Inspection Reports for Magnolia Gardens
594 Murray Hill Road Southern Pines, NC 28387, Southern Pines, NC, 28387
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
11.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
115% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Follow-Up
Deficiencies: 3
Date: Sep 8, 2025
Visit Reason
The Adult Care Licensure Section and the Moore County Department of Social Services conducted a follow-up survey and complaint investigations on 09/03/25-09/05/25 and 09/08/25. The complaint investigations were initiated by Moore County Department of Social Services on 07/17/25, 07/29/25, 08/20/25, and 09/03/25.
Complaint Details
Complaint investigations were initiated by Moore County Department of Social Services on 07/17/25, 07/29/25, 08/20/25, and 09/03/25, leading to this follow-up survey and complaint investigation.
Findings
The facility failed to ensure adequate supervision of Resident #1 who was found outside the facility overnight after falling from his wheelchair, resulting in neglect. Additionally, the facility failed to initiate CPR for Resident #7 who was found unresponsive and without a pulse, resulting in neglect. The facility also failed to submit a required written death notification for Resident #7 within 3 days.
Deficiencies (3)
Failed to ensure supervision of Resident #1 who was outside the facility overnight after falling from his wheelchair.
Failed to ensure staff initiated CPR for Resident #7 found not breathing and without a pulse.
Failed to provide a written death notification for Resident #7 within 3 days as required.
Report Facts
Duration resident was outside unsupervised: 10
Correction date deadline: 2025
Incident time: 1.41
EMS arrival time: 1.52
Resident #7 time of death: 1.53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication aide/supervisor | Named in Resident #1 supervision failure and incident report. | |
| Executive Director | Interviewed regarding Resident #1 incident and Resident #7 emergency response. | |
| Assistant Executive Director | Interviewed regarding Resident #1 incident and video footage. | |
| Personal Care Aide | Named in Resident #7 incident and failure to initiate CPR. | |
| Resident Care Coordinator | Interviewed regarding CPR certification and emergency response. | |
| Special Care Coordinator | Interviewed regarding CPR response on 08/16/25. | |
| Administrator | Interviewed regarding emergency response and death reporting. | |
| Resident #7's Primary Care Provider | PCP | Interviewed regarding Resident #7's health status and emergency response. |
Inspection Report
Capacity: 110
Deficiencies: 15
Date: Aug 5, 2025
Visit Reason
The report documents a Construction Section Biennial Survey conducted to assess compliance with applicable physical plant, building, fire safety, and housekeeping regulations for Magnolia Gardens, a licensed adult care home.
Findings
Multiple deficiencies were cited including failure to comply with physical plant requirements, inadequate emergency release switch key availability, missing hand grips in bathrooms, unsafe corridor handrails, unsafe outside premises, poor housekeeping and maintenance issues, hazards related to oxygen bottle storage, failure to maintain fire safety and electrical equipment in safe operating condition, and lack of exhaust ventilation in specified areas.
Deficiencies (15)
Facility not in compliance with code requirements for emergency release switch keys; not all staff carry keys and some emergency release cylinders do not function.
Not all toilets equipped with hand grips.
Corridor handrails not maintained to support a 250 pound concentrated load; loose rail observed.
Outside premises not maintained in a clean and safe condition; torn screens with sharp metal points present hazard.
Walls, ceilings, and floors not kept clean, functional, and in good repair; water damage, stains, dust accumulation, missing transition strips, buckling floors, and damaged doors noted.
Facility not maintained free from hazards; electrical panels obstructed and oxygen bottles improperly stored unsecured.
Failure to maintain emergency fire alarm system devices and equipment in safe operating condition; fire alarm panel in trouble mode, detectors missing or hanging.
Failure to maintain building fire safety systems; unsealed cable penetrations and gaps in fire resistant ceilings.
Electrical emergency/safety lighting equipment not maintained; emergency lights not illuminating, emergency light removed, exit sign not illuminated.
Inoperable call bells endangering residents; call bell not working in Room 306.
Electrical equipment not maintained safely; outlet near sink did not trip with tester.
Plumbing equipment not maintained safely; unsecured toilet and clogged sink with standing water.
Fire safety equipment not maintained; doors do not latch properly, sprinkler heads obstructed by lint, grease buildup on hood suppression system, fire extinguisher not serviced annually.
Mechanical equipment not maintained; heavy grease accumulation on kitchen exhaust hood and fire suppression equipment.
Exhaust ventilation not maintained in specified spaces; exhaust fan not working in Community Bath by SCU Dining.
Report Facts
Licensed beds: 110
Special Care Unit beds: 32
Weight load requirement: 250
Code required clearance: 36
Number of oxygen bottles: 7
Date of inspection: Aug 5, 2025
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jan 9, 2025
Visit Reason
The Adult Care Licensure Section and the Moore County Department of Social Services conducted an annual survey of Magnolia Gardens on January 8-9, 2025.
Findings
The facility failed to provide timely and unhurried feeding assistance to Resident #8 immediately upon receipt of her meal, as observed during breakfast on January 9, 2025. Staff interruptions and inadequate assistance delayed feeding, although Resident #8 eventually finished her meal.
Deficiencies (1)
Failed to provide feeding assistance to Resident #8 immediately upon receipt of her meal, resulting in delayed feeding and lack of unhurried assistance.
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Sep 23, 2021
Visit Reason
The Adult Care Licensure Section and the Moore County Department of Social Services conducted an annual survey and complaint investigation on 09/22/21-09/23/21. The complaint was initiated by Moore County Department of Social Services on 09/18/21.
Complaint Details
The complaint was initiated by Moore County Department of Social Services on 09/18/21 related to a resident eloping from the facility without staff knowledge and other care and safety concerns.
Findings
The facility failed to ensure wander protection bracelets and exit doors equipped with sounding devices were in proper working order for residents diagnosed with dementia or Alzheimer's disease. Additionally, the facility failed to provide supervision for a resident who eloped from the facility without staff knowledge, failed to administer medications as ordered for two residents, failed to keep medication carts locked when unattended, failed to properly witness medication disposal, and failed to ensure visitor screening for COVID-19 as per CDC and NCDHHS guidelines.
Deficiencies (8)
Failed to ensure wander protection bracelets and exit doors equipped with sounding devices were in proper working order for residents diagnosed with dementia or Alzheimer's disease.
Failed to provide supervision for a resident who eloped from the facility without staff knowledge.
Failed to ensure physician notification for a resident with wandering and exit seeking behaviors who eloped from the facility.
Failed to administer medications as ordered for two residents including errors with acid reflux medication, topical cream, and thyroid medication.
Failed to ensure medication cart on Assisted Living unit was locked when not under direct supervision of staff.
Failed to assure medications disposed of in the facility were witnessed by a licensed pharmacist or designee.
Failed to ensure visitor screening for COVID-19 was conducted according to CDC and NCDHHS guidelines.
Failed to ensure every resident had the right to receive care and services which are adequate, appropriate, and in compliance with rules and regulations as related to supervision.
Report Facts
Medication error rate: 10
Residents with wander protection bracelets: 5
Resident elopement distance: 70
Temperature: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Named in medication administration errors and medication disposal findings. | |
| Maintenance Director | Responsible for checking wander protection bracelets. | |
| Executive Director | Provided information about wander protection bracelets, supervision, and investigation of resident elopement. | |
| Business Office Manager | Provided information about wander protection bracelets and visitor screening. | |
| Resident Care Coordinator | Expected to be notified of exit seeking behaviors. | |
| Primary Care Provider | Interviewed regarding resident elopement and care. |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jan 9, 2020
Visit Reason
The Adult Care Licensure Section and the Moore County Department of Social Services conducted an annual and follow-up survey and complaint investigation on 01/07/20-01/09/20.
Complaint Details
The survey included a complaint investigation related to tuberculosis testing, resident rights violations, and medication administration errors.
Findings
The facility was found deficient in multiple areas including tuberculosis testing for staff and residents, implementation of physician's orders, resident rights violations, medication administration errors, and infection control practices.
Deficiencies (8)
Facility failed to ensure 1 of 6 sampled staff was tested for tuberculosis with a TB skin test upon hire.
Facility failed to ensure 1 of 7 sampled residents had completed tuberculosis testing upon admission.
Facility failed to ensure physician's orders were implemented for 1 of 7 sampled residents related to care for a skin tear.
Facility failed to assure residents were treated with respect and dignity related to denying a resident cigarettes and speaking and treating residents in a rude and disrespectful manner.
Facility failed to administer medications as ordered by a physician for 1 of 7 residents observed on the medication pass related to administering an as needed pain medication.
Facility failed to ensure the electronic Medication Administration Record (eMAR) was accurate for 1 of 7 residents observed on the medication pass related to not removing a discontinued medication from the eMAR, documenting the administering of a medication but administering a different medication, and not documenting the effectiveness of an as needed medication.
Facility failed to assure 1 of 7 residents observed during the medication pass only received borrowed medications in an emergency; a medication was administered to the wrong resident.
Facility failed to implement an infection control policy consistent with CDC guidelines related to a medication aide not wearing gloves during insulin administration.
Report Facts
Sampled staff: 6
Sampled residents: 7
Resident #8 oxycodone tablets administered: 71
Resident #8 oxycodone tablets remaining: 49
Resident #9 FSBS: 328
Units of Novolin R administered: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Personal Care Aide / Medication Aide | Failed to have valid TB skin test upon hire |
| Staff B | Medication Aide | Did not wear gloves during insulin administration |
| Administrator | Interviewed regarding multiple deficiencies and oversight responsibilities | |
| Business Office Manager | Responsible for ensuring staff had TB skin test upon hire | |
| Special Care Unit Coordinator | Interviewed regarding TB skin test documentation and resident rights | |
| Resident Care Coordinator | Responsible for medication order faxing and eMAR approval |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Jul 2, 2019
Visit Reason
This is a biennial follow-up construction survey conducted to verify correction of previously identified deficiencies related to building code compliance and physical plant requirements.
Findings
The facility failed to meet code requirements related to the special locking system on exits, sprinkler protection in closets, storage items obstructing sprinkler heads, and improper storage of oxygen cylinders. Some deficiencies were not corrected and further action is required.
Deficiencies (4)
Failed to meet code requirements for the special locking system of locks on the exits.
Closets in resident rooms on 200 & 300 Halls lack sprinkler protection.
Storage items stacked closer than 18 inches below, obstructing sprinkler heads in AL Linen Storage and Main Kitchen Pantry.
Improper storage of oxygen cylinders; an oxygen cylinder was stored in a beverage crate in the Resident Care Coordinator's office.
Inspection Report
Capacity: 142
Deficiencies: 9
Date: Feb 7, 2019
Visit Reason
This is a Construction Section Biennial Survey report conducted to assess compliance with building codes and physical plant requirements for Magnolia Gardens, a licensed adult care home.
Findings
The facility was found to have multiple deficiencies including lack of wiring diagrams for special locking systems, sprinkler protection issues, unpleasant odors, hazards due to clutter and grease buildup, improperly latched fire doors, unsecured oxygen cylinders, non-operational emergency lighting and exhaust fans, and kitchen equipment lacking staff-controlled locking features.
Deficiencies (9)
Special locking system on exits lacked wiring diagram and system components location map at the FACP; closets in 200 & 300 Halls lacked sprinkler protection or documentation of fire separation.
Unpleasant odors present in the 400 Hall and carpet showed racetrack markings from wheelchair usage.
Facility was not maintained free of obstructions and hazards; storage items stacked closer than 18 inches below sprinkler heads in AL Linen Storage and Main Kitchen Pantry.
Kitchen range exhaust hood filters had excessive grease buildup.
Interior doors (SCU/Dining and Room 303) were out of adjustment and did not latch, preventing containment of fire and/or smoke.
Oxygen bottles in Room 309 were not secured to the structure or stored in approved racks.
Emergency wall light in Living Room/400 Hall did not illuminate in emergency mode (finding dated 08/17/2017).
Mechanical exhaust fan in Community Rest Room/100 Hall was not operational (finding dated 08/17/2017).
All kitchen cooking equipment lacked locking features controlled by staff to limit resident use; AL Kitchen range had no power control switches to limit resident use.
Report Facts
Licensed beds: 110
Special care beds: 32
Inspection Report
Capacity: 110
Deficiencies: 8
Date: Feb 3, 2017
Visit Reason
This is a Construction Section Biennial Survey conducted to assess compliance with physical plant requirements and building codes for Magnolia Gardens, including evaluation of the original facility and the 2012 addition increasing capacity to 110 beds.
Findings
Multiple deficiencies were cited related to physical plant maintenance including failure to maintain emergency release keys for magnetic locks, unsecured toilets, lack of ground fault interrupters in wet locations, incomplete fire protection coverage, breaches in fire-rated ceiling construction, non-operational emergency lighting, doors that do not latch properly, and disconnected dryer venting.
Deficiencies (8)
Facility has not maintained emergency release switch keys for magnetic locks on exit doors; not all staff carry keys as required.
Toilets in Central Bathing/SCU and Rooms 510/512 are not secured to the floor.
Electrical ground-fault protection not maintained; GFCI receptacle in Room 204 Bathroom did not reset when tested.
Telephone closet adjacent to Room 114 lacks sprinkler coverage.
Breaches in one-hour rated ceiling construction at Kitchen water heater closet and Power Room invalidate fire protection integrity.
Emergency lighting failed to operate properly; exterior emergency wall lights at multiple locations did not illuminate when tested.
Interior doors at Room 119, Whirlpool Bath/200 Hall, and Central Bathing/400 Hall do not latch properly, preventing containment of fire and smoke.
Dryer vent to exterior is disconnected in the Assisted Living Laundry Room.
Report Facts
Total licensed capacity: 110
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