West Village Post Acute
8 North Texas Avenue, Greenville, SC 29611 · For profit - Limited Liability company · 132 certified beds · (864) 295-1331 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2022
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- 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
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing 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) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 improved from 2 to 3 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 | 5.8% | 11.9% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.5% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.9% | 3.1% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.8% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 7.0% | 12.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 31.0% | 21.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.4% | 90.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.5% | 5.1% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 24.1% | 16.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.5% | 15.3% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.4% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 40.0% | 78.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 23.2% | 24.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 13.0% | 13.9% | 12.0% | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
42.1% 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 28 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 47% 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 | 42.1%CMS range 29.7–54.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.6%CMS range 6.8–17.1 | 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 — 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 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 | 1.01 | 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 132 beds and averages 124.5 residents a day — about 94% 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 3.28 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.54 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 2.84 hrs/resident/day on weekends vs 3.46 on weekdays — 18% thinner on weekends. RN hours go from 0.56 to 0.49 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%.
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 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.
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 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · G2022-10-13 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review, and interviews, the facility failed to ensure 1 Resident (R)59 of 8 residents reviewed for abuse was free from abuse. This deficient practice resulted in physical harm to R59 when R274 entered R59's room, while the resident was in bed, and punched her in the face. R59 sustained fractures of the zygomatic arch (cheekbone) and orbital area (eye socket). Findings include: Review of the facility policy titled Abuse a Neglect - Clinical Protocol, dated 03/18 indicated .Residents have the right to be free from abuse, neglect. misappropriation of resident property and exploitation. This includes but is not limited to freedom from.physical abuse.Protect residents from abuse. neglect. exploitation or misappropriation of property by anyone including, but not necessarily limited to .other residents. 1. Review of R59's electronic medical record (EMR) titled admission Record, located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-01-16 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure beverages were served in a safe and sanitary manner to residents who ate in their rooms. This deficient practice had the potential to affect all residents who received beverages from the facility. Findings include: During an observation on 01/12/26 at 11:41 AM, staff on Unit 3 dispensed tea from a container on top of the food delivery cart, then carried the food tray with the uncovered cup of tea from the food delivery cart outside room [ROOM NUMBER] past the nurses' station to room [ROOM NUMBER]. During an observation on 01/12/26 at 5:30 PM, staff on Unit 1 poured tea from a container on top of the food delivery cart near the nurses' station, then walked the tray with the uncovered tea to room [ROOM NUMBER]. Staff then poured tea into another cup, placed it on a tray, and carried the uncovered tea to room [ROOM NUMBER]. During an observation on 01/15/26 at 11:32 AM, Certified Nursing Assistant (CNA)1 poured tea and coffee from the container on…
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 · E2026-01-16 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
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 follow the planned menu. Specifically, the facility served the incorrect portion size for the pureed diets for the lunch meal on 01/13/26. This failure had the potential to affect 13 residents who received pureed diets. Findings include: Review of a facility policy titled Menus, revised 10/2017, indicated, Menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy. Review of the facility menu for the lunch meal served on 01/13/26, indicated the pureed baked salmon should be a 4-ounce (oz) portion, pureed chicken should be a 4 oz portion, and the pureed collard green should be a 1/2 cup portion. During observations of the lunch meal on 01/13/26 beginning at 11:22 AM revealed, [NAME] 4 plated the lunch meal. [NAME] 4 used a green #12 (2.67 oz) scoop to serve the pureed salmon and the pureed collard greens, and a 2-oz serving spoon to serve the pureed chicken. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-16 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, review of facility policy, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the status of 1 (Resident (R)81) of 2 residents reviewed for pressure ulcers. Specifically, R81's Quarterly MDS, with an Assessment Reference Date (ARD) of 12/09/25, did not reflect that the resident had intravenous (IV) access, specifically a peripherally inserted central catheter (PICC). Findings include: Review of the facility policy titled Resident Assessments revised on 10/2023, indicated, . 12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews. Review of the CMS Long-Term Care Facility RAI 3.0 User's Manual, version 1.19.1, dated 10/2024, revealed, Chapter 3: MDS Items, O0110: Special Treatments, Procedures, and Programs specified, O0110O1, IV Access Code IV access, which refers to a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-16 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to ensure a care plan was in place to address the care needs associated with the use of a peripherally inserted central catheter (PICC) line for 1 (Resident (R)81) of 2 sampled residents reviewed for pressure ulcers. Specifically, the facility resolved a care plan addressing R81's PICC line on 12/04/25 and one was never re-initiated, despite ongoing PICC line use and access. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered, revised in 03/2022, indicated, 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The policy further indicated, . 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-16 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to provide Resident (R)45 with an ordered oral nutritional supplement and failed to serve the correct portion size to the resident during the lunch meal on 01/13/26. This deficient practice affected 1 of 5 sampled residents reviewed for nutrition. Findings include: Review of a facility policy titled Food and Nutrition Services, revised 10/2017, indicated, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The policy specified, . 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. Reivew of R45's admission Record indicated the facility admitted R45 on 05/17/16. According to the admission Record, the resident had a medical history to include diagnoses of, but not limited to: dysphagia, speech and language deficits following cerebral infarction, and dementia. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-16 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
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 provide care and treatment according to professional standards for peripherally inserted central catheter (PICC) lines (long thin flexible tube inserted through a peripheral vein in the upper arm and advanced to the large vein near the heart) for 1 (Resident (R)81) of 2 residents reviewed for PICC lines. Specifically, the facility failed to ensure R81's PICC line dressing was secure and changed per physician order and facility policy. Findings include: Review of a facility policy titled Central Venous Catheter Care and Dressing Changes, revised June 2025, indicated, . 5. Change the dressing if it becomes damp, loosened, or visibly soiled and: a. at least every 7 [seven] days for TSM [transparent semi-permeable membrane] dressing; b. at least every 2 [two] days for sterile gauze dressing (including gauze under a TSM unless the site is not obscured); or c. immediately if the dressing or site appears compromised. The policy also specified under a section titled Documentation 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 · D2026-01-16 · 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
Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff used the proper personal protective equipment (PPE) during the care of a resident on Enhanced Barrier Precautions (EBPs) for 1 (Resident (R)81) of 2 residents reviewed for infection control. Findings include: Review of the facility policy titled Enhanced Barrier Precautions, revised in December 2024, indicated, 1. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities. 2. Enhanced barrier precautions apply when: and indicated, b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; and c. Contact precautions do not otherwise apply. The policy continued, 5. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheostomies. The policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-14 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, facility document review, and facility policy review, the facility failed to report an allegation of abuse to the state survey agency timely for 1 (Resident #1) of 3 residents reviewed for abuse/neglect. Findings included: A facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised 08/2022, indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The policy further indicated, If resident abuse (staff to resident and/or resident to resident), neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator. a. All allegations of staff to…
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 before2024-11-15 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 facility policy, record reviews and interviews, the facility failed to ensure resident rights were upheld related to voting in the Presidential Election, for 8 of 8 residents reviewed for Resident Rights. Finding include: Review of the undated facility policy titled, Resident Rights documented, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: g. Exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. Be supported by the facility in exercising his or her rights. i. Exercise his or her rights without interference, coercion, discrimination or reprisal from the facility, j. Be informed about his or her rights and responsibilities. During interviews with residents at a Resident Council Meeting at an unspecified date and time, three residents verbalized that they did not get the opportunity to vote in the Presidential Election on 11/05/24. The residents also stated that they filled out the voter registration form, but never got…
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 · D2024-11-15 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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, observation and interviews, the facility failed to ensure Resident (R)79's Protected Health Information (PHI) was maintained in a private manner, for 1 of 9 residents observed during medication administration. Findings included: Review of the facility policy titled Confidentiality of Information and Personal Privacy with a revision date of February 2021, documented, Our facility will protect and safeguard resident confidentiality and personal privacy . 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records . 4. Access to resident personal and medical records will be limited to authorized staff and business associates. Review of R79's Face Sheet revealed R79 was admitted to the facility on [DATE], with diagnoses including but not limited to: paraplegia, diabetes mellitus type two, morbid obesity, post traumatic stress disorder, schizoaffective disorder, and major depressive disorder. During an observation on 11/14/24 at 10:18…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · D2024-11-15 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 on review of facility policy, observation, and interviews, the facility failed to remove expired medication cards in 1 of 6 medication carts reviewed. Findings include: Review of the facility policy titled, Storage of Medications revised on November 2020, documents, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to dispensing pharmacy or destroyed. During an observation on 11/14/24, of the Medication Cart B on Unit 3, revealed three cards of expired Tramadol 50 mg (milligram) half tablets. Card one had an expiration date of 8/2024 and had 13 half tablets remaining, card two (full card) had an expiration date of 10/2024 and card three (full card) had an expiration date of 10/2024. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-10-13 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner and hygiene and food handling standards were followed to prevent the potential spread of foodborne illness to 115 of 123 total residents (eight residents received nutrition via feeding tubes). Specifically, concerns were noted with the dishwasher water temperatures, hand hygiene when touching ready to eat foods, cleanliness of kitchen surfaces, labeling and dating of foods, wearing hair coverings, cross contamination when handwashing, and food storage. Findings include: Review of the dietary policy titled, Environment dated September 2017 revealed, All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition . The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including . walls . The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces . All…
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 · E2022-10-13 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and policy review, the facility failed to ensure palatable food was served to 5 of 64 sampled residents (Resident (R)1, R81, R102, R66, and R76). Residents complained foods were not flavorful and were not hot when they received their meals. Findings include: Review of the facility's policy titled, Food: Quality and Palatability dated September 2017 revealed, Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature . Food palatability refers to the taste and/or flavor of the food. During an interview on 10/12/22 at 8:56 AM, R1 stated the breakfast was cold and she would not eat it. She had been served grits, scrambled eggs, and beverages. R1 stated she was not provided butter for the grits, and she did not like grits without it. Observation revealed she did not have butter or margarine on her tray. Review of R1's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/05/22, located in the electronic…
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 before2022-10-13 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review, obsevations, and interview, the facility failed to ensure residents received care and services in a dignified manner for 1 of 2 residents reviewed for dignity (Resident (R) 119). Staff entered R119's room on two occasions and turned off his call light without addressing R119 or attempting to determine what he needed. Findings include: Review of the undated facility policy titled Dignity read, 1. Residents are treated with dignity and respect at all times .8. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice .13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity . R119's Order Summary Report located in the electronic medical record (EMR) under the orders tab, indicated R119 was admitted [DATE] with diagnoses including multiple sclerosis, and cognitive communication disorder. R119's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 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 · D2022-10-13 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, observations, record review, and interview, the facility failed to ensure 1 of 1 resident (Resident (R) 82) had their call light within reach. Findings include: Review of undated facility policy titled, Signal System Policy revealed, Call light shall be placed within the reach of the resident. During an observation on 10/11/22 at 1:03 PM; 10/11/22 at 4:45 PM; 10/12/22 at 7:35 AM; 10/12/22 at 8:25 AM; 10/12/22 at 12:37 PM and 10/13/22 at 7:35 AM, R82's call light was on the floor on the right side, at the head of the bed. Review of R82's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 03/08/22 with medical diagnoses that included acute respiratory failure and speech and language deficits following cerebral infarction. Review of R82's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 09/09/22 revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident was moderately impaired. During…
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 · D2022-10-13 · tag F0563 — failed to protect the right to visitors — isolatedHonor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
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 residents were allowed to have visitors of their choosing for 1 of 1 Resident (R)121 reviewed for visitation. R121 was not allowed visits from his responsible party. Findings include: Review of the facility's undated policy titled Visitation read, .Policy interpretation and implementation: 1. Residents are permitted to have visitors of their choosing at the time of their choosing .Reasonable Clinical and Safety Restrictions: 1. Some visitation may be subject to reasonable clinical and safety restrictions that protect the health, safety, security and/or rights of the facility's residents such as: .b. denying access or providing limited and supervised access to an individual if that individual is suspected of abusing, exploiting, or coercing a resident until an investigation into the allegation has been completed or has been found to be abusing, exploiting, or coercing a resident . Review of R121's face sheet, located in the electronic medical record (EMR) under the profile tab,…
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 · D2022-10-13 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policy, record review, and interviews, the facility failed to act upon a grievance for 1 of 2 Residents (R)6 reviewed for personal property. Findings include: Review of facility policy titled, Resident Council, dated 12/31/15 revealed, Follow up to resident concerns shall be documented in the Resident Council Meeting minutes the following month .The Administrator/designee shall review and respond to all resident issues. Review of facility policy titled, Grievances/Complaints, Filing, dated 04/01/17 revealed, Any resident may file a grievance or complaint . regarding his or her stay at the facility. Review of R6's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed an admission date of 06/28/22 with diagnoses that included chronic obstructive pulmonary disease and anxiety disorder. Review of R6's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 10/03/22, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident…
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 · D2022-10-13 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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, record review, observation, and interviews, the facility failed to ensure the right to be free from restraints was exercised for 1 of 1 Resident (R)175 reviewed for restraints. Specifically, staff physically restrained (restrict freedom of movement) of R175 when she was placed in a geri-chair. The facility's deficient practice had potential to inflict mental anguish and/or physical harm to R175. Findings include: Review of the facility policy titled Use of Restraints, dated 04/17 indicated, Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Review of R175's electronic medical record (EMR) titled admission Record, located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of unspecified dementia without behavioral disturbances. Review of R175's admission Minimum Data Set in the EMR under the MDS tab with an Assessment Reference Date…
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 · D2022-10-13 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the policy review, record review, observations, and interviews, the facility failed to provide a program of ongoing activities for 1 of 3 Residents (R)121 reviewed for activities. Findings include: The facility policy titled Room Visit Program date 12/31/15 indicated, It is the policy of this facility to provide recreational opportunities for the residents who cannot or choose not to leave their room. The Activity Director will develop an individualized activity plan based on each resident's needs, interest, and abilities. Residents will be visited on a regularly scheduled basis. POLICY Purpose: To assure all residents receive an opportunity for socialization and stimulation .3. Residents who cannot or choose not to leave their rooms will be seen three times per week, more frequently if time allows .8. The activity staff will maintain a record of what activities are provided for each resident. This is based on previously enjoyed leisure pursuits and new interests the resident may have developed . Review of R121's face sheet, located in the electronic medical…
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 · D2022-10-13 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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, record review, observation, and interviews, the facility failed to ensure 3 Residents (R)91, R118, and R120 had therapy ordered splints applied to prevent the development of contractures. Findings include: Review of the facility policy titled Resident Mobility and Range of Motion, dated 07/17 indicated .Residents will not experience an avoidable reduction in range of motion (ROM).Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM . 1. Review of R91's electronic medical record (EMR) titled admission Record, located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of nontraumatic intracerebral hemorrhage. Review of a document provided by the facility titled Visual/Bedside [NAME] Report, dated 06/08/22 failed to identify R91 required the use of splints. Review of R91's admission Minimum Data Set (MDS) in the EMR under the RAI tab with an Assessment…
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 before2022-10-13 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to prevent weight loss for 1 of 4 residents reviewed for nutrition (Resident (R) 60). The facility failed to ensure R60 was provided with physician ordered built up utensils and nursing staff assist the resident at mealtimes. R60 had a 7.72% weight loss from 09/05/22 to 10/13/22. Findings include: Review of R60's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 08/24/22, located in the electronic medical record (EMR) under the MDS tab, indicated she was admitted to the facility 09/11/20 with diagnoses including Parkinson's Disease and dementia. The MDS indicated R60 weighed 99 pounds. According to the MDS, R60 had a significant weight loss and was not on a physician prescribed weight loss plan. Review of R60's Order Summary Report dated 10/13/22 revealed physicians orders for: Large portions at meals with a start date 10/20/21; Mighty shake three times a day for nutrition with a start date of 4/21/22; and Regular diet, with built up utensils and a handled cup with all meals,…
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 · D2022-10-13 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 policy review, review of Centers for Disease Control and Prevention (CDC) guidelines, and interview, the facility failed to revise their pneumococcal vaccine policy to current pneumococcal vaccination guidelines. This failure increased the risk for residents not vaccinated per guidelines to contract pneumonia. The facility also failed to offer one (Resident (R) 107) out of a survey sample of five reviewed for pneumococcal vaccination, who received the PPSV [Pneumococcal Polysaccharide Vaccine] 23, but there was no evidence the resident received the PCV13 [Pneumococcal conjugate vaccine] prior to the updated guidance from the CDC for pneumococcal vaccinations. Findings include: Review of the CDC website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, effective 01/28/22, indicated . CDC recommends pneumococcal vaccination for all adults 65 years or older . For adults 65 years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give 1 dose of PCV…
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
No federal fines in the current CMS record.
Part of a chain
This home belongs to PACS GROUP — 274 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 | 2.9 | -0.9 vs chain |
| Health inspection | 2 of 5 | 2.5 | -0.5 vs chain |
| Staffing | 2 of 5 | 2.5 | -0.5 vs chain |
| Quality measures | 3 of 5 | 4.4 | -1.4 vs chain |
The other 273 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 273; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| TRUIST BANK | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 07/16/2024 |
| JERGENSEN, JOSHUA | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER | since 01/01/2024 |
| MITCHELL, JOHN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER | since 01/01/2024 |
| HANCOCK, MARK | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 02/15/2024 |
| HOLCK, JUSTIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/09/2025 |
| MAULDIN, ELIZABETH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/22/2024 |
| WHEELER, KERRY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2021 |
| 8 NORTH TEXAS AVENUE LLC | Organization | ADP OF THE SNF | since 02/15/2024 |
| PACS GROUP, INC. | Organization | ADP OF THE SNF | since 02/15/2024 |
| PACS HOLDINGS, LLC | Organization | ADP OF THE SNF | since 02/15/2024 |
| PROVIDENCE ADMINISTRATIVE CONSULTING SERVICES INC | Organization | ADP OF THE SNF | since 09/01/2021 |
| PROVIDENCE GROUP NH, LLC | Organization | ADP OF THE SNF | since 02/15/2024 |
| ZOOZEN LLC | Organization | ADP OF THE SNF | since 02/15/2024 |
| MURRAY, JASON | Individual | ADP OF THE SNF | since 02/15/2024 |
CMS files one row per role, so the 21 rows in the source record cover these 14 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.
7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 91% 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 $282K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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 425102. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-16, 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.