Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 - Rock Hill during CMS and state inspections, most recent first.
A Laundry Aide was observed handling soiled linen and clothing without wearing gloves, contrary to facility policy requiring PPE use. The aide collected, tied, and replaced soiled linen bags with bare hands across multiple units, and both the Laundry Manager and Administrator confirmed that gloves should have been worn during these tasks.
A resident with severe cognitive impairment and a history of violent behavior was subjected to physical, verbal, and mental abuse by an LPN. The LPN used inappropriate language and physically hit the resident, escalating the situation. Witnesses confirmed the LPN's actions, and the facility failed to adhere to its policy on abuse prevention.
The facility failed to provide palatable meals as per menu specifications, with surveyors observing bland and freezer-burnt food items. Residents expressed dissatisfaction, noting the food was unappetizing and lacked flavor. The CDM stated no grievances were received and mentioned reliance on frozen items for meals.
The facility failed to ensure proper food storage and handling, with expired and improperly sealed items found in the kitchen. The CDM admitted staff do not check expiration dates, and was observed preparing food without a beard restraint. Additionally, the ice machine was found dirty with a mold-like substance.
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of cockroaches in the kitchen area. Cockroaches were seen on the floor near the stove, on a bag of bread, and on the dishwasher. The Kitchen Manager initially claimed it was his first time seeing roaches but later admitted to having seen them before and contacting Ecolab.
A facility failed to follow proper wound care procedures for a resident with a stage 2 pressure ulcer. The resident's wound was not healing as expected, and during an observation, the Wound Care Nurse did not adhere to Enhanced Barrier Precautions, failing to wear a gown and perform hand hygiene after removing the resident's blanket. The nurse admitted to being nervous and unaware of the lapse in procedure.
A facility failed to provide physician-ordered restorative services for a resident with a left-hand contracture. Despite orders for range of motion exercises and splint application, documentation did not show the splint was used, and staff provided inconsistent accounts of care. The resident reported the splint had not been used in months, and it no longer fit. The LPN responsible did not report refusals, and the OT confirmed the splint was not used as intended.
A facility failed to dispose of expired medications and biologicals on one medication cart. An observation revealed expired items, including eye drops and lab-vacutainers. Interviews with an LPN and the Administrator confirmed that staff are responsible for auditing carts daily to ensure expired items are removed and documented.
A resident with a stage 2 pressure wound was not provided proper infection control during wound care. The Wound Care Nurse failed to don a gown as required by Enhanced Barrier Precautions, despite signage indicating the need for PPE. The nurse admitted to forgetting the precautions due to nervousness.
A resident with multiple medical conditions, including dementia and atrial fibrillation, was not properly assessed by an LPN after a CNA reported changes in the resident's condition. The LPN failed to perform a thorough assessment or notify the physician, leading to a delay in care. The resident was later found unresponsive and pronounced dead after emergency services were called. This incident was identified as an Immediate Jeopardy situation due to non-compliance with federal regulations on abuse, neglect, and exploitation.
A resident experienced verbal abuse from an LPN, who made derogatory comments about the resident's bowel movement in front of others. The resident, who was cognitively intact, felt humiliated by the LPN's behavior. The incident was corroborated by the resident's roommate and reported to the Social Services Director.
A long-term care facility failed to protect residents from the misappropriation of medications, including controlled substances and routine medications. One resident missed doses of oxycodone, another had issues with tramadol delivery, and a third missed doses of Ozempic due to medication unavailability. The Assistant Director of Nursing failed to secure narcotic medications properly, leading to their misappropriation, and was subsequently terminated for policy violations.
Failure to Ensure Proper PPE Use During Soiled Linen Handling
Penalty
Summary
Staff failed to follow facility policy regarding the use of personal protective equipment (PPE) when handling soiled linen and clothing. Multiple observations showed a Laundry Aide collecting and handling bags of soiled linen from various units without wearing gloves, despite the facility's policy requiring gloves and gowns to be donned when handling soiled items. The Laundry Aide was seen tying, removing, and replacing soiled linen bags with bare hands, only using hand sanitizer after handling the bags. Interviews with the Laundry Manager and the Laundry Aide confirmed that gloves were not being worn during these tasks, with the Laundry Aide stating that gloves could not be worn and the Laundry Manager acknowledging that gloves were not available in the soiled utility rooms. The Administrator also confirmed that staff are expected to wear gloves when handling soiled linen, both in the utility rooms and laundry room, as per facility policy.
Failure to Protect Resident from Abuse by LPN
Penalty
Summary
The facility failed to protect a resident from physical, verbal, and mental abuse by an LPN. The incident involved the LPN using inappropriate language and physically hitting the resident after the resident hit the LPN. Witnesses observed the LPN's actions, and the State Agency determined that any reasonable person in the same situation would experience adverse psychosocial harm. The resident involved had a history of severe cognitive impairment, traumatic brain injury, schizophrenia, and other conditions that contributed to violent behavior and unsteadiness. Upon returning from the hospital, the resident became belligerent and combative, refusing to get off the stretcher and hitting staff members. The LPN responded by antagonizing the resident, using derogatory language, and physically pushing the resident, which escalated the situation further. The incident was reported to the police, and a police report documented the assault and battery. Interviews with staff and witnesses revealed that the LPN's actions were not isolated, as the LPN continued to belittle and physically engage with the resident, even after the resident had calmed down. The facility's policy on abuse, neglect, and mistreatment was not adhered to, resulting in the failure to protect the resident from harm.
Removal Plan
- Resident resides in the facility without negative effect.
- Medical Director notified of incident. No reported concerns.
- Resident was reviewed and observed for physical and or psychosocial issues, none identified.
- Incident Reported to all three state agencies at time of notification.
- Alleged perpetrator was suspended immediately pending investigation.
- Administrator/Designee interviewed alert and oriented residents and observed non-oriented residents for signs and symptoms of abuse.
- Director of Nursing/Designee completed body audits on interviewed and observed residents.
- A review of the 24-hour report and facility activity report was completed by the Facility Administrator to identify possible allegations of abuse or neglect and to review residents with change of conditions. No concerns identified.
- Facility Staff were re-educated by the Administrator on Abuse, Neglect and Misappropriation policy including: Identification of abuse or neglect, by observable and objective evidence, witness reports of unusual occurrence or patterns or trends of potential abuse or neglect. Abuse is the willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual of goods or services that are necessary to maintain physical, mental and psychosocial wellbeing. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse.
- Immediate identification and removal of the alleged perpetrator.
- Identification and assessment of the alleged victim.
- Reporting immediately to Facility Abuse Coordinator, Director of Nursing, and Social worker regardless of time of day.
- This reeducation began immediately and was completed. Any staff not receiving this information prior to this date will receive prior to next schedule shift. This education will be presented in New Hire and agency staff orientation.
- Administrator contacted Regional Ombudsman.
- Director of Nursing or ADON will observe care of residents to monitor for forceful and/or aggressive care of residents and will address any identified issue at time of discovery.
- Social Services Director will interview alert and oriented residents randomly to validate that residents feel safe and have no concerns of aggressive treatment.
- The results of this monitoring will be presented to the Quality Assurance/Performance improvement Committee for review and recommendation. Any identified concerns will be addressed at the time of discovery.
- Ad Hoc QAPI was held.
- The Medical Director was notified of the Immediate Jeopardy.
Deficiency in Meal Quality and Preparation
Penalty
Summary
The facility failed to ensure that meals served to residents were palatable and prepared according to menu specifications. During observations by surveyors, test trays revealed that the food items, including sweet mashed potatoes, watery squash, a burnt dinner roll, bland chopped Polish sausage, and Salisbury steak, were either bland, under-seasoned, or tasted freezer burnt. Residents expressed dissatisfaction with the meals during a resident council meeting, stating that the food was not appetizing, lacked flavor, did not look good, and seemed not fresh. The Certified Dietary Manager (CDM) reported not receiving any grievances related to food services and mentioned that the facility primarily uses frozen items for meals, occasionally cooking fresh items for residents.
Deficiencies in Food Storage, Handling, and Sanitation
Penalty
Summary
The facility failed to ensure proper food storage and handling practices in the kitchen, as observed during a survey. Several expired food items, including cartons of sweet tea and tomato juice, were found in dry storage, along with moldy apple juice and improperly sealed orange juice, dinner rolls, and hashbrowns. Additionally, an open, undated, and unlabeled bag of unidentified cubed meat was found in the refrigerator. The Certified Dietary Manager (CDM) admitted that staff do not check food deliveries for expiration dates, assuming the items are new, and mentioned that the Vitality juices had just been removed from the freezer. Furthermore, the facility did not ensure that kitchen staff wore appropriate hair and beard restraints during meal preparation. The CDM was observed preparing food without a beard restraint, stating he was busy and had forgotten it. The ice machine was also found to be improperly cleaned, with a black mold-like substance on the inside white panel. The CDM indicated that the maintenance man was responsible for cleaning the ice chest monthly, and claimed it had been cleaned the previous day.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of cockroaches in the kitchen area. During an observation on July 31, 2024, at 10:45 AM, multiple cockroaches were seen crawling on the floor near the stove. Further observations on August 1, 2024, revealed a cockroach crawling on a bag of bread at 10:57 AM and another on the dishwasher at 12:15 PM. The facility's undated pest control policy states that it will maintain an effective program to prevent or eliminate infestations of pests and rodents. During an interview on July 31, 2024, at 11:30 AM, the Kitchen Manager initially stated that he had never seen any roaches before and it was his first time seeing them. However, in a follow-up interview, he admitted to having seen some roaches a while back and mentioned that they had contacted Ecolab to address the issue.
Failure to Follow Proper Wound Care Procedures
Penalty
Summary
The facility failed to ensure proper wound care procedures were followed for a resident with a stage 2 pressure ulcer on the right buttock. The resident, who was admitted with conditions including diabetes mellitus type 2 and a non-pressure chronic ulcer of the buttock, had a pressure wound that was not progressing towards healing. The physician's orders specified cleaning the wound with normal saline solution or wound cleanser, applying honey hydrogel, and covering it with a ZETUVIT silicone border dressing. During an observation, the Wound Care Nurse did not adhere to Enhanced Barrier Precautions as indicated by the signage on the resident's door. The nurse did not wear a gown and failed to perform hand hygiene after removing the resident's blanket, which is against the facility's policy for performing a dressing change. The nurse later admitted to being nervous and unaware of not following the proper procedure.
Failure to Provide Restorative Services for Resident
Penalty
Summary
The facility failed to provide physician-ordered restorative services for a resident, identified as R3, who was admitted with multiple diagnoses including hemiplegia, hemiparesis, and a left-hand contracture. The resident was cognitively intact and did not exhibit behaviors of care rejection. The physician's orders and care plan specified that R3 should receive range of motion exercises and have a left-hand splint applied for 6.5 hours three times a week. However, documentation from the facility did not show evidence of the splint being applied, nor were there any documented refusals from the resident. Interviews and observations revealed that the splint was not being used as ordered. R3 reported that the splint had not been used in months, and it no longer fit due to lack of regular use. Staff members, including an LPN and CNAs, provided inconsistent accounts regarding the application of the splint and the documentation of care. The LPN responsible for the restorative therapy program admitted to not reporting refusals and not witnessing any refusals from R3. The occupational therapist confirmed that the splint was intended to prevent further contracture and was not being used as intended.
Expired Medications and Biologicals Not Properly Disposed
Penalty
Summary
The facility failed to properly dispose of expired medications and biologicals on one of its medication carts, specifically Medication Cart B located on Hall 200. During an observation, it was found that the cart contained expired items, including two Systane Complete Eye drops with an expiration date of March 20, 2024, two Lab-vacutainers with an expiration date of February 28, 2023, and two Urine C&S with an expiration date of April 30, 2023. This indicates a lapse in the facility's adherence to its policy, which mandates the immediate removal and proper disposal of outdated, contaminated, or deteriorated medications and biologicals. Interviews conducted with the Licensed Practical Nurse (LPN) and the Administrator revealed that the facility's protocol requires all nursing staff to audit their medication carts daily to ensure no expired medications are present. The LPN confirmed the presence of expired items and acknowledged the responsibility of nursing staff to discharge and document expired medications. The Administrator reiterated that expired medications should be disposed of and documented as per the facility's policy, emphasizing the responsibility of nursing staff to check their carts daily for expired items.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control procedures during wound care for a resident, identified as R26, who was on Enhanced Barrier Precautions (EBP) due to a stage 2 pressure wound on the right buttock. The facility's policy, last revised on 05/15/23, mandates the use of personal protective equipment (PPE) such as gloves and gowns for residents with wounds, regardless of MDRO colonization status. During an observation, the Wound Care Nurse (WCN) did not don a gown before performing wound care on R26, despite the signage indicating EBP requirements. R26 was admitted with diagnoses including diabetes mellitus type 2, depression, and a non-pressure chronic ulcer of the buttock. A progress note from 07/25/24 indicated that the wound was not healing as expected, with an increase in surface area and moderate serous exudate. The WCN acknowledged awareness of the EBP but admitted to not applying the PPE due to nervousness and forgetting the precautions. This oversight in following the infection control protocol led to the deficiency noted in the report.
Failure to Provide Timely Care and Assessment for Resident
Penalty
Summary
The facility failed to provide appropriate care and services to ensure the quality of life for a resident, identified as R1, who had multiple medical conditions including dementia, altered mental status, and atrial fibrillation. R1 was admitted with a Full Code status, indicating that resuscitation efforts should be made in the event of a cardiac or respiratory arrest. On the day of the incident, a Certified Nursing Assistant (CNA) noticed that R1's breathing had slowed and that he was not responding as usual. The CNA notified the Licensed Practical Nurse (LPN), who briefly checked on R1 but did not perform a thorough assessment or notify the physician. Approximately 20 minutes later, the CNA found R1 unresponsive and not breathing. Emergency services were called, and CPR was initiated, but R1 was pronounced dead shortly after. Interviews with staff revealed that there was a lack of timely and appropriate response to R1's change in condition. The LPN admitted to not providing care until R1 was unresponsive and failed to document the incident or notify the physician as required by the facility's policy. The facility's policy on abuse, neglect, and change in condition emphasizes the importance of timely assessment and communication with medical staff. However, in this case, the LPN did not adhere to these guidelines, resulting in a failure to provide necessary care to R1. The incident was identified as an Immediate Jeopardy situation, indicating a serious threat to the health and safety of residents, and was related to non-compliance with federal regulations regarding freedom from abuse, neglect, and exploitation.
Removal Plan
- A review of the 24-hour report and facility activity report was completed by the Facility Administrator to identify possible allegations of abuse or neglect and to review residents with change of conditions.
- Facility Staff were re-educated by the Administrator on Abuse, Neglect and Misappropriation policy.
- Facility Administrator/Interim DON will re-educate licensed staff on Change of Condition.
- Administrator contacted Regional Ombudsman.
- The Director of Nursing/Designee will review the 24-hour report and the Facility Activity report to identify any documentation regarding a change of condition, abuse and validate that the resident has been assessed appropriately, physician notified, responsible party notified, and orders implemented properly. This includes diagnostic testing and results.
- The results of this monitoring will be presented to the Quality Assurance/Performance Improvement Committee for review and recommendation. Any identified concerns will be addressed at the time of discovery.
- Ad Hoc QAPl was held.
- The Medical Director was notified of the Immediate Jeopardy.
Verbal Abuse Incident Involving LPN
Penalty
Summary
The facility failed to protect a resident from verbal abuse by an LPN, as evidenced by multiple interviews and record reviews. The incident involved a resident who was cognitively intact, with a BIMS score of 14 out of 15, and had medical conditions including generalized anxiety disorder and a stage 3 pressure ulcer. The resident was subjected to derogatory comments by the LPN regarding a bowel movement incident. The LPN referred to the resident in a demeaning manner, calling her 'Stinky' and making comments about the smell in front of the resident's roommate and others. The resident expressed feeling humiliated by the LPN's behavior, which included loud and rude remarks about the smell and asking the roommate if a mask was needed. The roommate corroborated the resident's account, noting the LPN's loud and inappropriate comments. The Social Services Director also confirmed that the resident reported the LPN's derogatory remarks. The Director of Nursing and the Administrator, both new to their positions, were unable to provide information regarding the abuse allegation.
Misappropriation of Medications in LTC Facility
Penalty
Summary
The facility failed to protect residents from the misappropriation of medications, specifically controlled substances and routine medications. The facility's policy on abuse, neglect, exploitation, or mistreatment prohibits the misappropriation of a resident's property and/or funds. However, the facility did not adhere to its policy regarding the receipt and handling of controlled substances, which requires a licensed nurse to verify the contents and quantity of medications upon delivery and to secure them immediately in a locked compartment. One resident, who was admitted with diagnoses including spinal stenosis and pressure ulcers, did not receive scheduled doses of oxycodone due to the medication being on hold. Another resident, with chronic pain and other conditions, had issues with tramadol delivery, which required a signature for refill and was temporarily pulled from an emergency kit. A third resident, with diabetes and obesity, missed doses of Ozempic because the medication was not available, and attempts to obtain an early refill were denied by insurance. Interviews revealed that the Assistant Director of Nursing (ADON) signed for the delivery of narcotic medications but failed to secure them properly, leading to their misappropriation. The Director of Nursing (DON) confirmed the misappropriation of medications for the three residents. The ADON was terminated for violating facility policy, and the facility administrator attempted to address the missing medications with the pharmacy, but insurance issues prevented timely replacement.
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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.
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Nursing homes near Rock Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rock Hill Post Acute Care Center | 0.3 mi | ★★★★★ | 2 | 0 |
| Westminster Health & Rehab Center | 0.7 mi | ★★★★★ | 3 | 0 |
| Pruitthealth- Rock Hill | 1.1 mi | ★★★★★ | 12 | 0 |
| White Oak Manor - Rock Hill | 1.3 mi | ★★★★★ | 0 | 0 |
| Willow Brooke Court At Park Pointe Village | 3.5 mi | ★★★★★ | 0 | 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.