Below 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 Edgefield Post-acute during CMS and state inspections, most recent first.
Food service sanitation and equipment maintenance deficiencies were identified when kitchen and storage equipment were observed with rust, mold, food debris, and leaks. The handwashing sink lacked a nearby trash receptacle, the walk-in refrigerator floor was rusted from a leaking drainpipe, a reach-in refrigerator had food debris, the ice machine had rust at the hinge, and the walk-in freezer door and surrounding surfaces had mold. Sanitizer readings in the dish area were 100 PPM instead of the expected 200 PPM, and the dish room drain was backing up due to improper drain alignment.
A facility failed to keep several resident rooms and shared bathrooms in good repair. Surveyors observed a broken AC unit, rusted and damaged fixtures, chipped furniture with exposed particle board, cracked drywall, broken and missing floor tiles, and a shared bathroom that smelled of urine. The MD stated he was unaware of multiple damaged areas, said some issues needed to be entered into TELS, and acknowledged he did not have a routine maintenance or repair policy.
Dining assistance did not preserve resident dignity for three residents. Two residents who were dependent for eating were left waiting while other residents were served, then later moved and assisted with meals. An IP was also observed standing while feeding a resident from a bowl beside an empty chair, and the IP referred to the residents as "feeders." The facility policy required meal assistance to be provided with attention to safety, comfort, and dignity, including not standing over residents and avoiding labels.
Unauthorized Medication and Glucometer Kept at Bedside: A resident with a tracheostomy, diabetes, CKD, COPD, and other chronic conditions had Azithromycin stored in a trach supply container and a personal blood glucose glucometer kept on the bed/bedside table despite no order or assessment authorizing self-administration. Staff identified the medication as not supposed to be at the bedside, but it was left in the room, and an LPN later confirmed there was no order for bedside meds or self-testing.
A resident with Alzheimer’s disease who was receiving hospice services was care planned for falls risk and behaviors including crawling out of bed, but the record did not show an order or assessment authorizing the use of positioning pillows that staff used to prevent rolling or falling out of bed. Staff observed two pillows placed under the flat sheet at the resident’s head and feet for that purpose. The record also lacked documented informed consent for a chair alarm, even though staff confirmed the alarm was attached to the resident’s wheelchair and used to keep her from getting out of it.
A resident with a BIMS score of 12/15 had an urgent hospital transfer after a change in condition, but the facility’s proposed transfer/discharge notice did not include the appeal process or the agency handling appeals. The SSD said she was unsure which agency handled appeals and was unaware the form lacked this information, and the MDSC stated she was unsure of the process.
Inaccurate MDS Coding for Pneumococcal Vaccination Status: The facility coded two residents as up to date on pneumococcal vaccination even though the EMR only showed prior PPSV23 doses and no evidence that the residents or their representatives were offered PCV20 or PCV21. The MDSC/acting DON and RDCS stated they were unaware of the updated CDC guidance and confirmed the MDSs were inaccurate.
A resident found crawling on the floor after a potential unwitnessed fall did not receive ordered neuro checks with VS. Another resident with severe cognitive impairment had open sacral/buttock areas documented without measurements or consistent wound detail, despite repeated skin findings and later notes describing a sacral decubitus ulcer. A third resident who was dependent for positioning and mobility was repeatedly observed in a Broda chair with shoulder bolsters loose, hanging off, or missing, leaving the chair without proper lateral support.
Failure to Investigate Potential Unwitnessed Fall: A resident with a history of falls and high fall risk was found crawling on the floor toward the door, but the facility did not complete a root cause analysis or identify why the resident was on the floor. Staff stated no fall investigation was done because the behavior was considered typical for the resident and was not treated as a fall.
Failure to Document Bed Rail Alternatives and Consent: The facility failed to ensure alternatives were tried before side rails were used, and failed to document risk/benefit discussion and signed informed consent for a resident with severe cognitive impairment and heart failure. The EMR bed rail assessment showed no alternatives explored and no consent documentation, yet the resident was observed in bed with side rails up on both sides, and an LPN could not recall whether the required discussion or consent had occurred.
Improper PPE availability and incorrect TBP signage were observed for two residents on contact/droplet precautions. One resident had RSV and conflicting room signage, while a housekeeper entered the room wearing personal work gloves and stated extra-large disposable gloves were not available in the drawer. For the other resident, EBP signage was posted instead of contact/droplet signage, and staff entered without PPE until the MDSC intervened; an LPN also stated eye protection was not worn when entering the first resident's room.
A resident with an indwelling urinary catheter and impaired cognition was given Cipro for UTI despite no documented signs or symptoms of infection in the chart. After a urology visit, a UA showed abnormal results, but the culture was not completed, the NP said he started the antibiotic prophylactically, and the facility confirmed there was no documented McGeer criteria review or follow-up after the contaminated urine report.
Failure to Offer Updated Pneumococcal Vaccination: The facility failed to offer updated pneumococcal vaccination options to two residents who had previously received PPSV23. EMR review showed no evidence that either resident or their representative was offered PCV20 or PCV21, despite the facility policy requiring vaccines to follow current CDC guidance. During interview, the acting DON and RDCS stated they were unaware of the updated CDC recommendations.
Food Service Sanitation and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain kitchen equipment and food storage areas in a clean and sanitary condition and failed to ensure sanitizing solutions were maintained at effective concentrations. During kitchen observations, the handwashing sink lacked a nearby trash receptacle for paper towels, requiring staff to walk across the cooking area to discard them after handwashing. The walk-in refrigerator floor was rusted from a leaking drainpipe, with a loose threshold and an uneven floor surface with a noticeable dip. The second reach-in refrigerator had multiple red, pink, and brown food debris stains on the bottom interior surface, and the Dietary Manager and Certified Dietary Manager later confirmed the debris remained and had not been cleaned. The reach-in ice machine had rust along the door hinge and remained in use, and the walk-in freezer door and surrounding surfaces had a splotchy gray substance identified by the CDM as mold that had been present for approximately 12 years. The dish machine logs showed quaternary ammonium sanitizer readings of 100 PPM when the standard for sanitation was 200 PPM, and the DM also tested sanitizer buckets and obtained a reading of 100 PPM, which she stated was not sufficient for proper sanitation. The dish room sink drain was observed backing up with soap suds because the drainpipe was not properly aligned with the floor drain. A Dietary Aide stated she did not know the required chemical concentration because she was new. The CDM stated sanitizer buckets should be changed every two hours and that dish room sanitizer should be maintained at 100-200 PPM, with 200 PPM being the expected effective concentration. The Administrator stated the rusty ice machine should not be used because it could cause illness and acknowledged the dish room drainpipe alignment issue had been known previously.
Resident Rooms and Bathrooms Not Maintained in Good Repair
Penalty
Summary
The facility failed to maintain resident rooms and bathrooms in good repair for 5 of 49 sampled rooms, including Rooms 129, 200/203, 225, 227, and 224/226. Survey observations identified damaged air conditioning units, chipped and broken furniture with exposed particle board, cracked drywall, broken and missing bathroom floor tiles, damaged bathroom fixtures, and a shared bathroom that smelled of urine. In Room 129, the air conditioning unit was broken, the controller was filled with dust, the metal cover was rusted and falling off with paint flecking, and the resident’s bed footboard and armoire had chipped surfaces and exposed particle board. Additional observations found three broken floor tiles in the bathroom for Room 200/203, cracked and missing tile pieces near the toilet, cracked drywall above the air conditioning unit and around the sink, and damaged drywall around the toilet and across from it in another bathroom. The shared bathroom for Rooms 223/225 had cracked drywall behind the toilet, and the shared bathroom for Rooms 224/226 smelled of urine and had a sink scraped along the edges. The Maintenance Director stated the air conditioning unit in Room 129 required full replacement and that he was not aware of the damage. He also stated he was unaware of several other damaged areas, said some items needed to be entered into TELS, and acknowledged he attempted room rounds about once per month, primarily to change light bulbs, but did not have a policy for routine maintenance or repairs.
Dining Assistance Did Not Preserve Resident Dignity
Penalty
Summary
The facility failed to promote and maintain dignity during dining services for 3 of 21 residents reviewed who ate in the Main Dining Room. On 04/15/26, R33 and R37 were brought to the dining room and seated together, but they were not given their meal trays while the other 19 residents were served. R33 was later moved to another table at 12:45 PM, provided a meal tray, and assisted with eating, and R37 was moved at 12:50 PM and then assisted with his meal. The facility policy titled, Assistance with Meals, stated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting them and avoiding labels such as feeders. During the same dining observation, the Infection Preventionist was observed standing while assisting R61 with his meal, feeding the resident from a bowl while standing beside him and saying, "You don't have to be afraid." An empty chair was next to the resident. R33’s record showed diagnoses including convulsions, intellectual disabilities, legal blindness, aphasia, hearing loss, cataract, protein-calorie malnutrition, dysphagia, cognitive communication deficit, and type 2 diabetes mellitus, and he was dependent for eating. R37’s record showed diagnoses including anemia, hip fracture, non-Alzheimer’s dementia, seizure disorder, and malnutrition, with severe memory impairment, severely impaired decision-making, and dependence on staff for eating. During interview, the Infection Preventionist stated that R33 and R37 were "feeders" and were served last, and confirmed staff should sit while assisting residents with meals. The MDS Coordinator also confirmed that staff should sit while assisting residents with meals.
Unauthorized Medication and Glucometer Kept at Bedside
Penalty
Summary
The facility failed to ensure medications were not left at the bedside for a resident who had not been assessed as able to self-administer medications. R11 was admitted with multiple diagnoses including dependence on a ventilator, tracheostomy status, type 2 diabetes mellitus, morbid obesity with alveolar hypoventilation, anxiety disorder, chronic kidney disease, chronic respiratory failure with hypoxia, and mood disorder. Review of the quarterly MDS dated 04/13/26 showed a BIMS score of 13 out of 15, indicating the resident was cognitively intact, and also noted that the resident was taking antibiotics. However, the care plan contained no information about self-administration of medications or antibiotic use, and the physician orders did not authorize self-administration or bedside medication storage. No assessment was found in the record evaluating the resident’s ability to safely self-administer medications. During observation, Azithromycin was found stored in a three-drawer plastic container in the resident’s room, and the resident stated it had been kept with trach supplies since moving in and that her home doctor had her testing her blood sugar with her own meter. A box of Azithromycin 250 mg tablets from CVS was later found in the bottom drawer of the tracheostomy supply container, and an LPN stated the medication was not supposed to be kept at the bedside. The resident also had a personal blood glucose glucometer on the bed and bedside table, and staff stated the resident should not have the glucometer in the room or self-administer blood sugar testing. Despite identifying the medication as unauthorized, the LPN left the CVS medication in the resident’s room. Another LPN later confirmed there was no physician order for bedside medications or self-administration and stated that medications found in a resident’s room should be removed, verified, and not left at the bedside.
Failure to Assess Positioning Devices and Document Consent for Chair Alarm
Penalty
Summary
The facility failed to ensure that one resident was properly assessed for the use of positioning devices intended to reduce the risk of rolling, crawling, or falling out of bed, and also failed to ensure that informed consent was obtained and documented for the use of a chair alarm. The resident was admitted with a diagnosis including Alzheimer’s disease and was receiving hospice services. The MDS indicated staff could not determine the resident’s BIMS score, that the resident could ambulate with supervision or touching assistance, and that she was totally dependent on staff for all ADLs. The assessment also indicated the facility used no restraints with the resident, including a chair alarm. The resident’s care plan identified risk for falls due to a history of falls and crawling out of bed, and also identified psycho-social behaviors of crawling out of bed, disrobing, and combativeness with staff related to dementia. However, the physician orders did not contain an order for an assessment authorizing the use of positioning devices that could restrict the resident’s movement, and there was no order for a chair alarm. The progress notes also did not contain evidence of informed consent for the use of a chair alarm. During observation, the resident was seen in bed with the bed in a low position, and staff stated there were times she would dangle her legs off the bed. Later, staff observed that the resident would attempt to roll out of bed, and two pillows were found under the flat sheet on the side of the resident’s head and feet. Staff confirmed the pillows were positioned to prevent the resident from rolling or falling out of bed. Staff also confirmed a chair alarm was attached to the resident’s wheelchair, and stated it was used to prevent the resident from getting out of the wheelchair. A hospice nurse stated hospice did not provide the facility with a chair alarm, and the acting DON stated that a request for informed consent for the positioning pillows and chair alarm was not provided by the end of the survey.
Transfer Notice Missing Appeal Information
Penalty
Summary
The facility failed to ensure that Resident 12 and the resident representative were provided a written bed hold policy and a transfer notice that included the appeal process after an emergent hospital transfer. Review of the admission record showed the resident was admitted to the facility on [DATE]. The admission MDS with an ARD of 01/06/26 showed a BIMS score of 12 out of 15, indicating the resident was cognitively intact. Review of the resident’s progress note dated 01/17/26 showed a change in condition and an order to send the resident to the hospital for urgent evaluation and treatment. Review of the Notice of Proposed Transfer/Discharge dated 01/19/25 showed the document did not include the appeal process or the entity information that handled appeals. During interview, the SSD stated she was unsure which agency handled appeals and believed it was in [NAME], SC, and said she was unaware the facility transfer form did not include this information. The MDSC stated she was unsure of the process and expected the facility to be in compliance with regulations.
Inaccurate MDS Coding for Pneumococcal Vaccination Status
Penalty
Summary
The facility failed to ensure accurate MDS assessments for 2 of 2 residents reviewed, R94 and R109, because their pneumococcal vaccination status was coded as up to date even though the record did not show that the updated CDC vaccine requirements had been followed. The report cites CDC guidance stating that after a prior PPSV23 dose, a dose of PCV15, PCV20, or PCV21 should be given at least 1 year later and that the pneumococcal series is then complete. It also cites the RAI Manual requirement that assessment information must reflect the resident’s actual status during the observation period and be validated for accuracy by the IDT completing the assessment. For R94, the EMR showed admission on 11/30/21, a quarterly MDS with ARD 03/24/26 indicating the resident was up to date on pneumococcal vaccine, and an immunization record showing PPSV23 given on 12/03/21. There was no evidence that the resident or representative was offered PCV20 or PCV21. For R109, the EMR showed admission to the facility, a quarterly MDS with ARD 04/02/26 indicating the resident was up to date on pneumococcal vaccine, and an immunization record showing PPSV23 given on 10/06/22. There was no evidence that the resident or representative was offered PCV20 or PCV21. During interview, the MDSC who was also the acting DON and the RDCS stated they were unaware of the updated CDC requirements and confirmed the MDS assessments for both residents were inaccurate.
Failure to complete ordered neuro checks, document skin wounds, and maintain Broda chair positioning
Penalty
Summary
Neurological checks were not completed after a resident was found crawling on the floor, which was treated as a potential unwitnessed fall. The resident had been admitted with a history of falls, could walk with supervision or touch assistance, and had care plan entries noting a history of crawling on the floor and crawling out of bed. After the resident was found crawling toward the door, the nurse assessed the resident and documented no injuries. The NP was notified and ordered neurological checks with vital signs every 15 minutes for 1 hour, every 30 minutes for 1 hour, hourly for 4 hours, and then every 4 hours for 24 hours, but there was no evidence in the record that the ordered checks were implemented. Open skin areas on another resident were not assessed and documented according to the facility’s wound care and skin assessment policies. The resident was admitted with multiple diagnoses including uropathy, chronic kidney disease, UTI, and urinary retention, and had a BIMS score of 7, indicating severely impaired cognition. The care plan identified the resident as at risk for skin breakdown and noted redness to the sacrum on readmission. Nursing skin assessments repeatedly described discoloration to the buttocks and small open areas in the coccyx area, while later skin notes described a large open area to the sacral area with pink and red tissue and active bleeding, and another note described open areas without measurements or the number of areas identified. The wound nurse stated she could not find documentation of measurements for the open areas since admission. Proper positioning and use of a Broda chair were not maintained for a resident with severe intellectual disability, legal blindness, aphasia, hearing loss, impaired cognition, and severely impaired decision-making skills. The resident was dependent for positioning and mobility and used a manual wheelchair. During multiple observations, the left shoulder bolster on the Broda chair was loose, hanging off the side, or not in place, and at times no shoulder bolsters were positioned on either side. Staff stated the bolsters were intended to provide lateral support and should be properly placed each time the resident was positioned in the chair, but the cushions were observed slipping down or remaining loose.
Failure to Investigate Potential Unwitnessed Fall
Penalty
Summary
The facility failed to complete a root cause analysis for a potential unwitnessed fall involving one resident who was found crawling on the floor toward the door. The resident had been admitted with a history of falls, could walk with supervision or touch assistance, and was assessed as high risk for falls with a score of 28 on two separate fall risk assessments. The care plan identified the resident as at risk for falls and noted a history of crawling on the floor, as well as psychosocial behaviors of crawling out of bed. On 01/22/26, nursing staff were called to the resident’s room and found the resident crawling on the floor, with no injuries noted after assessment. The record did not contain evidence of a root cause analysis for the crawling event, and the facility did not identify why the resident was found on the floor. During interviews, the Administrator stated no fall investigation was completed because the family reported the resident had a history of placing herself on the ground, and the MDS Coordinator/acting DON and Regional Director of Clinical Services stated the crawling was considered a typical behavior and was not treated as a fall.
Failure to Document Bed Rail Alternatives and Consent
Penalty
Summary
The facility failed to ensure that alternative measures were tried before side rails were installed, failed to document discussion of the risks and benefits of bed rail use, and failed to obtain signed informed consent before bed rail use for one resident. The facility policy titled Bed Safety and Bed Rails stated that bed rails are prohibited unless criteria for use have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. Resident R64 was admitted with diagnoses including hypertensive heart disease with heart failure and had a BIMS score of 3 out of 15, indicating severe cognitive impairment. The EMR showed a care plan stating the resident may use quarter side rails for mobility as clinically indicated, but the bed rail/entrapment risk evaluation documented no exploration of alternatives and no documentation of risks versus benefits or informed consent, and it indicated bedrails were not being considered or used. Despite this, the resident was observed in bed with side rails up on both sides, and later was observed sitting on the edge of the bed with side rails still present. An LPN stated she completed the admission bedrail assessment but could not remember whether alternatives, risk/benefit discussion, or informed consent had occurred, and the MDSC stated there should not be bedrails on a resident's bed if the assessment indicated they were not in use or being considered.
Improper PPE Availability and Incorrect Transmission-Based Precaution Signage
Penalty
Summary
The facility failed to ensure proper PPE and transmission-based precaution signage were in place for two residents placed on contact/droplet precautions. Review of the facility policy indicated that when a resident is placed on transmission-based precautions, appropriate notification is to be placed on the room entrance door and on the front of the chart so personnel and visitors are aware of the required precautions. For one resident, the medical record showed a positive RSV test and a physician order for contact/droplet precautions, but observations showed conflicting signage on the room door, including Enhanced Barrier Precautions at one point and later contact/droplet signage. During an observation, a housekeeper entered the room wearing bright green and black work gloves and stated he wore those gloves before entering a TBP room and took them home to wash them; he also stated the facility did not provide extra-large gloves. The top drawer contained only medium and large disposable gloves, and the housekeeping supervisor stated extra-large gloves were available but were not in the drawers for staff use. For the second resident, the medical record showed a physician order for contact/droplet precautions for RSV, but the room had EBP signage posted instead of contact/droplet signage. During observation, several staff entered the room without PPE such as a gown and gloves until the MDSC instructed them to don proper PPE. The MDSC, acting DON, confirmed the incorrect sign was posted and stated a contact/droplet precaution sign was not posted to alert staff of the PPE required. An LPN later stated she did not don eye protection when entering the first resident's room, acknowledged the EBP sign was not accurate, and stated the room should have had contact and droplet precautions in place because the resident in Bed A had tested positive for influenza.
Antibiotic Used Without Documented Infection
Penalty
Summary
The facility failed to ensure an antibiotic was not used without a diagnosed infection for one resident who was admitted with diagnoses including uropathy, chronic kidney disease, urinary tract infection, and urinary retention, and who had an indwelling urinary catheter and severely impaired cognition. Review of the resident’s record showed no documentation of signs or symptoms of a UTI from admission through the urology appointment. After the urology visit, a urinalysis and culture and sensitivity were ordered, and the urinalysis showed abnormal findings including positive nitrites, turbid urine, protein 3+, blood 4+, innumerable WBCs, RBCs 50-100, and bacteria 2+. The resident was then ordered Cipro 250 mg twice daily for 5 days for UTI, and the MAR showed the antibiotic was administered from the evening of 04/10/26 through the morning of 04/15/26. Progress notes documented that the resident had no odor, abdominal pain, burning, dysuria, hematuria, or abdominal discomfort while on Cipro. The MDS Coordinator stated the urinalysis was contaminated and the culture could not be performed, and confirmed there was no follow-up after the contaminated urine report was discussed with the NP. The NP stated he started Cipro prophylactically and had not seen the culture and sensitivity report. The facility also confirmed there was no documentation that the resident’s antibiotic use and UTI diagnosis were reviewed using McGeer’s criteria.
Failure to Offer Updated Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer pneumococcal vaccination to 2 of 5 residents reviewed, Residents R94 and R109, or their representatives, in accordance with nationally recognized standards. The facility policy titled Pneumococcal Vaccine stated that all residents are offered pneumococcal vaccines and that administration is to follow current CDC recommendations. The CDC guidance reviewed indicated that residents who previously received PPSV23 should be given one dose of PCV15, PCV20, or PCV21 at least 1 year after the last PPSV23 dose, after which the pneumococcal series is complete. R94 was admitted on 11/30/21 and the EMR showed receipt of PPSV23 on 12/03/21, but there was no evidence that the resident or representative was offered PCV20 or PCV21. R109 was admitted on [DATE] and the EMR showed receipt of PPSV23 on 10/06/22, but there was no evidence that the resident or representative was offered PCV20 or PCV21. During interview on 04/17/26 at 8:40 AM, the MDSC, acting DON, and the RDCS stated they were unaware of the updated CDC recommendations for pneumococcal vaccines. The facility's Infection Preventionist was unavailable to be interviewed while onsite.
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What surveyors actually found near you
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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 Edgefield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare - North Augusta | 15 mi | ★★★★★ | 2 | 0 |
| Aiken Rehabilitation And Care Center | 17.5 mi | ★★★★★ | 8 | 0 |
| Pruitthealth- Aiken | 18.4 mi | ★★★★★ | 5 | 1 |
| Pruitthealth- North Augusta | 18.7 mi | ★★★★★ | 2 | 0 |
| Carlyle Senior Care Of Aiken | 18.7 mi | ★★★★★ | 7 | 2 |
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