Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Woodruff Manor during CMS and state inspections, most recent first.
Failure to assess and care plan for self-management of supplemental oxygen. A resident with COPD, respiratory failure, and moderate cognitive impairment was ordered oxygen at 2 L via NC every shift, but was observed off oxygen and stated they decided when to use it, removed and reapplied the cannula themselves, and turned the machine on and off. The care plan addressed oxygen use by staff but did not address independent oxygen management, and staff confirmed no formal assessment or care plan had been completed for self-management.
The facility failed to keep complete and accurate wound documentation for two residents with pressure injuries. One resident with severe cognitive impairment had a coccyx pressure injury, but the EMR lacked weekly wound measurements and descriptions, and some skin checks incorrectly stated the skin was intact or there were no skin issues. Another resident with dementia and mobility impairment had heel breakdown and a left heel DTI, but wound assessments and measurements were sent by e-mail to management instead of being documented in the EMR, and some notes did not include assessment details while treatment continued.
A resident with a statin allergy was mistakenly given another resident's medications, including a statin, by an LPN who misidentified the patient during medication administration. The error was discovered after the medications were given, and the resident was subsequently monitored for adverse effects, with no immediate harm reported.
The facility failed to properly store and label food items, with expired and unlabeled products found in storage areas. Despite a policy for regular checks, the Dietary Manager admitted that staff inspections were not effectively implemented, leading to this deficiency.
The facility failed to maintain sterile and non-expired medications and biologicals, as expired items were found in treatment carts and storage rooms. Staff interviews revealed inconsistent practices in checking for expired items, with no set schedule, leading to expired items remaining in use. The facility's policy on immediate removal and disposal of outdated medications was not consistently followed.
A facility failed to follow hand hygiene protocols during a wound care procedure for a resident with a pressure ulcer. The RN did not change gloves after removing a soiled dressing, contrary to the facility's policy. The RN admitted the error, and interviews with the DON and Infection Prevention Nurse confirmed the correct procedure.
A facility failed to maintain a medication error rate below 5%, with an observed rate of 28%. An LPN administered several medications to a resident at a time that did not align with the prescribed schedule, without obtaining a physician's order. Interviews revealed a lack of communication and adherence to protocol, contributing to the high error rate.
The facility failed to follow infection control practices during medication administration. A nurse used a pulse oximeter on a resident and returned it to the cart without cleaning it. Another nurse did not perform hand hygiene after removing gloves before administering medication. The DON confirmed that hand hygiene is required between residents and after glove removal.
A resident successfully eloped from the facility by crawling through a window, resulting in a skin tear and being found on a highway by local law enforcement. The resident had expressed a desire to leave but was not taken seriously by staff. The care plan did not include measures for wandering or elopement, and the facility's policy on resident checks and elopement was not effectively implemented.
Failure to Assess and Care Plan for Self-Management of Supplemental Oxygen
Penalty
Summary
The facility failed to ensure that one resident receiving supplemental oxygen was assessed and had a care plan developed for self-management of oxygen therapy. The resident was admitted with diagnoses including respiratory failure with hypoxia, pneumonia, COPD, chronic combined systolic and diastolic heart failure, end-stage renal disease, atrial fibrillation, cognitive communication deficit, and diabetes mellitus. A quarterly MDS showed a BIMS score of 12, indicating moderate cognitive impairment, and also indicated the resident received oxygen therapy while in the facility. The physician order required oxygen at 2 liters via nasal cannula every shift related to COPD. An observation showed the resident was not in the room and the nasal cannula tubing was hanging from the side of the bed. During interview, the resident stated they decided when to use supplemental oxygen, removed the nasal cannula in the morning, reapplied it around 8:00 PM, and turned the oxygen machine off and on themselves. The care plan identified the resident as at risk for altered respiratory status and directed staff to apply oxygen as ordered, but it did not address the resident self-managing oxygen therapy. Staff interviews confirmed the resident had not been assessed for independent oxygen management and no care plan had been developed for that purpose, while staff gave differing accounts of whether the resident or staff were responsible for managing the oxygen.
Incomplete and inaccurate wound documentation in resident medical records
Penalty
Summary
The facility failed to ensure medical records were complete and accurate for 2 residents reviewed for pressure ulcers/injuries. Facility policy required documentation of wound site condition, care, observations, clinical assessment, and skin inspection, and the pressure ulcer policy required weekly whole-body audits and wound documentation that included wound measurements, description, treatment, and related notifications. Surveyors found that the required wound information was not consistently present in the residents’ electronic medical records (EMRs). One resident was admitted with diagnoses including anorexia, protein-calorie malnutrition, muscle weakness, and vitamin D deficiency, and had severe cognitive impairment with a BIMS score of 5. The resident’s care plan identified impaired skin integrity and a Stage 2 pressure injury to the coccyx, and treatment orders were in place for wound cleansing, dressings, and ongoing wound care. Although treatment administration records showed wound care was provided, the EMR did not contain weekly measurements or weekly descriptions of the wound. Skin Only Evaluations also conflicted with the presence of the wound, with some entries stating the resident’s skin was intact or that there were no skin issues. During interview, an LPN stated the wound care nurse assessed and documented the wound, but those notes were not in the resident’s medical record. The DON and Administrator stated they expected wound care notes to be in the EMR and acknowledged the documentation problem. The second resident had diagnoses including cerebral aneurysm, dementia with behavioral disturbance, anxiety, muscle weakness, difficulty walking, coordination problems, and psychosis, and had severe cognitive impairment and mobility impairment. Staff notes documented heel breakdown and a pink area to the buttocks, but there was no documented assessment of those areas at that time. Subsequent skin notes stated there were no current skin issues while treatment continued, but did not include measurements or assessment details. Weekly wound information was instead sent by RN1 through e-mail to management staff, showing a left heel DTI that changed in size and color over time, yet the wound assessments and measurements were not documented in the resident’s EMR. The DON and ADON stated they received and reviewed the weekly wound reports, but did not verify that the assessments were entered into the medical record, and the DON stated she became aware during the survey that the wound assessments were not documented in residents’ EMRs.
Medication Administration Error: Resident Given Another Resident's Medications
Penalty
Summary
A resident with a history of joint replacement, cerebral infarction, pulmonary hypertension, and a documented allergy to statins was administered another resident's medications, including donepezil, buspirone, namenda, and lipitor. The error occurred when an LPN, after reviewing the electronic medical record, mistakenly pulled and administered the wrong medications during the evening medication pass. The resident's care plan indicated a risk for adverse effects from antianxiety medications, and the MAR clearly listed the statin allergy. The LPN realized the mistake after returning to the electronic record and immediately reported the incident to supervisory staff. Interviews confirmed that the resident received medications not prescribed to them, including a statin to which they were allergic. The error was discovered promptly, and the resident was assessed and monitored for adverse reactions. The incident was communicated to the resident's representative, the on-call physician, and the pharmacy. The pharmacist director was not informed until later. The resident did not report any immediate adverse effects from the medications administered in error.
Deficient Food Storage Practices
Penalty
Summary
The facility failed to adhere to its own policy regarding the storage and labeling of food items, which could potentially affect all residents receiving food from the kitchen. During an inspection, it was observed that dry food storage contained 18 boxes of Barnum's Animal Crackers that were past the manufacturer's use-by date. Additionally, in the walk-in freezer, there were two containers of blueberries that were open, not sealed, and lacked both an open date and an expiration date. Similarly, in the walk-in cooler, a bag of parmesan cheese and a carton of Thick & Easy were found open without any labeling of open or expiration dates. The Dietary Manager disclosed that staff are responsible for conducting thorough checks of food items on Mondays and Thursdays, coinciding with the arrival of new orders, to ensure expired items are removed. However, the observations made during the inspection indicate that these checks were not effectively implemented, leading to the presence of expired and improperly labeled food items in storage. This oversight in following the facility's food safety and sanitation guidelines represents a deficiency in maintaining proper food storage practices.
Expired and Improperly Stored Medications and Biologicals
Penalty
Summary
The facility failed to ensure that medications and biologicals were kept sterile and not expired, as observed in two medication and treatment carts. During an inspection, several expired items were found, including Hydrofera Blue Ready-Transfer Antibacterial Foam Dressings, Xeroform Occlusive Gauze Patches, Kerlix Bandage Rolls, and Sage M-Care Meatal Cleansing cloths. Additionally, opened and partially used items were noted, which compromised their sterility. Interviews with the Director of Nursing (DON) and nursing staff revealed inconsistencies in the process of checking for expired items, with no set schedule for these checks, leading to expired items remaining in the carts. Further observations in the medication storage rooms revealed expired Airborne chewable tablets. Interviews with nursing staff indicated that there was no specific day assigned for checking expiration dates, and expired medications were not consistently removed. The DON mentioned that expired creams were kept in the medication storage room until the pharmacy picked them up, and there was a lack of clarity on the process for handling expired narcotics. The facility's policy required that outdated or deteriorated medications be immediately removed and disposed of, but this was not consistently followed, contributing to the deficiency.
Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during a wound care procedure for a resident with a pressure ulcer. The resident, who was admitted with multiple diagnoses including stenosis of the carotid artery, diabetes mellitus with neuropathy, hypothyroidism, hypertension, and a pressure ulcer on the right heel, was observed during a dressing change. The Registered Nurse (RN) involved in the procedure did not change gloves after removing the soiled dressing from the resident's left foot, which is a breach of the facility's hand hygiene policy. The policy, aligned with the World Health Organization's guidelines, mandates hand hygiene before a clean procedure, after exposure to body fluids, and after touching the resident's surroundings. During the dressing change, the RN initially donned gloves after washing her hands but failed to remove them after handling the soiled dressing, proceeding to clean the wound with the same gloves. This action was contrary to the facility's protocol, which requires glove removal and hand sanitization after removing a soiled dressing. The RN acknowledged the mistake during an interview, attributing it to nervousness. Interviews with the Director of Nurses and the Infection Prevention Nurse confirmed the correct procedure, emphasizing the importance of glove removal and hand hygiene after handling soiled materials.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 28%. This deficiency was identified through a review of the facility's policy, observations, record reviews, and interviews. The facility's policy on medication administration emphasizes the importance of adhering to the 'Ten Rights of Medication Administration Practice,' including administering medications at the right time. However, during an observation, an LPN administered several medications to a resident at a time that did not align with the prescribed schedule. The medications, including Vitamin B12, Levofloxin, Gabapentin, Azithromycin, Sertraline, Ethambutol, and Biktarvy, were all ordered for administration at 0800, but were given later without a physician's order to do so. Interviews with the LPN, RN, and DON revealed a lack of communication and adherence to protocol. The LPN did not obtain an order from a physician to administer the medications at a later time, despite the resident's request to delay due to feeling unwell. The RN was unaware of the situation and did not contact the Nurse Practitioner. The DON confirmed that the medications were administered late and without proper authorization, noting that the Gabapentin was also given at an inappropriate time. The facility's failure to follow proper procedures and obtain necessary orders contributed to the high medication error rate.
Infection Control Deficiencies in Medication Administration
Penalty
Summary
The facility failed to adhere to infection control practices during medication administration and the handling of multi-use medical equipment. During a medication observation, a registered nurse retrieved a pulse oximeter from the medication cart, used it on a resident, and returned it to the cart without cleaning it. The nurse acknowledged the oversight, stating that medical equipment should be cleaned after each use. Additionally, a licensed practical nurse was observed wearing gloves while retrieving medications but did not perform hand hygiene after removing the gloves before administering the medication to a resident. The nurse confirmed that hand hygiene should have been performed after glove removal. The Director of Nurses stated that hand hygiene is required between each resident and after glove removal during medication passes.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to properly supervise a resident, resulting in the resident's successful elopement from the facility. On the evening of 05/24/24, the resident crawled through the window in his room and was later found by local law enforcement on a highway. The resident was taken to a local hospital and suffered a skin tear to the right forearm while crawling out of the window. The resident's care plan did not include any measures related to wandering or elopement prior to the incident, despite the resident being identified as at risk for elopement due to diagnoses such as depression, bipolar disorder, and dementia. The resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating cognitive intactness, and had not exhibited wandering behaviors according to the Annual Minimum Data Set (MDS). However, the resident had expressed a desire to go home and had made comments about wanting to leave the facility, which were not taken seriously by the staff. On the night of the elopement, the resident was last seen going to his room around 9:30 PM, and the facility was notified by the police at approximately 12:30 AM that the resident had been found on Highway 101. Interviews with staff revealed that the resident did not appear to be nervous, exit-seeking, or upset prior to the elopement. The staff were engaged in their usual duties, such as charting, putting residents to bed, and passing medications. The facility's policy on resident checks and elopement was not effectively implemented, as evidenced by the resident's ability to open the window and exit the facility undetected. The facility's failure to properly supervise the resident and secure the environment led to the resident's elopement and subsequent injury.
Removal Plan
- Resident sent to ER for evaluation when located.
- Resident assessed with no major injury.
- Resident returned safely to facility.
- Post-elopement procedures initiated and family at bedside.
- Resident window secured to prevent exit.
- Resident relocated to interior, courtyard-view room for safety.
- Resident care plan has been reviewed and revised as needed.
- Resident evaluated by in-house provider and Lifesource Psychiatry for follow up.
- All residents are at risk. Resident check completed for all residents.
- All resident windows were assessed and secured to prevent exit. This includes all resident room windows and common area windows.
- All resident and common area windows were assessed and secured to prevent resident exit.
- Added a motion detector alarm to the exterior gate.
- Staff educated on motion detector alarm initiated by Administrator, DON, or designee.
- Staff education on Wander/Elopement risk; Precautions and missing resident powerpoint and Resident check/Elopement policy 100.149 initiated by SNF Educator or designee.
- Audits for window security were initiated and will continue daily for 4 weeks, then weekly for 4 weeks, then 3 times per week for 4 weeks.
- Continue elopement drills daily for 4 weeks, then weekly for 4 weeks, then 3 times per week for 4 weeks.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 58 citations issued within 25 miles in the last 12 months — including the 6 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Woodruff
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fountain Inn Post Acute | 10.5 mi | ★★★★★ | 4 | 0 |
| Mountainview Nursing Home | 13.4 mi | ★★★★★ | 1 | 1 |
| Simpsonville Post Acute | 13.7 mi | ★★★★★ | 0 | 0 |
| White Oak At North Grove Inc | 14.4 mi | ★★★★★ | 1 | 0 |
| Southpointe Healthcare And Rehabilitation | 14.8 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Woodruff Manor.
100% money-back within 48 hours.
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.