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Sumter East Health & Rehabilitation Center

880 Carolina Avenue, Sumter, SC 29150 · For profit - Limited Liability company · 176 certified beds · (803) 775-5394 Medicare & Medicaid certified

Call the home — (803) 775-5394 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0602, F0604) — most recent Mar 2025Resident-funds citation (F0568)2 actual-harm citations1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$29,135 in federal fines
Insights

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

Worth asking about
  • it has abuse, neglect, or exploitation citations (F0602, F0604) — most recent Mar 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0568)
  • it has 2 actual-harm citations
  • 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 (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $29,135 in federal fines (most recent 2025-03-20)
  • 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.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
(803) 774-4500 · Call to confirm hours
Pharmacy
615 Bultman Drive · (803) 305-6194 · Call to confirm hours
Grocery
280 S Pike W · (803) 305-1093 · Call to confirm hours
Park
1305 Clara Kellogg Dr · (803) 436-2102 · Typically dawn to dusk
Place of worship
129 W Moore St · (803) 775-5089

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 5 of 5
Short-stay residentsrehab / post-hospital 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 held steady at 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.7%11.9%15.4%better
Long-stay residents who lose too much weight7.8%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.2%0.6%0.9%better
Long-stay residents with a urinary tract infection0.2%1.3%2.0%better
Long-stay residents with depressive symptoms0.2%3.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.0%3.2%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened14.3%12.7%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.0%21.0%18.9%better
Long-stay residents given the seasonal flu vaccine89.0%90.6%95.3%typical
Long-stay residents with pressure ulcers5.0%5.1%4.7%typical
Long-stay residents with worsening bladder/bowel control15.9%16.7%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table7.1%15.3%17.1%better
Short-stay residents who newly got an antipsychotic medication1.3%1.5%1.4%typical
Short-stay residents given the seasonal flu vaccine35.2%78.0%79.4%worse
Short-stay residents rehospitalized after admission32.4%24.3%22.6%worse
Short-stay residents with an outpatient ER visit16.4%13.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.072.041.67worse
Long-stay outpatient ER visits per 1,000 resident days1.791.841.80typical

* 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.

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.

34.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 82 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

34.5%U.S. median 51.5%
Got home and stayed home
11.7%U.S. median 10.7%
Went back to hospital
34.6%U.S. median 56.6%
Met the expected recovery
0.21U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 34.6% 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 81 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 0.21 therapist hours per resident per day in 2026Q1 — more than 25% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF34.5%CMS range 24.7–47.251.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.7%CMS range 8.5–16.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge34.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge54.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge28.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting89.6%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge83.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.2%CMS range 3.6–9.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.981.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.27
RN hours/ resident / day
0.98
LPN hours/ resident / day
1.69
Aide hours/ resident / day
2.94
Total nurse hours/ resident / day
0.16
RN hoursweekends
44.2%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 176 beds and averages 167.3 residents a day — about 95% occupied, or roughly 9 beds typically open. It runs essentially full — expect a waiting list. 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 2.94 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.27 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.69 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 2.54 hrs/resident/day on weekends vs 3.10 on weekdays — 18% thinner on weekends. RN hours go from 0.32 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% 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

9
deficiencies at the latest standard inspection (2026-03-10)
7
at the previous standard inspection (2024-10-11)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

31 citations, most serious first. The 13 most serious are shown; the remaining 18 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-10-11 · 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 review of facility policy, interview, and record review, the facility failed to provide appropriate supervision for Resident (R)78, resulting in R78 successfully eloping from the facility. On 10/09/24 at 11:28 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 09/26/24. The IJ was related to 42 CFR 483.25 - Free of Accidents Hazards/Supervision/Devices. On 10/10/24 at approximately 1:40 PM, the facility provided an acceptable IJ Removal Plan. The survey team validated the facility's corrective actions and determined the facility put forth good faith attempts to address the non-compliance. The IJ is considered at Past Non-Compliance with a correction date of 09/30/24. An Extended Survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings Include: Review of an undated facility policy titled Elopements and Wandering 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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Actual harm · Gcited before2025-03-20 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure 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

    Based on review of facility policy, record review and interview, the facility failed to protect Resident (R)1 from being physically restrained by Certified Nursing Assistant (CNA)1. Specifically, CNA1 grabbed both of R1's hands, held them crossed against R1's upper chest during incontinence care, for 1 of 3 residents reviewed. On 03/20/25 at 2:00 PM the Administrator and the Director of Nursing were notified that the failure to protect a resident from being physically restrained constituted IJ at F604. On 03/20/25 at 2:00 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 03/02/25. The IJ was related to 483.12 Freedom from Abuse, Neglect, and Exploitation. On 03/20/25 at 7:20 PM, the facility provided an acceptable IJ Removal Plan. On 03/20/25, the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F604, at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-09-29 · 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 observation, interview, record review, and facility policy review, the facility failed to properly supervise 1 of 2 residents to prevent a fall, resulting in injury. Specifically, Resident (R)3 wandered into a staff break room and tripped and fell over a hole in the floor, resulting in R3 suffering a closed head injury and pain. This failure constituted actual harm. Findings include: A review of the un-dated facility's policy titled, Accidents and Supervision indicated, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes Identifying hazards and risks, implementing interventions to reduce hazards and risks, monitoring for effectiveness, and modifying interventions when necessary. 1.) Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-03-10 · 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 observation, interview, and facility policy review, the facility failed to ensure food was stored off the floor, failed to label, date, and cover stored food, and failed to discard food with expired use by or best by dates in two of two facility kitchens. These failures had the potential to create an environment for food-borne illnesses which could affect 165 residents who consumed food prepared from the facility's two kitchens.Findings include:Review of the facility's undated policy titled, Date Marking for Food Safety, indicated, Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. Policy Explanation and Compliance Guidelines for Staffing: 1. Refrigerated, ready-to-eat, time/temperature control for safety food (i.e. perishable food) shall be held at temperatures of 41 [degrees] F [Fahrenheit]. for a maximum of 7 days. 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded . 4. The marking system shall consist of a food label, 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-03-10 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, and facility policy review, the facility failed to complete an assessment of the building to determine where Legionella and other opportunistic waterborne pathogens can grow and spread. Additionally, there was no diagram of the water maintenance as it flows through the facility. This had the potential to affect 168 of 168 residents who resided at the facility. These failures had the potential to allow for the growth of waterborne pathogens to be unnoticed and placed residents at risk for the spread of infections. Findings include:Review of the facility's Infection Prevention and Control Program under number 17, indicated, Water Management, provided by the facilities, infection preventionist, revealed an assessment of the building was not completed where Legionella could grow and spread. a. A water management program has been established as part of the overall infection prevention and control program. b. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems. c. The Maintenance…

    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 · D2026-03-10 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 policy review, the facility failed to ensure one of 20 supplemental residents was assessed for self-administration of medications Resident (R) 177. R177 had seizure medications at her bedside; however, she had not been assessed for or ordered by her physician to be able to self-administer her medications. This failure placed the resident at an increased risk of seizure activity if the medications were not administered as ordered by the physician. Findings include:Review of the facility's policy titled, Resident Self-Administration of Medication, dated 2025, revealed, A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely . When determining if self-administration is clinically appropriate . the results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record .…

    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 · D2026-03-10 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 one of five residents Resident (R)18 reviewed for unnecessary medications out of a total sample of 35 had adequate indication for the use of an antipsychotic medication. R18 was ordered Seroquel (Quetiapine), an antipsychotic medication for schizophrenia, without documented evidence of the diagnosis. This failure placed the resident at risk of receiving unnecessary medications. Findings include:Review of the facility undated policy titled, Restraint Free Environment revealed, . If a medication was initially administered for a medical symptom and continues to be administered in the absence of such symptom, the facility should re-evaluate the need for such medication to ensure that it does not sedate the resident or make it easier for the staff to care for the resident . Review of R18's admission Record, located under the Profile tab of the EMR, revealed the resident was admitted on [DATE] with diagnoses that include…

    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 · D2026-03-10 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, interviews and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a facility fall for one of three residents reviewed for falls Resident (R)150 out of a total sample of 35. This failure had the potential to lead to lack of care plan interventions to prevent falls. Findings include:Review of the facility's undated policy titled, MDS 3.0 Completion revealed, . Persons completing part of the assessment must attest to the accuracy of the section they completed by signature and indication of the relevant sections.Review of R150's admission Record, located under the Profile tab of the electronic medical record (EMR), indicated R150 was admitted on to the facility on [DATE] with diagnoses of acquired absence of right leg below knee (BKA), lack of coordination and abnormalities of gate and mobility.Review of R150's Progress Note, dated 01/17/26 at 1:39 PM and located under the Progress Notes tab of the EMR, revealed, Staff 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 · D2026-03-10 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy, the facility failed to ensure the comprehensive care plan was developed to accurately reflect the indication of the resident's use of an antipsychotic medication for one of five sampled residents Resident (R)18 reviewed for unnecessary medications out of a total sample of 35. This failure placed the resident at risk of staff not meeting the resident's care needs. Findings include:Review of the facility's undated policy titled, Comprehensive Care Plan, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality . The care planning process will include an assessment of the resident's strengths 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 before2026-03-10 · 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, interview, and policy review, the facility failed to ensure one of 35 sampled residents Resident (R)6 care plan was revised to reflect the resident's end of life wishes. R6's wishes was to be a Do Not Resuscitate (DNR); however the resident's care plan documented the resident wanted to receive life saving measures of cardio-pulmonary resuscitation (CPR) in the event her heart stopped or she stopped breathing. This failure placed R6 at risk to receive CPR against her wishes for a natural death, potentially causing serious injury from compressions or psychosocial harm related to her preference not being honored. Findings include:Review of the policy titled, Comprehensive Care Plans, dated 2025, revealed, The comprehensive care plan will describe, at a minimum, the following:a. The services that are to be furnished to attain or maintain the resident's highest practicablephysical, mental, and psychosocial well-being'b. Any services that would otherwise be furnished, but are not provided due…

    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 · D2026-03-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 policy review, the facility failed to implement care to prevent pressure ulcer development for one of four residents reviewed for pressure ulcers Resident (R)6 out of 35 sampled residents. R6's interventions for the prevention of pressure ulcers were not being implemented. This failure placed R6 at risk for development of pressure ulcers.Findings include:Review of R6's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including stroke, diabetes, heart failure, and encephalopathy.Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/19/26 and located under the MDS tab of the EMR revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS), score of three out of 15 which indicated there resident was severely cognitively impaired. The MDS also revealed the resident did not exhibit any…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-10 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, interviews, and policy review, the facility failed to honor known food preferences for one resident Resident (R)155 of four residents reviewed for food out of 35 sampled residents. This failure had the potential to cause R155's nutritional needs to go unmet. Findings included:Review of R155's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an original admission date of 03/10/25 and diagnoses which included, type 2 diabetes mellitus with hyperglycemia, and chronic kidney disease.Review of R155's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/19/26 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R155 was cognitively intact.Review of R155's current Care Plan, provided by the facility and most recently revised on 03/02/26, contained a Focus, which indicated, I [Resident #155's name] have an actual nutritional problem or potential nutritional problem r/t [related to] Diabetes,…

    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 · F2024-10-11 · tag F0908 — failed to keep essential equipment working — widespread
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, observation and interview, the facility failed to ensure 3 of 3 clothes dryers in the East Building did not contain an excessive amount of lint. The lint was located above the lint baskets and onto the wiring. Findings include: Review of the facility policy titled Care of Equipment states, To review the use and care of all equipment used by the Laundry Department to perform their daily duties. Laundry departments work with 2 types of equipment. Large pieces (washers/dryers, etc). Larger equipment must be maintained on a regular basis. Preventative Maintenance (PM) work may be the responsibility of the Maintenance Department in some buildings, but the Laundry Supervisor must still be familiar with the daily cleaning and simple maintenance. Laundry Equipment - Dryers Lint screens must be cleaned every two or three loads. The bottom of the dryers must also be lint free. The drums of dryer should be cleaned after each load to prevent any type of trash or lint from heating up and melting to the inside. The area between the drum and walls of the dryers…

    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
Show the remaining 18 citations
  • Potential for harm · E2024-10-11 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review, and interview, the facility failed to provide services and interventions to prevent significant weight loss for 3 of 4 resident's reviewed for nutrition, Resident (R)3, R 17, and R78. Findings Include: Review of an undated facility policy titled, Weight Monitoring, revealed, . The facility will ensure that all residents maintain acceptable parameters of nutritional status . Further review of the Compliance Guidelines section, revealed, 1. The facility will utilize a systemic approach to optimize a resident's nutritional status 2. A comprehensive nutritional assessment will be completed upon admission on residents ., 3. Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan ., 4. Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the residents' assessed needs and current professional standards to maintain acceptable…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-11 · tag F0582 — isolated
    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 the facility policy, record review and interview, the facility failed to provide the required documents to notify Resident (R)63 and R125 regarding medicare eligibility and coverage for 2 of 3 residents reviewed for advance beneficiary notices. Findings include: Review of the facility policy titled, Advance Beneficiary Notices, states: 4. The facility shall inform Medicare beneficiaries of his or her potential liability for payment. A liability notice shall be issued to Medicare beneficiaries of his or her potential liability for payment. A liability notice shall be issued to Medicare beneficiaries upon admission or during a resident's stay. 5. The current CMS-approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). Contents of the form shall comply with related instructions and regulations regarding the use of the form. a. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CMS-10055. c. A Notice of Medicare Non-Coverage (NOMNC),…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-11 · 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, interview, and record review, the facility failed to ensure that Resident (R)18 who needed respiratory care was provided with such care that was consistent with professional standards of practice for 1 of 2 residents reviewed for oxygen therapy. Findings include: Review of the undated facility policy titled Oxygen Administration revealed, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. 1. Oxygen is administered under orders of a physician . Review of R18's Face Sheet revealed R18 was admitted to the facility on [DATE], with diagnoses including but not limited to: chronic respiratory failure, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Review of R18's Quarterly Minimum Data Set with an Assessment Reference Date of 08/26/24, revealed that R18 had a Brief Interview for Mental Status (BIMS)…

    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 before2024-10-11 · 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 review of facility policy, observations, and interviews, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance to professional standards including expiration dates for 3 of 3 Medication Storage Rooms, 1 out of 4 Medication Carts , and 1 out of 3 Treatment Carts. Findings include: Review of the facility policy, copyright 2024 (The Compliance Store, LLC), titled, Medication Storage, states It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 8. Unused medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, observations, interviews, and record review, the facility failed to properly clean a glucometer machine. Findings include: Review of the facility's policy titled, Blood Glucose Monitoring copyright date 2023 revealed, It is the policy of this facility to preform blood glucose monitoring to diabetic residents as per physician's orders. Policy Explanation and Compliance Guidelines 2. The nurse will perform the blood glucose test utilizing the facility's glucometer as per manufacturer's instructions. 3. The nurse will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy. Procedure 18. Clean and disinfect the glucometer as per manufacturer's instructions. During an observation on 10/10/24 at 8:16 AM, Licensed Practical Nurse (LPN)2 cleaned a glucometer machine with an alcohol wipe. During an interview on 10/10/24 at 10:00 AM, Director of Nursing (DON) stated, Glucometer machines are cleaned with our Bleach…

    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 · E2023-09-29 · tag F0602 — failed to protect residents from theft of their belongings — pattern
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, interview, observation, and record review, the facility failed to protect 7 of 19 residents from misappropriation of medications. Specifically, Licensed Practical Nurse (LPN)2 diverted medications from Residents (R)5, R6, R13, R14, R15, R16, and R17 during the months of August and September 2023. Findings include: Review of the undated facility policy titled Abuse, Neglect and Exploitation revealed, 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. Review of R5's Face Sheet revealed R5 was admitted to the facility on [DATE] with diagnoses including, but not limited to: muscle weakness, gout, and chronic kidney disease. Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/28/23, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R5 was cognitively intact.…

    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 · Ecited before2022-10-20 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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, record review, policy review, and staff interview, the facility failed to maintain one (main building kitchen) of two kitchens in sanitary condition to prevent potential contamination of food that could result in food borne illness for residents who received meals from the dietary department. Specifically, the facility: - failed to ensure stainless-steel service carts, food preparation (prep) tables, the inside of the microwave, the kitchen heating, ventilation, and air conditioning (HVAC) vents, the ice machine, and other kitchen equipment/surfaces were free of rust, dust, and/or debris. - failed to ensure the kitchen floor was maintained in good repair. Additionally, the facility failed to ensure staff wore gloves while handing a resident's food during meal tray delivery and set-up on 1 (300 Hall) of 8 halls. The failed practices had the potential to affect all residents who received meals from the kitchen, including residents who received meals on the 300 Hall. Findings included: 1. Review of a facility policy titled, Environment, dated September 2017 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-10-20 · tag F0925 — failed to control pests — pattern
    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, interviews, and policy review, the facility failed to maintain an effective pest control program for 3 of 3 residents (R)89, R28, and R108) interviewed and 1 of 2 kitchens observed to eradicate roaches and maintain the facility free of pests. This failure had the potential to cause a diminished quality of life for the residents. Findings include: A review of the facility pest control policy titled, Pest Control, with a revised date of 09/2017, specified, A program will be established for the control of insects and rodents for the Dining Services department. During an interview on 10/20/22 at 10:49 AM, the Administrator stated that although the facility pest control policy only addressed pest control for the dining department, the policy applied to the whole facility. During an interview with R89 on 10/17/22 at 10:12 AM, the resident was observed lying in bed, and a small roach was observed crawling on the resident's mattress. The resident stated there were roaches in the room. The resident noted they often saw roaches by the sink area and by the window 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-20 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to maintain the dignity for 2 (Resident (R)11 and R68) of 3 residents reviewed for dignity. Specifically, staff allowed R11 to dine on soiled linens while wearing a soiled brief and dine with dirty hands and fingernails. The facility also failed to provide a privacy cover for R68's indwelling urinary catheter collection bag. Findings include: Review of a facility policy titled, Resident Dignity and Personal Property, with a revision date of June 2007, indicated, The facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy. Further review of the policy under Procedure indicated residents should be Groom appropriately and to resident's desire. The policy did not include any direction for covering a collection bag for an indwelling urinary catheter. 1. A review of the admission Record for R11 revealed the resident had diagnoses…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-20 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure 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

    Based on record review, observations, and staff interviews, the facility failed to assess for the use of a lap belt restraint for 1 Resident (R)91 of 1 resident reviewed for restraints. Findings include: Review of the admission Record for R91 revealed the resident had diagnoses that included dementia and contracture of bilateral lower extremities. A review of R91's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/19/22, revealed a Brief Interview for Mental Status (BIMS) was not completed as the resident was rarely/never understood. Per the Staff Assessment for Mental Status, the resident was severely cognitively impaired. The MDS indicated the resident used a trunk restraint daily. Review of R91's care plan, initiated 09/21/22, revealed a focus area that the resident required the use of a soft belt restraint when out of bed in the wheelchair with interventions which included to observe proper placement of the soft seat belt. A physician order, dated 09/07/22, revealed an order for a device belt, a soft waist belt, to be on the resident when up in a…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-20 · 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 facility policy review, record review, observation, and interviews, the facility failed to revise a care plan to include a behavioral problem for 1 Resident (R)11, of 28 reviewed. Findings include: Review of the facility's policy titled, Comprehensive Care Plan, revised May 2021, indicated the purpose of the care plan was to provide effective and person-centered care for each resident. Further review of the policy revealed Minimum Requirements of the Comprehensive Care Plan. The comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The plan must address the resident's individual needs, strengths, and preferences. Continued review of the policy revealed The care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or a change in condition. A review of the admission Record for R11 revealed the resident had diagnoses which included…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-20 · 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 document review, the facility failed to investigate and identify the root cause of a fall for 1 (Resident #91) of 1 resident reviewed for accidents. Additionally, the facility failed to ensure an assessment of Resident #91 was completed and documented after the fall. Findings included: Review of Resident #9's admission Record revealed the resident's diagnoses included dementia and bilateral contractures of the lower extremities. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status was not completed. Per the MDS, Resident #91 was severely cognitively impaired and required extensive assistance of two people for transfers and required total assistance of two people for bed mobility. Per the MDS, Resident #91 did not have any falls during the look-back period. A review of Resident #91's care plan, dated 09/21/2022, revealed the resident was at risk of falls with a goal to minimize risks and injury potential. The…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to determine the medical justification for the use of an indwelling urinary catheter and failed to secure an indwelling urinary catheter with a leg strap for 1 (Resident #68) of 1 resident reviewed with a urinary catheter. Findings included: A review of the facility policy titled, Indwelling urinary catheter (Foley) care and management, revised on 11/19/2021, indicated, Inappropriate or unnecessary use of an indwelling urinary catheter can result in catheter-associated urinary tract infection (CAUTI). CAUTIs are the most common type of health care-associated infection in adult patients. Researchers estimate that as many as 70% of these infections are preventable by following evidence-based practices. The policy also indicated staff should, Review the necessity of continued urinary catheter use; remove the catheter as soon as it's no longer clinically indicated to reduce risk of CAUTI. Additionally, per the policy,…

    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 · D2022-10-20 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to maintain a medication error rate of 5% or less. During medication administration observation, four nurses were observed administering medications to six residents for a total of 26 opportunities with two errors, which yielded a medication error rate of 7.69%. Findings included: Reference: According to Multivitamins and minerals Uses, Side Effects & Warnings - Drugs.com, referenced on 11/09/2022: Minerals (especially taken in large doses) can cause side effects such as tooth staining, increased urination, stomach bleeding, uneven heart rate, confusion, and muscle weakness or limp feeling. 1. During medication administration observation on 10/19/2022 at 8:43 AM, Licensed Practical Nurse (LPN) #5 was observed to prepare and administer cetirizine (an antihistamine used to relieve allergy symptoms) 10 milligrams (mg) to Resident #87. A review of Resident #87's physician's orders indicated that, on 08/09/2022, staff were directed to administer cetirizine 5 mg one time daily to Resident #87. In an interview on…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-20 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility policy titled, Medication Reordering, observation, and interviews, the facility failed to ensure Resident (R)1 received an ordered dose of a Prenatal Vitamin Plus Low Iron on 12/21/22 as ordered by the physician for 1 of 5 residents observed during Medication Administration. Findings Include: Review of the facility policy titled, Medication Reordering, states, It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biological's in a timely manner to meet the needs of each resident. The Policy Explanation and Compliance Guidelines: #1 states, The facility will utilize a systemic approach to provide or obtain routine and emergency medications and biological's in order to meet the needs of each resident. #2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. #7. states, If medication is not available notify pharmacy, or back up pharmacy to refill. An observation on 12/21/22…

    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 · D2022-10-20 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to follow-up on Resident #106's request to be evaluated for dentures. This affected 1 (Resident #106) of 3 residents reviewed for dental services. Findings included: A review of Resident #106's admission Record revealed the resident's payer source was Medicaid. A review of a dental Summary Report for ]Resident #106], dated 03/16/2022, indicated the resident wanted to be evaluated for a new set of dentures. A review of a dental Summary Report for [Resident #106], dated 09/22/2022, indicated the resident was edentulous (being without teeth). A review of Resident #106's quarterly Minimum Data Set (MDS), with an assessment reference date of 10/02/2022, indicated the resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14. According to the MDS, the resident required extensive assistance with personal hygiene (how the resident maintained personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands). In an interview on 10/17/2022 at…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and staff interview, the facility failed to ensure staff followed infection control practices related to hand hygiene and wound care supplies during wound treatment for 1 Resident(R)106, of 1 resident observed receiving wound care. Specifically, observations of wound care for R106 revealed staff failed to follow hand washing protocols between glove changes when changing a wound dressing, failed to set up wound care supplies on a clean surface, and failed to ensure contaminated supplies were not returned to a treatment cart after use. Findings include: A review of a facility policy titled Wound Care Procedure for Major Wounds, dated 02/2018, revealed the following: Set up the supplies on a clean surface at the bedside (cover the surface with a clean impervious barrier before putting the supplies out), put gloves on, remove the soiled dressing and place in a bag at the bedside, remove gloves, wash your hands, put on clean gloves, clean the wound according to the…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2022-10-20 · tag F0568 — pattern
    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, document review, and policy review, the facility failed to ensure a resident received a quarterly statement related to a personal funds account for 1 Resident (R)106 of 2 residents reviewed for personal funds. Findings included: A review of a facility policy titled Resident Trust Accounts, last revised September 2021, revealed under a heading of Fundamental Information with a sub-heading of Regulations, The resident or the resident's legal/personal representative must be provided with an individual accounting of all transactions on a quarterly basis and upon request. A review of an admission Record revealed the facility admitted R106 to the facility on [DATE]. The record identified both the resident and family member #1 as Billing Responsible Party. A review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed R106 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R106 had intact cognition. During an interview on 10/17/22 at 11:07 AM, R106 stated 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

“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

$29,135 in federal fines across 4 penalties.

  • $4,433 — penalty dated 2025-03-20
  • $8,018 — penalty dated 2024-10-11
  • $8,783 — penalty dated 2024-10-11
  • $7,901 — penalty dated 2023-09-29

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
SCSNF INVESTMENT GROUP LLCOrganizationDIRECT OWNERSHIP INTERESTsince 11/08/2022
BHGSC HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST99%since 11/08/2022
CARESTRONG LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/08/2022
MICHAEL ALLEN BOKOR REVOCABLE LIVING TRUST AGREEMENT DATED MAY29, 2008Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/08/2022
GREENWALD, MICHAELIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/08/2022
BOKOR, MICHAELIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2022
HATTON, BRYANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/04/2024
MAUNG, PETERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/17/2023

CMS files one row per role, so the 14 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$13.1M
Net patient revenuemost recent cost report
+1.0%
Operating marginrevenue minus expenses
$657K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 70%Medicare 6%Other / private 24%

About 70% 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 $657K 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

$250per resident / day
operating cost
$7,592per month
≈ monthly operating cost
$252per day
avg. revenue, all payers

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

What families pay in SC

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 425107. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-10, 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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