between the facility and the dialysis center, including missing communication forms and inadequate documentation of vital signs. Interviews with facility staff, including agency nurses and the Director of Nursing (DON), revealed inconsistencies in the process of preparing residents for dialysis. The staff were expected to ensure that residents had a communication form with vital signs and medication lists before leaving for dialysis. Upon return, another set of vitals was to be documented. However, the resident often went to dialysis without the necessary communication forms, and the staff did not consistently document the required information. The DON confirmed that the staff did not meet the expectations for maintaining communication forms in the resident's book. The Facility Administrator (FA) acknowledged the issue, noting that the resident's dialysis communication book was not readily available and that the staff failed to adhere to the expected procedures. Despite efforts to locate the missing communication forms, the FA could not provide an explanation for the staff's failure to maintain proper documentation. This deficiency in communication and documentation was identified through observations, interviews, and record reviews, highlighting a lapse in the facility's adherence to its Dialysis Contract obligations.
Inadequate Training and Oversight in Colostomy Care
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) were provided with the necessary competency training for colostomy care and maintenance. Specifically, a CNA was observed providing skilled nursing care to a resident's colostomy wafer, which was beyond their scope of practice. This incident involved a resident with a colostomy who required partial to extensive assistance with activities of daily living due to moderate cognitive impairment. The resident's care plan indicated the need for proper colostomy care to prevent skin breakdown and ensure the ostomy remained functional. Observations and interviews revealed that CNAs were regularly tasked with changing colostomy wafers and bags, a responsibility that should have been performed by licensed nursing staff. An LPN admitted to directing CNAs to perform these tasks and did not sign off on treatment administration records when CNAs completed the treatments. The Director of Nursing was unaware of this practice and stated that there was a policy in place to ensure staff worked within their scope of practice. The report highlights a lack of appropriate training and oversight, leading to CNAs performing tasks beyond their qualifications, potentially causing harm to the resident's stoma.
Improper PPE Use During Colostomy Care
Penalty
Summary
The facility failed to ensure that staff used proper Personal Protective Equipment (PPE) while providing colostomy care to a resident, identified as R17. The facility's policy on Transmission Based/Standard Precautions and Enhanced Barrier Precautions, revised on May 15, 2023, requires healthcare workers to implement Universal/Standard Precautions whenever there is occupational exposure to blood and body fluids. Enhanced Barrier Precautions (EBP) require the use of PPE, including gowns and gloves, during high-contact resident care activities. R17, who was admitted with multiple diagnoses including Methicillin-resistant Staphylococcus aureus (MRSA) and a pressure ulcer, had an order for Enhanced Barrier Precautions related to MRSA for colostomy care. During an observation, a Certified Nursing Assistant (CNA) was seen entering R17's room, which had signage indicating Enhanced Barrier Precautions, without sanitizing their hands or donning the required PPE. The CNA proceeded to check R17's colostomy bag without wearing a gown, gloves, or mask, as required by the facility's policy. In an interview, the CNA acknowledged the failure to follow proper procedures, stating they should have worn the appropriate PPE. The Director of Nursing and the Administrator confirmed that staff are expected to use proper PPE and perform hand hygiene when providing direct care to residents on Enhanced Barrier Precautions.
Failure to Notify Provider of Critical Blood Sugar Levels
Penalty
Summary
The facility failed to notify the on-call provider regarding a significant change in a resident's condition, specifically failing to communicate critical lab blood sugar readings in a timely manner. The resident, who had a history of diffuse traumatic brain injury, type 2 diabetes mellitus, seizures, and muscle weakness, was found to have a critical blood sugar level over 500. Despite this, there was no documentation that the provider was notified of this critical value, and the resident's blood sugar levels were not properly recorded in the medical record. Interviews with staff revealed inconsistencies in the handling of the resident's condition. One LPN stated that she would typically re-draw the blood sugar and report it to the provider if it was outside normal limits, but did not consider a reading of 200 to warrant immediate reporting. Another LPN claimed to have reported the critical blood sugar value to the on-call provider and received instructions to monitor the resident closely, but could not provide documentation to support this. The Family Nurse Practitioner (FNP) and Director of Nursing (DON) both emphasized the expectation that staff should report abnormal findings immediately, especially if the resident is experiencing significant changes in condition. The lack of proper documentation and timely communication with the provider ultimately led to the resident's condition not being adequately addressed. The resident passed away at the hospital, and the facility's failure to follow its own policy on notifying providers of significant changes in condition was evident. Interviews with the facility administrator and other staff members confirmed that the expected protocols were not followed, contributing to the deficiency in care provided to the resident.
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Illustrative
What surveyors actually found near you
We read the 72 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Spartanburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spartanburg Hospital For Restorative Care Snf | 0 mi | ★★★★★ | 1 | 0 |
| White Oak Manor - Spartanburg | 0.3 mi | ★★★★★ | 4 | 0 |
| White Oak At North Grove Inc | 1.4 mi | ★★★★★ | 1 | 0 |
| Physical Rehabilitation And Wellness Center Of Spa | 1.9 mi | ★★★★★ | 7 | 2 |
| Summit Hills Skilled Nursing Facility | 2.7 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.