Springdale Healthcare Center
146 Battleship Road, Camden, SC 29020 · For profit - Limited Liability company · 148 certified beds · (803) 432-3741 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $16,985 in federal fines (most recent 2025-05-21)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (64%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 6.9% | 11.9% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.8% | 6.3% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.5% | 3.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.3% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 11.0% | 12.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 29.7% | 21.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.6% | 90.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.4% | 5.1% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 9.7% | 16.7% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.6% | 15.3% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 63.6% | 78.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 15.7% | 24.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 26.4% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.64 | 2.04 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.50 | 1.84 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
47.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 87 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 33.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 45 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.12 therapist hours per resident per day in 2026Q1 — more than 8% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 29% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 47.4%CMS range 37.4–56.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 14.3%CMS range 11.2–17.9 | 10.7% | Oct 2022–Sep 2024 | worse than U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 33.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 33.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 24.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 96.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 5.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.0%CMS range 4.2–10.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.36 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 148 beds and averages 136.8 residents a day — about 92% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.30 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.22 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.93 hrs/resident/day on weekends vs 3.45 on weekdays — 15% thinner on weekends. RN hours go from 0.25 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 64% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-05-21 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review and interview, the facility failed to ensure Resident (R)5 was free from significant medication errors. Specifically, R5 was discharged from the hospital and admitted to the facility on [DATE], with physicians orders for seizure medications, the facility failed to administer the medication as ordered resulting in the resident experiencing seizure activity and being sent to the hospital, for 1 of 1 resident reviewed for significant medication errors. On 05/21/25 at 10:35 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 05/06/25. The IJ was related to 42 CFR 483.45 - Pharmacy Services. On 05/21/25 at 11:32 AM, the facility presented an acceptable plan of removal. On 05/21/25 at 1:30 PM, the survey team validated the facility's corrective actions and determined that the facility showed due diligence in addressing the noncompliance. The SA is considering this IJ at Past…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2023-04-19 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, facility document and policy review, the facility failed to protect seven (Resident (R)230, R44, R70, R91, R26, R37, and R39) of ten residents reviewed for abuse, from physical and/or psychosocial abuse perpetrated by another resident and/or staff member. Specifically, residents were not free from resident-to-resident physical abuse. Residents were slapped, hit, and/or pushed to the ground, with one resident (R91) being transported to the hospital for facial abrasions and chest wall tenderness, after being physically abused by another resident, who had previously physically abused two other residents. In addition, residents were not free from psychosocial abuse perpetrated by a Licensed Practical Nurse (LPN) who used a telephone to film and share images of cognitively impaired residents who could not give consent. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment, revised [DATE], revealed, The facility leadership…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-23 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review and interview, the facility failed to update and revise Resident (R)25's Care Plan to reflect the resident's election for Do Not Resuscitate (DNR) status for 1 of 3 residents reviewed.Findings include: Review of the facility policy titled Care Plan Process, Person-Centered Care with a complete revision date of [DATE], documented, The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident . Person-centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices . The services provided or arranged by the facility, as outlined by the comprehensive person-centered care plan, will meet professional standards of quality. Procedures: 6. The Interdisciplinary Team (IDT) will review for effectiveness and revise the person-centered care plan after each…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-23 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, observation, record review, and interview, the facility failed to maintain accurate narcotic medication records for 2 of 6 medication carts reviewed for medication storage. Findings include:Review of the facility policy titled Medication Management Program with a complete revision date of 05/05/23, revealed, Preparing for the Medication Pass: . 8. Documentation of medications administered is completed according to State and Federal requirements. The initials and verifying signature are generally required . Security and Safety Guidelines: . 9. Controlled substances are accounted for each patient/resident on a Controlled Substance Record (obtained from the contract pharmacy) . Administering the Medication Pass: . 11. Immediately after administering the medication to the resident, the authorized staff or licensed nurse will return to the medication cart and document medication administration with initials on the MAR.During a count of the narcotic medications in one medication cart on the 100 Hall, revealed seven instances of the count of Residents'…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-23 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the facility policy, observation, record review and interview, the facility failed to ensure a medication administration rate of less than 5 percent for 3 out of 29 opportunities for error. The medication administration error rate was 10.34 percent. Findings include:Review of the facility policy titled Medication Administration - Insulin Pen under Preparing the Pen documented, . 2. Removes the external pen cover and inspects the excessive air in the cylinder and that the internal screw mechanism is attached to the internal plunger. 3. Wipes the rubber stopper on the end of the pen with an alcohol pad. 4. Removes the tabbed paper seal from the outer cap of a new single-use safety insulin pen needle. 5. Screws the needle into the rubber stopper unit it stops . Priming the Pen: 1. Removes the outer needle cap and dials 2 units. 2. Points the pen up and presses the plunger button to expel 2 units of insulin. 3. Repeats these steps as needed until a drop of stream of insulin appears at the needle tip.Review of the facility policy titled Medication Administration,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-23 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the facility policy, observation and interview, the facility failed to ensure Resident (R)85 and R11 were free from significant medication errors related to insulin administration via a Kwik Pen, for 2 of 2 residents observed receiving insulin by Licensed Practical Nurse (LPN)1.Findings include:Review of the facility policy titled Medication Administration - Insulin Pen under Preparing the Pen states, . 2. Removes the external pen cover and inspects the excessive air in the cylinder and that the internal screw mechanism is attached to the internal plunger. 3. Wipes the rubber stopper on the end of the pen with an alcohol pad. 4. Removes the tabbed paper seal from the outer cap of a new single-use safety insulin pen needle. 5. Screws the needle into the rubber stopper unit it stops . Priming the Pen: 1. Removes the outer needle cap and dials 2 units. 2. Points the pen up and presses the plunger button to expel 2 units of insulin. 3. Repeats these steps as needed until a drop of stream of insulin appears at the needle tip.Review of R11's Face Sheet revealed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-23 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation, record review and interview, the facility failed to ensure the facility were free of pests in 3 resident rooms on 2 different units.Review of the facility policy titled Pest Control with a complete revision date of 06/20/23, documented, Facility will maintain an effective pest control program to prevent or eliminate infestation of pests and rodents. Review of a Service Report from Ecolab with a service date of 01/22/26, revealed, Inspected selected areas. Inspected and treated selected areas. Rooms serviced today: 113 331. Rooms maybe returned to service after sitting one hour and a thorough deep clean. PEST ACTIVITY FOUND. Further review of the Service Report revealed, AREA Patient/Guest Rooms - Interior - Interior FINDINGS Bed Bugs noted during treatment 311 ACTION NEEDED/TAKEN This area was inspected and serviced. The last section of the Service Report revealed, MATERIAL MATERIAL APPLIED: Finito QTY USED: 92.0 OZ REGULATORY NUMBER 25B APPLICATION TARGET PEST:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-03-01 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, kitchen cleaning schedule review, and facility policy review, the facility failed to ensure the kitchen floor was free of debris and kept clean in a sanitary condition and failed to ensure the kitchen deep fryer was kept clean in 1 of 1 kitchen. The deficient practice had the potential to affect all 143 residents in the facility who receive meals prepared in and served from the facility's kitchen. Findings include: Review of the facility's policy titled, Nutrition Policies and Procedures Sanitation & Food Safety in Food and Nutrition Services, dated 06/20/23, revealed The Certified Dietary Manager (CDM) will assume responsibility for the food safety and sanitation . The policy indicated, The CDM develops, implements, and monitors a cleaning schedule that assigns specific cleaning responsibilities to specific individuals. Cleaning tasks are initialed as they are completed .The CDM provides a cleaning schedule for each area and piece of equipment in the kitchen. During the initial kitchen observation on 02/25/25 at 6:00 PM, the entire kitchen floor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-01 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to ensure residents received their medications in a timely manner according to physician's orders for 6 residents (Resident (R)34, R46, R72, R97, R102, and R107). This failure had the potential to lead to unwarranted medication side effects or improperly treated medical conditions. Findings include: Review of the facility policy titled Medication Management Policy last revised 01/15/25 revealed Preparing for the Medication Pass .7. Medications are administered no more than one (1) hour before to one (1) hour after the designated the medication pass time . 11. Immediately after administering the medication to the resident, the authorized staff or licensed nurse will return to the medication cart and document medication administration with initials on the MAR. If a medication is not administered, the authorized staff or licensed nurse must explain why it was not given. During an observation on 02/27/25 at 5:54 PM, revealed Registered Nurse (RN)1 on the 200-hall medication cart preparing to administer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-01 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of facility policy, the facility failed to ensure: 1. staff used proper personal protective equipment (PPE) and/or performed hand hygiene with residents who required enhanced barrier precautions (EBP) for 2 residents (Resident (R)65 and R93), 2. proper sanitization of patient care equipment between uses for 2 (R35 and R1) residents, 3. Housekeeping staff used appropriated PPE and performed hand hygiene while cleaning rooms under EBP, and 4. immunization and education regarding the risks and benefits of the COVID-19 immunization was offered to 3 of 5 residents (Resident (R)62, R65, and R93) reviewed for COVID-19 immunizations out of a total sample of 33 residents. Failure to perform adequate infection control practices increased the risk of cross contamination and spread of infection. Findings include: 1. The facility staff failed to wear all required PPE and/or perform hand hygiene when caring for residents under EBP. Review of the facility's policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-01 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record reviews, and facility policy review, the facility failed to notify the physician for 1 resident's (Resident (R) 134) change in condition out of a sample of 33 residents. This failure delayed the physician in treating pressure ulcers. Findings include: Review of the facility's policy titled Documentation- Licensed Nursing revised 05/05/23 and provided by the facility indicated, . The initial evaluation of the patient/resident will be completed as soon as possible, but no later than 24 hours following admission or re-admission. Review of the facility's policy titled Wound care policies and procedures revised 06/01/15, and provided by the facility indicated, . Licensed Nurse performs a head to toe check of the patient's/resident's skin, . 2. Any significant abnormal findings are reported to the patient's/resident's physician . Review of the facility's policy titled Wound care policies and procedures reference revised 09/07/17, provided by the facility stated . Staff should remain alert to potential changes in the skin condition and should evaluate, report…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-01 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to complete a thorough investigation of an altercation for 2 of 7 residents (Resident (R)59 and R0) reviewed for abuse out of a total sample of 33 residents. Findings include: The Leadership Policies and Procedures addressing the Subject: Abuse, Neglect, Exploitation or Mistreatment, revised [DATE]. Under the subheading Component V: Reporting/ Response 2.) An analysis is completed to determine what changes are needed if appropriate, to prevent further occurrences. Component VI: Investigation, states The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc Are thoroughly investigated and appropriate actions are taken. Under 4.) Investigations are prompt, comprehensive, and responsive to the situation and contain founded conclusions. Review of R59's Face Sheet located in the electronic medical record (EMR) revealed R59 was admitted to the facility on [DATE], with multiple diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · D2025-03-01 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and facility policy review, the facility failed to implement care plans for 2 residents (Resident (R)80 and R93) out of a sample of 33 residents. This failure placed the residents to be at risk for unmet care needs. Findings include: Review of the facility's policy titled, Care Plan Process, Person-Centered Care revised 05/05/23 and provided by the facility stated, .The services provided or arranged by the facility, as outlined by the comprehensive person- centered care plan, will meet professional standards of quality .Thru ongoing assessment, the facility will initiate person-centered care plans when the resident's clinical status or change of condition dictates the need such as but not limited to falls . Review of the facility's policy titled, Person-Centered Care Plan revised 06/09/23 and provided by the facility stated, .The person-centered care plan is interdisciplinary and created to guide facility staff in providing the treatment, care, and services…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-01 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and facility policy review, the facility failed to ensure that care conferences were held for 2 of 4 residents (Resident (R)72, and R86) reviewed for care conferences of 33 sampled residents. The failure increased the risk of the resident's preferences and concerns not being included in the plan of care. Findings include: Review of the facility policy titled Care Plan Process, Person-Centered Care revised 05/05/23 indicated, .Person-centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Person-centered care includes trying to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and understanding the resident's life before coming to reside in the nursing home .The IDT [Interdisciplinary Team] will invite participation from the resident and the resident's legal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record reviews, and facility policy review, the facility failed to assess and monitor the nutritional status of 1 of 4 residents (Resident (R)46) reviewed for weight loss in a total sample of 33 residents. Findings include: Review of the facility policy titled Weighing the resident, revised on 02/26/24 stated .If the month-to-month weight shows more than a five-percent gain or loss, the patient/resident is reweighed in the presence of licensed personnel. 3. Record all weights per facility protocol. 4. If there is an actual 5% or more gain or loss in one month, notify the patient/resident/family, physician, and the Registered Dietician. Document this notification per facility protocol .9. Unplanned and undesired weight variance will be evaluated for significance utilizing the following guidelines: 3% in one week, 5% in 30 days, 7.5% in 90 days, and 10% in 180 days . Review of R46's undated Face Sheet located in the electronic medical record (EMR) under the Resident tab, revealed an admission date of 12/27/18 with a primary diagnosis of heart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the facility policy, record reviews and interviews, the facility failed to ensure 2 topical medications for wounds, were not left unattended in a dementia resident's room. Specifically, Dakin's Solution full strength and Remedy Barrier Creme were left in Resident (R)1's room unattended for an unknown amount of time for 1 of 2 residents reviewed for neglect. Findings include: Review of the facility policy titled, Medication Storage, General Guidelines for Storage of Medication and Biological's, states: Policy: 1. Medications and biological's are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. In accordance with State and Federal laws, the facility will store all drugs and biological's in locked compartments under proper temperatures and other appropriate environmental controls to preserve their integrity. 2. The Medication and biological supply is only accessible to licensed nursing personnel, pharmacy personnel or authorized staff members. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-04-08 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record reviews, document reviews, and facility policy review, the facility failed to protect the residents' right to be free from physical and verbal abuse perpetrated by staff for 2 (Resident (R)1 and R3) of 3 sampled residents reviewed for abuse. Findings included: A review of the facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment, revised on 10/23/2019, revealed, 1. The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately. The policy specified, 1. Abuse. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-08 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, document review, and facility policy review, the facility failed to timely report an allegation of physical abuse to the state survey agency for 1 (Resident (R)3) of 3 sampled residents reviewed for abuse. Findings include: The facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment, revised on 10/23/19, revealed, 2. The Facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. A review of R3's Resident Face Sheet revealed the facility admitted the resident on 01/10/22, with diagnoses that included chronic pain syndrome, osteoarthritis, and anxiety…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-04-19 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview, and review of facility policy, the facility failed to ensure foods stored in the refrigerator, freezer, and dry storage were labeled, dated, and sealed shut after opening. This failure had the potential to affect all 138 residents in the facility who consumed food from the kitchen. Findings include: Review of the facility's policy titled, Food Safety in Receiving and Storage, dated 08/01/2020, stated Place food that is repackaged in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. Label both the container and its lid with the contents, the date, and discard date .Refrigerated foods are to be properly covered, labeled, dated with a use-by date. On 04/17/23 at 10:13 AM, the following observations in the kitchen were made with and verified by the Dietary Manager (DM): 1. The dry storage room contained two bags of pasta, cereal, and confectionary sugar, which were not labeled when opened and/or dated with a use-by date. 2. The walk-in freezer contained one bag of chocolate chips and one bag of beef patties that were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-04-19 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview and review of the facility's policy and procedures, the facility failed to ensure that the laundry room provided space for separation of processing clean and dirty laundry; was free of trash on the floor, and that clean linen was properly covered from environmental contaminations from the open window and dusty fan. Findings include: During an observation of the laundry room on 04/19/23 at 11:45 AM to 12:15 PM, accompanied by the Housekeeping Supervisor, Laundry Aide and Maintenance Director the following conditions of the laundry room were noted and verified. The laundry room entrance door was not locked and was accessible from the 200 hall. One of the three resident halls. The laundry room had 5-6 open bins with clear plastic bags of dirty laundry to be processed. The two washing machines were located beside the binds. Clean clothing, that was uncovered, was hanging on a rack directly in front of the washing machines. There was a large trash bin 10-15-gallon size filled to the top, uncovered with disposable gowns, gloves and other items located…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-04-19 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interviews, the facility failed to maintain a clean homelike environment for 11(R118, R53, R36, R26, R115, R119, R39, R27, R59, R49, and R110) of 24 resident rooms toured during the survey conducted from 04/17/23 through 04/19/23. Findings include: During observations conducted on 04/17/23 through 04/19/23 from at 9:00 AM - 6:30 PM revealed: *R118's room the base boards were missing. *R53's walls were bare and not homelike, there was chipped paint, and patches of missing paint on walls and dirty curtains. *R36's walls were bare and not homelike, there was chipped paint, and patches of missing paint on walls, a long hole in wall, and dirty privacy curtains. *R26's walls were bare and not homelike, there was chipped paint, and patches of missing paint on walls, *R115's walls were bare, and not homelike. *R119's walls were bare, and not homelike, there was chipped paint, and patches of missing paint on walls. *R39's walls were bare, and not homelike, there was chipped paint, and patches of missing paint on walls. *R27's walls were bare, and not homelike,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-19 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to ensure for one Resident(R)46 of two residents reviewed for advanced directives had the decision-making capacity when explaining and signing the full code status. Findings include: Review of the facility's policy titled Advance Directives, dated [DATE], indicated This policy and procedure provides instructions to facility staff for obtaining, honoring, and implementing advance directives to the fullest extent of the law .Advanced Care Planning is a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions .Healthcare decision making refers to possessing the ability to make decisions regarding health care and related treatment choices .Upon admission to the facility and throughout the resident stay, the facility will determine the resident's decision-making…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-19 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure one Resident (R)112) of one resident reviewed for hospitalization, received a written bed hold policy upon emergent transfer to the hospital. Findings include: Review of the facility's policy titled Facility's Policy and State Requirements for Temporary Leave Bed-Hold, dated 06/2009, stated If a resident leaves the facility for temporary hospitalization or therapeutic leave, the resident or his/her representative may ask the facility to hold the resident's bed until the resident is ready to return (bed-hold). The resident and/or his/her representative will be given a copy of the facility's bed-hold policy before the resident actually leaves for his/her temporary leave or hospitalization. In the case of an emergency hospitalization, the bed hold policy may accompany the resident to the hospital or will be given to the resident or his/her legal representative within 24 hours of the resident's hospitalization. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure residents who were independent on staff for oral care, received services for one resident (R)53) of five residents reviewed for Activities of Daily Living (ADL) assistance. Findings include: Observation and interview on 04/17/23 at 12:36 PM of R53, resident stated he does not like the care he receives and has not received a shower in a couple of months, R53 could not specify a date. Observation of the R53 fingernails revealed they were long with brown color debris underneath. Observation on 04/19/23 at 9:44 AM of R53, the resident was observed with hair uncombed, and nails were long with dark color debris underneath. Review of R53's undated, Electronic Diagnosis List located in the electronic medical record (EMR), under the Diagnoses tab, included need for assistance with personal care, unspecified lack of coordination, and generalized muscle weakness. Review of R53's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab, with an Assessment Reference Data (ARD) dated 04/11/23 revealed R53's Brief…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-19 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to ensure that one of five residents (R69), reviewed for unnecessary medications, was free from unnecessary psychotropic medication use. R69's current medication orders included an as needed (PRN) anti-anxiety medication (Ativan) for more than 14 days without a stop date for reassessment of the resident's mental stability and continued need for the psychoactive medication. Findings include: Review of R69's quarterly Minimum Data Set (MDS) found under the MDS tab of the Electronic Medical Record (EMR), with an Assessment Reference Date (ARD) date of 02/23/23, revealed R69 had a Brief Interview for Mental status (BIMS) score of 15/15, indicating the resident is cognitively intact. R69 required supervision and minimal staff assistance with Activities of Daily Living (ADLs). The MDS documented zero behaviors exhibited by R69 for the seven-day assessment period. Additionally, the MDS documented R69 received antianxiety and antipsychotic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$16,985 in federal fines across 1 penalty.
- $16,985 — penalty dated 2025-05-21
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to FUNDAMENTAL HEALTHCARE — 66 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.4 | -1.4 vs chain |
| Health inspection | 2 of 5 | 2.5 | -0.5 vs chain |
| Staffing | 1 of 5 | 2.2 | -1.2 vs chain |
| Quality measures | 4 of 5 | 3.4 | +0.6 vs chain |
The other 65 homes this chain runs (chain average 2.4★, per CMS)
Showing 40 of 65; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PALMETTO HEALTH CARE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 06/18/2009 |
| TABLER, KENNETH | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 08/15/2015 |
| CHANG, BINYUE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2024 |
| FUNDAMENTAL ADMINISTRATIVE SERVICES LLC | Organization | ADP OF THE SNF | — | since 09/23/2006 |
| FUNDAMENTAL CLINICAL AND OPERATIONAL SERVICES, LLC | Organization | ADP OF THE SNF | — | since 09/23/2006 |
| HANLEY, KATELYN | Individual | ADP OF THE SNF | — | since 03/21/2023 |
CMS files one row per role, so the 9 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 80% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in SC
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the South Carolina Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 425169. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-23, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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