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The Heritage At Lowman Rehab And Healthcare

201 Fortress Drive, White Rock, SC 29177 · Non profit - Corporation · 152 certified beds · (803) 732-3000 Medicare & Medicaid certified

Call the home — (803) 732-3000 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation$14,664 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $14,664 in federal fines (most recent 2024-09-04)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)

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 2 of 5
StaffingFrom payroll records (PBJ) 4 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

Urgent care / clinic
109 Hummingbird Ct · (803) 732-6670 · Call to confirm hours
Pharmacy
1330 Dutch Fork Rd · (803) 749-1666 · Call to confirm hours
Grocery
Food Lion1.7 mi
11107 Broad River Rd · (803) 732-4453 · Call to confirm hours
Park
1007 Bickley Rd · (803) 781-2031 · Typically dawn to dusk
Place of worship
2081 Dutch Fork Rd · (803) 781-2134

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 2 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 increased11.7%11.9%15.4%better
Long-stay residents who lose too much weight5.5%6.3%5.4%typical
Long-stay residents with a catheter left in their bladder0.9%0.6%0.9%typical
Long-stay residents with a urinary tract infection2.6%1.3%2.0%worse
Long-stay residents with depressive symptoms8.0%3.1%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.4%3.2%3.3%typical
Long-stay residents whose ability to walk worsened25.8%12.7%16.1%worse
Long-stay residents on antianxiety or hypnotic medication14.6%21.0%18.9%better
Long-stay residents given the seasonal flu vaccine68.3%90.6%95.3%worse
Long-stay residents with pressure ulcers9.1%5.1%4.7%worse
Long-stay residents with worsening bladder/bowel control13.4%16.7%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table26.4%15.3%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.9%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine61.2%78.0%79.4%worse
Short-stay residents rehospitalized after admission36.6%24.3%22.6%worse
Short-stay residents with an outpatient ER visit11.6%13.9%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.632.041.67worse
Long-stay outpatient ER visits per 1,000 resident days1.821.841.80typical

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.

49.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 246 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.1%U.S. median 51.5%
Got home and stayed home
11.3%U.S. median 10.7%
Went back to hospital
45.1%U.S. median 56.6%
Met the expected recovery
0.31U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 45.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 142 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 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% 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 SNF49.1%CMS range 43.2–55.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.3%CMS range 8.5–14.010.7%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 discharge45.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge49.3%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 discharge44.4%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 identified95.1%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 setting98.7%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 discharge100.0%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 stay0.9%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 worsened4.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.3%CMS range 6.4–13.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.971.02Oct 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

0.59
RN hours/ resident / day
0.93
LPN hours/ resident / day
2.58
Aide hours/ resident / day
4.11
Total nurse hours/ resident / day
0.42
RN hoursweekends
46.3%
Total nursing turnover
40.9%
RN turnover

How full it usually is: this home is certified for 152 beds and averages 129.4 residents a day — about 85% occupied, or roughly 23 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 4.11 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 2.58 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 3.45 hrs/resident/day on weekends vs 4.37 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.66 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% 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

4
deficiencies at the latest standard inspection (2025-12-09)
14
at the previous standard inspection (2024-09-04)

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.

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · Gcited before2024-05-14 · 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 interviews, record review, and review of facility policy, the facility failed to maintain resident safety from harm for 1 of 1 resident. Specifically, while providing incontinent care to Resident (R)1 on 04/01/24, staff walked away from R1, resulting in R1 falling to the floor and suffering a hematoma of the scalp, skin tear and hematoma over the right elbow/forearm, and acute closed fracture of the tibia and fibula. Findings include: Review of the facility policy titled Falls with a revision date of 04/04/22 revealed, the facility will identify each patient/resident who is at risk for falls and develop and implement a plan of care. Qualified staff will complete a Fall Risk Evaluation to determine if the patient/resident is a fall risk. Fall risk evaluation assists in identifying the appropriate preventative interventions that will be recorded in the resident's medical record/care plan. Review of R1's Face Sheet revealed that R1 was admitted to the facility on [DATE] with diagnoses to include but not…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-12-09 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and review of facility policy, the facility failed to maintain safe temperatures in 4 of 4 refrigerators in the nourishment rooms on the units. This failure has the potential to cause harm by increasing the risk of foodborne illnesses.Findings include: Review of the facility policy titled Refrigerators and Freezers with a revised date of December 2022 documented: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. 1. Acceptable temperature ranges are 35 degrees F to 40 degrees F for refrigerators and less than 0 degrees F for freezers. 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. 3. Actions necessary to correct the temperatures will be recorded on the tracking sheet. Review of the December 2025 temperature log for the refrigerator in the Demascus unit nourishment room revealed six of six recorded temperatures were above…

    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 · Ecited before2025-12-09 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, observation and interview, the facility failed to ensure outdated/expired medications were removed from the medication carts and not stored with other medications in use for residents in 3 of 8 medication carts.Findings include:Review of the facility policy titled Storage of Medications states: The facility stores all drugs and biologicals in a safe, secure, and orderly manner . 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . 8. UNOPENED INSULIN VIALS/PENS SHOULD REMAIN REFRIGERATED UNTIL USE; once in use. an expiration date must be placed on the vials/pens.During an observation on 12/09/25 at 3:30 PM of Medication Cart A on the [NAME] wing revealed the following: Insulin Aspart Injection 100 units/ml (U-100) vial, manufactured by Novo Nordisk with lot #RZFWGOO, open date of 11/04/25, expired on 12/02/25. Promethegan 25 mg suppository, ten count, lot #L5040531 in the top drawer 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-09 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility policy, interview and record review, the facility failed to ensure Resident (R)4 was offered showers and/or bed baths daily according to her preferences for 1 of 4 residents reviewed for Activities of Daily Living.Findings include: Review of the facility policy titled, Resident Shower and Bathing, states as the policy statement, The facility will provide residents with assistance for bathing and showering in accordance with their individual care plan, ensuring that personal hygiene needs are met, preferences are honored, and resident rights and safety are maintained. Review of R4's Face Sheet revealed the facility admitted R4 on 10/09/19 with diagnoses including, but not limited to, pulmonary edema, chronic respiratory failure with hypoxia, lack of coordination, central corneal ulcer and generalized muscle weakness. Review of R4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/25 revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating R4's cognitive ability for decision making was 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-09 · 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 review of the facility policy, the manufacturer's recommendations, observations and interviews, the facility failed to ensure a medication administration error rate of less than 5%, for 2 of 25 opportunities for error. The medication error rate was 8%. Findings include:Review of the facility policy titled Insulin Pens revealed the Policy Statement reads, Facility staff will follow proper infection control storage, administration, and documentation practices to ensure safe insulin delivery and compliance with regulatory requirements. Under section 3, Prime the Pen documented: 1. Dial 2 units on the dose selector. 2. Hold the pen with the needle pointing upward. 3. Tap the pen gently to move air bubbles to the top. 4. Press the injection button until insulin appears at the tip. If insulin does not appear, repeat priming until a drop is seen. If no insulin appears after 3-4 attempts, discard the pen and notify the nurse/pharmacy.Review of the manufacturer's recommendations for administering insulin using an insulin pen documented: How to Use . 7. Wipe the tip of the pen where…

    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 · D2025-08-06 · 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 record review, interviews, and review of facility policies, the facility failed to identify and communicate a change in the breakdown of skin in the perineal area for Resident (R)2 for 1 of 1 resident reviewed for changes in skin condition.Findings include:Review of the facility policy titled, Change in Resident's Condition or Status, with a revision date of 02/2021, revealed, The facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a(an):.d. significant change in the resident's physical/emotional/mental condition. A 'significant change' of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting).Review 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-04 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    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 interview and record review the facility failed to ensure trigger behaviors were identified for the use of an antipsychotic medication for one resident (Resident (R) 40) and failed to ensure psychotropic medications had an end date for three residents (R71, R10, R57). This failure placed the residents at risk of unmet care needs and a diminished quality of life. Findings include: 1. Review of the Face Sheet located in the Admission tab of the electronic medical record (EMR) revealed R40 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a neurological disease) and dementia. Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with and assessment reference date (ARD) of 06/26/24 revealed R40 had a Brief Interview for Mental Stats (BIMS) score of zero out of 15 which indicated he was severely cognitively impaired, had no behaviors, and was administered an antipsychotic medication daily during the observation period. Review of R40's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-04 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and policy review, the facility failed to ensure three Residents (R)282, R71, and R36) discontinued medications were removed from two of four medication carts. This had the potential for the medications to be diverted or for residents to receive medications with no current physician order. Findings include: Review of the facility policy Medication Labeling and Storage dated 02/23, provided by the facility, revealed . If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items . 1.During an observation on 09/04/24 at 10:07 AM, with Licensed Practical Nurse (LPN)1, of the A cart, revealed R282 had dronabinol (for nausea) 2.5 mg (milligram) and oxycodone (pain medication) 15 mg in the narcotic drawer of the medication cart. LPN1 confirmed R282's dronabinol 2.5 mg and oxycodone 15 mg were in the medication cart with no current orders 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 · E2024-09-04 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, the facility failed to ensure pneumonia vaccinations were offered and/or provided for three of five residents (Residents (R) 25, R43, and R100) reviewed for immunizations of 30 sample residents. This failure placed the residents at risk for pneumonia. Findings include: Review of facility's policy titled, Vaccination of Residents, dated April 2023, revealed .All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident has already been vaccinated . Review of the undated CDC (Centers for Disease Control) located at www.cdc.gov revealed Complete series: PCV [Pneumococcal conjugate vaccine] 13 at any age & PPSV [Pneumococcal polysaccharide vaccine] 23 at [AGE] years of age or older and then at five years. Together, with the patient, vaccine providers may choose to administer PCV20 to adults greater than [AGE] years of age who have already received PCV13 or PPSV 23 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-04 · 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 observation, interview, record review, and review of facility policy, the facility failed to ensure one resident (Resident (R) 108) of one resident out of a sample of 30 residents was given the opportunity to make choices regarding being able to utilize regular plates and utensils instead of Styrofoam containers and plastic utensils during a COVID-19 outbreak on the unit. This failure placed the resident for a diminished quality of life. Findings include: Review of the facility's policy titled, Resident Self-Determination and Participation, dated February 2021, revealed Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life . Review of an undated facility's policy titled, Isolation Precautions, dated December 2020, revealed .Dishes, Glasses, Cups, and Eating Utensils .No special precautions are needed for dishes, glasses, cups, or eating utensils .Reusable dishes and utensils are used…

    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 · D2024-09-04 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, the facility failed to ensure one of one resident (Resident (R) 95) reviewed for care planning of 30 sample residents was afforded the right to participate in his care planning process. This failure placed the resident at risk of not being aware of the goals and outcomes of his care. Findings include: Review of facility policy titled, Care Planning-Interdisciplinary Team, dated September 2013, revealed .Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident .The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan .Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family . Review of the Face Sheet located in the Admissions tab of the electronic 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
Show the remaining 13 citations
  • Potential for harm · D2024-09-04 · 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, record review, staff interview and policy review, the facility failed to ensure that a resident was assessed for self-administration of medications prior to medications being left at the bedside for one of 30 sampled residents (Resident (R)114). This failure had the potential for the resident to over medicate themselves or medications being accessed by other residents. Findings include: Review of R114's Face Sheet located under the Resident Info tab in the electronic medical record (EMR) revealed R114 was readmitted to the facility on [DATE] with the diagnosis of dementia, congestive heart failure and asthma. Review of R114's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/05/24 and located under the MDS tab in the EMR revealed R114 was coded as having a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which represented R114 was cognitively intact. Review of R114's Physician Orders located under the Orders tab in the EMR revealed an order dated…

    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 · D2024-09-04 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the CMS-10055 (Centers for Medicare and Medicaid Services) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) was accurate and complete prior to discharge from Medicare part A skilled services for two of three residents (Resident (R) 40 and R120) reviewed for SNF Beneficiary Protection of 30 sample residents. This failure placed the residents and/or representatives at risk of not being fully informed. Findings include: 1.Review of the Face Sheet located in the Admissions tab of the electronic medical record (EMR) revealed R40 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease (a neurological disease). Review of the ABN notice provided to the resident representative indicated that R40 no longer required skilled care effective 03/16/24. Review of Section D of the ABN revealed, In patient stay at this facility .The patient no longer requires skill level nursing care. Medicare will not pay for your stay 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-04 · 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 policy review, the facility failed to ensure Care Plans for behavioral symptoms were developed for three (Residents (R)115, R120, and R25) of 30 sampled residents reviewed for care plans. This failure could cause unmet care needs for the residents. Findings include: Review of the facility policy titled Care Plans, Comprehensive person-Centered revised 12/26, revealed 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 . 2. The care plan interventions are derived from a thorough analysis of the information gathered as part other comprehensive assessment . 8. The comprehensive, person-centered care plan will: . b. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 10. identifying problem areas and their causes, 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 · D2024-09-04 · 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 interview, record review, and review of facility policy, the facility failed to ensure the Comprehensive Care Plan was accurate for one resident (Residents (R) 40) of 30 sample residents reviewed for care plans. This failure placed the resident at risk of unmet care needs. Findings include: Review of the facility's policy titled, Care Plans-Comprehensive Person-Centered, dated December 2016, revealed .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 comprehensive, person-centered care plan will .Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Review of the Face Sheet located in the Admission tab of the electronic medical record (EMR) revealed R40 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-04 · 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

    Based on observation, interview, record review, and policy review, the facility failed to ensure one Resident's (R) 94 heels were elevated as ordered out of three residents reviewed for pressure ulcers out of a sample of 30 residents. This failure had the potential for R94's deep tissue injury to reoccur. Findings include: Review of the facility policy titled Prevention of Pressure Injuries revised April 2020, revealed 1. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. Review of R94's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 06/11/24, located in the MDS tab of the electronic medical record (EMR), revealed an admission date of 01/13/22. R94 had no Brief Interview for Mental Status (BIMS) score and R94's cognition was severely impaired. R94 had diagnoses of hemiplegia or hemiparesis, anxiety, and depression, at risk for pressure ulcers, and had no deep tissue injury. Review of R94's Care Plan dated 01/13/22 to present, located in the EMR under the Care…

    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 · D2024-09-04 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 carry out orders for a splint/palm protector for one (Resident (R)94) of two residents reviewed for range of motion (ROM) out of a sample of 30 residents. This failure had the potential cause further decrease of ROM and/or pain for the resident. Findings include: Review of the facility policy titled Resident Mobility and Range of Motion revised 07/17, revealed . 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Review of R94's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 06/11/24, located in the MDS tab of the electronic medical record (EMR), revealed an admission date of 01/13/22. R94 had no Brief Interview for Mental Status (BIMS) score and R94's cognition was severely impaired. R94 had diagnoses of hemiplegia or hemiparesis, anxiety, and depression, and no splint or brace assistance. Review of R94's Care Plan dated 01/13/22 to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-04 · 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, record review, interview, and facility policy review, the facility failed to properly store an oxygen tank in one of three resident's room out of 30 sampled residents (Resident (R)100) and in one of four storage rooms ([NAME] unit). This failure had the potential for the pressurized oxygen inside the tank to rapidly escape causing injury or damage to surrounding objects or residents. Findings include: 1.Review of R100's Face Sheet located under the Resident Info tab in the electronic medical record (EMR) revealed R100 was admitted to the facility on [DATE] with the diagnosis of acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and other viral pneumonia. Review of R100's Physician Orders located under the Orders tab in the EMR revealed an order dated 05/23/24 for Oxygen (O2) at 3 L/min [sic] [liters per minute]. During an observation on 09/02/24 at 12:20 PM, revealed an oxygen tank was free standing on the floor in R100's room without being secured 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-04 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    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 observation, interview, record review and policy review, the facility failed to maintain acceptable nutritional parameters by not monitoring weights for accuracy, accurately assessing weight changes after readmission, monitoring meal intake, providing meal assistance, providing meal set-up, and/or providing a meal tray for three (Residents (R)68, R120, and R115) of eight sampled residents reviewed for nutrition. This had the potential to cause further weight loss without a root cause analysis and/or additional interventions put in place. Findings include: Review of the facility policy titled Weighing The Resident dated 01/08/24, revealed . 2. If the month-to-month weight shows more than a five-percent gain or loss, the patient/resident is reweighed. Review of the facility policy titled Food and Nutrition Services revised 10/17, revealed Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration…

    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 · D2024-09-04 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a prophylactic antibiotic was monitored to ensure continued efficacy for one of two residents (Resident (R) 16) of 30 sample residents reviewed for antibiotic stewardship. This failure placed the resident at risk of unmet care needs related prolonged use of an antibiotic. Findings include: Review of the facility's policy titled, Infection Prevention and Control Program, dated October 2018, revealed .An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .Antibiotic Stewardship .Culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities .Medical criteria and standardized definitions of infections are used to help recognize and manage infections .Antibiotic usage is evaluated and practitioners are provided feedback on reviews .…

    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 · Ecited before2023-11-03 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the facility failed to secure 2 of 2 medication carts on 1 (Hall 400) of 4 halls. Findings included: A review of a policy titled, Security of Medication Cart, last revised in April of 2007, revealed, The medication cart shall be secured during medication passes. A policy interpretation and implementation section revealed, 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 2. Medication carts must be securely locked at all times when out of any nurse's view. 3. When the medication cart is not being used, it should be locked and parked at the nurses' station or inside the medication room. 1. During an observation on 11/02/2023 at 1:24 PM, a medication cart for resident rooms 401-413 was observed unlocked, unattended, and out of view of a nurse. The medication cart was located against a wall outside a dayroom on Hall 400. Resident rooms 401-413 were located around the corner from the medication cart. During 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-03 · 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, interview, record review, and document and policy review, the facility failed to appropriately clean 1 of 2 glucometers following its use on Hall 400. Findings included: Review of a policy titled, Obtaining a Fingerstick Glucose Level, last revised in October of 2011, revealed, 18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. Review of an undated manufacturer's recommendation for cleaning the glucometer, Section B - Cleaning, revealed, Contact with blood presents a potential infection risk. We suggest cleaning the meter between patients and To clean the outside of your blood glucose meter, use a lint-free cloth dampened with soapy water or isopropyl alcohol (70-85%). To disinfect the meter, dilute 1 [milliliter] of household bleach (5%-6% sodium hypochlorite solution) in nine [milliliters] of water to achieve a 1:10 dilution (final concentration of 0.5%-0.6% sodium hypochlorite). Review…

    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 · E2022-07-19 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, document review, and staff interview, the facility failed to follow the menus for the correct amount of food to be served for 21(Resident (R) 43, R42, R12, R41, R108, R112, R11, R75, R80, R62, R103, R160, R96, R99, R260, R16, R64, R98, R95, R24, and R51) of 21 resident trays observed. This had the potential to affect 114 of 120 residents in the facility who receive their meals from the kitchen and the potential for the 21 residents not to receive the appropriate calories and nutrients. Findings include: On 07/18/22, [NAME] 1 (C1) was observed serving the lunch meal for the 100 unit from 12:15 PM through 12:24 PM. C1 was observed using a 3-ounce ladle to serve the regular spinach, the pureed spinach, and the pureed dressing. At 12:15 PM, prior to beginning the meal service, C1 verified she was using a 3-ounce scoop to serve the regular spinach, the puree spinach, and the puree dressing. During the observation, C1 served 21 meal trays for the first 100-unit cart. Review of the First Cart Resident List and the Roster Report provided by the facility revealed this…

    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 · D2022-07-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was dependent on staff for activities of daily living (ADLs) received the necessary services to maintain personal hygiene, specifically a shower. This involved one of 26 sampled residents (Resident (R) 107). Findings include: Review of R107's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/20/22 indicated R107 was admitted to the facility from the hospital on [DATE] with a diagnosis of fracture; multiple trauma. The resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which revealed the resident was cognitively intact. This assessment indicated R107 required one person physical assistance with bathing. Review of document provided by facility titled Damascus CNA Assignment Sheet indicated R107 was scheduled for a shower on the 3:00 PM to 11:00 PM shift Tuesdays, Thursdays and Saturdays, which would have given the opportunity for 13 showers. Review of Occupational…

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

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

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

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

Fines & penalties

$14,664 in federal fines across 2 penalties.

  • $6,152 — penalty dated 2024-09-04
  • $8,512 — penalty dated 2024-05-14

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

Who owns this facility

Owner / managerTypeRoleSince
LUTHERAN HOMES OF SC, INC.OrganizationDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 09/23/1994
COLEMAN, CHARLESIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2023
SHEPKE, FRANKIndividualCORPORATE OFFICER; ADP OF THE SNFsince 02/02/2015
KNOWLES, AMANDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/17/2024
CURANA HEALTH OF SOUTH CAROLINA PCOrganizationADP OF THE SNFsince 01/01/2022
FORVIS MAZARS LLPOrganizationADP OF THE SNFsince 05/01/2018
PHARMACY CORPORATION OF AMERICAOrganizationADP OF THE SNFsince 10/31/2013
SPECTRUM PARENT, INC.OrganizationADP OF THE SNFsince 08/19/2015
MILAS, MONICAIndividualADP OF THE SNFsince 11/01/2022

CMS files one row per role, so the 14 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

5 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.

$13.3M
Net patient revenuemost recent cost report
+2.4%
Operating marginrevenue minus expenses
$1.0M
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 52%Medicare 11%Other / private 37%

This home reported $1.0M 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

$307per resident / day
operating cost
$9,346per month
≈ monthly operating cost
$315per 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 425100. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-09, 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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