Magnolia Manor - Greenwood
1415 Parkway Drive, Greenwood, SC 29646 · For profit - Limited Liability company · 88 certified beds · (864) 227-9500 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $13,075 in federal fines (most recent 2025-12-30)
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure 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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 fell from 2 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.3% | 11.9% | 15.4% | better |
| Long-stay residents who lose too much weight | 11.8% | 6.3% | 5.4% | worse |
| 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 | 2.2% | 1.3% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 5.5% | 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 | 2.5% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.7% | 12.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 28.3% | 21.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 76.9% | 90.6% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 5.4% | 5.1% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 4.5% | 16.7% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.2% | 15.3% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.5% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 28.6% | 78.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 26.8% | 24.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 17.5% | 13.9% | 12.0% | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
43.0% 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 33 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 35.0% 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 20 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 0.19 therapist hours per resident per day in 2026Q1 — more than 21% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% 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 | 43.0%CMS range 31.4–59.2 | 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 | 10.7%CMS range 6.9–16.6 | 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 | 35.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 35.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.4%CMS range 4.4–14.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.31 | 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 88 beds and averages 83.3 residents a day — about 95% occupied, or roughly 5 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 3.25 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 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 2.71 hrs/resident/day on weekends vs 3.47 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.52 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% 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.
25 citations, most serious first. The 13 most serious are shown; the remaining 12 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-04-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure that Resident (R)1 had adequate supervision to prevent a successful elopement on 04/05/2026.On 04/20/26 at 4:25 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 04/05/26. The IJ was related to 42 CFR 483.25 - Freedom from Accidents and Hazards.On 04/20/26 the facility provided an acceptable IJ Removal Plan. On 04/20/26 the survey team, validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The SA is considering this IJ at Past Noncompliance as of 04/07/26. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care.Findings include:Review of the facility policy titled, Elopement with a last revision date of 11/01/17, revealed, To safely and timely redirect…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2025-12-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review, and staff interviews, the facility failed to ensure that Resident (R)1 was adequately supervised to prevent elopement. R1 was noted to have eloped on 12/13/2025. R1 was last seen by facility staff in the facility at approximately 5:30 PM. Facility was made aware that R1 was found outside the facility at 6:06 PM by first responders. According to weather.com, the weather in [NAME], SC on 12/13/25 was a high of 65 degrees Fahrenheit (F) and a low of 49F with sunset at 5:19 PM.As a result of Complaint #2697173, on 12/30/2025 at 2:40 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations could cause psychosocial harm.On 12/30/2025 at 3:08 PM, the survey team provided the Administrator with a copy of the Centers for Medicare and Medicaid Services (CMS) Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 12/13/2025. The IJ was related to F689 Free of Accident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · Jcited before2025-06-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY (2.) Based on review of the facility policy, observations, record reviews and interviews, the facility failed to ensure R131 was free from potential accidents, related to smoking on facility grounds for 1 of 4 residents identified for smoking. R131 being observed smoking unsafely, on the property of a smoke-free facility on 06/13/2025. On 06/13/2025 at 1:31 PM, the SA presented the Administrator with an IJ template related to this incident. On 06/13/2025 at 5:00 PM, the facility presented an acceptable IJ removal plan. Verification of the plan revealed the facility implemented their removal plan as of 06/16/25 at 6:30 PM. The facility remained out of compliance at a lower scope/severity level of D. Findings include: A review of the facility policy titled, Smoking Policy, Guidelines with a revision date 11/01/2017 states: Policy:Facility's Leadership will establish and enforce a specific smoking policy for Facility patients/residents, visitors and employees, outlining the parameters, if any, under which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-30 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, record review, and interviews, the facility failed to ensure appropriate post-fall interventions were developed and implemented through care plan revision for 1 of 3 residents reviewed for falls Resident (R)2. This failure had the potential to place the resident at risk for additional falls and injury.Findings include:Review of the facility's policy titled, Care Plan Process, Person Centered Care with a revision date of 05/05/23 revealed, Policy: 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 and quality care. The facility will coordinate the development of the person-centered care plan within the required timeframes. Procedures: 9. Thru ongoing assessment, the facility will initiate person-centered care plans when the resident's clinical status or change of condition dictates the need such as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-06-16 · 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
Based on review of the facility policy, observations, and interviews, the facility failed to ensure foods that were stored in the freezer, refrigerators and dry food storage were appropriately sealed, labeled, dated with a use by date, and/or discarded after the manufacturer's expiration date. This had the potential to affect all residents who received meal trays from the kitchen. Findings include: Review of the facility's policy titled, Food Safety in Receiving and Storage, with a revision date of 6/20/2023 revealed, Receiving Guidelines 6. Check expiration dates and use by dates to assure dates are within acceptable parameters; General Food Storage Guidelines 3.) .Label both the container and its lid with the common name of the contents, the date, it was transferred to the new container and the discard date; Dry Storage guidelines 2. Tightly seal open packages to prevent contamination or place food in covered container. Review of the facility's policy titled, Dating and Labeling Food Guidelines, updated 2/4/2024, revealed .when opening food in dry storage, make sure food has 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 · D2025-06-16 · 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 a review of the facility policy, record reviews, and interviews, the facility failed to report to the State Survey Agency an incident that occurred on 03/23/2025. The facility neglected to identify R78 was no longer in the facility, or was her whereabouts known to facility staff. Findings include: A review of the facility policy titled Abuse, Neglect, Exploitation or Mistreatment with a complete revision date of 11/01/2017 stated, The Facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures . Review of R78's Face Sheet…
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 · D2025-06-16 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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, observations, record reviews and interviews, the facility failed to notify Resident (R)7 and R78 or their resident representative (RR) of bedholds, including bed reserve payments 2 of 2 residents. Findings include: Review of the facility policy titled, Facility's Policy and State Requirements for Temporary Leave Bed-Hold revised 06/2009 revealed If a resident leaves the facility for temporary hospitalization or therapeutic leave, the resident or his/her representative may ask the Facility to hold the resident's bed until the resident is ready to return (bed hold). The resident and/or his/her representative will be given a copy of the Facility's bed-hold policy before the resident actually leaves for his/her temporary leave or hospitalization. In the case of an emergency hospitalization, the bed hold policy may accompany the resident to the hospital or will be given to the resident or his/her legal representative within twenty-four (24) hours of the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-16 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the facility policy, observations, record review and interviews, the facility failed to ensure a medication administration error rate of less than 5 percent. The medication administration error rate was 8 percent for 2 out of 25 opportunities observed for error. Findings include: Review of the facility's policy titled, Medication Management Program revised 05/05/2023, revealed, Policy: 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. Security and Safety Guidelines: 16. Medications are dispensed at the time of administration. Pre-pouring or dispensing for a later administration is not permitted. Administering the Medication Pass 7. The authorized staff member prepares one resident's medication at a time. B. Do not touch the medication when opening a bottle or unit dose package C. If a medication which is not in a protective container is dropped, it should be discarded according to policy. 15. If a medication is unavailable,…
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 · D2025-06-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, observations and interviews, the facility failed to ensure expired medication and biologicals, and 4 loose unidentified pills were removed from 2 of 2 medication carts. The facility further failed to remove open and expired items from 1 of 2 treatment carts. Findings include: Review of the facility's policy titled, 8.2 General Guidelines for Storage of Medication and Biologicals, revised [DATE], revealed Policy: Medications and biologicals 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 biologicals in locked compartments under proper temperatures and other appropriate environmental controls to preserve their integrity. Procedures: 5. Medications with manufacturer's expiration date expressed in month and year (e.g., May, 2019) will expire on the last day of the month. (unless a sooner expiration date has been placed on the package by…
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 · D2025-06-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and interviews, the facility failed to ensure the useof gowns during catheter and wound dressing changes 2 of 2 residents reviewed, Resident (R)35and R57. Findings include: Review of the facility's policy titled, Transmission Based/Standard Precautions, and Enhanced Barrier Precautions revised on 05/15/23 revealed, Policy: 1. The facility will use transmission-based precautions when the routes of transmission is not completely interrupted using standard precautions alone. These are applied as needed based on the epidemiology of the infecting organism or infectious disease syndrome. There may be some diseases that have multiple routes of transmission which more than one transmission-based precaution may be required. Transmission-based precautions will always be used in addition to standard precautions. 2. Health care workers (HCW) will implement Universal/Standard Precautions whenever there is occupational exposure to blood and body fluids. Procedures: Enhanced…
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 before2024-11-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, observation and facility policy review, the facility failed to supervise 1 (Resident (R)6) of 3 sampled residents reviewed for accidents. Specifically, the facility failed to supervise R6, who the facility determined was high risk for falls and required staff assistance with showers/bathing, during a shower on 10/06/24. R6 fell from a shower chair when staff left the resident in the shower room unattended and the resident sustained redness to the knees. Findings include: Review of a facility policy titled, Fall Management, revised 05/05/23, indicated, 1. The facility will identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls. 2. Qualified staff will complete the Fall Risk Evaluation to determine if patient/resident is a fall risk. 3. The fall management program includes education for staff in creative, functional strategies while recognizing patients/resident's rights and highest practicable level of function.…
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 before2024-07-27 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to ensure resident care plans were updated to include revised appropriate fall interventions for 3 (Residents (R)1, R2, and R3) of 3 sampled residents reviewed for falls. Findings include: Review of a facility policy titled, Fall Management, revised on 05/05/23, revealed, 6. The care plan reflects individualized interventions that are reassessed and revised as needed. Review of a facility policy titled, Care Plan Process, Person-Centered Care, revised on 05/05/23, revealed, 9. Thru ongoing assessment, the facility will initiate person-centered care plans when the resident's clinical status or change of condition dictates the need such as but not limited to falls and pressure ulcer development. 1. Review of a Resident Face Sheet revealed the facility admitted R1 on 11/03/23, with diagnoses including but not limited to: altered mental status, abnormalities of gait and mobility, muscle wasting and atrophy, unsteadiness on feet, muscle weakness, lack of coordination, hemiplegia and hemiparesis (muscle…
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 before2024-07-27 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure staff followed the facility policy for fall management and conducted neurological evaluations and post fall nursing documentation for 72 hours for 3 (Residents (R)1, R2, and R3) of 3 sampled residents reviewed for falls. Findings include: Review of a facility policy titled, Fall Management, revised on 05/05/23, revealed, 7. Neurological evaluations will be performed for a resident who sustains an unwitnessed fall, regardless of the resident's cognitive status at the time of the incident. The policy revealed, 9. Post fall nursing documentation for 72 hours, every shift will be completed to monitor the development of late effect or complications of the fall. Review of a facility policy titled, Neurological Checks (Neuro Checks), revised 05/05/23, revealed, The licensed nurse will perform neurological checks following any type of actual or suspected head injury of for changes in level of consciousness. The policy revealed,…
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 · Ecited before2024-07-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 on interview, record review, and facility policy review, the facility failed to ensure staff conducted fall risk assessments and accurately coded fall risk assessments for 3 (Residents (R)1, R2, and R3) of 3 sampled residents reviewed for falls. Findings include: Review of a facility policy titled, Fall Management, revised on 05/05/23, revealed, 1. Qualified staff evaluates all patient/residents for fall risk at a minimum upon admission, quarterly, with a significant change, and post-fall. 2. The Fall Risk Evaluation assist in identifying the appropriate preventative interventions that will be recorded on the patient/resident's care plan. 1. Review of a Resident Face Sheet revealed the facility admitted R1 on 11/03/23, with diagnoses including but not limited to: altered mental status, abnormalities of gait and mobility, muscle wasting and atrophy, unsteadiness on feet, muscle weakness, lack of coordination, hemiplegia and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side, dementia, and 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.
- Potential for harm · D2024-07-27 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to ensure staff notified the resident's physician and/or the resident's responsible party (RP) of a fall for 2 (Resident (R)1 and R3) of 3 sampled residents reviewed for falls. Findings include: Review of a facility policy titled, Fall Management, revised on 05/05/23, revealed, 8. The physician and family are promptly notified, and an incident report is completed. Review of a Resident Face Sheet revealed the facility admitted R1 on 11/03/23. According to the Resident Face Sheet, R1 was admitted to the facility with diagnoses including but not limited to: altered mental status, abnormalities of gait and mobility, muscle wasting and atrophy, unsteadiness on feet, muscle weakness, lack of coordination, hemiplegia and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side, dementia, and cognitive communication deficit. Review of a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/05/24, revealed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-27 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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, and facility policy review, the facility failed to ensure staff accurately coded a Minimum Data Set (MDS) for 1 (Resident (R)2) of 3 sampled residents reviewed for falls. Findings include: Review of a facility policy titled, Minimum Data Set (MDS), revised on 09/28/23, revealed, A licensed nurse will conduct or coordinate each assessment with the interdisciplinary team. An MDS, which is a comprehensive, accurate, standardized reproducible assessment will be completed for each resident, using the RAI [resident assessment instrument] process. Facility staff complete a comprehensive assessment of each resident's need, strengths, goals, life history, and preferences, and offer guidance for further assessment once problems have been identified. The policy revealed, 1. Review the resident's medical record. This review may include pre-admission activities. Identify resident's status, care and services rendered during the Observation Period for the current assessment. Review is 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 · D2024-04-08 · 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 in record review, interviews, and review of facility policy, the facility failed to ensure Residents (R)1 and R2 were free from verbal abuse for 2 of 2 residents reviewed. Findings include: Review of the facility's undated policy titled Abuse, Neglect, Exploitation, or Mistreatment revealed, The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse . 1. Definitions as defined by CMS section 483.5: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using…
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 before2023-12-27 · 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
Based on review of facility policy, interview and record review, the facility failed ensure the dignity and resident rights of 1 of 3 residents. Specifically, on 11/22/23, Certified Nursing Aide (CNA)1 posted a video of Resident (R)1 to TikTok (a social media platform). Findings include: Review of facility policy titled, Dress Code/Phone Policy Updates last revised on December 2019 revealed that the facility forbids pictures of residents, other than as part of activity where legal disclosures are signed, and the posting of patient information on social media sites. Review of R1's Face Sheet revealed R1 was admitted to the facility 08/24/20 with diagnoses including, but not limited to: Alzheimer's, dementia and anxiety. Review of R1's Quarterly Minimum Data Set (MDS) with an unspecified Assessment Reference Date (ARD) revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15, indicating severe cognitive impairment. Review of a screen capture of a TikTok video revealed the recording was taken from behind R1 with a caption that read POV - Me Telling My Resident My…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-12-01 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of the facility's policy, the facility failed to ensure all glasses were allowed to be air dried before stacked, all equipment was clean after washing, and items in dry storage were dated. These failures had the potential to affect all 76 residents in the facility who consumed food from the kitchen. Findings include: Review of the facility's policy titled, ''Food Safety in Receiving and Storage,'' dated 06/20/23 revealed, ''. Check expiration dates and use-by dates to assure the dates are within acceptable parameters . Place food that is repackaged in a leak-proof container with the name of the contents, the date, and discard date.'' On 11/29/23 at 9:18 AM, the following observations in the kitchen were made and verified by the Dietary Manager (DM) and the Kitchen Supervisor (KS): 1. 12 plastic glasses ready for use were wet on the inside and stacked. 2. The Robot Coupe food processor's plastic container had dried food particles on the inside and outside of the container and on the lid. 3. The dry storage room contained vanilla wafers and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-01 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to revise their pneumococcal vaccine policy to reflect current pneumococcal vaccination guidelines. This failure increased the risk for residents to not be vaccinated per current guidelines. Findings include: Review of the CDC recommendations, revised on 02/09/23, indicated ''.CDC recommends pneumococcal vaccination for all adults 65 years or older . If PCV20 [pneumococcal conjugate vaccine] is used, a dose of PPSV23 is NOT indicated . For adults 65 years or older who have only received PPSV23 [Pneumococcal polysaccharide vaccine], CDC recommends you . Give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults 65 years or older who have only received PCV13, CDC recommends you either . Give 1 dose of PCV20 at least 1 year…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-01 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a Level I Pre-admission Screening Resident Review (PASSAR) was accurate for 1 of 24 residents, Resident (R)31. This failure had the potential for residents with mental disorders not to receive identified specialized services. Findings include: Review of the facility's policy titled, ''PASSAR Documentation Policy'' dated 06/09/23, read, ''. Individual seeking admission to a Medicaid Certified nursing facility (NF) receives a PASSAR Level I Screen for intellectual disability (ID) or developmental disability (DD) or mental illness (MD) before or upon admission . The care plan will be reviewed and updated as needed, quarterly and with significant changes to evaluate and validate the effectiveness of interventions and adjust, as necessary . Any resident with newly evident or possible serious mental disorder, ID or a related condition must be referred by the facility to the appropriate state-designated mental health or intellectual disability authority for review.'' Review of R31's ''Face Sheet'' 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 before2023-10-24 · 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 the facility policy, record review, and interviews, the facility failed to honor a resident's wishes related to medication refusals for 1 of 1 resident. Specifically, Resident (R)1 did not want to take an ordered medication for stool softer, however Registered Nurse (RN)1 attempted to force R1 to take the medication. Findings include: Review of the facility's policy titled, Medication Administration Program, dated 05/05/23, revealed 3-Honor resident choices and activities, as much as possible, consistent with the person-centered comprehensive care plan. 9. The authorized staff member or licensed nurse must explain to the resident the type of medication to be administered. The resident has the right to be informed of all medications that are administered. 14. The resident has the right to refuse medication. It is, however, the nurse's responsibility to review with the resident the consequences of their refusal and document accordingly. If the resident continues to refuse, document on the MAR.…
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 before2023-10-24 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews and review of facility policy, the facility failed to ensure the physician's medication orders were accurately documented for 1 of 1 resident, Resident (R)1. Findings include: Review of the facility's policy titled, Medication Administration Program dated 05/05/23 revealed, Section Guidelines for Implementing an Efficient Medication Pass, Honor resident choices and activities, as much as possible, consistent with the person-centered comprehensive care plan. Section Administering the Medication Pass, the authorized staff member or licensed nurse must explain to the resident the type of medication to be administered. The resident has the right to be informed of all medications that are administered. The resident has the right to refuse medication. It is, however, the nurse's responsibility to review with the resident the consequences of their refusal and document accordingly. If the resident continues to refuse, document on the MAR. Note the refusal or ingestion of less than 100%…
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 · D2021-12-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of the facility's policy, the facility failed to provide activities of daily living to a resident who was unable to carry out activities of grooming and personal hygiene. Resident #42's nails were long and curled under. One (1) of two (2) residents reviewed for activities of daily living. Findings include: A review of the facility's policy titled Activities of Daily Living, Optimal Function dated 8/30/17 revealed, .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 Resident #42 was admitted to the facility on [DATE] with diagnoses including but not limited to Contracture, Muscle Wasting and Atrophy, Contracture of Muscle, Age-Related Physical Debility, Other Muscle Spasm, Personal History of Traumatic Brain Injury, Unspecified Lack of Coordination, Quadriplegia, Muscle Weakness (Generalized), Joint Derangement, Other…
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 before2021-12-10 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and review of the facility policy, the facility failed to ensure the medication error rate was not five (5) percent or greater. The facility had a medication error rate of 12%. This deficient practice affected one of seven residents observed for medication administration. Findings include: A review of the facility's policy titled Medication Management Program with a revision date of 7/13/21 read Policy: 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 .Preparing for the Medication Pass .4. Authorized staff must understand: A. Indications or reason for therapy. B. Effectiveness for achieving the therapeutic goal. C. Drug actions. D. The 8 Rights for administering medications: 1) The Rights 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 8)…
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
$13,075 in federal fines across 2 penalties.
- $9,113 — penalty dated 2025-12-30
- $3,962 — penalty dated 2023-12-01
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to FUNDAMENTAL HEALTHCARE — 66 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.4 | -1.4 vs chain |
| Health inspection | 1 of 5 | 2.5 | -1.5 vs chain |
| Staffing | 2 of 5 | 2.2 | -0.2 vs chain |
| Quality measures | 2 of 5 | 3.4 | -1.4 vs chain |
The other 65 homes this chain runs (chain average 2.4★, per CMS)
Showing 40 of 65; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| THI OF SOUTH CAROLINA, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 08/30/2003 |
| GOFORTH, EDITH | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 07/06/2006 |
| LEARY, VALERIE | Individual | CORPORATE OFFICER | — | since 01/31/2005 |
CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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 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 $447K 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
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 425172. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-16, 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 →
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