Deficiencies per Year
12
9
6
3
0
Moderate
Unclassified
Inspection Report
Follow-Up
Deficiencies: 1
Aug 17, 2023
Visit Reason
Biennial Follow Up Construction Survey conducted to verify correction of previous deficiencies related to facility construction and ventilation.
Findings
One deficiency remains from the Biennial Construction Survey: the exhaust fans in the resident bathroom on the third floor did not appear to be working, resulting in inadequate exhaust ventilation and potential buildup of humidity and odors.
Deficiencies (1)
| Description |
|---|
| Facility did not maintain exhaust ventilation in specified spaces; exhaust fans in the third floor resident bathroom were not working. |
Inspection Report
Annual Inspection
Deficiencies: 2
Mar 16, 2022
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Magnolia Glen on March 16-17, 2022 to assess compliance with state regulations.
Findings
The facility failed to ensure that 6 of 7 exit doors accessible to residents were equipped with sounding alarm devices as required for the safety of residents who were intermittently disoriented or had dementia, resulting in a resident eloping from the facility. This failure was deemed a Type B Violation detrimental to resident health, safety, and welfare.
Severity Breakdown
Type B Violation: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure 6 of 7 exit doors accessible to residents were equipped with sounding devices that activated when doors were opened, compromising safety of residents with disorientation and dementia, resulting in elopement of Resident #2. | Type B Violation |
| Facility failed to assure all residents received care and services adequate and appropriate in compliance with relevant laws related to physical environment, specifically door alarms for safety. | Type B Violation |
Report Facts
Exit doors without sounding devices: 6
Residents sampled: 5
Residents intermittently disoriented: 3
Residents with dementia: 2
Resident elopement incident date: Mar 14, 2022
Safety checks frequency: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Reported Resident #2 missing and initiated search | |
| Lead Medication Aide | Provided information on resident wandering behaviors and facility door alarm status | |
| Resident Care Coordinator | Discussed resident confusion, wandering risks, and facility policies | |
| Assisted Living Director | Described resident elopement incident and facility alarm system status | |
| Maintenance Supervisor | Described door alarm system responsibilities and maintenance | |
| Executive Director | Discussed facility alarm system knowledge and resident safety policies | |
| Contracted Primary Care Provider | Provided expert opinion on resident safety and door alarm requirements |
Inspection Report
Capacity: 66
Deficiencies: 9
Sep 12, 2019
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 2002 Edition of the North Carolina Building Code(s), Institutional Occupancy, and the 1996 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
Multiple deficiencies were cited including failure to meet fire-resistance-rated construction requirements, lack of current sanitation and fire safety inspection reports, missing hand grips in bathrooms, corridors obstructed, hazards related to unsecured oxygen cylinders, lack of regular fire safety rehearsals, unsafe and non-operating building emergency equipment, improper control over kitchen range, and failure to maintain required exhaust ventilation systems.
Deficiencies (9)
| Description |
|---|
| Storage room over 100 square feet used for combustibles lacks required 1-hour fire-resistance-rated enclosure with 45 minute rated door; door is only 20 minute rated. |
| Facility failed to maintain current annual fire sprinkler system inspection and fire alarm system inspection reports. |
| Bathrooms lack hand grips at commodes accessible to residents, affecting safety and maneuverability. |
| Corridors are not free of obstructions, including a chair blocking an exterior exit door. |
| Building not maintained free of hazards; unsecured portable medical oxygen cylinder standing on floor. |
| Fire safety rehearsals not performed regularly each shift quarterly as required. |
| Building emergency equipment not maintained in safe and operating condition; exit signs missing directional indicators and face plates; firestopped seals missing in mechanical/electrical rooms; smoke tight corridor doors malfunctioning. |
| Ovens and ranges in resident activity rooms lack proper staff control; range energized with no staff present. |
| Facility failed to maintain required exhaust ventilation system in mechanically exhausted rooms; ventilation system not working except in 1st floor therapy half bathroom. |
Report Facts
Licensed capacity: 66
Inspection Report
Plan of Correction
Capacity: 66
Deficiencies: 7
Oct 29, 2015
Visit Reason
Biennial Construction Survey to assess compliance with physical plant standards and building safety codes.
Findings
Multiple physical plant deficiencies were identified including improper use of resident bathrooms for storage, electrical outlets in wet locations lacking ground fault protection, fire and smoke resistance issues with doors, unlabeled emergency HVAC shutdown switches, inadequate maintenance of the commercial kitchen hood fire extinguishing system, improper storage of medical oxygen cylinders, and missing fire sprinkler escutcheon plates.
Deficiencies (7)
| Description |
|---|
| Resident toilet rooms and bathrooms were utilized for storage, specifically the Third Floor Whirlpool used for vendor's furniture storage. |
| Electrical power receptacles in wet areas lacked ground fault protection; the GFCI outlet in the Third Floor Whirlpool had no power and could not be tested. |
| Fire and smoke resistance of doors to hazardous areas was not maintained; multiple corridor and lounge doors did not close or latch properly, some held open by wedges or bricks. |
| Emergency shutdown switches for HVAC air handlers were not labeled, risking delay in smoke containment. |
| Commercial kitchen hood fire extinguishing system lacked required inspections and maintenance documentation; gas cutoff valve missing cover plate. |
| Portable medical oxygen cylinders were improperly stored unsecured in a beverage crate in the Third Floor Soiled Utility. |
| Fire sprinkler escutcheon plate missing in the east stair tower, potentially allowing smoke and heat passage. |
Report Facts
Licensed bed capacity: 66
Inspection Report
Annual Inspection
Deficiencies: 2
Oct 22, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Magnolia Glen on 10/21/15 - 10/22/15 to assess compliance with adult care home regulations.
Findings
The facility failed to assure residents had proper table service with non-disposable place settings during meals and snacks, instead using Styrofoam and plastic disposable items regularly. Additionally, the facility did not offer snacks to all residents three times daily as required, and there was no system in place to monitor snack provision.
Deficiencies (2)
| Description |
|---|
| Facility failed to assure residents had table service during meals and snack times that included a napkin and non-disposable place settings consisting of at least a knife, fork, spoon, plate, and beverage containers appropriate for the foods served. |
| Facility failed to offer snacks to all residents three times a day as required and did not include snacks in the planned menus. |
Report Facts
Meals prepared for residents eating in room: 7
Observation time: 75
Number of residents interviewed: 12
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