Sedgewood Manor Health Care Center
1645 Ridge Road, Hopkins, SC 29061 · For profit - Corporation · 38 certified beds · (803) 776-3873 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- 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
- a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (60%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 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 | 14.9% | 11.9% | 15.4% | typical |
| Long-stay residents who lose too much weight | 19.5% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.8% | 0.6% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 1.0% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 3.1% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.0% | 3.2% | 3.3% | better |
| Long-stay residents on antianxiety or hypnotic medication | 30.6% | 21.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.6% | 90.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.7% | 5.1% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 28.7% | 16.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.0% | 15.3% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.7% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 83.0% | 78.0% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 16.3% | 24.3% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 21.3% | 13.9% | 12.0% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ 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.
52.2% 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 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 55% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% 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 | 52.2%CMS range 37.5–70.2 | 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 | 10.2%CMS range 6.7–16.6 | 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 | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 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 | 3.5% | 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 | 7.1%CMS range 3.5–12.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.24 | 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 38 beds and averages 29.0 residents a day — about 76% occupied, or roughly 9 beds typically open. It usually has some room. 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 3.84 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 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 3.32 hrs/resident/day on weekends vs 4.05 on weekdays — 18% thinner on weekends. RN hours go from 0.31 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 60% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.
- Potential for harm · E2025-12-30 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
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 call lights were within reach for Resident (R)1, R2, R3, R8 and R9, 5 of 5 rooms reviewed for call light placement.Findings include:Review of the facility's policy titled, Call Lights: Accessibility and Timely Response with a copyright date of 2025 states, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.Policy Explanation and Compliance Guidelines5. Staff will ensure the call light is within reach of the residents and secured, as needed.Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with the diagnosis including but not limited to muscle weakness (generalized), unspecified sequelae of cerebral infarction, dementia, and essential…
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 before2025-07-29 · 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 facility policy, observations and staff interviews, the facility failed to properly label and discard expired food items in 1 of 1 main kitchen and 1 of 1 resident nourishment refrigerator. This failure to follow proper food storage protocols presents a potential risk to the health and safety of the 33 residents who consume food prepared in the facility's kitchen.Review of an undated facility policy titled Labeling, Dating, Rotating Foods revealed the following: Food must be rotated while in storage to maintain quality and limit the growth of pathogens. Food items must be rotated so the items with the earliest use-by or expiration dates are used before those listed with later dates. The first in, first out method (FIFO) is used to rotate foods refrigerated, frozen, and/or dry goods so that items dated earlier are used first. Identify food's use-by or expiration date. Identifiers include item name, date entering facility, and date of manufacturer expiration. Dispose of food on the date of expiration. Any food taken out of the original container must have a delivery…
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 · D2025-07-29 · 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 review of facility policy, record review and interviews, the facility failed to ensure that an allegation of abuse was immediately reported to the abuse coordinator for 1 of 3 residents, Resident (R) 31 reviewed for abuse. This failure had the potential to expose the victim to ongoing harm and allow harmful behavior to continue without intervention.Review of the undated facility policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation revealed, It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations withing prescribed timeframes.Review of R31's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including, but not limited to: type 2 diabetes mellitus, schizoaffective…
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 · D2025-07-29 · 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 review of facility policy, record review, observations, and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for Resident (R4), 1 of 3 residents reviewed for ADL care. Specifically, staff failed to provide showers and nail care for R4, who was dependent on staff for assistance with ADLs.Review of the facility's undated policy titled Activities of Daily Living (ADLs) revealed, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE] with diagnoses including but not limited to: cerebral infarction due to thrombosis of the right middle cerebral artery, morbid…
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 · D2025-07-29 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility policy, record reviews, observations, and interviews, the facility failed to provide an ongoing resident-centered program designed to meet the resident's interests, hobbies, and cultural preferences in order to promote physical, mental, and psychosocial well-being for 1 of 2 residents reviewed for activities, Resident (R)35.Review of an undated facility policy titled, Activities states, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. Activities may be conducted in different ways: One-to-One Programs, Person Appropriate - activities relevant to the specific needs, interests,…
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 · D2025-07-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of facility policy, the facility failed to follow physician orders for changing oxygen tubing and nasal cannulas for 3 of 3 residents (R) R7, R32 and R42 reviewed for respiratory care. This failure has the potential for harm due to increased risk of infection. Review of the undated facility policy titled Oxygen Administration revealed, 5b. Change Oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Review of R7's face sheet showed she was admitted to the facility on [DATE]. Her diagnoses included but were not limited to: chronic obstructive respiratory disease (COPD; a lung disease causing shortness of breath), chronic respiratory failure, generalized anxiety disorder, and muscle weakness. Review of R7's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/09/25 showed she has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating she has no cognitive deficit. Her MDS…
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 · D2025-07-29 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, and employee record reviews, the facility failed to provide yearly performance evaluations for Certified Nursing Assistants (CNAs), for 3 of 5 CNAs reviewed for yearly performance evaluations; CNA3, CNA4,and CNA5. Review of CNA3's employee record revealed she has a hire date of 04/20/23. She received her last performance review on 05/10/24. She received a rating of Excellent in all areas except one. Her 2025 performance review had not yet been completed as of 07/28/25. Review of CNA4's employee record revealed she has a hire date of 02/24/16. She received her last performance review on 02/28/24. She was rated Excellent and Good in all areas. When Surveyor initially asked for her file on 07/28/25, Human Resources (HR) revealed CNA4's 2025 review was not yet completed. Later in the day on 07/28/25, HR informed Surveyor CNA4's 2025 was completed. She was rated Good in all areas.Review of CNA5's employee record revealed she has a hire date of 04/25/24. When Surveyor initially asked for CNA5's employee record, HR revealed CNA5's 2025 review was not yet completed. 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 · D2025-07-29 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and Daily Nursing Hours sheet reviews, the facility failed to visibly post the Daily Nursing Hours sheets on a daily basis where residents, staff, and visitors could visibly access them. During an observation on 07/27/25 at 9:59 AM, the Daily Nursing Hours sheets were posted in one of two resident hallways outside the Director of Nursing (DON) office. The office was located within the facility and was not readily accessible to visitors as they entered the facility. The date on the sheet that was visible was 07/24/25. Under the Daily Nursing Hours sheet dated 07/24/25 was a Daily Nursing Hours sheet dated 07/21/25. During an interview with Regional Consultant on 07/27/25 at 4:30 PM, he revealed, We do not post the Daily Nursing Hours sheets in the front of the building. We have always posted these at the nurses' station. I do not know if the sheet would be visible to others that don't go to the nurses' station or past it if the resident's room is not down that hallway. He then agreed that all visitors would not actually see the Daily Nursing Hours…
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 · D2025-07-29 · 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 facility policy, record reviews, observations and staff interviews, the facility failed to ensure a medication error rate below 5% during medication administration for 2 of 25 opportunities for error; the error rate was 8 percent. Specifically, Resident (R) 30 did not receive two medications for which there were active physician orders, resulting in a medication omission error. Review of the undated facility policy titled, Medication Administration, states, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician.Observation of medication pass on 06/28/25 at 8:34 AM, Licensed Practical Nurse (LPN)1 was observed preparing to administer medications to R30. R30 had active physician orders for the following medications: Calcitriol Oral Capsule 0.25 mcg, to be administered by mouth once daily at 9:00 AM for renal disease and Sensipar (Cinacalcet HCl) Oral Tablet 30 mg, to be administered by mouth once daily at 9:00 AM for renal disease. At the time of observation, LPN1 confirmed that…
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 · D2025-07-29 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
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, observations and interviews, the facility failed to failed to provide appropriate assistive devices for 1 of 2 Residents (R) reviewed for food. Specifically, R22 did not receive an ordered cup with two handles and lid during meals. This failure has the potential for harm due the potential loss of independence with feeding self.Review of the undated policy titled, Use of Assistive Devices revealed, Assistive devices are tools, products, types of equipment, or technology that help individuals perform tasks and activities . Assistive devices include . g. Eating utensils. The policy also stated, The facility will provide assistive devices for residents who need them.Review of R22's face sheet showed she was admitted to the facility on [DATE]. Her diagnoses included, but were not limited to: anxiety, dementia and dysphagia (trouble swallowing).Review of R22's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/25 showed she has a Brief…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 8 citations
- Potential for harm · F2024-07-10 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
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 the services of a Registered Nurse (RN) were used for at least eight consecutive hours a day, seven days a week. A review of the nursing schedule provided by the facility revealed an RN was not on site for eight consecutive hours a day on the weekends for seven (7) consecutive months, from January 2024 through July 2024. This failure had the potential to affect the provision of registered nursing assessments and services to all 32 residents in the facility. The findings included: A Review of the facility's undated policy titled, Nursing Services and Sufficient Staff revealed 8. Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. A review of registered nursing timecard reports revealed the following days of no RN on staff for at least eight consecutive hours with the resident census each day: January 2024 01/20/2024-37(census) 01/21/2024-37 (census) 01/27/2024-37 (census) 01/28/2024-37 (census) February 2024 02/03/2024-32 (census)…
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 before2024-07-10 · 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, interviews and review of the facility policy, the facility failed to discard expired food items for 1 of 1 kitchen area. Findings Include: Review of the facility policy titled, Food Storage without a revision date, revealed, All stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of all foods. Place new items behind supply in stock of the same item; in this way oldest stock is always used first. Supervision is necessary to make sure that the person designated to put stock away is rotating it properly. Review of Storage policy from Optima Solutions titled, Guidelines for Storage revealed, Bread must be stored in pantry area at room temperature for five to seven days. Review of Flowers Bakeries Sheet revealed, All European bakers thaw and serve bread or rolls have a 270-day shelf life when kept frozen at zero degrees and five to seven days when kept at room temperature. Flowers guarantees a minimum of 45 days product shelf life at time of delivery. During an observation on 07/08/24 at 10:35…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-07-10 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the review of facility policy, interviews, and record review, the facility failed to develop, implement, and monitor the Antibiotic Stewardship Program. This failure placed all residents at risk for the potential transmission of infections and communicable diseases. Findings include: A review of the facility policy titled, Antibiotic Stewardship Program, with no revision date, revealed 11. Documentation related to the program is maintained by the Infection Preventionist, including, but not limited to: a. Action plans and/or work plans associated with the program. b. Assessment forms. c. Antibiotic use protocols/algorithms. d. Data collection forms for antibiotic use, process, and outcome measures. e. Antibiotic stewardship meeting minutes. f. Feedback reports. g. Records related to the education of physicians, staff, residents, and families. h. Annual reports On the following dates, a request was made to the administrative staff regarding documentation related to the Antibiotic Stewardship Program. Requested 07/08/2024 at approximately 1:00 PM. Regional Consultant.…
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 · E2024-07-10 · tag F0947 — failed to train nurse aides adequately — patternEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews and interviews, the facility failed to ensure all nurse aide personnel have completed the required 12 hours of training per employment year based on the hire date for 07 out of 14 Certified Nursing Assistants (CNAs). Findings include: A review of the undated facility policy titled, Competency Evaluation, revealed Policy: It is the policy of this facility to evaluate each employee to ensure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents. Policy Explanation and Compliance Guidelines: 1. The knowledge and skills required among staff to meet residents' needs are determined through the facility assessment process. 2. Evaluating the competency of staff is accomplished through the facility's training program. 4. Subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations. 8. Employee competency forms are maintained in the Director of Nursing's office for the current training year, then…
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 · D2024-07-10 · 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
Based on observations, interviews, record review, and review of facility policy, the facility failed to ensure the environment remained as free from potential accident hazards as possible for 1 of 1 resident (R)23. Specifically medications were found at R23's bedside. Findings include: Review of the facility policies titled Medication Administration and Medication Storage with no revision date noted, states that medication are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. 18. Observe resident consumption of medication. 1c. During medication pass, medications must be under the direct observation of the person administering medication or locked in the medication storage area/cart. Review of Medication Administration Policy with an in-service dated 07/08/2024, revealed a total of five licensed practical nurses and one registered nurse signatures that attest to reading of the Medication Administration Policy. Review of R23's face sheet revealed 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 · D2024-07-10 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and facility policy the facility failed to maintain an effective pest control program. Findings Include: Review of the undated facility policy titled, Pest Control Program, revealed, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Effective pest control program is defined as measures to eradicate and contain common household pests (e.g. bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats). During a review of the Service Inspection Reports for June 2024 revealed Open Conditions of unsealed cracks and crevices, doors have gaps allowing pest entry, back door has gaps, cracks and gaps in the ceiling, and there is standing water under appliance/machinery/equipment in the kitchen. During an observation on 07/08/24 at 10:15 AM in the common area, of which the surveyors were housed for survey, revealed approximately 10-15 flies throughout the day. 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 · E2022-03-11 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a system of records of receipt of controlled drugs, in sufficient detail, to enable an accurate reconciliation until disposition of destruction and identification of the method of destruction used for controlled medications. Specifically, the facility had the potential for drug diversion with controlled substances and failed to ensure a system of receipt and disposition of all controlled drugs in sufficient detail to ensure an accurate reconciliation and the controlled drugs destruction log did not contain the destruction method for controlled medications. Findings include: Review of consultant pharmacy A contract dated [DATE] revealed no agreement related to destruction and/or supervision of controlled substances for destruction. Review of facility contract with Prisma Health Senior Care PACE (Providing All inclusive Care for the Elderly) program dated [DATE] revealed no contracted services for pharmacy provided to the facility. 1. An observation…
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 · D2022-03-11 · 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 and interview, the facility failed to ensure hand hygiene for 1 of 1 Residents ((R) 30) prior to lunch and the laundry area was free of potential spread of infections. Specifically, the facility failed to provide hand hygiene for residents prior to meals and ensure no dust, holes, or exposed plaster was noted in the laundry area. Findings include: 1. During the lunch observation on 03/08/22 at 12:45 PM revealed R30 sitting in a wheelchair in the common area in front of the nurses station while meal trays were being passed out by staff. R30 observed with no meal tray as the other resident noted in the area was eating lunch. R30 was observed playing with the top of and inside of her brief before being wheeled to her room by Certified Nursing Assistant (CNA)1 with no hand hygiene performed prior to meal set-up. During an interview on 03/08/22 at 2:00 PM, CNA1 stated, Normally we don't offer the residents anything to wipe their hands with prior to eating. I didn't offer R30 anything to wipe her hands with. I thought she was just playing with the top part of her…
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. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2025-10-29 for 85 days
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| GARRARD, LOUIS | Individual | DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; LIMITED PARTNERSHIP INTEREST; ADP OF THE SNF | since 07/01/2019 |
| MAUNG, PETER | Individual | ADP OF THE SNF | since 07/01/2019 |
CMS files one row per role, so the 6 rows in the source record cover these 2 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.
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.
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 425370. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-29, 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.