Piedmont Post-Acute
109 Bentz Road, Piedmont, SC 29673 · For profit - Limited Liability company · 88 certified beds · (864) 845-5177 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- it has 1 actual-harm citation
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,018 in federal fines (most recent 2024-12-14)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.0% | 11.9% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 6.3% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.4% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 7.0% | 3.1% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.2% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.2% | 12.7% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 19.0% | 21.0% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 96.7% | 90.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.7% | 5.1% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 15.8% | 16.7% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.3% | 15.3% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.1% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 93.2% | 78.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 26.7% | 24.3% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 15.4% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.38 | 2.04 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.12 | 1.84 | 1.80 | better |
* 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.
53.6% 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 98 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 75.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 24 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 0.58 therapist hours per resident per day in 2026Q1 — more than 87% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% 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 | 53.6%CMS range 45.3–62.1 | 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 | 13.6%CMS range 10.2–19.2 | 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 | 75.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 66.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 54.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 10.2% | 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 | 10.0%CMS range 6.5–16.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.11 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 88 beds and averages 81.8 residents a day — about 93% occupied, or roughly 6 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 3.45 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.82 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 2.93 hrs/resident/day on weekends vs 3.66 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.50 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · G2024-12-14 · 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 interview, record review, and facility document and policy review, the facility failed to ensure two staff members assisted with a mechanical lift transfer for 1 Resident (R)1 of 4 residents reviewed for mechanical lift transfers. The failure resulted in R1 sustaining a laceration to the top right side of their head, which required three staples to repair. Findings included: A facility policy titled, Lifting Machine, Using a Mechanical, revised 07/2017, revealed, 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 2. Mechanical lifts may be used for tasks that require: a. Lifting a resident from the floor; b. Transferring a resident from bed to chair; c. Lateral transfers; d. Lifting limbs; e. Toileting or bathing; or f. Repositioning. 3. Types of lifts that may be available in the facility are: a. Floor based full body sling lifts; b. Overhead full body sling lifts; and c. Sit-to-stand lifts. 4. Lift design and operation vary across manufactures. Staff must be trained and demonstrate competency using the specific machines or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-04-04 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility policy review, the facility failed to ensure staff checked temperatures of all foods placed on the steam table for hot holding prior to meal service. Specifically, staff failed to check temperatures of additional batches of food added to the steam table during meal service on 04/03/2026. This had the potential to affect 80 residents who received food from the facility kitchen. Findings included: Review of a facility policy titled, Serving Temperatures for Hot and Cold Foods, effective 2020, revealed, The cook will take temperatures of hot and cold food items using approved food thermometers prior to each meal service. During an observation on 04/03/2026 at 12:36 PM, Dietary Aide (DA)21 placed a new batch of fried chicken on the tray line and plated a plate for a resident and did not take the temperature of the fried chicken. The Assistant Dietary Director (ADD) asked DA21 if she took the temperature of the chicken and DA21 revealed she did not. During a continued observation of the tray line for lunch on 04/03/2026 at 12:55 PM, a new pan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-04-04 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure staff followed infection control practices to help prevent the development and transmission of communicable diseases and infections, which affected 1 of 1 resident, (Resident (R)92), reviewed for tracheostomy care, 1 of 1 resident, (R9), reviewed for pressure ulcers, and 1 of 1 resident, (R87), reviewed for transmission based precautions. The facility also failed to implement a complete water management program for Legionella prevention, which had the potential to affect all the residents in the facility. Findings included: 1. Review of a facility policy titled, Tracheostomy Care, revised 10/2023, revealed, The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. The policy revealed, Procedure Guidelines included, 8. Remove old dressings. Pull soiled glove over dressing and discard into appropriate receptacle, and 9. Perform…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-04 · tag F0759 — failed to keep medication error rate low — patternEnsure 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 observation, interview, record review, and facility policy review, the facility failed to maintain a medication error rate of 5 percent (%) or less. There were 6 errors out of 44 opportunities, which resulted in a medication error rate of 13.64% for 3 (Residents (R)22, (R)14, and (R)62) of 3 residents observed for medication administration. Findings included: Review of a facility policy titled, Administering Medications, revised 04/2019, indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame. 1. An admission Record indicated the facility admitted R22 on 03/23/2026. According to the admission Record, the resident had a medical history that included but was not limited to a diagnosis of gastro-esophageal reflux disease without esophagitis. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/30/2026, revealed R22 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. Review of R22's Order Summary Report, with active orders…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-04 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, facility policy review, and review of manufacturer guidelines, the facility failed to follow a physician's order to remove a lidocaine patch for 1 (Resident (R)62) of 3 residents observed for medication administration. Findings included: Review of a facility policy titled, Administering Medications, revised 04/2019, indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame. Review of Manufacturer guidelines titled, Lidoderm, dated 01/2015, revealed, Apply Lidoderm to intact skin to cover the most painful area. Apply the prescribed number of patches (maximum of 3), only once for up to 12 hours within a 24-hour period. Review of R62's admission Record revealed the facility admitted R62 on 12/24/2025. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of infection and inflammatory reaction due to indwelling urethral catheter and muscle weakness. Review of R62's quarterly Minimum Data Set (MDS) with an Assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure sufficient bowel monitoring for 1 (Resident (R)26) of 1 sampled resident reviewed for bowel monitoring. Findings included: A facility policy titled, Bowel Management Protocol, dated 02/15/2015, revealed, It is the policy of this facility to ensure that residents are free from complications secondary to constipation. This will be accomplished through adequate assessment, tracking and treatment as indicated. The policy also indicated, Normal bowel pattern is once every day up to once every three (3) days. Constipation results from factors such as immobility, decreased activity, and as a side effect of numerous medications. The policy also indicated, CNAs [certified nursing assistants] to document each shift the number of bowel movements and size of bowel movements on the resident flow record. The policy also indicated, The Unit Manager will review the resident flow record daily and compose a list of those residents having not had a BM [bowel movement] in three (3)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, record review, observation, and interview, the facility failed to ensure staff provided catheter care appropriately for 1 (Resident (R)69) of 1 resident reviewed for catheter care.Findings included: Review of a facility policy titled, Catheter Care, Urinary, revised 09/2014 revealed, The purpose of this procedure is to prevent catheter-associated urinary tract infections. The policy revealed, Steps in the Procedure included, 13. With nondominant hand separate the labia of the female resident or retract the foreskin of the uncircumcised male resident. Maintain the position of this hand throughout the procedure; 14. Assess the urethral meatus; and 15. For a female resident: Use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward, cleansing stroke. Change the position of the washcloth with each downward stroke. Next, change the position of the washcloth and cleanse around the urethral meatus. Do not allow the washcloth to drag on the resident's skin or bed linen. With a clean washcloth, rinse with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-04 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to ensure a resident's medical record accurately reflected the removal of a lidocaine patch ordered by the physician for 1 (Resident (R)62) of 3 residents observed for medication administration. Findings included: Review of a facility policy titled, Charting and Documentation, revised 07/2017, revealed, 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. An admission Record revealed the facility admitted R62 on 12/24/2025. According to the admission Record, the resident had a medical history that included but was not limited to a diagnosis of muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/27/2026, revealed R62 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. The MDS indicated R62 received a scheduled pain medication regimen. Review of R62's Order Summary Report, with active orders as of 04/01/2026, revealed an order…
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 · F2025-04-09 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure: 1.Correct serving sized utensils were used to ensure portion sizes at meals, which had the potential for all residents who received food from the kitchen to have unmet food intakes and potentially to have weight loss. 2. Resident (R)65 received the appropriate texture food (pureed) for dysphagia which had the potential for the resident to choke. Findings include: During an observation on 04/08/25 between 11:50 AM and 12:30 PM, of the meal service, [NAME] (C) 1 was observed plating food to be served to residents. The preplanned menu identified the meal included sliced pork roast, mashed potatoes, and green beans. C1 was observed using the same size scoops for the mashed potatoes, the green beans, and altered textured foods that had been prepared as well. The regular diets were served one slice of pork roast. During an interview on 04/08/25 at 11:55 AM, the Dietary Manager (DM) was asked for the menu spread sheets and or menu…
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 before2025-04-09 · 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 and interview, the facility failed to ensure food was prepared in a sanitary manner, failed to ensure foods were dated and failed to ensure the equipment storage area was maintained in a sanitary condition. This had the potential to affect 81 of 82 residents who consumed food from the kitchen. Findings include: 1.During the initial tour completed on 04/07/25 between 9:20 AM and 9:50 AM with the Dietary Manager (DM) the following observations were noted: Diet Aide (DA) 1, was working in the dish room assisting with washing and stacking dishes. DA1 had a beard and a ponytail, neither were covered with a hair restraint. During an interview on 04/07/25 at 9:25 AM, DA1 confirmed he should be wearing hair restraints. 2.During an observation with the DM on 04/07/25 at 9:30 AM, a box of Mighty Shakes was found on a shelf in the walk-in refrigerator, the box was dated 03/11/25. The DM said the Might Shakes are delivered to the facility frozen, and are thawed in the refrigerator and then had a shelf life of 21 days after removing them from the freezer. When asked what…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-09 · 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 review of the facility policy, observations, interviews and record review, the facility failed to ensure oxygen was administered per physician orders for three of three residents reviewed for respiratory care (Resident (R)13, R24 and R76) out of 23 sampled residents. This failure placed the residents at risk for unmet respiratory needs and at risk for respiratory complications. Findings include: Review of the facility's undated policy titled, Oxygen Administration, revealed .Steps in the Procedure .5. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered . 1.Review of R13's admission Record revealed R13 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia. Review of R13's Orders revealed O2 [oxygen] @ [at] 2liters via NC [nasal cannula] every shift . dated for 02/07/25. Review of R13's Care Plan revealed a focus initiated on 02/19/25 of End of Life: Resident requires Hospice…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · D2025-04-09 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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's policy, record review, and interviews, the facility failed to ensure residents with Post Traumatic Stress Disorder (PTSD) received trauma informed care which included identifying triggers of their trauma experiences for one of three sampled residents (Resident (R) 78) reviewed for mood/behavior out of 23 sampled residents. This failure placed the resident at an increased risk of re-traumatization. Findings include: Review of the facility's undated policy titled, Trauma Informed Care and Culturally Competent Care revealed, Purpose: To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of the trauma survivors by minimizing triggers and/or re-traumatization .Definitions .Trigger' is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening .General Guidelines .4. Triggers are highly individualized. Some…
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 · D2025-04-09 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, observation, interview and record review, the facility failed to ensure alternatives of similar nutritive values were offered when foods were refused and failed to ensure staff obtained preferences for three (Residents (R) 8, 145and R77) reviewed out of a sample size of 23 residents. This placed these residents at risk for weight loss. Findings include: Review of the facility's undated policy titled, Resident Food Preferences, revealed Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team .1. Upon the resident's admission (or within twenty-four (24) hours after his/her admission) the dietitian or nursing staff will identify a resident's food preference .3. Dietary staff will document the resident's food and eating preferences in the meal ticketing system . 1. Review of R8's admission Record revealed the resident was admitted to the facility on [DATE]. Review of the R8's quarterly Minimum Data Set (MDS) with an Assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-01 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to ensure that the Ombudsman was notified of a hospitalization for Resident (R)83 in a timely manner for 1 of 5 residents reviewed for hospitalizations. Findings include: The facility admitted R83 with diagnoses including but not limited to, left femur fracture and alzheimer's. Review of Nurses' notes on 02/28/24 revealed documentation that stated, 11/14/2023 at 7:54 AM Residents roommate stated that the resident fell and hit her head trying to get to the bathroom. The roommate yelled out for staff. When this nurse got into the room and observed the resident she was noted to have an open area to her left eyebrow. This nurse applied a pressure dressing to the area and called Third Eye. Spoke with MD, ordered to send resident to the ER for evaluation, RP notified and resident was sent to hospital. There was no evidence in the record that the Ombudsman was notified of the transfer. Further review of the Nurses' notes revealed a note dated, 11/14/23 - resident arrived via stretcher, accompanied by two EMT personnel. She is alert…
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 · D2024-03-01 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the facility policy titled, Accommodation of Needs, and Activities of Daily Living (ADLs), Supporting, observations, record reviews and interviews, the facility failed to implement the comprehensive plan of care for Resident (R)24, related to activities of daily living. Specifically, R24 was observed with heavy beard growth on his face and to the base of his neck for 1 of 3 residents reviewed for Activities of Daily Living, related to grooming. Findings include: Review of the facility policy titled, Accommodation of Needs, revised March 2021, states in the policy statement,Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well being. In order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining, independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. Review of the facility policy titled, Activities of Daily Living…
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 · D2024-03-01 · 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
Based on review of the facility policy titled, Accommodation of Needs, and Activities of Daily Living (ADLs), Supporting, observations, record reviews and interviews, the facility failed to ensure R24 received the care and services during ADL care related to shaving. Specifically, R24 was observed with heavy beard growth on his face and to the base of his neck for 1 of 3 residents reviewed for Activities of Daily Living related to grooming. Findings include: Review of the facility policy titled, Accommodation of Needs, revised March 2021, states in the policy statement,Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well being. In order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining, independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, states…
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 · D2024-03-01 · 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 review of facility policy, record review, observation, and interview, the facility failed to provide 1 of 1 resident,(R)68, resident centered activities based on resident's preferences, interests, and choice. Findings include: Review of the facility policy titled, Activity Programs, with revised date of August 2006, states 1. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. 2. Activities are scheduled seven days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs. 7. Individualized and group activities are provided that: Reflect the schedules, choices, and rights of the residents; are offered at hours convenient to the residents, including evenings, holidays and weekends; reflect the cultural and religious interests, hobbies, life experiences, and personal preferences of the residents. Review of R68's face sheet revealed he 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.
- Potential for harm · Dcited before2024-03-01 · 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 facility policy review, record review and observations, the facility failed to administer oxygen therapy within professional standards related to the storage of respiratory equipment when not in use for 2 (Resident (R)15 and R39) of 3 residents reviewed for respiratory care. Findings include: Review of the facility policy titled, Oxygen Administration, revised October 2010, revealed Purpose Statement: The purpose of this procedure is to provide guidelines for safe oxygen administration. Check the tubing connected to the oxygen cylinder to assure it is free of kinks. Securely anchor the tubing so that it does not rub or irritate the resident's nose, behind the resident's ears, etc. Discard used supplies into designated containers. Review of R15's Face Sheet indicated the facility admitted the resident on 08/13/2023, with diagnoses including, but not limited to; chronic combined systolic (congestive) heart failure chronic obstructive pulmonary disease, major depressive disorder, post-traumatic stress…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-01 · 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 the facility policy titled, Adverse Consequences and Medication Errors, and Insulin Pen Administration Steps, observations and interviews, the facility failed to ensure a medication administration error rate less than 5 percent. Specifically, the medication Questran for Resident (R)1 was ordered to be mixed in 8 ounces of liquid and it was mixed in 4 ounces of liquid and administered. The medication, Potassium Extended Release for R6, was crushed and administered with other crushed medications for R6. The Insulin, Novolog, Flex Pen for R1 was not primed correctly, nor was it administered correctly for R1. The medication error rate was 12 percent for 3 out of 25 opportunities for error. Findings include: Review of the facility policy titled, Adverse Consequences and Medication Errors, states under,Medication Errors, 1. A medication error, is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing…
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 · D2024-03-01 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the facility policy titled, Adverse Consequences and Medication Errors, and Insulin Pen Administration Steps, observations and interviews, the facility failed to ensure Resident (R)1 and R6 were free from significant medication errors. Specifically, the medication Questran for R1 was ordered to be mixed in 8 ounces of liquid and it was mixed in 4 ounces of liquid and administered. The medication, Potassium Extended Release for R6, was crushed and administered with other crushed medications for R6. The Insulin, Novolog, Flex Pen for R1 was not primed correctly, nor was it administered correctly for R1 for 2 of 2 residents reviewed receiving medications with significant medication errors. Findings include: Review of the facility policy titled, Adverse Consequences and Medication Errors, states under,Medication Errors, 1. A medication error, is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing…
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 · D2024-03-01 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the facility policy titled,Storage of Medications, observations and interviews, the facility failed to ensure medications and biologicals that were expired were removed from storage and not stored on 1 of 1 treatment carts and 2 of 2 medication carts. Findings include: Review of the facility policy titled, Storage of Medications, states, The facility stores all drugs and biological's in a safe, secure, and orderly manner. 2. Drugs and biological's are stored in the packaging, containers or other dispensing systems in which they are received. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biological's are returned to the dispensing pharmacy or destroyed 5. Hazardous drugs are clearly marked and stored separately from other medications. An observation on [DATE] at 08:55 AM, during medication administration, revealed Registered Nurse (RN)3 removing a Fentanyl 25…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-01 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 review of the facility policy, record review, observations, and interviews, the facility failed to accurately document and record on the Medication Administration Record (MAR), the administration of narcotic medications for 1 Resident (R)5, of 1 resident reviewed for medication administration. Findings include: Review of the facility policy titled, Administering Medication, revised April 2019, revealed Policy Statement, Medications are administered in a safe and timely manner, and as prescribed. The individual administrating the medication initials the resident ' s medication administration record (MAR) on the appropriate line after giving each medication and before administering the next ones. As required or indicated for medication, the individual administering the medication records in the resident ' s medical record: the date and time the medication was administered; the dosage; the route of administration; any complaints or symptoms for which the drug was administered; any results achieved and when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-01 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and review of facility policy, the facility failed to properly sanitize, store and handle laundry. This failure has the potential to decrease the likelihood of preventing the development and transmission of communicable disease and infections within the facility. Additionally, the facility failed to ensure proper hand hygiene was demonstated during handling of medications during medication administration. Findings include: Review of facility's policy entitled, Laundry and Bedding, Soiled dated Revised September 2022 indicated, Handling 1. (a) Contaminated laundry is bagged or contained at the point of collection (i.e. location where it was used). 1.(b) Leak-resistant containers or bags are used for linens or textiles contaminated with blood or body substances. Transport 2.) There are no additional requirements (e.g. double bagging or categorizing as biohazard ) for transporting linen from rooms where transmission-based precautions are in effect. Review of Ecolab invoices and visits dated 02/23/22 for liquid laundry built detergent and liquid laundry…
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
$8,018 in federal fines across 1 penalty.
- $8,018 — penalty dated 2024-12-14
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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.9 | -0.9 vs chain |
| Health inspection | 2 of 5 | 2.5 | -0.5 vs chain |
| Staffing | 2 of 5 | 2.5 | -0.5 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 273 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 273; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PALMETTO COMMUNITY HEALTHCARE, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/29/2021 |
| IGDAL, HENRY | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 09/21/2021 |
| HALL, REINALDO | Individual | W-2 MANAGING EMPLOYEE | — | since 10/04/2022 |
| APT, FREDERICK | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| HANCOCK, MARK | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| JERGENSEN, JOSHUA | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| MITCHELL, JOHN | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $289K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in SC
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the South Carolina Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 425314. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-04, 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.