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Southpointe Healthcare and Rehabilitation

35 Southpointe Drive, Greenville, SC 29607 · For profit - Corporation · 120 certified beds · (864) 288-1415 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent Jun 2026Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$14,433 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Jun 2026
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • 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 (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,433 in federal fines (most recent 2024-04-12)
  • its payroll-based staffing rating is low (1/5)

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
35 Southpointe Dr · (864) 288-1415 · Call to confirm hours
Pharmacy
1750 Woodruff Rd · (864) 987-7086 · Call to confirm hours
Grocery
Lidl0.1 mi
1866 Woodruff Rd · (888) 654-3515 · Call to confirm hours
Park
Asheton0.8 mi
Asheton Way , Simpsonville, SC 29681, United States · Typically dawn to dusk
Place of worship

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 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 2 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.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased3.7%11.9%15.4%better
Long-stay residents who lose too much weight5.3%6.3%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.2%1.3%2.0%better
Long-stay residents with depressive symptoms0.0%3.1%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.5%3.2%3.3%worse
Long-stay residents whose ability to walk worsened3.9%12.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication30.0%21.0%18.9%worse
Long-stay residents given the seasonal flu vaccine95.5%90.6%95.3%typical
Long-stay residents with pressure ulcers4.5%5.1%4.7%typical
Long-stay residents with worsening bladder/bowel control9.1%16.7%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table15.1%15.3%17.1%better
Short-stay residents who newly got an antipsychotic medication3.2%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine80.9%78.0%79.4%typical
Short-stay residents rehospitalized after admission27.3%24.3%22.6%worse
Short-stay residents with an outpatient ER visit23.5%13.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.262.041.67worse
Long-stay outpatient ER visits per 1,000 resident days2.681.841.80worse

* 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.

§ 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.

47.7% 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 46 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.7%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
65.7%U.S. median 56.6%
Met the expected recovery
0.15U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 65.7% 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 35 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 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF47.7%CMS range 34.3–59.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 7.0–15.210.7%Oct 2022–Sep 2024no 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 discharge65.7%56.6%Oct 2024–Sep 2025CMS 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 discharge57.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge51.4%50.0%Oct 2024–Sep 2025CMS 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 identified98.3%98.7%Oct 2024–Sep 2025CMS 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 setting95.2%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.8%CMS range 4.4–12.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.051.02Oct 2022–Sep 2024CMS 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

0.24
RN hours/ resident / day
1.05
LPN hours/ resident / day
1.85
Aide hours/ resident / day
3.14
Total nurse hours/ resident / day
0.14
RN hoursweekends
53.2%
Total nursing turnover
57.1%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 111.2 residents a day — about 93% occupied, or roughly 9 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 3.14 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.24 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 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 2.63 hrs/resident/day on weekends vs 3.35 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.27 to 0.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

3
deficiencies at the latest standard inspection (2026-03-27)
0
at the previous standard inspection (2025-03-07)

Deficiencies are more than at the previous inspection — worsening. 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.

ABCDEFGHIJKL

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.

23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.

  • Immediate jeopardy · J2024-04-12 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 review of facility policy, record review, interviews, and review of video footage, the facility failed to protect Resident (R)1 from mental and verbal abuse for 1 of 3 residents reviewed for abuse. Specifically, 2 (two) Certified Nursing Assistants (CNA)s video recorded their interaction with R1 and posted the video to social media. On 04/12/24 at 12:45 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 04/09/24. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 04/12/24 at 1:19 PM, the facility provided an acceptable IJ Removal Plan. On 04/12/24, the survey team, validated the facility's corrective actions and determined the facility put forth good faith attempts to address the non-compliance. The IJ is considered at Past Non-Compliance as of 04/10/24. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Immediate jeopardy · Kcited before2023-07-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure 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 The facility admitted R70 on 05/23/2023 with diagnoses including, but not limited to, physical debility, muscle weakness, alcoholic cirrhosis of the liver, muscle wasting and atrophy of the left and right hand, chronic pain, alcohol abuse and nicotine dependence. Review on 07/10/2023 at 12:10 PM of the medical record for R70, revealed sign out sheets for leave of absence starting on 06/14/2023 through 07/09/2023. R70 went out to smoke, signing a leave of absence 40 times during that period of time. He only signed back in 16 times. There is no documentation to ensure the smoking supplies were taken from the resident and secured in a locked area or compartment any of the 40 days. On 06/16/2023, R70 signed out, leave of absence at 9:23 AM to smoke and signed back in on 06/16/2023 at 8:20 PM. On 06/19/2023, R70 signed out, leave of absence to smoke and signed back in at 8:00 PM. Review on 07/10/2023 at 1:25 PM of a form titled, Authorizations, Consents, & Acknowledgements, revealed, Policies. The policies include:…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-29 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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, observation, and interview, the facility failed to properly assess Resident (R)1 for the appropriateness of the self-administration of prescription chlorhexidine mouthwash, for 1 of 3 residents reviewed. Findings include:Review of the facility policy titled Self-Administration of Medications with a revision date of 04/17/24, revealed, Policy: The resident may choose to self-administer medication(s) according to applicable state and federal law and regulation upon completion of an assessment by the Interdisciplinary Care Team (IDT). Procedures: 1. A Resident choosing to self-administer medications will be assessed and evaluated by the Interdisciplinary Care Team (IDT) in order to determine if it is safe for him/her to self-administer medication. Review of R1's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses included, but not limited to, dental caries (cavities), hemiplegia (paralysis on one side of the body) affecting her right…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-29 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, record review, observation, and interview, the facility failed to ensure resident health information was properly concealed from unauthorized viewing during a random observation of medication administration.Findings include:Review of the facility policy titled Safeguarding Electronic Protected Health Information with an email revision date of 04/29/22, revealed, Procedures: . 1. F. Access to electronic protected health information is limited to employees who need the information for treatment, payment or facility operations purposes. H. Employees log off the network or, at a minimum, lock their workstation when leaving the work area.During a random observation on 06/29/26 at 11:25 AM, revealed an unattended medication cart that was unlocked with the narcotics book open and the computer showing a resident's information, clearly visible. Registered Nurse (RN)1 verified this observation. During an interview on 06/29/26 at 11:26 AM, RN1 revealed the medication cart should have been locked, and the narcotics book and the computer should have been…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-29 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    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, interview and record review, the facility failed to ensure Resident (R)12's right to be free from misappropriation of resident property by failing to prevent or protect the resident's three rings from being taken without the resident's consent. This deficient practice was identified in 1 of 4 residents reviewed for misappropriation of property.Findings include:Review of the facility's policy titled Abuse, Neglect, Exploitation, or Mistreatment, revised on 11/01/17, revealed that the facility's leadership prohibits neglect, mental, physical, and verbal abuse, involuntary seclusion, corporal punishment, and misappropriation of a resident's property or funds. The policy states that alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of resident property must be reported immediately. The policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful temporary or…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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

    Based facility policy review, observation, and interview, the facility failed to ensure housekeeping chemicals were securely locked and stored outside of resident areas. Findings include:Review of the facility's Maintenance/Housekeeping policy titled Micro-organisms with an original date of 03/2006, revealed, Maid Carts: . 4. Never leave maid carts unattended with chemicals exposed for patient/resident safety. Chemicals should be kept with housekeeper. During a random observation on 06/29/26 at 11:20 AM, revealed two housekeeping carts unattended in the Resident lounge of the 100 Hall. Six residents were noted to be seated in the lounge watching tv. Both housekeeping carts were unlocked and contained a liquid smelling of bleach in the mop bucket. Inside the unlocked compartment of the first cart was a can of air freshener. A bottle of liquid soap was on the lower shelf. Inside the unlocked compartment of the second cart was: Tylex spray, Xotic Team air freshener spray, Pure Bright RTU germicidal spray, and Glass cleaner spray. Both Housekeeping Aide (HA)1 and HA2 verified 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-29 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 facility policy review, record review, observation, and interview, the facility failed to ensure medication was discontinued after the physician's ordered end date. Specifically, the facility failed to remove chlorhexidine mouthwash from Resident (R)1's bedside, for 1 of 3 residents reviewed. Findings include:Review of the facility policy titled Self-Administration of Medications with a revision date of [DATE], revealed, Procedures: . 4.G. The nursing staff will rotate bedside stock and will remove expired, discontinued, or recalled medications. Review of R1's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses included, but not limited to, dental caries (cavities), hemiplegia (paralysis on one side of the body) affecting her right dominant side, visual loss in the right eye, cognitive communication deficit, and personal history of traumatic brain injury. Review of R1's active orders did not show a current order for chlorhexidine mouthwash. Review of R1's Medication…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-29 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based facility policy review, record review, observation, and interview, the facility failed to ensure medication was properly and securely stored during two random observations. Findings include:1. Review of the facility policy, Medication Management Program with an email revision date of 01/15/25, revealed, Security and Safety Guidelines: . 3. The medication cart is locked when not in use and in direct line of sight.During a random observation on 06/29/26 at 11:25 AM, revealed an unattended medication cart that was unlocked with the narcotic book open. Registered Nurse (RN)1 verified the observation. During an interview on 06/29/26 at 11:26 AM with RN1, she revealed the medication cart should have been locked. She stated she was going back and forth to a resident's room giving the resident her medications. RN1 revealed she was going back and forth from the cart to the room to look at the resident's information and she forgot to lock the cart and close the narcotics book and computer. During an interview on 06/29/26 at 11:26 AM, the Unit Manager (UM)1 verified the medication cart…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 facility policy review, record review, observation, and interview, the facility failed to ensure staff provided nail care to residents unable to carry out activities of daily living (ADLs), which affected 1 (Resident (R)87) of 2 residents reviewed for ADL assistance. Findings included: Review of a facility policy titled, Activities of Daily Living, Optimal Function, revised 05/05/2023, indicated, The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene. Review of a Resident Face Sheet revealed the facility admitted R87 on 02/09/24. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of depression, chronic obstructive pulmonary disease, hypotension, and unspecified intellectual disabilities. An Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/15/2026, revealed R87 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-27 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents were free from significant medication errors, which affected 1 (Resident (R)10) of 8 residents reviewed for medication administration. Findings included: A facility policy titled, Medication Management Program, revised 05/05/25, revealed, The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements. The policy also indicated, Preparing for Medication Pass included, 4. Authorized staff must understand: A. Indications or reason for therapy, B. Effectiveness for achieving therapeuticgoal [sic], C. Drug actions, and D. The '8 Rights' for administering medication, which included 1) The Right Patient/Resident, 2) The Right Drug, 3) The Right Dose, 4) The Right Time, 5) The Right Route, 6) The Right Charting, 7) The Right Results, and 8) The Right Reason. The policy revealed, Administering the Medication Pass included, 5. The authorized staff…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-27 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review, record review, observation, and interview, the facility failed to ensure staff provided food that accommodated residents' food allergies and preferences, which affected 1 (Resident (R)110) of 1 resident reviewed for food concerns. Findings included: A facility policy titled Food Preferences; Diet History, revised 10/15/25, indicated, Food Preferences will be completed upon admission for each patient/resident and documented in the medical record. The policy indicated Procedures included, D. If the preference list is not completed on or prior to admission, the Certified Dietary Manager (CDM) or designee reviews and updates food preferences with the patient/resident within 72 hours of admission as part of the initial patient/resident visit and documents in the medical record, and G. The CDM refers to the preferences list when making the tray ticket and when collecting data. A Resident Face Sheet indicated the facility admitted R110 on 03/03/26. According to the Resident Face Sheet, the resident had a medical history that included diagnoses 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-23 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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, record review, interviews, facility policy and the Department of Health and Human Services Centers for Medicare & Medicaid Services pathway, the facility failed to maintain infection prevention and control practices for 1 of 1 residents reviewed for colostomy care, Resident (R)1. Findings include: Review of the Department of Health and Human Services Centers for Medicare & Medicaid Services Infection Prevention, Control & Immunizations Pathway, dated 8/2024 Enhanced Barrier Precautions (EBP): EBP use is evaluated when investigating specific care activities, such as wound care, enteral feeding, urinary catheter care, etc. EBP are indicated during high contact care activities for residents with infection or colonization with a CDC targeted MDRO (when contact precautions do not apply) or for any resident who has a chronic wound and/or indwelling medical device.High-contact resident care activities include dressing, bathing/showering, transferring, toileting, providing hygiene, changing linens…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · D2024-02-08 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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 record review and review of facility's weight policy, titled Weighing the Resident, the facility failed to provide documentation that Resident (R)1 had a 5 % or more weight loss with reviews by facility's dietitian regarding nutritional status with recommendations for interventions for 1 of 1 resident reviewed for weight loss. Findings include: Review of the facility policy titled, Weighing the Resident with a revision date of 5/5/23 indicates; 3. Record all weights on the Monthly Weight form or 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 Nutrition/Culinary Services Director. Document this notification per facility protocol. 5. The facility dietitian reviews the patient's/resident's nutritional status and makes recommendations for intervention in the nutritional progress notes if significant weight change is noted. 6. Review significant, unplanned changes and insidious gradual weight loss or gain trends in weights at the weekly Long-Term Care Coordination meeting. 7. Update 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-07-12 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    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 the facility policy titled, Medication Storage, observations, and interviews, the facility failed to ensure 1 of 4 medication carts and 1 of 1 treatment carts was locked and secured away from ambulating residents. The facility further failed to ensure expired medications were removed from 4 of 4 medication carts, 1 of 2 med storage rooms, and 1 of 1 treatment carts. The findings included: Review of the facility's policy titled, Medication Storage, revealed 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. The medication and biological supply is only accessible to licensed nursing personnel, pharmacy personnel or authorized staff members. Procedures: Number 5 states, Medications 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 interview, observation, and record review the facility failed to ensure that 1 Resident (R)69 out 3 residents dressings were changed according to the physician's orders. In addition, the facility failed to ensure that the wound care was provided as physician ordered for 1 (R40) of 3 residents reviewed for wound care. Specifically, R40 did not receive wound care on 07/07/2023. Findings Include: A review of the facility's policy, Wound Care Policy and Procedures, revised on 06/01/2015 revealed the cover dressing should have a date, time, and initial on it. A review of Resident 69's Face Sheet revealed the facility admitted the resident with diagnoses which included Type 2 diabetes mellitus, other encephalopathy, gastrostomy status, pressure ulcer of other site unstageable, pressure ulcer of left heel unstageable, dementia, diabetic neuropathy, and chronic diastolic congestive heart failure. A review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed R69 had a Brief Interview for Mental Status…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-12 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility policy, observations, interviews, and record review, the facility failed to maintain a resident's dignity during meal service for 1 (Resident (R)40) of 6 residents reviewed for dignity. Findings include: A review of a facility policy titled Patient/resident Rights, revised 10/01/2020, indicated, the facility employs measures to ensure patient and resident personal dignity, well-being, and self-determination are maintained and will educate patients and residents regarding their rights and responsibilities. The facility treats each resident with respect and dignity. The facility provides care for each resident in a manner that promotes, maintains, or enhances quality of life, recognizing each resident's individuality. A review of a facility policy titled Nutrition Policies and Procedures, revised 08/01/2020, indicated, Subject: Meal Delivery; Policy: Nursing and Culinary staff will work together to enhance the quality of the dining experience. Satisfaction with the dining experience leads to an improved appetite and can enhance quality of life.…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-12 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 interviews, record review, and facility policy review, the facility failed to develop a comprehensive person-centered care plan for 2 (Resident (R)69 and R71) of 22 residents whose comprehensive care plans were reviewed. Specifically, the facility failed to develop a comprehensive care plan for R69 for a diagnosis of diabetes and R70 for smoking. Findings include: Review of the facility's policy titled, Care Plan Process, Person-Centered Care revised on 05/05/23 indicated, 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 that meet professional standards of quality care. 1. A review of R69's Face Sheet revealed the facility admitted the resident with diagnoses which included but was not limited to; type 2 diabetes mellitus, other encephalopathy, gastrostomy status, major depressive disorder, pressure ulcer of other site unstageable, pressure ulcer of left…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 review of facility policy, record reviews and interviews, the facility failed to ensure Resident (R)13 was provided care and services daily related to bathing for 1 of 3 residents reviewed for activities of daily living (ADLs). Findings include: Review of the facility's policy titled Nursing Policies and Procedures, Subject: Activities of Daily Living, Optimal Function, Complete Revision: May 5, 2023 Definition: Activities of daily living (ADL's), refer to tasks related to personal care including grooming, dressing, oral hygiene, transfer, bed mobility, eating, bathing and communication system. Review of R13's Face Sheet revealed the facility admitted R13 with diagnoses including, but not limited to, cellulitis of the right lower limb, candidal stomatities, morbid obesity, and need for assistance with personal care. During an interview on 07/09/23 at 1:23 PM, R13 stated that the facility staff were not providing the care and services she needed for bathing, changing, and to get dressed in clean clothes daily. Review of R13's electronic medical record (EMR) revealed a plan…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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

    Based on review of facility policy, observation, interview, and record review the facility failed to ensure blood glucose was monitored while a resident was prescribed insulin for 1 resident (R69) out of 3 residents reviewed with a diagnosis of diabetes. Findings include: A review of the facility's policy titled Blood Glucose Monitoring revised on 05/05/23 revealed The facility provides point of care blood glucose monitoring according to standards of practice and infection prevention and control principles. Review of Resident 69's Face Sheet revealed the facility admitted R69 with diagnoses which included but was not limited to; type 2 diabetes mellitus, other encephalopathy, gastrostomy status, major depressive disorder, pressure ulcer of other site unstageable, pressure ulcer of left heel unstageable, dementia, diabetic neuropathy, overactive bladder, and chronic diastolic congestive heart failure. Review of R69's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/23, revealed R69 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-12 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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 and record review the facility failed to ensure ongoing communication, assessment of the resident's condition, and monitoring for complications before and after dialysis treatment for 1 Resident (R)72, of 1 reviewed for dialysis. Findings include: A review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed R72 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated the resident had a severe cognitive impairment. The MDS also revealed the resident received dialysis treatments three times a week. Review of R72's comprehensive care plan initiated on 06/23/2023 revealed the resident received dialysis. Interventions to include dialysis three times a week and was at risk for increases shortness of breath, chest pain, nausea and vomiting, itchy skin, and an infected access site. Review of R72's physician's orders dated 03/08/2023 revealed the resident attended hemodialysis on Monday, Wednesday, and Friday with a chair time of 10:45 AM. During record review for…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-12 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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 interview and record review, the facility failed to monitor for behaviors and adverse effects for 1 of 5 residents reviewed for unnecessary medication. Resident (R)61 was ordered Seroquel (an antipsychotic medication) 100 mg every evening and 50 mg every day. The facility did not monitor R61 for behaviors the medications were meant to treat or possible adverse effects the medications may have had. Findings include: Review of policy titled, Pharmacy Services Policies and Procedures, revised on 04/01/2022, revealed that The facility will monitor and document the resident's response to psychotropic medication for efficacy and adverse consequences. Monitoring includes symptoms / behaviors / or side effects, progress toward the therapeutic goals, adverse consequences, and effectiveness of non-pharmacological approaches. R61 was admitted to the facility on [DATE] with diagnoses including, but not limited to, dementia without behavioral disturbance, primary insomnia, muscle weakness, generalized 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-12 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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, the package insert for Flonase, observations, and interviews, the facility failed to ensure a medication error rate, during med pass, less than five (5) percent. The med error rate is 19.23%. The findings included: Review of the facility policy titled, Medications Administration - Insulin Pen, states under preparing the pen: 2. Remove the external pen cover and inspect the excessive air in the cylinder and ensure the internal screw mechanism is attached to the internal plunger. 3. Wipe the rubber stopper on the the end of the pen with an alcohol pad. 5. Screw the needle into the rubber stopper until it stops. Priming the Pen: 1. Remove the outer needle cap and dials 2 units. 2. Point the pen up and press the plunger button to expel 2 units of insulin. 3. Repeat these steps as needed until a drop or stream of insulin appears at the needle tip. 4. Shake the insulin off the needle top. Setting the dose selector clockwise to proper dosage. Review of the facility policy titled, Medication Administration, states: 2. Compares medication label 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-12 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure 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, observations, and interviews, the faciliy failed to ensure Resident (R)90, R21 and R46 were free from significant medication errors during medication administration on 07/11/2023. Findings include: Review of the facility policy titled, Medications Administration - Insulin Pen, revealed under preparing the pen: 2. Remove the external pen cover and inspect the excessive air in the cylinder and ensure the internal screw mechanism is attached to the internal plunger. 3. Wipe the rubber stopper on the the end of the pen with an alcohol pad. 5. Screw the needle into the rubber stopper until it stops. Priming the Pen: 1. Remove the outer needle cap and dials 2 units. 2. Point the pen up and press the plunger button to expel 2 units of insulin. 3. Repeat these steps as needed until a drop or stream of insulin appears at the needle tip. 4. Shake the insulin off the needle top. Setting the dose selector clockwise to proper dosage. Review of the facility policy titled, Medication Administration, states: 2. Compares medication label with order transcribed…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$14,433 in federal fines across 1 penalty.

  • $14,433 — penalty dated 2024-04-12

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 →

RatingThis homeChain avg
Overall 2 of 52.4-0.4 vs chain
Health inspection 3 of 52.5+0.5 vs chain
Staffing 1 of 52.2-1.2 vs chain
Quality measures 3 of 53.4-0.4 vs chain
The other 65 homes this chain runs (chain average 2.4★, per CMS)
1 of 5Avir at MemorialDenison, TX 1 of 5Bennettsville Health And Rehabilitation CenterBennettsville, SC 1 of 5Calhoun Convalescent CenterSaint Matthews, SC 1 of 5Corinth Rehabilitation Suites on the ParkwayCorinth, TX 1 of 5Forest Haven Nursing And Rehabilitation CtrCatonsville, MD 1 of 5Julia Manor Nursing And Rehabilitation CenterHagerstown, MD 1 of 5Lake Emory Post Acute CareInman, SC 1 of 5Magnolia Manor - GreenwoodGreenwood, SC 1 of 5Magnolia Manor - InmanInman, SC 1 of 5Magnolia Manor - Rock HillRock Hill, SC 1 of 5Northampton Manor Nursing And Rehabilitation CenteFrederick, MD 1 of 5Oakbrook Health And Rehabilitation CenterSummerville, SC 1 of 5Oakland Nursing & Rehabilitation CenterOakland, MD 1 of 5Physical Rehabilitation And Wellness Center Of SpaSpartanburg, SC 1 of 5Riverside Health and RehabCharleston, SC 1 of 5San Gabriel Rehabilitation and Care CenterRound Rock, TX 1 of 5Springdale Healthcare CenterCamden, SC 2 of 5Berlin Nursing And Rehabilitation CenterBerlin, MD 2 of 5Bremond Nursing and Rehabilitation CenterBremond, TX 2 of 5Fairfield Nursing & Rehabilitation CenterCrownsville, MD 2 of 5Faith Healthcare CenterFlorence, SC 2 of 5Falcon Ridge RehabilitationHutto, TX 2 of 5Hillside Heights Rehabilitation SuitesAmarillo, TX 2 of 5Horizon Health And Rehabilitation CenterLas Vegas, NV 2 of 5Lancaster Health and RehabilitationLancaster, SC 2 of 5Las Ventanas De SocorroSocorro, TX 2 of 5Magnolia Manor - GreenvilleGreenville, SC 2 of 5Midlands Health & Rehabilitation CenterColumbia, SC 2 of 5Mira Vista CourtFort Worth, TX 2 of 5Moran Nursing And Rehabilitation CenterWesternport, MD 2 of 5North Las Vegas Care CenterNorth las Vegas, NV 2 of 5Pavilion at Glacier ValleySlinger, WI 2 of 5Sandy Lake Rehabilitation And Care CenterCoppell, TX 2 of 5Spanish Hills Wellness SuitesLas Vegas, NV 2 of 5Terra Bella Health and Wellness SuitesHouston, TX 2 of 5The Pavilion At CreekwoodMansfield, TX 2 of 5Villa Rosa Nursing And Rehabilitation, LLCMitchellville, MD 3 of 5Bridgecrest Rehabilitation SuitesHouston, TX 3 of 5Crimson Heights Health & WellnessHumble, TX 3 of 5Devlin Manor Nursing And Rehabilitation CenterCumberland, MD

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 / managerTypeRoleShareSince
THI OF SOUTH CAROLINA, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL100%since 08/30/2003
CARROLL, RAVAUNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/15/2025
FUNDAMENTAL ADMINISTRATIVE SERVICES LLCOrganizationADP OF THE SNFsince 08/30/2003
FUNDAMENTAL CLINICAL AND OPERATIONAL SERVICES, LLCOrganizationADP OF THE SNFsince 08/30/2003
FORGIONE, LISAIndividualADP OF THE SNFsince 05/01/2021

CMS files one row per role, so the 7 rows in the source record cover these 5 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.

$10.9M
Net patient revenuemost recent cost report
-1.5%
Operating marginrevenue minus expenses
$618K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 81%Medicare 8%Other / private 11%

About 81% 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 $618K paid to related parties (affiliated landlords or management companies) in its most recent 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

$286per resident / day
operating cost
$8,692per month
≈ monthly operating cost
$282per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in South Carolina
$9,034/mo
Nursing home (semi-private)
$9,612/mo
Nursing home (private)
$5,350/mo
Assisted living

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 425361. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-27, 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.

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