Magnolia Manor Rock Hill: Neglect Death Immediate Jeopardy - SC
Twenty minutes later, the man was dead.
That sequence of events, documented in a federal inspection report following a June 2024 complaint survey at Magnolia Manor in Rock Hill, South Carolina, earned the facility a citation for immediate jeopardy, the most serious level of deficiency federal inspectors can assign, one reserved for situations where a facility's failures have placed residents in immediate risk of serious harm or death.
The resident, identified in inspection records only as R1, was a man living with dementia, altered mental status, hypertensive heart disease, cerebral ischemia, metabolic encephalopathy, Type 2 diabetes, and atrial fibrillation. He had been admitted to the facility on a date redacted from the public record. His advance directive was on file. It said full code, meaning if his heart stopped, staff were required to perform CPR.
The night shift certified nursing assistant, CNA3, said he last checked on R1 at around 4:30 in the morning during his rounds. R1 was fine, he said. Nothing unusual.
CNA1 arrived for the day shift at approximately 5:55 AM. During shift change, she and CNA2 noticed that R1's breathing had slowed. He was not talking. He was not responding the way he normally did. CNA1 notified LPN1, the licensed practical nurse on duty, and also told CNA3, who confirmed that R1 had not been in that condition during the night shift.
LPN1's response, as CNA1 described it to inspectors, was to walk into R1's room, look at him, and then go sit at the nurses' station.
LPN1 told inspectors a version that was slightly different in sequence but not in substance. She said it was reported to her that R1 "did not look right." She said she went to his room, looked at him, and then went to check his code status. She did not assess him. She did not call a physician. She did not call 911. She did not touch him.
Approximately 20 minutes after CNA1 first raised the alarm, CNA1 came back to LPN1 and told her R1 was now unresponsive. That is when LPN1 called a code and retrieved the crash cart.
By then, according to the deputy coroner who spoke with inspectors, R1's actual time of death was approximately 7:00 AM. When Rock Hill Fire Department units arrived at 7:23 AM, the first responders found R1 unresponsive, not breathing, and cold to the touch. The EMS report from Piedmont Medical Center, whose unit arrived at 7:28 AM, documented what first responders told them on arrival: nursing home staff had last had contact with R1 approximately 45 to 60 minutes before he was found, and he had been at his normal baseline at that time.
The EMS report noted that nursing home staff had provided "some CPR" before their arrival. Death was called at 7:33 AM.
LPN1 told inspectors she could not provide documentation from the morning of the incident. She could not recall any.
The physician, LPN1 confirmed, was never notified. Not when CNA1 first reported the change in R1's condition. Not during the 20 minutes when he was still alive and unresponsive to the nurse who looked at him and walked away. Not at any point during the incident.
The facility's own policy, reviewed by inspectors, required nursing staff to provide timely notification to medical staff when a resident's condition changed. The facility's interim Director of Nursing, interviewed by inspectors at 12:34 PM on the day of the survey, said the protocol was straightforward: CNA notices a change, notifies the nurse, nurse assesses the resident, nurse contacts the provider as needed. The DON also said explicitly that residents on palliative care who carry a full code designation require CPR just like any other full code resident.
None of that happened.
What makes the timeline particularly stark is the gap between what the nursing staff knew and what they did with that knowledge. CNA1 recognized, at shift change, that something was wrong. She said so out loud. She reported it to the nurse. The nurse looked at the man and walked away.
CNA2 told inspectors that R1 died while CNA1 was cleaning him up, and that LPN1 had been notified. CNA3, the night shift aide, said he did not know whether CPR was ever initiated or whether EMS had been called, because day shift staff were the ones who found R1 and he was not present.
The deputy coroner placed time of death at approximately 7:00 AM. EMS was not called until after R1 was found unresponsive. The fire department was not en route until 7:19 AM. By the time anyone with medical training attempted resuscitation, the man whose advance directive said he wanted to be coded had been dead, by the coroner's estimate, for roughly 33 minutes.
The facility submitted an Immediate Jeopardy removal plan. It listed nine corrective steps. Staff were re-educated on the abuse, neglect, and misappropriation policy. Licensed staff were to be re-educated on recognizing and responding to changes in condition. The administrator reviewed activity reports going back through the period in question to look for other possible instances of neglect. The regional ombudsman was contacted. A quality assurance committee was to monitor the issue for three months.
Item one on the removal plan read: "R1 no longer resides in the facility."
He does not. He died in his room on a morning when a nursing assistant saw what was coming before it arrived, said so, reported it, and watched the nurse on duty look at the man and return to her desk.
The inspection report does not say whether R1 had family who were notified before he died, or whether anyone who loved him knew what the hours before his death looked like. It does not say whether LPN1 remains employed at the facility. It does not say whether the physician who was never called has been informed of what the record shows.
What it says is that a man with dementia and a heart condition and a directive that said fight for me lay in a room in Rock Hill while the nurse responsible for his care checked his paperwork and sat down, and that by the time anyone ran toward him with a crash cart, the coroner would later say he had already been gone for half an hour.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Magnolia Manor - Rock Hill from 2024-06-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 5, 2026 · Our methodology
Magnolia Manor - Rock Hill in Rock Hill, SC was cited for immediate jeopardy violations during a health inspection on June 10, 2024.
Twenty minutes later, the man was dead.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.