Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aiken Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with type 2 DM and severe cognitive impairment had a blood sugar of 421, but the RN did not notify the physician as required by the insulin order and instead gave the top of the sliding scale. The NP and on-call physician both stated they were not notified, and there was no progress note or communication book entry documenting the event.
A resident with CVA-related hemiplegia and intact cognition alleged that someone tossed them out of bed during a fall, but the facility’s initial state report omitted the abuse allegation and only described the injury. The DON confirmed the statement was an allegation of abuse, said the nurse did not report it, and stated the facility did not report the allegation to the state agency within the required timeframe.
Failure to Thoroughly Investigate Allegation of Abuse: A resident with CVA-related hemiplegia, intact cognition, and dependence for transfers fell and sustained a head laceration after stating that someone tossed them out of bed. Although the statement was an allegation of abuse, the facility’s follow-up report did not include interviews with other residents or staff about abuse.
Failure to provide ordered wound treatment for a resident with a right heel pressure ulcer. The resident had multiple comorbidities including stroke-related hemiplegia, DM2 with neuropathy, PVD, and a Stage 4 pressure ulcer. The care plan directed staff to complete wound care as ordered, but the TAR showed missed treatments on two weekend days. An LPN and the DON confirmed the treatments were not provided, and the treatment nurse stated weekend wound care was done by floor nurses.
Incomplete fall investigation and lack of new interventions after resident fall: A resident with hemiplegia, hemiparesis, generalized weakness, and severe cognitive impairment was found on the floor beside the bed. Nursing documented assessment, notification of the NP, supervisor, and family, and initiation of an incident report, but the IDT fall record was left incomplete with no root cause, no immediate or additional interventions, and no care plan update. Interviews with the LPN, LPN/UM, DON, and Administrator confirmed the fall had not been fully reviewed by the IDT at the time of survey.
Medication Error Rate Exceeded 5% During Eye Drop Administration: Surveyors found a 10.3% medication error rate after an RN administered three ophthalmic medications to a resident back-to-back without waiting between drops. The resident had diagnoses including macular degeneration and type 2 DM with mild non-proliferative diabetic retinopathy, and the facility policy and manufacturer guidance both required waiting at least 5 minutes between different eye drops.
Missed Insulin Order During Admission: A resident with type 2 DM and diabetic CKD was admitted with a hospital discharge order for sliding scale insulin lispro, but the order was not carried over into the facility record right away. The NP’s initial review did not include insulin on the med list, the MAR did not show the order until later, and staff confirmed the insulin was missed during admission processing and follow-up review.
A resident with type 2 DM and severe cognitive impairment was admitted after a hospital stay, but the facility failed to transcribe the insulin lispro order from the hospital discharge summary into the admission orders. The insulin was not included on the resident’s medication list during the NP’s initial visit, and staff later acknowledged the order was missed during admission order entry and review.
The facility failed to follow menu portions for pureed diets, affecting 104 residents. Observations revealed incorrect portions of chicken, sweet potatoes, and missing pureed bread. The CDM acknowledged the issue, noting the absence of correct scoop sizes, which were recently ordered.
A resident's Oxycodone was misappropriated due to a failure in following the facility's narcotic sign-off policy. The LPN did not conduct a physical count of the medication during shift changes, leading to a discrepancy in the medication count. The resident, with conditions including Alzheimer's and chronic pain, missed a scheduled dose, prompting an investigation that revealed the policy non-compliance.
The facility failed to report a misappropriation of a resident's narcotic medication and a fall incident involving another resident within the required timeframes. The misappropriation was discovered by an LPN, but the report was delayed by five days due to a lack of adherence to narcotic sign-off policies and the administrator's misunderstanding of reporting requirements. Additionally, a resident's fall resulting in a fracture was not reported until 16 days later, as the facility awaited a confirmed diagnosis.
The facility failed to report an abuse allegation between two residents to the state agency within the required timeframe. A verbal altercation escalated to a physical incident, resulting in a bruise on one resident's arm. The incident was reported a day later than required by the facility's policy. The residents involved had significant medical histories, with one being cognitively intact and the other having moderate cognitive impairment.
Failure to Notify Physician of Critical Blood Sugar Result
Penalty
Summary
The facility failed to notify the physician of an elevated blood sugar over 400 mg/dL for one resident, despite a physician order to call if blood sugar results were greater than 400 mg/dL. The resident was admitted on 03/30/26 with a history of type 2 diabetes mellitus with diabetic chronic kidney disease and had severe cognitive impairment, with a BIMS score of 00 on the 5-day MDS. The resident’s baseline care plan identified diabetes as a focus area and directed staff to follow treatment orders, monitor for complications, monitor conditions and progress, and report changes to the DON and physician. The April 2026 order summary included an order for insulin lispro before meals and at bedtime with instructions to call the physician if results were greater than 400 mg/dL. RN15 later stated in an email that when the resident’s evening blood sugar was over 400, she should have called the provider but failed to do so and administered the top of the sliding scale instead. NP2 stated she was not notified of the resident’s blood sugar result of 421 and learned of it through the resident’s spouse, and she noted there was no progress note or documentation in the communication book. NP16, the physician on call, stated she was not notified of the blood sugar of 421 and expected to be called for that result. The DON and Administrator both stated staff should have notified the physician as ordered.
Failure to Report Allegation of Abuse Within Required Timeframe
Penalty
Summary
The facility failed to ensure that a resident’s allegation of physical abuse was reported to the state survey agency within 2 hours. The resident was admitted with a history of hemiplegia and hemiparesis following a cerebral infarction affecting the non-dominant left side, and an annual MDS showed a BIMS score of 15, indicating intact cognition. The resident was dependent on staff for several bed mobility tasks and required a mechanical lift with two staff for transfers per the care plan. After a fall, the resident stated that someone tossed them out of bed and onto the floor. The post-fall evaluation documented this statement, but the facility’s initial report to the state agency described only that the resident sustained a fall with a one-inch laceration to the right side of the head and did not include the allegation of abuse. The DON stated the statement was an allegation of abuse, that the nurse did not report it, and that the facility did not report the allegation to the state agency. The DON and Administrator stated that allegations of abuse were expected to be reported immediately to leadership and then to the state within the required timeframe.
Failure to Thoroughly Investigate Allegation of Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was thoroughly investigated for one resident. The resident was admitted with a history of hemiplegia and hemiparesis following a cerebral infarction affecting the non-dominant left side, had intact cognition with a BIMS score of 15, and was dependent on staff for bed mobility and transfers. The care plan directed staff to use a mechanical lift with two staff for transfers and to monitor, document, and report changes in condition and function. After a fall in which the resident sustained a one-inch laceration to the right side of the head, the resident stated that someone tossed them out of bed and onto the floor. The facility’s initial report identified the fall and injury, but the five-day follow-up report did not include interviews with other residents about abuse or interviews with staff about abuse. The DON stated that the statement that someone threw the resident out of bed was an allegation of abuse, and the ADM stated that an allegation of abuse was expected to be investigated within five business days or more time requested if needed.
Failure to Provide Ordered Wound Treatment
Penalty
Summary
The facility failed to provide ordered wound treatments for one resident with a pressure ulcer to the right heel. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral vascular infarction, type II diabetes mellitus with diabetic neuropathy, gout, anemia, peripheral vascular disease, and a pressure ulcer. A significant change MDS showed the resident had a BIMS score of 14 and one Stage 4 pressure ulcer that was not present on admission/readmission. The care plan directed staff to administer treatments as ordered and monitor for effectiveness, and the active order required the right heel to be cleaned with normal saline, treated with Santyl ointment, and covered with bordered gauze daily. Review of the April 2026 Treatment Administration Record showed no documented evidence that the right heel treatment was provided on Saturday and Sunday. The treatment nurse stated she worked weekdays and that weekend wound treatments were completed by floor nurses. An LPN who worked the day shift on one of the missed days stated she did not provide wound treatment for the resident and said she would have documented it if she had. The DON stated she spoke with the nurses responsible for the resident's care and both told her they did not provide the wound treatment that weekend, and the DON stated she expected all wound treatments to be provided as ordered.
Incomplete fall investigation and lack of new interventions after resident fall
Penalty
Summary
The facility failed to ensure a resident’s fall was investigated with a root cause analysis and immediate or new interventions were implemented after the fall. The resident, admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction affecting the left non-dominant side, and generalized muscle weakness, also had a five-day MDS showing a BIMS score of 0, indicating severe cognitive impairment. The resident’s care plan identified fall risk related to impaired mobility and decreased safety awareness, with interventions to anticipate needs, keep the call light within reach, respond promptly to requests for assistance, follow the fall protocol, and have PT evaluate and treat as ordered and as needed. After the resident was found on the floor beside the bed, nursing documentation showed the resident was assessed, assisted back to bed, and had vital signs taken. The note also stated the resident was alert with confusion, the nurse practitioner, supervisor, and family were notified, an incident report was initiated, and the call light and bed were in a safe position. However, the IDT Fall record for the event had multiple sections left blank, including the resident’s contributing diagnoses, medications, laboratory results, root cause of the fall, immediate interventions, whether the IDT agreed with those interventions, additional interventions, and whether the care plan had been reviewed and updated. Interviews confirmed the fall review was not completed at the time of survey. The LPN who completed the IDT Fall record stated she did not determine the root cause and did not implement new interventions, and she did not know why the form was left incomplete. The LPN/UM and DON stated the fall had not been reviewed by the IDT, no new interventions had been implemented, and the care plan had not been updated. The Administrator stated the fall had not yet been reviewed by the IDT because surveyors entered the building before the clinical meeting occurred, and the DON stated the investigation, including root cause determination and care plan update, was not completed because the facility did not have a clinical meeting that week.
Medication Error Rate Exceeded 5% During Eye Drop Administration
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent. Surveyors found 3 medication errors out of 29 total opportunities, resulting in a 10.3% medication error rate and affecting 1 resident during the medication administration task. The deficiency involved administration of multiple ophthalmic medications to a resident with diagnoses including macular degeneration and type 2 diabetes mellitus with mild non-proliferative diabetic retinopathy without macular edema. During a medication pass observation, an RN administered one drop each of dorzolamide-timolol eye drops, brimonidine 0.2% eye drops, and timolol 0.5% eye drops into the resident’s left eye one right after the other without waiting between drops. The resident’s orders later reflected instructions to wait 5 minutes between different eye drops, and the facility policy and manufacturer information reviewed by surveyors stated that when more than one topical ophthalmic product is used, the medications should be administered at least five minutes apart. The RN stated she gave the drops back-to-back because they were all due at the same time, and the NP stated the nurse should have known to wait three to five minutes between each eye drop.
Missed Insulin Order During Admission
Penalty
Summary
The facility failed to ensure that one resident with type 2 diabetes mellitus and diabetic chronic kidney disease was free from a significant medication error involving insulin. The resident was admitted with a hospital discharge summary that listed insulin lispro 2-12 units subcutaneously before meals and at bedtime per sliding scale, and the resident’s baseline care plan identified diabetes as a focus area with directions to follow orders and monitor for complications. The resident also had severe cognitive impairment, with a BIMS score of 00 on the 5-day MDS. The resident’s April 2026 order summary later included an insulin lispro sliding scale order, but the resident’s progress note from the NP’s initial visit stated the discharge summary, MAR, and POC were reviewed and did not include insulin on the medication list. The MAR did not reflect the sliding scale insulin order until 04/04/26, and there was no documented evidence that the resident received insulin as ordered before 04/04/26 at 9:00 PM. Staff interviews confirmed the insulin order was missed during admission processing and hospital follow-up review, and the DON stated the order was missed from the hospital discharge summary to the admitting orders.
Missed transcription of hospital insulin order on admission
Penalty
Summary
The facility failed to transcribe an insulin order from the hospital discharge summary into the resident’s admission orders for a resident admitted with type 2 diabetes mellitus with diabetic chronic kidney disease. The resident had severe cognitive impairment with a BIMS score of 00. The hospital discharge summary listed insulin lispro 100 units/mL injectable solution, 2-12 units subcutaneously before meals and at bedtime per sliding scale, but the facility’s April 2026 order summary did not contain that insulin order until an order dated 04/04/26. The resident’s baseline care plan identified diabetes as a focus area and directed staff to follow treatment orders and monitor for complications, but the insulin was not included on the resident’s medication list in the NP’s initial progress note. During interviews, RN/SUP14 stated she missed entering the resident’s insulin order when she entered the admission orders. NP2 stated that if insulin was on the discharge summary, it should have been ordered on admission, and she acknowledged that she overlooked the insulin during the hospital follow-up visit. The DON stated the insulin order was missed from the hospital discharge summary to the admitting orders, and the Administrator stated her expectation was that admitting orders be transcribed completely from the hospital discharge summary to the resident’s medical record.
Failure to Follow Menu Portions for Pureed Diets
Penalty
Summary
The facility failed to ensure that menus were followed for correct portions and components of pureed diets, potentially affecting all 104 residents who ate meals from the kitchen. The facility's policy required that menus meet the nutritional needs of residents based on the Recommended Daily Allowance (RDA) and that portions be stated in ounces. However, during the preparation of the lunch meal, it was observed that the pureed diets did not include the required 2 oz. of pureed bread, and the portions of chicken and sweet potatoes were less than specified in the menu. The regular diets also had incorrect portions, with only 3 oz. of vegetables and sweet potatoes served instead of the 4 oz. specified. The Certified Dietary Manager (CDM) acknowledged the issue when it was brought to their attention and noted that the correct scoops and portions should have been used. The CDM also mentioned that the kitchen did not have the correct scoop sizes when they first arrived in the position, and they had recently ordered the necessary utensils. The deficiency was identified during the tray line meal service, and the first cart with approximately 16 trays had already left the kitchen before the issue was addressed.
Misappropriation of Resident's Oxycodone Due to Policy Non-Compliance
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their medication, specifically Oxycodone, a controlled substance. The resident, who was admitted with conditions including Alzheimer's, dementia, palliative care, anxiety, and chronic pain, did not receive a scheduled dose of Oxycodone. A review of the facility's records showed discrepancies in the medication count, with 28 tablets signed for but only 20 tablets present during a reconciliation by a hospice nurse. This discrepancy was not identified until a later date when the resident missed a dose, prompting an investigation. The investigation revealed that the Licensed Practical Nurse (LPN) responsible for the medication administration did not follow the facility's policy for narcotic sign-off during shift changes. The LPN admitted to not conducting a physical count of the narcotics during the shift exchange and was unaware of the facility's policy regarding narcotic sign-off. The Director of Nursing and Facility Administrator confirmed that the facility's policy requires a narcotic count at each shift change to ensure accuracy, which was not adhered to in this case. Attempts to interview the Registered Nurse involved in the shift exchange were unsuccessful.
Failure to Timely Report Misappropriation and Fall Incident
Penalty
Summary
The facility failed to report an allegation of misappropriation of a resident's property within the required timeframe. A resident, who was admitted with conditions including Alzheimer's, dementia, and chronic pain, was found to be missing a narcotic medication card. The incident was discovered by an LPN during medication administration, but the initial report to the state agency was delayed by five days. The LPN admitted to not following the facility's policy for narcotic sign-off, which contributed to the delay in reporting. The facility administrator was unaware of the requirement to report misappropriation as a theft, which further delayed the reporting process. Additionally, the facility did not report a fall incident involving another resident within the required 24-hour period. This resident, who had diagnoses including Parkinson's and osteoarthritis, sustained a fracture after a fall and was hospitalized. However, the reportable incident was not submitted until 16 days later, as the facility waited for a confirmed diagnosis of the fracture. The delay in reporting both incidents indicates a failure to adhere to state and federal regulations regarding timely reporting of abuse, neglect, and accidents.
Failure to Timely Report Resident Abuse Incident
Penalty
Summary
The facility failed to timely report an allegation of abuse involving two residents to the state agency. According to the facility's policy, any alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made. In this case, a verbal altercation between two residents escalated to a physical incident where one resident reportedly grabbed the other's arm, resulting in redness and later a bruise. The incident occurred on 03/14/2024, but the state survey agency was not notified until 03/15/2024 at 3:59 PM, which is beyond the required reporting timeframe. The residents involved had significant medical histories. One resident had a history of hemiplegia and hemiparesis following a stroke, among other conditions, and was cognitively intact with a BIMS score of 15 out of 15. The other resident had a history of encephalopathy and cerebral infarction, with moderate cognitive impairment indicated by a BIMS score of 12 out of 15. The delay in reporting the incident was identified during a review of the facility's records and interviews, highlighting a failure to adhere to the facility's abuse prevention and reporting policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Aiken
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth- Aiken | 2.4 mi | ★★★★★ | 5 | 1 |
| Carlyle Senior Care Of Aiken | 3 mi | ★★★★★ | 8 | 2 |
| Anchor Post Acute | 4.8 mi | ★★★★★ | 7 | 0 |
| Nhc Healthcare - North Augusta | 10.4 mi | ★★★★★ | 2 | 0 |
| Pruitthealth- North Augusta | 11.7 mi | ★★★★★ | 2 | 0 |
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