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Mountainview Nursing Home

340 Cedar Springs Road, Spartanburg, SC 29302 · Non profit - Corporation · 132 certified beds · (864) 582-4175 Medicare & Medicaid certified

Call the home — (864) 582-4175 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Nov 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$15,324 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2024
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $15,324 in federal fines (most recent 2024-01-22)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (80%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 1 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2191 Southport Rd · (864) 216-4840 · Call to confirm hours
Pharmacy
2198 Southport Rd · (864) 582-5822 · Call to confirm hours
Grocery
470 Cedar Springs Rd · (864) 431-3478 · Call to confirm hours
Park
Quail Dr · Typically dawn to dusk
Place of worship
140 Cedar Springs Pl · (864) 585-5526

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 1 of 5
Long-stay residentspeople who live here 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased27.3%11.9%15.4%worse
Long-stay residents who lose too much weight3.9%6.3%5.4%better
Long-stay residents with a catheter left in their bladder2.7%0.6%0.9%worse
Long-stay residents with a urinary tract infection3.9%1.3%2.0%worse
Long-stay residents with depressive symptoms0.3%3.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.7%0.1%0.1%worse
Long-stay residents with falls causing major injury4.3%3.2%3.3%worse
Long-stay residents whose ability to walk worsened36.9%12.7%16.1%worse
Long-stay residents on antianxiety or hypnotic medication27.0%21.0%18.9%worse
Long-stay residents given the seasonal flu vaccine48.6%90.6%95.3%worse
Long-stay residents with pressure ulcers5.9%5.1%4.7%worse
Long-stay residents with worsening bladder/bowel control21.2%16.7%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table35.6%15.3%17.1%worse
Long-stay hospitalizations per 1,000 resident days3.622.041.67worse
Long-stay outpatient ER visits per 1,000 resident days1.721.841.80typical

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

0.13U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.04hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.

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

Staffing

0.59
RN hours/ resident / day
1.25
LPN hours/ resident / day
2.71
Aide hours/ resident / day
4.55
Total nurse hours/ resident / day
0.51
RN hoursweekends
80.1%
Total nursing turnover
76.2%
RN turnover

How full it usually is: this home is certified for 132 beds and averages 120.8 residents a day — about 92% occupied, or roughly 11 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 4.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.71 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.78 hrs/resident/day on weekends vs 4.86 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.62 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 80% is well above the national median of 45%.

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

Inspection trend

9
deficiencies at the latest standard inspection (2024-11-23)
17
at the previous standard inspection (2023-02-28)

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.

ABCDEFGHIJKL

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

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-11-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure Resident (R)1 received adequate supervision to prevent an elopement on 11/01/25 at approximately 6:00 AM. Specifically, R1 was located by staff outside the facility lying on the ground. R1 was dressed in bedtime clothing (pajamas and slippers). According to weather reports on 11/01/25 at 5:55 AM, the weather was 36 Degrees Fahrenheit (F).On 11/07/25 at 1:34 PM, the survey team provided the Administrator and Assistant Administrator with a copy of the CMS IJ Template and informed the facility IJ existed as of 11/01/25. The IJ was related to 483.24 Quality of Care.On 11/07/25 at 4:12 PM, the facility provided an acceptable IJ Removal Plan. On 11/07/25 at 5:00 PM, the survey team validated the facility's corrective action and determined that the facility put forth due diligence in addressing this non-compliance. The SA is considering this IJ at Past Non-Compliance (PNC) as of 11/05/25.An Extended Survey was conducted 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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2026-06-12 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and facility policy review, the facility failed to revise a comprehensive person-centered care plan to reflect the Resident's (R)1 current fall interventions for 1 of 3 sampled residents reviewed for falls. Findings include: Review of the facility's undated policy titled, Care Plans, Comprehensive Person-Centered, revealed, 11. Assessments of residents are ongoing and care plans are revised as information about the residents and residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: and included, d. at least quarterly, in conjunction with the required quarterly MDS [Minimum Data Set] assessment. Review of the facility policy titled, Fall Management, dated 05/19/2024, revealed under the heading, C. Intervention included, g. Update the resident's care plan. Review of R1's admission Record revealed the facility admitted R1 on 03/12/2025. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of Alzheimer's disease with early onset,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of manufacturer guidelines, the facility failed to ensure a sheet was not applied in a manner that flattened the perimeter defined mattress cover which created the potential for accidents for 1 (Resident (R)1) of 3 sampled residents reviewed for falls. Findings include: Review of a document provided by the Maintenance Manager (MM) for a Posey Defined Perimeter Mattress Cover, revised on 09/07/2016, indicated, Wedge-shaped foam sections line the perimeter of the covers and help provide a gentle reminder to those lying in bed of the location of the mattress edges, and help provide a less restrictive environment than side rails. A graph on the document indicated Foam Sections - Height 4 (10 cm [centimeter).Review of R1's admission Record revealed the facility admitted R1 on 03/12/2025. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of Alzheimer's disease with early onset, emphysema, generalized muscle weakness, and contracture of the right and left…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-23 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 observations, record review, interviews, and facility policy review, the facility failed to follow infection control guidelines during an medication administration observation for two of seven resident observations (Resident (R) 13 and R19), during an observation of PPE (Personal Protective Equipment) for one of three COVID-19 positive residents (R24), and during a dressing change for one of one resident observation (R74) of 24 sample resident. These failures had the potential for spreading infections including COVID 19 to the vulnerable population in the facility. Findings include: Review of the facility's undated policy titled, Policies and Procedures - Infection Prevention and Control revealed: Policy Statement. The facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .Policy Interpretation and Implementation. 1. Infection prevention…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-23 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interviews, and review of facility policy, the facility failed to ensure two of two residents (R) 18 and R85 of three reviewed for abuse was free from resident to resident physical and verbal abuse out of a total sample of 24 residents. This had the potential for the residents to sustain injuries from the altercation. Findings include: Review of the facility's undated policy titled, .Abuse and Neglect Management Policy Statement revealed Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. [Facility Name] does not condone any form of abuse and will continually monitor [Facility Name] policies, procedures, training programs, systems, etc. to assist in preventing resident abuse is committed to protecting our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends,…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-23 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 and interview, the facility failed to ensure a written copy of the baseline care plan was provided to the resident and/or responsible party (RP) within 48 hours for one of one resident (Resident (R) 261) reviewed for baseline care plans. This failure had the potential for residents and/or RP not to be informed of the plan of care. Findings include: Review of R261's undated Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses which included epilepsy, anoxic brain damage, diabetes mellitus, and chronic pain. Review of R261's Progress Notes located under the Progress Notes tab in the hard copy of the medical record revealed a physician progress note, dated 10/30/24, which stated R261 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated R261 was moderately cognitively impaired. Review of R261's Acknowledgement of Receipt admission Baseline Care Plan, dated 10/24/24 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-23 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to develop a care plan for refusal of medications and meals for one (Resident (R)92) and failed to develop and implement a care plan for pressure ulcers for one of 24 sample residents R78. This failure had the potential for residents to have unmet care plan needs. Findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person Centered, dated 2017, revealed . The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment . 1. Review of R92's undated Face Sheet located under the Face Sheet in the electronic medical record (EMR) revealed R92…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-23 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 record review and interviews, the facility failed to ensure the care plan was revised to reflect an updated advanced directive status for one of one resident (Resident (R)92) reviewed for advanced directives. This failure had the potential for residents to have unmet care plan needs. Findings include: Review of R92's undated Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with the diagnosis of stroke, congestive heart failure, and major depressive disorder. Review of R92's quarterly Minimum Data Set (MDS) located under the MDS Assessments tab of the EMR with an Assessment Reference Date (ARD) of [DATE] revealed R92 had short- and long-term memory loss and rarely or never made decisions. Review of R92's Advance Directive located under the Advance Directive tab in the hard chart of the medical record revealed the daughter signed for a DNR (Do Not Resuscitate) on [DATE] with the admission paperwork that was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-23 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such 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 record review and interview, the facility failed to have collaboration of care with the dialysis center for one of one resident (Resident (R)38) reviewed for dialysis. This failure had the potential to put R38 at risk for lack of communication between the facility and the dialysis center. Findings include: Review of R38's undated Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) indicated R38 was admitted to the facility on [DATE] with diagnosis of cerebrovascular accident, end stage renal disease, and chronic kidney disease, stage five. Review of R38's quarterly Minimum Data Set (MDS) located in the EMR under the MDS Assessment tab with an Assessment Reference Date (ARD) of 08/18/24 revealed the resident was coded as receiving dialysis services while a resident in the facility. Review of R38's Physician Order located in R38's hard chart of the medical record, under the Orders tab, revealed orders, dated 06/20/23, which revealed R38 had dialysis on Mondays, Wednesdays,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-23 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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, interview, and facility policy review, the facility failed to ensure risk and benefits were explained to the resident and/or representative (RP) prior to the use of psychotropic medications and failed to ensure targeted behaviors and side effects were monitored for administered psychotropics for one of five residents (Resident (R)46) reviewed for unnecessary medications. This failure had the potential for excessive psychotropic administration and for the residents and/or representative not to be able to make an informed decision regarding the use of the psychotropic medications. Findings include: Review of the undated facility's policy titled, Antipsychotic/Psychotropic Medication Use, revealed . The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others .The attending physician will identify, evaluate and document, with input from other…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-23 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 accurately check the insulin pen that was being used to administer insulin to one of one resident (Resident (R)14) administered insulin out of seven residents being observed during the medication administration task. This failure had the potential for bloodborne pathogens to infect residents by using a reusable insulin pen to a resident other than the resident that it had been ordered for. Findings include: Review of the undated facility's policy titled, Administering Medications, revealed .The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time, and right method (route) of administration before giving the medication . During an observation of medication administration on 11/22/24 at 8:09 AM, the label on R14's Humalog insulin Kwik Pen read, Give 12 units every morning. The paper Medication Administration Record (MAR)located in a notebook on the medication cart for R14 matched the label for Humalog which was compared 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · D2024-11-23 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to have a permanently affixed compartment to store narcotics in the medication refrigerator on two of three units (North and [NAME] Units) which involved three of five residents (Resident (R) 259, R2, and R11) reviewed for medication storage of 24 sample residents This failure had the potential for these medications to be diverted. Findings include: Review of the facility's undated policy titled, Storage of Medications read in part, .Schedule II-V controlled medications are stored in separately lock, permanently affixed compartments . 1. Review of R259's undated Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed this resident was admitted to the facility on [DATE]. During an observation of the medication storage room on the North unit on 11/22/24 at 6:57 AM with Licensed Practical Nurse (LPN) 9, in the unlocked medication refrigerator, there was a transparent plastic container…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-02-28 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and review of facility policy, the facility failed to ensure food items stored in 1 of 1 walk in refrigerator were properly labeled and dated to prevent the risk of food borne illness. Findings Include: Review of the facility policy titled, Food Purchasing and Inspection of Food Deliveries dated 2020 revealed Guidelines: All food items will be purchased from approved vendors and received according to the following guidelines. Procedure: 4 Inspect all deliveries carefully. Check for appropriate labeling, temperature, appearance, texture, odor, and other factors important for food safety. 6. Any unsafe food items will be refused or discarded immediately, and proper credit received per vendor policy. Review of the facility policy titled, Food Safety with an effective date of February 1, 2015, revealed Purpose: To ensure food is stored in a manner to prevent contamination and preserve the nutritional content of all items in the establishment. Procedure: 14. Refrigerated Food Storage: f. All foods should be covered, labeled, and dated. All foods will be…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-02-28 · tag F0925 — failed to control pests — widespread
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility policy, the facility failed to ensure an effective pest control program for the environment to remain free from pests in 2 of 3 units observed for pests. Findings include: Review of the facility's policy titled, Infection Prevention and Control Manual Pest Control revealed The facility maintains an effective pest control program to remain free of pests and rodents. Facility wide-pest control strategies are developed emphasizing kitchens, cafeterias, laundries, central sterile supply areas, loading docks, garbage storage areas, construction activities, and other regions prone to pest infestations. An observation and interview during Medication Administration on 2/22/23 at 8:15 AM in Resident (R)60's room with Licensed Practical Nurse (LPN)1 revealed 2 dead water bugs in the resident's room. LPN1 further stated that the bugs used to be worse and when the facility had to replace the roof, that's when they got real bad and they were flying everywhere. An observation on 2/22/23 at 2:50 PM of R12's bathroom revealed a spider and spider-web.…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-28 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain a clean and clutter free environment in rooms [ROOM NUMBERS]. Review of 1 of 3 units observed for environment. Findings include: Review of a facility job description and specification for Housekeeping Assistant, last revised December 2015 revealed The Housekeeping Assistant assigned to the neighborhoods work under the direct supervision of the Executive Housekeeper, carrying out tasks designed to maintain the facility in a safe, clean orderly and attractive manner. Specific duties: 1.Clean all patient room daily including; cleaning lavatory, commode inside and out with Comet, with mop and clan rags daily. An observation and interview on 2/22/23 at 10:32 AM with Resident (R)9, who lives in room [ROOM NUMBER], revealed their bathroom, located in their room, with multiple bagged items filled with clothes and blankets. There were signs of dust and what appeared to be black mildew on the toilet and walls. R9 stated those bags have…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-28 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 reviews, interviews and review of the facility policy titled, Bed Hold and Return, the facility failed to ensure the resident or the resident's representative for Resident (R)91 and R43 received the bed hold and return policy upon transfer to the hospital or within a practicable amount of time after discharge to the hospital for 2 of 4 residents reviewed for hospitalization. Findings include: Review of the undated facility policy titled, Bed Hold and Return, states under Policy Statement, Our facility shall inform residents upon admission and prior to a transfer for hospitalizations or therapeutic leave of out bed-hold and return policy. The Policy Interpretation and Implementation, states, Number 1. Upon admission and when a resident is transferred for hospitalization or for therapeutic leave, the assigned social worker or designee will provide information concerning our bed-hold and return policy. Residents or RP (responsible party) will be notified of the transfer and reason for the transfer…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-28 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interview, the facility failed to ensure an OBRA assessment for Resident (R)5 was completed, accurate and transmitted timely for 1 of 1 residents reviewed for a Missing OBRA assessment. Findings include: Review on 02/23/23 at 3:04 PM of the CMS (Centers for Medicare and Medicaid Services) MDS 3.0 NH Final Validation, report for R5 revealed a target date of 11/12/22. A warning received after transmission states, Care Plan Completed Late: V0200B2 (CAA process signature date) is more that 14 days after the assessment reference date. The current record type, is Inconsistent record sequence. Under CMS sequencing guidelines, the type of assessment in this record does not logically follow the type of assessment in the record received prior to this one. Assessment Completed: The assessment completion date is more than 14 days after the assessment reference date. The target date on the last record identified for R5 was 08/29/22. During an interview on 02/23/23 at 03:30 PM with Minimum Data Set (MDS) assessment coordinator, she stated that she was not in 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-28 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews, and review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], the facility failed to ensure the MDS was complete and accurate for Resident (R)78. Specifically, Section G was not coded for 2 person assist with bed mobility, dressing, eating, toilet use, personal hygiene and bathing resulting in a fall with a major injury for 1 of 3 residents reviewed for falls with major injury. Findings include: The facility admitted R78 with diagnoses including, but not limited to, psychosis, neuropathy of the right hand, dementia, cerebrovascular accident, osteoarthritis, anxiety and behaviors. Review of the medical record for R78 revealed a Certified Nursing Assistant (CNA) plan of care which indicated R78 was to be assisted with all activities of daily living by 2 persons. Must have 2 CNAs providing care at all times. Further review on 02/22/23 at 12:30 PM of the medical record for R78 revealed a incident/accident report dated 01/25/23 in which R78 fell from the bed, while…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-28 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 facility policy, record review, and interviews, the facility failed to ensure a Preadmission Screen and Resident Review (PASARR) Level II was completed for 1 of 3 residents reviewed for PASARR. Specifically, Resident (R)4 did not have a PASARR Level II completed after a diagnosis of Mental Illness (MI). Findings Include: Review of an undated facility policy titled, Pre-admission Screening Policy (PASAR), revealed, Residents admitted to Mountainview Nursing Home will have a pre-admission screening completed prior to admission to assess for the need for special services and to assure placement is appropriate. If there are no indicators when the level I assessment is completed, resident will be accepted for admission. If resident does have indicators of a need for further services, then a Level II assessment must be completed by the appropriate agency. Should we admit a resident who requires Level II services, this will be coordinated with the appropriate agency. Review of R4's Face Sheet…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-28 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews, interviews, and review of the facility policy titled, Care Plans, Comprehensive Person-Centered, the facility failed to formulate and implement a comprehensive plan of care for Resident (R)78, which included 2 person assist with all activities of daily living. The facility additionally failed to formulate and implement a comprehensive plan of care for R32 for seizures, convulsions and epilepsy for 2 of 5 residents reviewed for unnecessary medications. Findings include: Review of the facility policy titled, Care Plans, Comprehensive Person Centered, revealed a policy statement which reads, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Policy Interpretation and Implementation, states, 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Number 7…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-28 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, observation, interview, and record review, the facility failed to continue orders for floating heels while in bed for Resident (R)43 for 5 of 6 days during the Recertification survey for1 of 1 reviewed for quality of care. Findings include: Review of facility policy titled, Quality of Care, revealed the facility will ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility will provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the residents medical condition(s); and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments. R43 was admitted to the facility on [DATE] with diagnoses including, but not limited to fracture of head of right femur, subsequent encounter for closed fracture with routine healing (12/13/22), chronic respiratory failure, cognitive…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-28 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 review of the facility policy titled, Suprapubic Catheter Care, record reviews, observations, and interviews, the facility failed to follow a procedure during suprapubic catheter care for Resident (R)22 to prevent infection of the urinary tract for 1 of 1 residents reviewed for catheter care. Findings include: Review on 02/23/23 at 02:15 PM of the facility policy titled, Suprapubic Catheter Care, states, The purpose of this procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. Steps in the procedure are, 1.Place the clean equipment on the beside stand or overbed table. Arrange the supplies so they can be easily reached. 2. Provide privacy. 3. If the resident's medical condition permits, assist the resident into the supine position. 4. Wash and dry your hands thoroughly. 5. Put on disposable gloves. 6. Place bed protector under resident and cover resident with a sheet, exposing only the catheter area. 7. Inspect the stoma site and skin around the stoma for any redness or skin breakdown. 8. Check urine 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation, record review, and interview, the facility failed to ensure proper storage and maintenance of Resident (R)84's nebulizer equipment, for 1 of 3 residents reviewed for respiratory therapy. Findings include: Review of the undated facility policy titled Administering Medications through a Small Volume (Handheld) Nebulizer revealed, The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Further review revealed under Steps in the Procedure, 29. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 30. Change equipment and tubing every seven days on Wednesday. Review of R84s Face Sheet revealed R84 was admitted to the facility on [DATE] with diagnosis included but not limited to chronic obstructive pulmonary disease (COPD)(A group of lung disease that block airflow and make it difficult to breathe). Review of R84's Quarterly Minimum Data Set…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-28 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary 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 record reviews, interviews, and review of the facility policy titled, Unnecessary Medications Use and Monitoring, the facility failed to ensure Resident (R)32 and R65 were free from unnecessary medications for 2 of 5 residents reviewed for Unnecessary Medications. The findings included: Review the facility's undated policy titled Unnecessary Medications Use and Monitoring, states, .the use of unnecessary medications will be monitored based on the resident's need, duration, effectiveness of therapy, and adverse consequences. The consultant Pharmacist will recommend discontinuation, and/or GDR of the medications that do not meet all regulations and requirements to the attending physician or prescribing practitioner. The procedure states, 1. The regulations associated with medication management include consideration of: . Indication and clinical need for the medication. . Dose . Duration . Adequate monitoring for efficacy and adverse consequences. . Preventing, identifying, and responding to adverse…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-28 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility policy titled, Unnecessary Medications Use and Monitoring, record review, and interviews, the facility failed to ensure Resident (R)32 was free from an, as needed, basis psychotropic medication and further failed to ensure a required, gradual dose reduction (GDR), was attempted for R78, who is currently prescribed an antipsychotic with the diagnosis of dementia with behaviors. Findings include: Review of the facility policy titled, Unnecessary Medications Use and Monitoring, states, .The use of unnecessary medications will be monitored based on the resident's need, duration, effectiveness of therapy, and adverse consequences. The consultant Pharmacist will recommend discontinuation, and/or GDR of the medications that do not meet all regulations and requirements to the attending physician or prescribing practitioner. The procedure states: 1. The regulations associated with medication management include consideration of: . Indication and clinical need for the medication. . Dose . Duration . Adequate monitoring for efficacy and adverse consequences. .…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-28 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews, interviews, and review of facility policy, the facility failed to provide or obtain laboratory services to meet the needs of Resident (R)65 for 1 of 1 residents reviewed. Findings include: Review of the facility's policy titled, Lab and Diagnostic Test Results-Clinical Protocol, undated, revealed the physician will identify and order diagnostic and lab tested based on the resident's diagnostic and monitoring needs; the staff will process test requisitions and arrange for tests; the laboratory, diagnostic radiology provider or other testing source will report test results to the facility. Review of R65's Face Sheet revealed the admission date of 11/29/18 and diagnoses including but not limited to, vascular dementia, chronic kidney disease, alzheimer's, congestive heart failure, and hypertension. Review of R65's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/22 revealed R65 had a Brief Interview for Mental Status (BIMS) score of 99, indicating severe impairment. Review of the Physician's telephone orders dated 01/31/23…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-28 · tag F0919 — failed to provide a working call system — isolated
    Make 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, interview, and review of the facility policy, the facility failed to ensure the resident call system was in working condition for 1 of 3 units observed for call light function. and failed to implement a procedure while call light system was inoperable. Findings include: Review of the facility policy titled Call System revealed, residents are provided with means to call staff for assistance through a communication system that directly calls a staff member or centralized work station. Each resident is provided with a means to call staff directly for assistance from his/her bed toileting/bathing facilities and from the floor. Call system communication may be audible or visual, and the system may wired or wireless. The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard. If visual communication is use, the light remains functional. If the resident has a disability that prevents him/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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-02-28 · tag F0582 — widespread
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview and facility policy, the facility failed to use the required CMS 10055 form to notify 3 of 3 residents of their Skilled Nursing Facility Advanced Beneficiary Notice (ABN) of Non-coverage. Findings include: Review of the facility's undated policy titled Policy and Procedure for Advanced Beneficiary Notice, revealed, At that time the bookkeeper will write a Medicare Non-Coverage letter to the resident or responsible party and attach the ABN (most recent version). Review of the Beneficiary Notice of residents discharged within the last six months revealed three residents that remained in the facility. Three of three of these residents were provided with a written notice of Medicare non-coverage, a CMS R-131 and a CMS 10123 form. During an interview on 02/21/23 at 3:45 PM with the Bookkeeper, revealed the form CMS R-131 the facility used, was the incorrect form and that form was an ABN for Medicare Part B, not for Medicare Part A. The bookkeeper stated when she googled the form to use for an ABN, that is what was provided. She concluded that 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-02-28 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility policy, documentation review, and interview, the faciltiy failed to post daily staffing for mutiple shifts as required by federal regulation. Findings include: Review of the facility policy titled, Staffing, Sufficient and Competent Nursing revealed Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Direct care daily staffing numbers (the number of nursing personnel responsible for providing direct care to residents) are posted in the facility for every shift. Record review on 2/21/23 at 1:00 PM revealed the following discrepancies of the daily posted schedule for the facility: 9/01/22 missing documentation for all shifts, 9/05/22 missing documentation for all shifts, 9/08/22 missing documentation for all shifts, 9/10/22 missing documentation for all shifts and 11/26/22 missing documentation for all shifts. An interview with the Staffing Scheduler on 2/21/23…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$15,324 in federal fines across 3 penalties.

  • $9,032 — penalty dated 2024-01-22
  • $2,098 — penalty dated 2024-01-02
  • $4,194 — penalty dated 2023-12-11

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
COMMUNITY SERVICES FOR THE AGING, INC.Organization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/01/2010
DILLARD, WILSONIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTORsince 07/01/2010
BURGESS, RICHARDIndividualCORPORATE DIRECTORsince 01/01/2021
BURNETT, PAULIndividualCORPORATE DIRECTORsince 07/01/2010
FEEMSTER, SAMIndividualCORPORATE DIRECTORsince 01/01/2021
HERRING, LEONIndividualCORPORATE DIRECTORsince 01/01/2021
MCCULLOCH, CAROLIndividualCORPORATE DIRECTORsince 01/01/2021
MILLER, EARLIndividualCORPORATE DIRECTORsince 01/01/2021
SHIPPY-GILBERT, KELLYIndividualCORPORATE DIRECTORsince 07/01/2010
SHIRLEY, BRENDAIndividualCORPORATE DIRECTORsince 07/01/2010
SISK, KEITHIndividualCORPORATE DIRECTORsince 01/01/2021
SUMMEY, MATTHEWIndividualCORPORATE DIRECTORsince 01/01/2021
WALTERS, KEVINIndividualCORPORATE DIRECTORsince 11/22/1988
WESSINGER, E. RALPHIndividualCORPORATE OFFICERsince 10/09/2012

CMS files one row per role, so the 15 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.

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

What families pay in SC

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 425027. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-23, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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