Oak Hollow of Georgetown Rehabilitation Center LLC
2715 South Island Road, Georgetown, SC 29440 · For profit - Limited Liability company · 84 certified beds · (843) 546-4123 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 a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 3 immediate-jeopardy problems — the most serious level
- the CMS record shows $10,312 in federal fines (most recent 2024-08-15)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
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) | 3 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 | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 improved from 1 to 2 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 | 19.0% | 11.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.1% | 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 | 0.4% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 3.1% | 6.5% | check this* — see note marked star 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 | 1.4% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 29.4% | 12.7% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 14.3% | 21.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 76.1% | 90.6% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 2.5% | 5.1% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.2% | 16.7% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.1% | 15.3% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 31.4% | 78.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 5.3% | 24.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 37.1% | 13.9% | 12.0% | check this† — see note marked dagger below the table |
| Long-stay hospitalizations per 1,000 resident days | 1.81 | 2.04 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.42 | 1.84 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
§ 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.
Therapy staffing: this home’s payroll records show 0.10 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 28% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.2%CMS range 7.6–18.1 | 10.7% | Oct 2022–Sep 2024 | no different from 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 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 | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.81 | 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 84 beds and averages 75.6 residents a day — about 90% occupied, or roughly 8 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 3.08 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.29 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.89 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 2.79 hrs/resident/day on weekends vs 3.20 on weekdays — 13% thinner on weekends. RN hours go from 0.33 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% is about the same as 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.
11 citations, most serious first — scroll within the box to see all.
- Immediate jeopardy · J2024-08-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 reviews, review of personnel files, interviews, and policy review, the facility failed to ensure care and services were provided in accordance with professional standards for 1 (Resident (R)77) of 3 closed records reviewed. Specifically, the facility failed to ensure nursing staff followed a resident's code status and physician order. The nursing staff performed Cardiopulmonary Resuscitation (CPR) on R77, even though the resident had selected Do Not Resuscitate (DNR). (Cross reference F835 and F867) On [DATE] at 8:45 PM, the facility's Administrator and Director of Nursing (DON) were informed that Immediate Jeopardy (IJ) existed related to the failure to provide sufficient administration to implement and monitor the facility system for communicating each residents' code status. The IJ began on [DATE], the date the Administrator failed to ensure the correct clinical operations related to code status. The IJ is related to 42 CFR 483.25 - Quality of Care. On [DATE] at 3:45 PM, the facility provided…
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.
- Immediate jeopardy · J2024-08-15 · tag F0835 — failed to run the facility competently — isolatedAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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, document review, job description review, staff interview and facility policy review, the facility Administrator failed to implement her job description to ensure the correct clinical operations related to resident's code status was followed. There is a potential for serious adverse outcomes because of the facility providing cardiopulmonary resuscitation (CPR) to a resident without confirming the code status, leading to possible injury. This also presents a risk for psychosocial harm related to end of life wishes for 1 of 1 resident (Resident (R)77) reviewed. (Cross reference F684 and F867) On [DATE] at 8:45 PM, the facility's Administrator and Director of Nursing (DON) were informed that Immediate Jeopardy (IJ) existed related to the failure to provide sufficient administration to implement and monitor the facility system for communicating each residents' code status. The IJ began on [DATE], the date the Administrator failed to ensure the correct clinical operations related to code…
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.
- Immediate jeopardy · J2024-08-15 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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, document review, staff interview, and facility policy review, the facility failed to take an adverse event to Quality Assurance and Performance Improvement (QAPI) for corrective action, specifically, on [DATE], facility nursing staff administered cardiopulmonary resuscitation (CPR) to 1 of 1 resident (Resident (R)77) who had a Do Not Resuscitate (DNR) order in the electronic medical record (EMR). There is a potential for serious adverse outcomes because of the facility providing CPR to a resident without confirming code status, leading to possible injury. This also presents a risk for psychosocial harm related to end of life wishes not being honored. (Cross reference F684 and F867) On [DATE] at 8:45 PM, the facility's Administrator and Director of Nursing (DON) were informed that Immediate Jeopardy (IJ) existed related to the failure to provide sufficient administration to implement and monitor the facility system for communicating each residents' code status. The IJ began on [DATE], 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 · Dcited before2025-08-28 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Number of residents sampled: 1Number of residents cited: 1Based on observation, interview, record review, facility document and policy review, and review of Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS) guidelines, the facility failed to follow enhanced barrier precautions (EBP) for 1 (Resident (R)6) of 1 resident observed during direct patient care. Specifically, Certified Nursing Assistant (CNA)7 did not don a gown while bathing R6, who had a feeding tube. Findings include: A facility policy titled, Enhanced Barrier Precautions, revised 07/31/2024, indicated, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The policy also indicated, Policy Explanation and Compliance Guidelines: 1. Prompt recognition of need: a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. The policy also indicated, 3. Implementation of Enhanced Barrier…
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 · F2024-08-15 · tag F0847 — widespreadInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on document review and interview, the facility failed to ensure the Addendum One-Arbitration Agreement located in the facility's admission packet contained all the fundamental requirements particularly indicating admission to the facility was not predicated on the resident signing the agreement and that the resident had thirty days to rescind the decision to sign the agreement. This failure has the potential to cause negative legal ramifications for all residents that signed the agreement due to the agreement not containing the regulated information. Findings include: Review of the undated facility Addendum One- Arbitration Agreement revealed the agreement did not contain information stating the resident did not have to sign the agreement for them to be admitted to the facility. In addition, instead of indicating the resident or representative has thirty days to rescind the agreement, the facility agreement stated, this Arbitration Agreement may be rescinded by written notice to the Facility from the Resident or Authorized Representative within three (3) business days 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 · Ecited before2024-08-15 · 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, document review, and facility policy review, the facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) while providing direct care for 2 of 3 residents (Resident (R)6 and R39) reviewed for Enhanced Barrier Precautions (EBP) of 21 sample residents. This failure could promote the spread of multi drug resistant organisms throughout the facility. In addition, the facility failed to ensure that the glucometer was cleaned according to manufacturer instructions for 1 of 2 residents (R58) of 21 sample residents. This failure has the potential to promote cross contamination between residents. Findings include: Review of facility's policy titled, ''Enhanced Barrier Precautions,'' revised 07/31/24, revealed, ''It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms . Policy Explanation and Compliance Guidelines . 2. Initiation of Enhanced Barrier…
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 · D2024-08-15 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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 and interviews, the facility failed to provide written notification to the resident, resident representative, and the Ombudsman, when the facility initiated a transfer/discharge for 2 of 3 residents (Resident (R)24 and R31) reviewed for hospitalization. Findings include: 1. Review of R24's Face Sheet found under the Profile Tab in the electronic medical record (EMR) revealed the resident was originally admitted to the facility on [DATE]. Review of R24's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/12/24, in the EMR under the MDS tab revealed the resident has a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. Review of R24's EMR revealed a Progress Note dated 07/01/24 at 8:32 AM, under the Progress notes tab indicated R24 was transferred to the hospital via EMS [Emergency Medical Services], due to nausea and vomiting. A subsequent note on 07/01/24 at 8:32 PM, indicated R24 was…
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 · D2024-08-15 · 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 observations, record review, staff interview, and facility policy review, the facility failed to ensure 1 (Resident (R)26) of 3 residents reviewed for falls conducted a root cause analysis of each fall and appropriate interventions to help prevent further falls. These failures resulted in repeated falls after R26 returned to the facility from the hospital from a previous fall on 07/21/24. Findings include: Review of the undated facility policy titled, Falls and Fall Risk, Managing revealed, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . Resident-Centered Approaches to Managing Falls and Fall Risk . if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . Monitoring Subsequent Falls and Fall Risk . The staff will…
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 · D2024-08-15 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 facility policy review, the facility failed to ensure that 1 of 1 resident (Resident (R)27) reviewed for side rail usage had required documentation completed prior to the use of the side rails and quarterly thereafter as long as the side rails were used. Findings include: Review of facility's undated policy titled ''Proper Use of Side Rails,'' revealed, ''The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms . General Guidelines . 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. bed mobility; b. ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. risk of entrapment from the use of side rails; and that 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 · D2022-09-02 · 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 review of the facility policy, record review, and interviews, the facility failed to ensure an allegation of abuse was reported to the State Survey Agency (SSA) within two hours as required for 1 (Resident (R)226) of 5 sampled residents reviewed for abuse. Specifically, on 04/04/22, R226 made an allegation of abuse; however, the facility did not report the allegation of the abuse to the SSA until 04/25/22. Findings include: Review of an undated facility policy titled, Abuse Prevention Program revealed that, as a part of the resident abuse prevention efforts, the facility's administration would, Investigate and report any allegations of abuse within timeframes as required by federal requirements. Review of an admission Record revealed R226 had diagnoses of end stage renal disease, type 2 diabetes mellitus, peripheral vascular disease, dementia, and hypertension. Review of a quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/14/22, revealed R226 had a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderate…
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 · D2022-09-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the facility's written procedure for tracheostomy care, record review, and interview, the facility failed to ensure a drain sponge (dressing) was in place around Resident (R)68's tracheostomy insertion site as ordered by the physician. This deficient practice affected R68, 1 of 2 sampled residents reviewed for respiratory care. Findings include: Review of an undated facility procedure titled, Tracheostomy Care revealed staff were to apply a fenestrated gauze pad (a gauze pad with a split or opening) around the insertion site. Review of an admission Record revealed R68 had diagnoses including tracheostomy status and acute and chronic respiratory failure. Review of a care plan, dated as revised 02/07/22, revealed R68 had a tracheostomy related to a diagnosis of chronic respiratory failure. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/05/22 revealed R68 was severely impaired in cognitive skills for daily decision making per a staff assessment of mental status. According to the MDS, R68 required extensive assistance with…
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
$10,312 in federal fines across 2 penalties.
- $5,156 — penalty dated 2024-08-15
- $5,156 — penalty dated 2024-08-15
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 REGIONAL HEALTH PROPERTIES — 5 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 | 2 of 5 | 1.4 | +0.6 vs chain |
| Health inspection | 2 of 5 | 1.6 | +0.4 vs chain |
| Staffing | 3 of 5 | 1.8 | +1.2 vs chain |
| Quality measures | 4 of 5 | 2.2 | +1.8 vs chain |
The other 4 homes this chain runs (chain average 1.4★, per CMS)
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 | Since |
|---|---|---|---|
| RHP OPERATIONS HOLDINGS, LLC | Organization | DIRECT OWNERSHIP INTEREST | since 05/01/2025 |
| REGIONAL HEALTH PROPERTIES INC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 05/01/2025 |
| 2014 HUD MASTER TENANT, LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 05/01/2025 |
| MORRISON, BRENT | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2025 |
| TAYLOR, KEN | Individual | MANAGING CONTROL - GOVERNING BODY | since 05/01/2025 |
| TENWICK, DAVID | Individual | MANAGING CONTROL - GOVERNING BODY | since 05/01/2025 |
| CRAVEN, ROBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2025 |
| FLANSBURG, CHRISTINE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2025 |
CMS files one row per role, so the 14 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
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 425048. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-28, 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 →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.