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The Oaks Post Acute

151 Lovely Drive, Orangeburg, SC 29115 · For profit - Limited Liability company · 122 certified beds · (803) 534-1212 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Jun 2025Resident-funds citation (F0568)1 immediate-jeopardy citation$98,607 in federal fines
Insights

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

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Jun 2025
  • it has a citation for mishandling residents’ money or property (F0568)
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $98,607 in federal fines (most recent 2026-01-13)
  • 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)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 3 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

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
151 Magnolia Village Parkway
Pharmacy
Walmart3.4 mi
332 Stonewall Jackson Blvd · (803) 997-6138 · Call to confirm hours
Grocery
1310 Cannon Bridge Rd · (803) 534-5703 · Call to confirm hours
Park
210 Cannon Bridge Rd · (803) 533-6020 · Typically dawn to dusk
Place of worship
3589 Rowesville Rd · (803) 531-4480

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 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 held steady at 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.4%11.9%15.4%better
Long-stay residents who lose too much weight8.9%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.6%0.9%better
Long-stay residents with a urinary tract infection0.3%1.3%2.0%better
Long-stay residents with depressive symptoms0.8%3.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.2%3.2%3.3%typical
Long-stay residents whose ability to walk worsened5.4%12.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.0%21.0%18.9%better
Long-stay residents given the seasonal flu vaccine62.7%90.6%95.3%worse
Long-stay residents with pressure ulcers6.1%5.1%4.7%worse
Long-stay residents with worsening bladder/bowel control6.6%16.7%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table16.1%15.3%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.5%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine26.6%78.0%79.4%worse
Short-stay residents rehospitalized after admission23.9%24.3%22.6%typical
Short-stay residents with an outpatient ER visit11.1%13.9%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.792.041.67typical
Long-stay outpatient ER visits per 1,000 resident days1.211.841.80better

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.

43.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 133 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

43.1%U.S. median 51.5%
Got home and stayed home
15.1%U.S. median 10.7%
Went back to hospital
61.1%U.S. median 56.6%
Met the expected recovery
0.28U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 61.1% 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 36 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 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF43.1%CMS range 35.5–49.551.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF15.1%CMS range 10.7–20.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge61.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge63.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge63.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay3.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.8%CMS range 5.8–13.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.211.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.16
RN hours/ resident / day
1.12
LPN hours/ resident / day
1.80
Aide hours/ resident / day
3.08
Total nurse hours/ resident / day
0.10
RN hoursweekends
45.3%
Total nursing turnover
37.5%
RN turnover

How full it usually is: this home is certified for 122 beds and averages 114.6 residents a day — about 94% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.08 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.16 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.80 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 2.74 hrs/resident/day on weekends vs 3.22 on weekdays — 15% thinner on weekends. RN hours go from 0.18 to 0.10 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

8
deficiencies at the latest standard inspection (2026-01-13)
5
at the previous standard inspection (2024-11-05)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

21 citations, most serious first. The 11 most serious are shown; the remaining 10 are one tap away and print in full.

  • Immediate jeopardy · J2024-11-05 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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 the facility failed to ensure that Resident (R)163, a resident with an Advanced Directive as Full Code received Cardiopulmonary Resuscitation (CPR) after being found unresponsive on 10/09/24. 1 of 1 reviewed for CPR. On 11/04/24 at 7:15 PM the Administrator and Director of Nursing (DON) were notified that the failure to initiate CPR on R163 on 10/09/24 after being found unresponsive constituted an Immediate Jeopardy (IJ). The IJ was determined to first exist on 10/09/24 at approximately 4:10 PM (time of death according to County Coroner's Office/ Electronic Medical Record). The facility presented a removal plan on 11/05/24 at 5:52 PM, the deficient practice remained at F678 at a lower scope and severity of D, the facilities failure constituted substandard quality of care at F678. The facilities removal plan for F678 included Audit completed by the Social Services Director (SSD) on all residents to ensure that all advanced directive paperwork is present 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-01-13 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility policy, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in 1 of 1 Kitchen, 1 of 3 Unit Nourishment Rooms, and 1 of 1 Medication Rooms.Review of the facility policy titled Food Receiving and Storage last revised in July 2014 revealed, Foods shall be received and stored in a manner that complies with safe food handling practices. Food Services, or other designated staff, will maintain clean food storage areas at all times. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. Refrigerated foods must be stored below 41F unless otherwise specified by law. Refrigerated foods will be stored in such a way that promoted adequate air circulation around food storage containers. Functioning of the refrigeration and food temperatures will be monitored at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-13 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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, observation, record review, and interview, the facility failed to maintain a clean, homelike environment for Residents (R)57, R71, and R95 for 2 of 3 units observed.Findings include: Review of the facility policy titled Resident's Rights revealed, Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. The rights include the resident's right to: a. A dignified existence . Review of the facility policy titled Cleaning and Disinfecting Residents' Rooms with a revision date of August 2013 revealed, General Guidelines: 1. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 2. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. During multiple observations on 01/11/26 and 01/12/26, a cart made of white PVC pipes was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-13 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation, record review, manufacturer labeling and interview, the facility failed to ensure proper storage of medications in 2 of 3 medications rooms and 1 of 6 medications carts.Findings include: Review of the facility policy titled Medication Labeling and Storage with a revised date of February 2023 documents, if the facility has discontinued, outdated or deteriorated medications, the dispensing pharmacy is contacted for instructions regarding or destroying these items and multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated . Review of the Aplisol Manufacturer (Endo) Labelling documented, Once entered, vial should be discarded after 30-days and the manufacturer package insert documented, Failure to store and handle Aplisol as recommended may result in a loss of potency and inaccurate test results. During an observation on 01/11/26 at approximately 11:31 AM, of the [NAME] (A Wing) Medication Room refrigerator revealed one opened and not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-13 · tag F0568 — isolated
    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
    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 interview, the facility failed to provide quarterly account statements for Resident (R)7's personal fund for 1 out of 1 resident reviewed for Personal Funds. Findings include:Review of the facility policy titled Accounting and Records of Personal Funds with a revision date of April 2021 revealed, Policy Statement: Our facility maintains accounting records of resident funds on deposit with the facility. Policy Interpretation and Implementation: . 5. Individual accounting records are made available to the resident through quarterly statements and upon request.Review of R7's Face Sheet revealed R7 was admitted to the facility on [DATE], with diagnoses including but not limited to type 2 diabetes, dementia, major depressive disorder, epilepsy, and high blood pressure. Review of R7's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/25 revealed R7 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating she…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation, record review, drug manufacturer recommendation and interview, the facility failed to notify a medical doctor or nurse practitioner of a clinical concern related to Resident (R)23. Furthermore, the facility failed to maintain stock of an ordered medication for R6. Findings include: Review of the facility policy titled Acute Condition Changes - Clinical Protocol with a revised date of January 2025 documented, The nursing staff will contact the physician based on the urgency of the situation. Review of the facility policy titled Medication Labeling and Storage with a revised date of February 2025 documented, The nursing staff is responsible for maintaining medication storage . in a . safe manner . and if the facility has . the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Review of R23's Face Sheet revealed R23 was admitted to the facility on [DATE] with diagnoses including but not limited to unspecified dementia,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, observation, interview, and record review, the facility failed to ensure proper usage or the hoyer lift, for 1 of 1 Resident R(49), reviewed for accident hazards/supervision/devices.Findings include:Review of the facility policy titled Lifting Machine, Using a Mechanical documents, Purpose: The purpose of this procedure is to establish the general principles for using a mechanical lifting device. It is not a substitute for manufacturer's training and instructions. General Guidelines: 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift . 4. Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility . Steps of Procedure: . 2. Measure the resident for proper sling size and purpose, according to manufacturer's instructions. 3. Select a sling bar that is appropriate for the resident's size and the task. 4. Prepare the environment: a. Clear an unobstructed path for the lift machine; b. Ensure there is…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 facility policy review, observation, record review and interview, the facility failed to provide respiratory care in accordance with professional standards. Specifically, the facility failed to ensure Resident (R)122's nebulizer machine, oxygen mask and medication chamber were clean and stored properly when not in use for 1 of 1 resident. Findings include:Review of the facility policy titled Oxygen Administration with a revised date of October 2010 documented, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure, if no order in place initiate nursing measure of oxygen administration when applicable. 2. Review the resident's care plan to assess for any special needs of the resident. Steps in the Procedure: . 7. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.On 01/13/26 at 9:00AM, a request was made 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility policy review, the facility failed to provide a safe and sanitary environment to help decrease the risk of infections. Specifically, the facility failed to offer residents hand hygiene prior to dining in the 400 Riverside Unit. Furthermore, the facility failed to prevent potential cross-contamination by housekeeping staff. Review of the facility policy titled Handwashing/Hand Hygiene with a revision date of October 2023, revealed, The Oaks Post Acute Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretation and Implementation: Administrative Practices to Promote Hand Hygiene: . 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies . 6. Residents, family members, and/or visitors are encouraged to practice hand hygiene.During an observation on 01/11/26 at 12:55 PM, the staff began bringing residents to 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-24 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure that Resident (R)3 was free from misappropriation by Certified Nursing Assistant (CNA)1, for 1 of 3 residents reviewed for misappropriation or property. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating last revised on September 2022, revealed All reports of resident abuse (including injuries of unknown origin, neglect, exploitation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and to other officials according to state law. The Administrator or individual making the allegation immediately…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-10 · tag F0641 — isolated
    Ensure 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 review of facility policy, record review and interview, the facility failed to accurately document Fall Risk Assessments, for 1 of 3 residents, Resident (R)1, reviewed for accidents/falls. This failure placed R1 at an increased risk for falls and injuries. Findings include: Review of the facility policy titled, Falls - Clinical Protocol last revised on 03/18, documents, 2. the nurse shall assess and document/report the following . i. All current medications and j. All active diagnoses . 3. The staff and practitioner will review each resident's risk factors for falling and document in the medical record . a. Examples of risk factors for falling include . multiple medications and medical conditions affecting the central nervous system. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's Disease, Dementia, essential (primary) hypertension and major depressive disorder. Review of R1's admission Minimum Data Set (MDS) with 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · Dcited before2025-03-10 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, observation and interview, the facility failed to ensure biologicals and supplements were stored appropriately. Findings included: Review of the facility policy titled Storage of Medications last revised on November 2020, documented, The facility stores all drugs and biologicals in a safe, secure, and orderly manner . 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. During a facility tour of the Riverside Hall on 03/10/25 at 12:38 PM and 1:00 PM, the following was observed to be stored on the floor: Four packages of Maximum Strength Anti-Itch Cream 1% Hydrocortisone Cream. Eleven boxes of Welmate Maximum Strength 4% Lidocaine Numbing Patches. Three eight ounce bottles of Povidone Iodine Solutions. One three pack of Gauze Rolls. One open box of wild berry flavor BOOST Breeze nutritional drinks. Two open boxes of BOOST Glucose Control nutritional drinks. One open box of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-11-05 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, observations and interviews, the facility failed to ensure biologicals were stored appropriately in 3 of 3 Medication Treatment Carts. Findings include: Review of the facility policy, copyright 2001 Med-Pass, Inc, titled, Medication Labeling and Storage documents, the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Medication Storage 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. During an observation on [DATE] at 12:23 PM, of the [NAME] Treatment Cart revealed the following: -Gentell rolled gauze bandage (4.5 x 4.1 YDS (11cm x 3.7m) Lot # 240217 exp 2027 02 16 Sterile and opened. -Silvercel Non-adherent antimicrobial Alginate Dressing with Easy Lift 10/4 1/4 in x 4 1/4 in (11cm x 11cm) Manufacturer…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-11-05 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and interviews the facility failed to ensure that the ice machine in 1 of 1 kitchen was kept clean and sanitized. Findings include: A facility policy regarding the ice machine was requested on 11/05/24 at 3:22 PM. At 5:15 PM, the Administer advised that a policy was not available. During the initial tour of the Kitchen on 11/03/24 at 9:55 AM, the ice machine was observed, in the presence of the Kitchen Manager (KM), to have a black moldlike substance around the ice dispenser. During an interview on 11/03/24 at 9:55 AM, the KM verified the the black moldlike substance in the ice machine and stated that it is her expectation that the ice machine is cleaned daily, at the end of the day. Attempted review of the kitchens cleaning logs, revealed there were no cleaning logs of the ice machine available. During an interview on 11/05/24 at 3:22 PM, the Administrator stated that it is expected that all equipment is maintained in a clean and sanitized manner.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-05 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, the facility failed to develop a Care Plan for Resident (R)163, related to Advance Directives, for 1 of 2 residents reviewed. Findings include: Review of the facility policy titled Care Plan, Comprehensive Person Centered last revised on March 2022, documented, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 1. The interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . 7. The comprehensice, person-centered care plan: a. includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation, interview, and record review, the facility failed to ensure Resident (R)52, who was dependent on staff for activities of daily living (ADLs), received the necessary services to maintain personal hygiene, for 1 of 6 residents reviewed. Findings include: Review of the facility policy titled, Activities of Daily Living (ADL), Supporting with a date of 2001, documented, Policy Statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support with assistance with: a. hygiene (bathing, dressing, grooming, and oral care) . Review of R52's admission Record revealed R52 was admitted to the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-14 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 review of the facility policy, record review, and interviews, the facility failed to notify Resident (R)1's responsible party (RP) of a change in skin condition when an unstageable wound was discovered for 1 of 3 records reviewed for quality of care. Findings include: Review of the facility policy, with a revision date of 2001, titled, Change in a Residents Condition or Status revealed under policy, Unless otherwise instructed by the resident, a nurse will notify the resident's representative when, there is a significant change in the residents physical status. Review of R1's Face Sheet revealed the facility admitted R1 on 12/25/2020 with diagnoses including, parkinsonism, chronic obstructive pulmonary disease and type 2 diabetes. Review of R1's treatment administration record (TAR) dated 05/17/2024, revealed a treatment order to, cleanse left trochanter with wound cleanser, and apply hydrogel, cover with bordered foam gauze daily for unstageable every shift. Review of the TAR revealed the signatures began on 05/17/2024, signed as treatment administered. Review of R1'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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-14 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility policy, record review, and interview, the facility failed to ensure a written grievance was filed for Resident (R)1 regarding care concerns for 1 of 3 residents reviewed for quality of care. Findings include; Review of the facility policy, revised April 2017, titled, Grievances/Complaints Filing revealed under policy, Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal. Record review of the facility Resident Grievance Log dated May 2024, does not record any concerns for R1. An interview with R1's Personal Representative on 06/14/2024 at 10:27 AM revealed, I visited about a month ago and had care concerns. I asked to speak to the head of nursing and the social worker, but they were both off, it was on Friday the 17th. I returned Monday, the 20th of May and met with the head of nursing, the social worker and the wound nurse. I had a lot of concerns about the care, the odors, R1's fall, and her hip wound, which I was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-10-07 · tag F0645 — pattern
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed accurately for 3 of 3 residents (Resident (R)77, R17, and R60) reviewed for PASRR. Findings include: Review of the facility's policy titled, Resident Assessment-Coordination with PASARR [preadmission screening and resident review] Program, dated 2022, indicated All applicants will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with State Medicaid rules for screening. PASARR level I- initial screening that is completed under admission .The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority .Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability or a related condition will be referred promptly to the state mental health or intellectual disability authority for 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-07 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 review of the facility policy, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were submitted within the 14-day period for 1 of 1 Resident (R)1, reviewed for resident assessments. Findings include: Review of the facility's policy titled, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/19, indicated Entry: Transmission date no later than entry date +14 calendar days; Comprehensive assessment: Transmission date no later than care plan completion date +14 calendar days; Discharge assessment: Transmission date no later than MDS completion date +14 calendar days. Review of the MDS with an Assessment Reference Date (ARD) of 04/27/22 revealed a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated R1 had severely impaired cognition. This MDS revealed R1 was admitted on [DATE]. Review of the MDS transmission logs provided by the MDS coordinator revealed: Entry MDS date 04/20/22; Submitted and accepted…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility policy, record review, and interview, the facility failed to ensure insulin was provided according to the sliding scale the Physician ordered for 1 (Resident (R)17) of 1 resident reviewed for insulin administration. Findings include: Review of the facility's policy titled Insulin Administration, reviewed 05/27/22, indicated Purpose: to ensure medication is given as ordered by the physician to the resident. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/27/22 revealed a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated R17 had severely impaired cognition. Review of the physician order provided by the Director of Nursing (DON) revealed Novolog Flexpen U-100 Insulin aspart: Before meal and at bedtime: 170 thru 200 give 2.0 units; 201-250 give 4.0 units; 251 thru 300 give 6.0 units; 301 thru 350 give 8.0 units; 351 thru 400 give 10.0 units. Start date 09/07/22. Review of the electronic medication administration record (eMAR) provided by the DON, dated 10/22 revealed: On 10/01/22: HS…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$98,607 in federal fines across 12 penalties.

  • $9,480 — penalty dated 2026-01-13
  • $13,627 — penalty dated 2024-11-05
  • $4,938 — penalty dated 2024-02-20
  • $4,938 — penalty dated 2024-02-12
  • $14,814 — penalty dated 2024-01-22
  • $4,938 — penalty dated 2024-01-08
  • $4,587 — penalty dated 2024-01-02
  • $13,762 — penalty dated 2023-12-11
  • $4,587 — penalty dated 2023-11-20
  • $4,587 — penalty dated 2023-11-13
  • $13,762 — penalty dated 2023-10-23
  • $4,587 — penalty dated 2023-08-21

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 PACS GROUP — 274 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.9-1.9 vs chain
Health inspection 1 of 52.5-1.5 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 4 of 54.4-0.4 vs chain
The other 273 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Anchor Post AcuteAiken, SC 1 of 5Arbor Post AcuteChico, CA 1 of 5Artesia Palms Care CenterArtesia, CA 1 of 5Arvin Post AcuteArvin, CA 1 of 5Ashland Post AcuteAshland, OR 1 of 5Bakersfield Post AcuteBakersfield, CA 1 of 5Beachwood Post-Acute & RehabSanta Monica, CA 1 of 5Brookshire Post AcuteDenver, CO 1 of 5Brushy Creek Post AcuteGreer, SC 1 of 5Buckeye Care And RehabilitationLancaster, OH 1 of 5Carnegie Park Post AcutePittsburgh, PA 1 of 5Cascade Terrace Post AcutePortland, OR 1 of 5Centennial Post AcuteAnchorage, AK 1 of 5Chandler Creek Post AcuteGreer, SC 1 of 5Chehalem Post AcuteNewberg, OR 1 of 5Country Hills Post AcuteEl Cajon, CA 1 of 5Delhi Post-AcuteCincinnati, OH 1 of 5Dublin Post AcuteDublin, OH 1 of 5Edisto Post AcuteOrangeburg, SC 1 of 5Evan Terrace Post AcuteMcMinnville, OR 1 of 5Forest Acres Post AcuteColumbia, SC 1 of 5Grandview Post AcuteCookeville, TN 1 of 5Great Plains Post AcuteWichita, KS 1 of 5Hemet Hills Post AcuteHemet, CA 1 of 5Highland Hills Post AcutePittsburgh, PA 1 of 5Highline Post AcuteDenver, CO 1 of 5Johns Island Post AcuteJohns Island, SC 1 of 5Karcher Post AcuteNampa, ID 1 of 5Kennedy Care CenterLos Angeles, CA 1 of 5Kern River Transitional CareBakersfield, CA 1 of 5Lakeview Post AcuteFlorissant, MO 1 of 5Marion Valley Post AcuteMarion, OH 1 of 5Mirage Post AcuteLancaster, CA 1 of 5Monroeville Post AcuteMonroeville, PA 1 of 5Napa Post AcuteNapa, CA 1 of 5North Royalton Post AcuteParma, OH 1 of 5Northstar Post AcuteCarson City, NV 1 of 5Overland Park Post AcuteOverland Park, KS 1 of 5Pikes Peak Post AcuteColorado Springs, CO 1 of 5Ridgeway Post AcutePetaluma, CA

Showing 40 of 273; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
TRUIST BANKOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 07/16/2024
JERGENSEN, JOSHUAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
MITCHELL, JOHNIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/18/2024
ARTS, JEFFIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/18/2025
KIZER, MELISSAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/03/2024
WILLIAMS, VANNAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2024
ORANGEBURG SC PROPERTY HOLDINGS LLCOrganizationADP OF THE SNFsince 04/01/2024
PROVIDENCE ADMINISTRATIVE CONSULTING SERVICES INCOrganizationADP OF THE SNFsince 04/01/2024

CMS files one row per role, so the 15 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$11.0M
Net patient revenuemost recent cost report
-2.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 62%Medicare 10%Other / private 28%

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

$331per resident / day
operating cost
$10,064per month
≈ monthly operating cost
$323per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in SC

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the South Carolina Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 425131. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-13, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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