Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
37% worse than South Carolina average
South Carolina average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 11, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following an elopement incident involving Resident 1 on 08/30/2025, where the resident left the facility unsupervised, posing immediate jeopardy to resident health and safety.
Findings
The facility failed to prevent accidents and adequately supervise residents, resulting in Resident 1 eloping from the facility and being exposed to potential harm. Immediate Jeopardy was identified and subsequently removed after corrective actions including increased supervision, staff education, and system improvements were implemented.
Complaint Details
The complaint investigation substantiated that Resident 1 eloped from the facility on 08/30/2025, was found outside the building unattended, and was at risk of serious harm. The facility was notified of Immediate Jeopardy on 09/11/2025, which was later removed after corrective actions were validated.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents, resulting in Resident 1's elopement. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Resident BIMS score: 4
Immediate Jeopardy removal date: Sep 3, 2025
Temperature: 90
Duration of safety checks: 72
Skin checks duration: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | Registered Nurse | Completed skin observation and assessment of Resident 1 after elopement |
| Life Enrichment Leader | Responded to call about Resident 1 outside the facility and assisted resident back inside | |
| Executive Director | Executive Director/Administrator | Notified of Immediate Jeopardy and confirmed elopement incident |
| Care Services Administrator | Care Services Administrator | Provided timeline of elopement and participated in interviews |
| Director of Nursing | Director of Nursing | Provided staff education and re-education on pager and roam alert policies |
| Assistant Director of Nursing | Assistant Director of Nursing | Involved in updating elopement binders and corrective actions |
| Scheduler | Interviewed regarding Resident 1's motivation for elopement | |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Last saw Resident 1 before elopement and provided information on resident behavior |
Inspection Report
Routine
Census: 51
Deficiencies: 4
Apr 2, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food storage, labeling, and expiration policies in the kitchen.
Findings
The facility failed to ensure that items in the refrigerator, freezer, and dry storage were properly sealed, labeled, and dated, and also failed to discard expired items. These deficiencies had the potential to affect all 51 residents consuming food from the kitchen.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Items in the walk-in cooler were not properly labeled, sealed, or dated according to facility policy. | Level of Harm - Minimal harm or potential for actual harm |
| Items in the walk-in dry storage were opened or unsealed with no open dates, including expired items. | Level of Harm - Minimal harm or potential for actual harm |
| Items in the walk-in freezer were not labeled or dated properly. | Level of Harm - Minimal harm or potential for actual harm |
| Bread items in a non-insulated mobile cabinet had use-by dates, some of which were expired or close to expiration. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 51
Dates of observations: Mar 31, 2025
Date of inspection: Apr 2, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Diet (DD) | Participated in observations and interviews regarding food storage and labeling | |
| Executive Chef (EC) | Participated in observations and interviews regarding food storage and labeling | |
| Director of Nursing (DON) | Interviewed regarding awareness of findings and expectations for dietary staff | |
| Facility Administrator (FA) | Interviewed regarding corrective actions taken by dietary staff |
Inspection Report
Routine
Deficiencies: 6
Apr 17, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including nurse staffing postings, medication administration, medication labeling and storage, food safety, infection control, and equipment safety.
Findings
The facility failed to post RN coverage on daily staffing logs, had medication administration errors including crushing medications labeled 'Do Not Crush', stored expired medications in medication and treatment carts, failed to maintain proper food temperatures and hand hygiene during meal service, and had lint buildup in commercial dryers posing a fire risk.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to post RN coverage on daily staffing posted for March 2024 to current date in April. | Level of Harm - Minimal harm or potential for actual harm |
| Medication administration error rate of 7.69% due to crushing medications labeled 'Do Not Crush' for Resident 8. | Level of Harm - Minimal harm or potential for actual harm |
| Medications that were outdated/expired or incorrectly labeled were not removed from storage and were found in medication and treatment carts. | Level of Harm - Minimal harm or potential for actual harm |
| Staff failed to practice proper hand hygiene during meal tray preparation and meal service; prepared food was held at improper temperatures in satellite kitchens. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure proper hand washing and enhanced barrier precautions during lunch meal service on one hall. | Level of Harm - Minimal harm or potential for actual harm |
| Lint buildup found in commercial dryers which could increase risk of overheating or fire. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 7.69
Medication error opportunities: 26
Expired Acetaminophen tablets: 14
Expired Vitamin D3 capsules: 29
Expired Trazodone tablets: 11
Expired Lemon Glycerine Swabs: 7
Food temperatures: 60
Food temperatures: 50
Food temperatures: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN2 | Licensed Practical Nurse | Administered crushed medications labeled 'Do Not Crush' to Resident 8. |
| RN2 | Registered Nurse | Confirmed medication administration practices for Resident 8 and acknowledged some medications cannot be crushed. |
| Director of Nursing | Director of Nursing | Interviewed regarding RN staffing postings and medication labeling issues. |
| Facility Administrator | Facility Administrator | Interviewed regarding new HR system and staffing postings. |
| CNA1 | Certified Nursing Assistant | Observed failing to wash hands during meal service and improper handling of PPE. |
| Cook1 | Cook | Observed not cleaning thermometer and improper food temperature handling. |
| Cook2 | Cook | Observed not cleaning thermometer and improper food temperature handling. |
| Certified Dietary Manager | Certified Dietary Manager | Interviewed regarding food temperature and hygiene expectations. |
| Registered Dietician | Registered Dietician | Interviewed regarding kitchen audits and food safety protocols. |
| CNA2 | Certified Nursing Assistant | Acknowledged lint buildup in commercial dryers. |
Inspection Report
Deficiencies: 1
Sep 5, 2023
Visit Reason
The inspection was conducted to ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well-being.
Findings
The facility failed to ensure that a member of the nursing staff had renewed her Licensed Practical Nurse (LPN) license in a timely manner for 1 of 3 licensed practical nurses reviewed. The expired license was not discovered by the facility until after it had lapsed, and the nurse was employed without an active license for a period of time.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that a Licensed Practical Nurse (LPN) renewed her license in a timely manner. | Level of Harm - Minimal harm or potential for actual harm |
Inspection Report
Complaint Investigation
Deficiencies: 7
May 13, 2022
Visit Reason
The inspection was conducted based on complaints regarding the use of unnecessary psychotropic medications, failure to timely report suspected abuse and neglect, failure to respond appropriately to alleged violations, improper pressure ulcer care, medication storage issues, food sanitation concerns, and garbage/refuse disposal problems.
Findings
The facility failed to ensure appropriate use of antipsychotic medication Seroquel for Resident 15, timely reporting of an unwitnessed fall and potential resident-to-resident abuse, and proper investigation of alleged sexual abuse. Deficiencies were also found in wound care procedures, medication storage, food sanitation, and garbage/refuse disposal.
Complaint Details
The complaint investigation included allegations of unnecessary use of psychotropic medication, failure to report and investigate abuse and neglect, improper wound care, medication storage issues, food sanitation violations, and improper garbage disposal. Some allegations were substantiated, including misuse of Seroquel, failure to report falls and abuse, and failure to investigate sexual abuse.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Use of antipsychotic medication Seroquel as a chemical restraint without appropriate diagnosis for Resident 15. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report an unwitnessed fall with major injury for Resident 15 and potential resident-to-resident abuse for Residents 29 and 24. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to investigate potential sexual abuse between Residents 29 and 24. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to follow proper wound care procedures for Resident 39, including inadequate hand hygiene and wound cleaning technique. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure safe medication storage in treatment carts, medication carts, and medication rooms, including expired and undated medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store, prepare, and serve foods under sanitary conditions in the main kitchen, including presence of undated opened food packages, unclean equipment, and staff personal items in food storage areas. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to properly dispose of garbage and refuse, including trash and leakage around dumpsters and grease trap with odors and flying insects. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication dosage: 12.5
Medication dosage: 25
Medication dosage: 20
Medication dosage: 1
Medication dosage: 5
Medication dosage: 50
BIMS score: 2
BIMS score: 6
Expired medication count: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Physician's Assistant | Wrote order to increase Seroquel dose for Resident 15 and discussed medication use | |
| Facility Administrator | Discussed expectations regarding antipsychotic medication use | |
| Director of Nursing (DON) | Interviewed regarding reporting of falls and abuse; unaware of some incidents | |
| Consultant Pharmacist | Provided input on medication appropriateness and monitoring | |
| RN1 | Registered Nurse | Performed wound care for Resident 39 with noted procedural deficiencies |
| ADON | Assistant Director of Nursing | Assisted with wound care and medication room interviews |
| LPN5 | Licensed Practical Nurse | Reported incident of potential sexual abuse and follow-up actions |
| Dietary Director | Confirmed food sanitation and refuse disposal deficiencies | |
| Chef | Confirmed food sanitation deficiencies |
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