Ridgeway Manor Healthcare Center
117 Bellfield Road, Ridgeway, SC 29130 · For profit - Corporation · 112 certified beds · (803) 337-2257 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0602), cited Mar 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 3 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 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 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.
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 | 15.3% | 11.9% | 15.4% | typical |
| Long-stay residents who lose too much weight | 3.2% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.9% | 0.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.9% | 1.3% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 3.1% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 1.5% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 2.6% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 29.8% | 12.7% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 27.6% | 21.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 95.6% | 90.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.7% | 5.1% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 9.1% | 16.7% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.0% | 15.3% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.9% | 1.5% | 1.4% | worse |
| Short-stay residents rehospitalized after admission | 23.8% | 24.3% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 16.5% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.44 | 2.04 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.88 | 1.84 | 1.80 | typical |
* 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.
Met the expected recovery: 40.0% 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 25 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 0.20 therapist hours per resident per day in 2026Q1 — more than 21% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.5%CMS range 7.2–17.5 | 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 | 40.0% | 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 | 40.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 52.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 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 | 2.8% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.31 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 112 beds and averages 91.1 residents a day — about 81% occupied, or roughly 21 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.87 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.31 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 2.83 hrs/resident/day on weekends vs 2.88 on weekdays — 2% thinner on weekends. RN hours go from 0.33 to 0.28 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%.
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 fewer than at the previous inspection — improving. 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.
30 citations, most serious first. The 13 most serious are shown; the remaining 17 are one tap away and print in full.
- Immediate jeopardy · J2025-03-05 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect 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 interview, record review, and facility policy review, the facility failed to monitor, protect, and prevent misappropriation of narcotic medication for 1 of 3 residents (Resident (R)8) reviewed for misappropriation out of a total sample of 21 residents. This failure had the potential to place all residents receiving narcotic pain medication at risk of serious harm of uncontrolled pain due to drug diversion. Cross-Reference: F755 Pharmacy Services. The facility's failure to ensure prevention of misappropriation of property related to narcotic drug diversion had the potential to cause serious harm. Immediate Jeopardy was identified on 03/03/25 and was determined to exist on 02/26/25 in the area of §483.12 Misappropriation F602 at a scope and severity (S/S) of J. The Administrator was notified of the Immediate Jeopardy on 03/03/25 at 8:35 PM. The facility was notified that an acceptable plan of removal had been accepted on 03/04/25 at 7:38 PM. The survey team validated implementation of the removal plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2025-03-05 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to provide and maintain pharmaceutical services for the receipt, disposition, reconciliation, and control of narcotic medication for 1 of 3 residents (Resident (R)8) reviewed for medications out of a total sample of 21 residents. This failure had the potential to place all residents receiving narcotic pain medication at risk of serious harm of uncontrolled pain due to drug diversion. Cross Reference: F602 Misappropriation. The facility's failure to ensure pharmaceutical services were provided to meet the needs of each resident had the potential to cause serious harm. Immediate Jeopardy was identified on 03/03/25 and was determined to exist on 02/26/25, in the area of §483.45 Pharmacy Services F755 at a scope and severity (S/S) of J. The Administrator was notified of the Immediate Jeopardy on 03/03/25 at 8:35 PM. The facility was notified that an acceptable plan of removal had been accepted on 03/04/25 at 7:38 PM. The survey team…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2025-03-05 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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 implement a Quality Assurance and Performance Improvement (QAPI) program when they did not adequately identify, analyze, and address issues impacting resident care through proper data collection, monitoring, and improvement initiatives related to pharmaceutical services. This had the potential to affect 85 of 85 residents who resided at the facility. The facility's failure to adequately identify, analyze, and address issues impacting resident care through proper data collection, monitoring, and improvement initiatives related to pharmaceutical services had the potential to cause serious harm to residents. Immediate Jeopardy was identified on 03/03/25 and was determined to exist on 02/26/25, in the area of §483.75 Quality Assurance and Performance Improvement at a scope and severity (S/S) of J. The Administrator was notified of the Immediate Jeopardy on 03/03/25 at 8:35 PM. The facility was notified that an acceptable plan of removal had been accepted on 03/04/25 at 7:38 PM. The survey team…
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 before2026-04-30 · 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, record review, staff interview, facility policy review, and Ecolab email, the facility failed to ensure the low-temperature dishwasher maintained the required final rinse temperature of at least 120 degrees Fahrenheit to ensure proper sanitization of dishware and utensils and reduce the potential for foodborne illness transmission. This deficient practice was identified in 1 of 1 main kitchens. Findings Include: Facility Policy: Dishwasher Temperature, Policy: It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures. Policy Explanation and Compliance Guidelines: 4. For low temperature dishwashers (chemical sanitization):a. The wash temperature shall be 120 degrees Fahrenheit.b. The sanitizing solution shall be 50ppm (parts per million) hypochlorite (chlorine on dish) surface in final rinse. An observation on 4/29/26 revealed a low temperature dishwasher temperature at 90 degrees Fahrenheit after wash and rinse. The sanitizer test strip was 100 ppm. A record review on 04/29/26…
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 · D2026-04-30 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews and interviews, the facility failed to ensure that one Certified Nursing Assistant (CNA) received a performance evaluation in 2025, for 1 of 5 direct-care staff records reviewed.Findings include:The Staffing Coordinator stated that the facility currently does not have a facility policy on performance evaluation expectations.Review of CNA1 staff file indicated a hire date of February 2023.Review of CNA1 staff file indicated that the last performance evaluation was completed on 01/15/25.In an interview on 04/30/26 at approximately 2:35 PM, the Director of Nursing (DON) stated that she is still learning the performance evaluation process, as she is new to the position at the facility. The DON stated that her expectation is for CNA performance evaluations to be conducted within 90 days of hire and annually thereafter. She reported that approximately one week ago, she completed three performance evaluations for nurses; however, no evaluations were completed for CNAs. The DON stated that a performance evaluation should have already been completed for CNA1 for the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-30 · 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 review of the facility policy, observations, and interviews, the facility failed to ensure an excessive amount of lint was removed from lint screens for 2 of 2 commercial clothes dryers in the main laundry room. Findings include:Review of the facility document titled, Direct Supply TELS indicated, lint catchers should be cleaned AFTER EACH LOAD.Review of facility policy titled Laundry , revised 12/23/2025, states the following:5. Laundry equipment will be used and maintained according to the manufacturer's instructions.Review of dryer manufacturer's instructions titled, Tumble Dryers, Operation/Maintenance, March 2021, pg. 22 states the following:2. End of day: a. Clean lint filter to maintain proper airflow and avoid overheating.An observation on 04/29/26 at 9:06 AM of two lint screens below the two dryers revealed the lint screens were excessive with lint. The Laundry Assistant (LA) was present during the observation. An observation on 04/29/26 at 1:15 PM of two lint screens below the two dryers, noted with excessive lint, and the walls and floor below the dryer with no…
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 · D2026-04-30 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to ensure that one Certified Nursing Assistant (CNA) received 12 hours of annual in-service training, for one of 5 direct-care staff records reviewed.Findings include:The Staffing Coordinator stated that the facility currently does not have a facility policy on annual training expectations.Review of CNA1 staff file indicated a hire date of February 2023.Review of CNA1 staff file indicated that a total of 8.5 hours of annual training was completed via Relias in 2025.In an interview on 04/30/2026 approximately 2:45 PM, the Director of Nursing (DON) stated that that she was not aware of the 12-hour minimum annual training requirement due to being new to the DON position. However, a Performance Improvement Plan (PIP) will be initiated to address the concern. She indicated that she is currently in the process of implementing a skills fair, and that she previously conducted an in-service for direct care staff upon assuming her role, which included topics such as dignity, respect, and resident rights. She further stated that her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-02-13 · tag F0835 — failed to run the facility competently — widespreadAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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 use its resources effectively and efficiently related to suspension of food service delivery, suspension of oxygen supply, and suspension of linen orders, and an incomplete facility assessment. This inaction in administering the facility had the potential to affect all residents living in the facility. Findings include:Review of an undated and unsigned policy titled, Business Continuity revealed, Policy: This facility plans for continuity of operations in the case of an emergency or disaster. Policy Explanation and Compliance Guidelines . 5. Critical resources have been identified. The facility maintains contracts with various vendors for obtaining supplies and materials in case of an emergency. a. Contracts with two or more vendors are maintained in case primary vendors are also affected. b. The facility has a means of communication with local/state Incident Command Center to relay needs in case of a prolonged event. c. Designated…
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 · F2026-02-13 · tag F0837 — widespreadEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
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 provide evidence of having a governing body, ensuring a facility assessment was complete to assess the overall management and operation of the facility, a failure to develop and implement bylaws and operational policies for the facility which resulted in a failure to ensure facility's Ethics and Compliance Program was implemented. These failures resulted in vendors not getting paid and a disruption in delivery of food and supplies to residents and had the potential to affect all residents living in the facility. Findings include:Review of an undated and unsigned policy titled Compliance and Ethics Program revealed, Policy: This facility is committed to compliance and has designed, implemented, and enforced a compliance and ethics program for . preventing and detecting . administrative violations . c. Sufficient resources and authority to reasonably assure compliance . Review of a document titled U.S. Foods Customer Account Application 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 · F2026-02-13 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — the official record, unedited, 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 the facility assessment was complete and to identify all necessary resources to attain and maintain resident needs, and failed to ensure active involvement of required participants. This inaction in administering the facility had the potential to affect all residents living in the facility. Review of the Facility assessment dated [DATE] revealed it was not signed and was reviewed with the QAA Committee on 04/10/25. Several sections were blank or incomplete, and many had no supporting documentation. There was no signature page or other documentation to identify the participating members included in the development of the assessment. During an interview with the Administrator and Regional Director of Operations on 02/11/26 at 4:30 PM, revealed that the facility assessment provided was the only facility assessment available for review.
- Potential for harm · Ecited before2026-02-13 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
Based on observation, record review, and interview, the facility failed to provide a sufficient amount of bath and bed linens, in good condition, in 2 of 2 linen closets reviewed out of a total of 2 linen closets in The Home building. This had the potential to affect 58 of 58 residents residing in The Home building in a total facility census of 92.Findings include:During the initial facility tour on 2/10/26 at 10:30 AM, with the Assistant Director of Nursing (ADON), the facility was observed to be comprised of two separate buildings. The two buildings were referred as The Home and The Manor. The Home building had three hallways (100, 200, and 300). The 100 and 200 hallway each had one linen closet. The 300 hallway had no linen closet. During a facility tour on 2/10/26 at 3:00 PM, linen closets were observed within the 100 and 200 hallways. Both linen closets were noted to contain fewer than 10 of each of the following: towels, washcloths, fitted sheets, flat sheets, and pillowcases. A washcloth was randomly selected from the closet which was thin and torn at the seam on one of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-13 · 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 observation, interview, and record review, the facility failed to completely and accurately document the suspected cause of a fracture for 1 (Resident (R)3) of 3 residents reviewed for accidents. Findings include:Review of an undated facility policy titled Documentation in Medical Record revealed, Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines . 4. Principles of documentation include but are not limited to . b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care . Review of R3's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/27/25, revealed a Brief Interview for Mental Status (BIMS) score of 0 out of 15; the resident was unable to complete the BIMS.Review of R3's Significant Change MDS with an ARD of 07/31/25…
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 · F2025-12-10 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility policies, observations, and interviews, the facility failed to ensure that all mechanical, electrical, and patient-care equipment was maintained in safe operating condition. Specifically, on 12/08/25, the facility's Heating, Ventilation, and Air Conditioning (HVAC) systems serving the 200 and 300 halls and the lobby were inoperable and/or unable to provide adequate heat, resulting in an inability to maintain required ambient temperatures for residents. This failure placed residents at risk for cold-related discomfort and adverse health outcomes.Findings include: Review of the facility policy titled HVAC Systems, last revised on 06/22/22, revealed, This facility maintains an HVAC system in a manner that protects resident health and safety from fire and extreme temperatures. Policy Explanation and Compliance Guidelines: 1. Documentation regarding the facility's HVAC system is maintained by the Maintenance Director. 2. HVAC installation and maintenance shall be in accordance with the manufacturer's specifications and the Life Safety Code (2012 version:…
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 17 citations
- Potential for harm · Fcited before2025-03-05 · 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 observations, interviews, and record review, the facility failed to ensure food stored in the main kitchen was labeled and dated. The failures had the potential to increase the prevalence and spread of foodborne illness and infection for 79 residents who receive food from the kitchen. 6 residents receive tube feedings with no food/fluids provided by the kitchen. Findings include: Review of the facility's undated policy titled, Food Storage stated Sufficient storage facilities are provided to keep foods safe . and by methods designed to prevent contamination . Rewrap packages of frozen food which have been opened. This prevents freezer burns and spoilage . Review of the facility's policy dated 02/2023 titled, Food Safety Requirements stated, . Food will also be stored . in accordance with professional standards for food service safety . Food safety practices shall be followed throughout the facility's entire food handling process . Storage of food in a manner that helps prevent deterioration or contamination of food, including from growth of organisms . Labeling, dating, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-05 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure Registered Nurse coverage was provided eight hours a day seven days a week for a total of seven days in July, August, and September 2024. The failure created the potential for the clinical needs of all residents not to be met. Findings include: Review of the facility's Job Description: Registered Nurse, provided by the Regional Director of Operations (RDO) noted, SUMMARY Assesses and evaluates the health status of resident/patient and provides care and treatment in accordance with physician orders and standards of practice. ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned Assesses patients by physical examination including pertinent diagnostic testing to determine health status. Administers medications and treatments. Participates in the care planning process and oversees implementation of the plan. Supervises LPNS [Licensed Practical Nurses] and Nursing Assistants. Oversees ADLS [activities of daily living] and documentation. Communicates with physicians regarding changes in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-05 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, record review and interviews, the facility failed to report an allegation of misappropriation of narcotic medication to the state survey agency within two hours for 1 of 3 residents (Resident (R)8) reviewed for abuse out of a total sample of 21 residents. This had the potential to allow continued misappropriation. Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 2024, revealed, . It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Misappropriation of Resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent . Reporting / Response. Reporting of all alleged violations to the Administrator, state…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and facility policy review, the facility failed to use nursing rights of medication administration while administrating a medication for 1 of 21 residents (Resident (R)8), reviewed for professional standards. This failure had the potential for residents being subject to adverse effects leading to worsening symptoms, long-term effects, and death. Findings include: Review of the facility's policy titled, Medication Administration revised 2022, revealed, . Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. a. Refer to drug reference if unfamiliar with the medication, including its mechanism of action or common side effects . Review of R8's Face Sheet, located in resident's electronic medical record (EMR) under the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-24 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, record reviews, and interviews, the facility failed to update Resident (R)1 and R2's care plan to reflect a person-centered change in status, related to potential desire/preference. 2 of 7 reviewed for Care Plans. Findings include: Review of the facility policy titled, Care Plan Revisions Upon Status Change, last revised 2021, revealed, The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Procedure for reviewing and revising the care plan when a resident experiences a status change: upon identification of a change in status, the nurse will notify the Minimum Data Set (MDS) Coordinator, the Physician, and the resident representative if applicable. The MDS Coordinator and the Interdisciplinary Team (IDT) team will discuss the resident condition and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-06-29 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 observations, interviews, and record review, the facility failed to maintain a clean and safe environment on 2 (Unit 100 and Unit 200) of 3 resident care units in 1 of 2 buildings. Findings include: 1. Observations during the initial tour on 06/27/23 at 8:30 AM revealed the following: room [ROOM NUMBER] - the baseboard underneath the window was away from the wall and laying on the floor. The window air conditioner unit did not fit securely in the window. There was a gap, approximately six inches long and two inches wide, between the air conditioner unit and the window frame; Rm 104A - the head of bed was crooked and loose; Rm 104B - the headboard was missing from the resident's bed, there was no privacy curtain to provide privacy for both residents, and the wall had heavy gouge marks; and Rm 112A - there were dried beige color splatter marks on feeding pump, pole, nightstand, and floor. During an interview on 06/28/23 at 2:20 PM, the Registered Nurse Unit Manager confirmed nursing staff were responsible…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-29 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of facility policy, the facility failed to follow the menu for 52 of 52 residents served mechanical soft or regular diets in the in 1 unit. Findings include: Review of the facility's undated policy titled Standardized Menus, revealed, . the facility will provide nourishing, palatable meals to meet the nutritional needs of the residents . Menus should have portions listed in ounces . Review of the facility's undated menu titled, Week 1 Revised Spring Summer revealed for 06/28/23, one cup of lasagna was to be served for the noon meal entrée. During an observation on 06/28/23 from 11:55 AM to 1:05 PM, the [NAME] was observed using a #8 scoop (half-cup scoop) to plate lasagna for the residents. The [NAME] placed one scoop of lasagna on each plate for residents receiving either a mechanical soft or regular diet. During an interview on 06/28/23 at 12:10 PM, the [NAME] confirmed she was using a #8 scoop to plate the lasagna. During an interview with the Dietary Manager (DM) on 06/28/23 at 1:05 PM, the DM stated she did not notice the residents…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-29 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 and record review, the facility failed to ensure one (Resident (R) 4) of 41 sampled residents had the right to choose health care providers consistent with her wishes. Findings include: Review of R4's Physician Orders, located under the Orders tab of the electronic medical record (EMR), revealed R4 was admitted to the facility on [DATE] with diagnoses that included but was not limited to; seizures, schizophrenia, and chronic respiratory disorder. Review of R4's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/01/23 and located under the MDS tab of the EMR, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. It was also recorded R4 was totally dependent on staff for transfers. During an interview with R4 on 06/27/23 at 10:48 AM, R4 stated that on 05/21/23 on the night shift, Certified Nursing Assistant (CNA)5 called her a derogatory name, sprayed Lysol on her bottom, handled her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-29 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy, the facility failed to release Resident (R)3's restraint during meals as ordered by the physician for 1 of 3 sampled residents reviewed for restraints. Findings include: Review of the facility's policy titled, Restraint Free Environment dated October 2022, revealed, . the length of time the restrain is anticipated to be used to treat the medical symptom, who may apply the restraint and the time and frequency that the restraint will be released . Review of R48's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed R48 was readmitted to the facility on [DATE] with diagnoses that included but was not limited to; cerebral infarction with residual deficits, repeated falls, and history of transient ischemic attacks. Review of R48's Physician Orders, dated 04/15/22, revealed, . release Merri-walker front bar every two hours and with meals, every shift for ambulation, mobility and independence .…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-29 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to conduct a thorough investigation of an allegation of abuse for 1 (Resident (R)4) of 41 sampled residents. Findings include: Review of the facility's undated policy titled, Abuse, Neglect and Exploitation revealed the facility was required to make efforts to ensure all residents are protected from physical harm and provide complete and thorough documentation of the investigation. Review of R4's Physician Order Sheet, revealed R4 was admitted to the facility on [DATE] with diagnoses that included but was not limited to; seizures, schizophrenia, and chronic respiratory disorder. Review of R4's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/01/23 and located in the electronic medical record (EMR) under the MDS tab, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. It was recorded R4 was totally dependent on staff for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-29 · 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, interview, and facility policy review, the facility failed to ensure 3 of 3 residents and their representatives (Resident (R)68, R96, and R98) reviewed for facility initiated emergent hospital transfer were provided with written transfer/discharge notice that contained all required information. This failure has the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of the facility policy titled Transfer and Discharge (Including AMA [Against Medical Advice]), with a copyright date of 2022, revealed, . The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge. b. The effective date of transfer or discharge. c. The specific location (such as the name of the new…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-29 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure 1 (Resident (R)85) of 41 sampled residents had an accurate Minimum Data Set (MDS) assessment. Findings include: Review of the RAI Manual dated 10/01/19, indicated, . It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment . Review of R85's admission Record located under the Profile tab of the electronic medical record (EMR), indicated the resident was admitted to the facility on [DATE] with diagnoses that included but was not limited to; acute respiratory failure with hypoxia, schizophrenia, pneumonia due to streptococcus pneumoniae, and cerebral ischemia. Review of R85's Annual 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 · D2023-06-29 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and review of facility policy, the facility failed to ensure that a care plan related to smoking was developed for 1 (Resident (R)85) of 41 sampled residents. This failure had the potential to cause the resident to not have adequate supervision while smoking. Findings include: Review of the facility's policy titled, Comprehensive Care Plans dated November 2017, read in part, . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Review of R85's electronic medical records (EMR) titled, admission Record, located under the Profile tab, revealed R85 was admitted to the facility on [DATE] with diagnoses that included but was not limited to; acute respiratory failure with hypoxia,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to ensure staff implemented interventions identified to aid in the prevention of harm with a fall for 1 (Resident (R)38) of 3 sampled residents reviewed for falls. This had the potential for R38 to sustain injuries from a fall. Findings include: Review of R38's electronic medical records (EMR) admission Record, located under the Profile tab, revealed R38 was admitted to the facility on [DATE] with diagnoses that included but was not limited to; malignant neoplasm of pelvic bones, sacrum, coccyx, ribs, sternum, and clavicle; major depressive disorder; and anxiety disorder. Review of R38's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/31/23 and located under the MDS tab of the EMR, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the R38 was cognitively intact. It was recorded R38 was dependent on the staff for all areas of daily living. The MDS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-29 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
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 and record review, the facility failed to ensure the appropriate coordination of hospice care by specifically failing to maintain hospice care plans, nurses' notes, certified nurse aide (CNA) notes, and/or hospice election forms and physician certification and recertification of the terminal illness specific to each resident for 2 (Residents (R)76 and R199) of 41 sampled residents. This failure had the potential to result in the interruption of the residents' coordination of care. Finding include: 1. Review of R76's electronic medical records (EMR) admission Record located under the Profile tab, revealed R76 was admitted to the facility on [DATE] with diagnoses that included but was not limited to; Alzheimer's disease, bilateral stenosis of carotid arteries, nutritional deficiency, and encounter for palliative care. Review of R76's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/07/23 and located under the MDS tab of the EMR, revealed under Section O…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-29 · tag F0909 — failed to maintain a comfortable temperature — isolatedRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and review of manufacturer's instructions, the facility failed to ensure bed frames and rails, if present, were inspected and serviced per the Manufacturer's Instructions for Use (MIFU) to minimize the risks of bed malfunction or resident injury. This failure had the potential to affect 98 of 98 residents who resided at the facility. Findings include: On 06/29/23 at 7:37 PM, the Director of Nursing (DON) provided a policy on the proper use of bed rails. The DON stated it was the only policy on beds that the facility had. Review of the provided policy titled, Proper Use of Bed Rails with a copyright date of 2022, revealed, . If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails . Installation and Maintenance of Bed Rails . The facility will assure the correct installation and maintenance of bed rails, prior to use. This includes: a. Check with the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible. b. Ensuring that the bed's dimensions are appropriate for the resident by .…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-06-29 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure 1 (Resident (R)199) of 41 sampled residents had a functioning call light system. This had the potential to affect the resident's ability to call for assistance. Findings include: Review of R199's electronic medical records (EMR) titled, admission Record, located under the Profile tab, revealed R199 was admitted to the facility on [DATE]. Review of R199's EMR titled, Medical Diagnosis located under the Diagnosis tab, revealed the resident was admitted to the facility with diagnoses that include but was not limited to; unspecified dementia, anxiety disorder, encounter for palliative care, severe sepsis, insomnia, acute resp with acute hypoxia, malignant neoplasm lower right lung stage IV, and pressure ulcer of the sacrum. Review of 199's EMR titled, admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/13/23 and located in MDS tab, revealed R199 had a Brief Interview for Mental Status (BIMS) score of 99 out…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| GARRARD, LOUIS | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2018 |
| MCCOLLUM, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2022 |
| SPARKS, DEBORAH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/01/2025 |
| MAUNG, PETER | Individual | ADP OF THE SNF | since 03/13/2026 |
CMS files one row per role, so the 8 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 88% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $247K 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 425158. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-30, 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.