Magnolia Manor - Rock Hill

Inspectors wroteBased on review of facility policy, observations and interviews, the facility failed to ensure that staff wore proper Personal Protective Equipment (PPE) when handling soiled linen/clothing. Specifically, a Laundry Aid was observed not wearing gloves, while handling soiled linen/clothing. Findings Include:Review of facility policy titled Maintenance/Housekeeping Policies and Procedures, original date 3/2006 revealed:Procedures: Personnel: 5. Personnel in the laundry services are properly garbed at all times. When handling soiled linens, gowns, and gloves, at a minimum will be donned. During an observation on 12/11/2025 at 9:37 AM, Laundry Aide (LA) was observed pushing a blue laundry bin from the laundry room to multiple units collecting bags with soiled linen/clothing. [...]

Inspectors wroteBased on review of facility policy, record review and interviews, the facility failed to protect Resident (R)1 from physical, verbal, and mental abuse by Licensed Practical Nurse (LPN)1. Specifically, LPN1 used inappropriate language to address R1. Furthermore, witnesses observed LPN1 physically hit R1, as a reaction to R1 hitting LPN1. The State Agency (SA) utilizing the Reasonable Person Approach, has determined that any reasonable person in the same situation would experience adverse psychosocial harm. On 01/13/25 at 3:18 PM, the Director of Nursing was notified that the failure to protect a resident from physical and verbal abuse constituted Immediate Jeopardy (IJ) at F600. On 01/13/25 at 3:18 PM, the survey team provided the Director of Nursing with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 11/22/24. The IJ was related to 42 CFR 483. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the meals served were palatable and prepared according to menu specifications. Taste tests of the foods prepared for the puree, mechanical and regular diets revealed the foods tasted freezer burnt, bland and was grossly under seasoned. Residents interviewed during the residential council meeting verbally expressed dissatisfaction with the meals.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure foods were stored properly and failed to ensure that kitchen staff wore hair/beard restraints during meal preparation. Additionally, the facility failed to ensure the ice machine was properly cleaned and sanitized, for 1 of 1 main kitchen.

Inspectors wroteBased on observations, interviews, record review and review of the facility policy, the facility failed to maintain an effective pest control program. Findings Include: Review of the undated facility policy titled, Pest Control revealed, Facility will maintain an effective pest control program to prevent or eliminate infestation of pests and rodents. During an observation on 07/31/24 at 10:45 AM, in the kitchen, revealed multiple cockroaches crawling on the floor near the stove. During an observation on 08/01/24 at 10:57 AM, in the kitchen, revealed a cockroach crawling on a bag of bread. During an observation on 08/01/24 at 12:15 PM, in the kitchen, revealed a cockroach crawling on the dishwasher. During an interview on 07/31/24 at 11:30 AM, the Kitchen Manager (KM) stated he had never seen any roaches before and it was his first time seeing them. [...]

Inspectors wroteBased on review of facility policy, observation, and interview, the facility failed to ensure proper procedure was followed during wound care to promote healing and/or to prevent infection for Resident (R)26, for 1 of 2 residents reviewed for wound care.

Inspectors wroteBased on observations, interviews, record review, and review of facility policy, the facility failed to provide physician ordered restorative services for Resident (R)3, for 1 of 3 residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly dispose of expired medication and biologicals for 1 of 5 medication carts.

Inspectors wroteBased on review of facility policy, observation, and interview, the facility failed to ensure proper infection control procedures were followed during wound care to prevent infection for Resident (R)26, for 1 of 2 residents reviewed for wound care.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to provide appropriate care and services to ensure Resident (R)1's quality of life, specifically Licensed Practical Nurse (LPN)1 failed to accurately assess R1, who expired approximately 30 minutes later. On [DATE] at 3:02 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.25 - Freedom from Abuse, Neglect, and Exploitation. On [DATE] the facility provided an acceptable IJ Removal Plan. On [DATE] the survey team validated the facility's corrective actions and the immediacy of the IJ was removed as of [DATE]. The facility remained out of compliance at F600 at a lower scope and severity of D. [...]

Inspectors wroteBased on interviews, record reviews, and review of facility policy, the facility failed to ensure Resident (R)1 was free from verbal abuse by Licensed Practical Nurse (LPN)1.

Inspectors wroteBased on review of facility policy, interviews, and record reviews, the facility failed to protect 2 of 3 residents from misappropriation of controlled substances and 1 of 3 residents from misappropriation of routine medications, Residents (R)1, R2, and R3.

Inspectors wroteBased on record review, interview and review of facility policy, the facility failed to prevent significant medication errors for 33 of 37 residents, on 1 of 3 units. Specifically, Residents (R)1, R19, R20, R23, R26, R27, R29, R30 and R31 did not receive medications on time as ordered by a physician. Additionally, R2, R4 - R18, R21, R22, R24, R25, R32, R35, R36 and R37 did not receive their scheduled 9:00 AM and 2:00 PM medications on 08/20/23.

Inspectors wroteBased on observations, interviews and review of facility policy, the facility failed to ensure 1 of 1 medication carts located on Unit 1 was secured and inaccessible to unauthorized personnel and residents.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to prevent an avoidable pressure ulcer to the right lateral calf for one Resident (R) 90 of five residents reviewed for pressure ulcer out of a total sample of 50 residents. The facility missed 24 opportunities to complete ordered skin assessments under the resident's brace and the resident sustained an avoidable stage IV pressure ulcer. Substandard Quality of Care (SQC) was identified at 43 CFR 483.25 treatment/services to prevent/heal pressure ulcers. The facility's Administrator and Director of Nursing (DON) were informed on 06/14/22 at 7:54 PM that Immediate Jeopardy existed at F686 related to the failure to ensure R90's skin was assessed underneath the brace to her right calf. The Immediate Jeopardy began on 02/17/22, the date R90 was admitted to the facility with a brace. [...]

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to notify the Registered Dietitian (RD) and the Nurse Practitioner (NP) of continued weight loss in one of four residents (Residents (R) 8) reviewed for significant weight loss in a total sample of 37 residents. The deficient practice had the potential to affect all residents who reside in the facility. Cross Reference:

Inspectors wroteBased on interviews and record reviews, the facility failed to implement and revise the care plan interventions to ensure that one of four residents (Resident (R) 8) reviewed for nutrition did not have significant weight loss out of a total sample of 37 residents.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to ensure an urinalysis (UA) and urine culture and sensitivity (C&S) tests were processed and reported to the facility for one of three residents (Resident (R) 67) reviewed for urinary tract infections in a total sample size of 37. Another urine specimen for UA and C&S was sent to the laboratory 12 days later after R67 continued with symptoms, which revealed R67 had a urinary tract infection (UTI).