Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Edisto Post Acute during CMS and state inspections, most recent first.
Inaccurate daily staffing postings showed that a RN was not listed for the required 8 consecutive hours on multiple days. The Staffing Coordinator confirmed the postings were incomplete or inaccurate, and the RDQA, DON, and HR Director described how staffing sheets were entered, corrected, and calculated.
Improper Food Storage and Labeling in Kitchen and Nourishment Rooms: Surveyors found multiple unlabeled and undated food items in the main kitchen, including raw chicken stored above potatoes, slimy lettuce, and open containers of food and condiments without dates. In three nourishment room refrigerators, staff food was mixed with resident food, several items were unlabeled or unidentified, a half-eaten candy bar was stored, and thermometers were missing from two refrigerators. The KM and DON confirmed the findings and stated staff food should not be stored with resident food items.
Dumpster Lid Left Open Due to Obstruction. Surveyors observed the rear entrance dumpster area and found one of the dumpster’s top lids was not closed. The KM tried to close it but could not because a tree branch was blocking the lid. Facility policy stated that garbage and refuse containers must be kept covered when stored or not in continuous use, and the KM stated dumpster lids were to be kept closed when not in use.
Failure to respect a resident’s dignity and personal space occurred when a CNA was observed sitting on the resident’s bed and using her cellphone in the resident’s room while the resident was out taking a break. The resident was cognitively intact with a BIMS score of 14/15 and stated he was unaware the CNA was in his room; the CNA said she was taking a break between resident care and that a break room was available, and the DON stated staff should not use cellphones during work hours and should treat resident rooms with respect.
A resident’s EMR face sheet was visible on a laptop mounted to a med cart while no staff were present nearby. The resident had diagnoses including contracture of the left hand, type 2 DM, weakness, and major depressive disorder, and her BIMS score showed she was not cognitively intact. An LPN said she stepped away to give the resident morning meds and believed the screen was secured because it was pulled out of line of sight, but also stated the EMR privacy screen should have been used. The DON and Administrator stated staff are expected to protect PHI and follow HIPAA guidelines.
Failure to Timely Report Allegation of Abuse: A resident with BIMS 15/15 and dependence for several ADLs reported that a CNA used a rough washcloth during perineal care and caused pain and soreness. The resident told therapy staff after not knowing who to notify, and the DON later stated the allegation was investigated and a 24-hour report was faxed to DHEC, but the facility failed to report the abuse allegation to the state agency within the required timeframe.
A resident with cerebral palsy and bipolar disorder expressed depression and suicidal ideations, including thoughts of cutting his wrist, and was sent out for psychiatric evaluation after telling SSD he wanted to speak with a mental health professional. The EMR showed the care plan had no interventions related to the resident’s recent suicidal ideations, and SSD and DON acknowledged the care plan had not been revised to reflect the significant change in mood status.
Failure to assess and provide activities to meet a resident’s interests and needs. A resident with severe cognitive impairment, dementia, and other diagnoses stated staff did not provide activities in her room. Activity documentation was incomplete, later EMR notes were entered all at once, and the AD could not locate quarterly activity assessments or current attendance records. The resident’s admission activity assessment noted an interest in books, newspapers, and magazines, but no follow-up assessments were found.
A resident with a history of falls and a fracture did not receive timely fall risk assessments as required by facility policy. Despite being at moderate risk for falls, the resident missed two assessments in 2024. Interviews with staff revealed that the floor nurses responsible for these assessments did not complete them, and the Assistant Director of Nursing confirmed the lack of updated assessments.
The facility failed to maintain resident dignity during meal assistance, as a CNA was observed standing over two residents while feeding them, contrary to policy. The DON acknowledged the protocol requiring staff to sit while feeding and noted recent training may not have covered this adequately.
A resident with metabolic encephalopathy, dementia, and depression was not accurately assessed in the MDS, as it failed to reflect the use of prescribed antipsychotic and antidepressant medications. The MDS Coordinator admitted to missing the coding, necessitating a modification.
A facility failed to develop a comprehensive care plan for a resident prescribed antipsychotic medication. The resident, with diagnoses including Dementia and Depression, was receiving Quetiapine Fumarate and Escitalopram Oxalate. The MDS assessment did not reflect the use of these medications, resulting in the absence of a care plan. The MDS Coordinator admitted to missing the coding, which led to this deficiency.
The facility failed to adhere to hand hygiene protocols during meal service, as a CNA was observed feeding two residents without washing hands between tasks. Staff interviews highlighted understaffing issues, which may have contributed to the deficiency. The DON confirmed the hand hygiene policy but noted a possible gap in training regarding feeding multiple residents.
Inaccurate Daily Staffing Postings
Penalty
Summary
The facility failed to ensure accurate daily posting of licensed staff hours worked, with review of staffing postings from 10/01/24 through 09/14/25 showing 9 days in which a RN was not listed for the required 8 consecutive hours in each 24-hour period. During interviews, the Staffing Coordinator confirmed the postings were inaccurate and/or incomplete and stated that the central supply clerk and she entered the numbers on the staff postings, while HR verified the postings. The Regional Director of Quality Assurance and the DON also confirmed that a RN was not listed on the posted staffing for the identified days and stated they were not aware the daily postings were inaccurate and/or incomplete. The HR Director stated that the staffing coordinator posts the staffing sheets daily, makes corrections throughout the day as needed to reflect staffing changes, and that HR performs the calculations the next day.
Improper Food Storage and Labeling in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety in the main kitchen and in three nourishment rooms. In the walk-in cooler, surveyors observed a container of lemons with no expiration date, a box of lettuce with no open or expiration date that appeared slimy with a red hue, premade pears and peaches in serving cups with no open or expiration date and no label, an undated and unlabeled container of unsweet tea, four bottles of salad dressing with no open or expiration date, and two open and thawed bags of raw chicken stored on the shelf above potatoes. In the walk-in freezer, surveyors observed two open and used bags of white round cheese slices, an open and used bag of tater tots, two bags of tuna, and an open and used bag of potato wedges dated 06/26/25, all without open or expiration dates except the potato wedges. In the Southwest nourishment room refrigerator, staff food was stored with resident foods and an unlabeled plastic bag of an unidentified item was present. In the North Hall nourishment room refrigerator, surveyors observed an open, half-eaten Hershey's candy bar, two open unlabeled bottles of water, an open unlabeled bottle of [NAME], two open unlabeled bottles of flavored syrup, and an open unlabeled bottle of Torani vanilla syrup; no thermometer was observed. In the East Hall nourishment refrigerator, surveyors observed three plastic bags of unlabeled, unidentified food items, an unlabeled plastic container with an unidentified brown substance, and an unlabeled plastic jug of an unidentified drink, and no thermometer was found. Facility staff confirmed the findings, and the KM and DON stated that staff food should not be stored with resident food items and that dietary was responsible for maintaining temperature logs.
Dumpster Lid Left Open Due to Tree Branch Obstruction
Penalty
Summary
The facility failed to ensure that trash container lids were kept closed when not in use. During an observation at the rear entrance dumpster area, surveyors found the dumpster container had two separate top lids, and the lid on the right side was not closed. The Kitchen Manager attempted to close the lid but was unable to because a tree branch was obstructing it. Review of the facility policy stated that all garbage and refuse containers must be kept covered when stored or not in continuous use, and that outside dumpsters will be kept closed and free of surrounding litter. The Kitchen Manager stated that dumpster lids were to be kept closed when not in use.
Failure to Respect Resident Room and Dignity
Penalty
Summary
The facility failed to provide dignity and respect for Resident 80 and his personal space when a CNA was observed sitting on the resident’s bed and using her cellphone in his room while he was out taking a break. The facility policy titled Dignity states that each resident shall be cared for in a manner that promotes and enhances well-being, self-worth, and self-esteem, and that residents are to be treated with dignity and respect at all times. The policy also states that residents’ private space and property are to be respected at all times and that staff do not handle or move a resident’s personal belongings without permission. Resident 80 was admitted with diagnoses including cerebral palsy, bipolar disorder, muscle spasm, and lack of coordination. His MDS showed a BIMS score of 14 out of 15, indicating he was cognitively intact. During observation and interview, the CNA stated she was not on a designated break but was taking a break between resident care and acknowledged that the facility has a break room further down the hall. Resident 80 stated he was not aware the CNA was sitting on his bed and taking a break, and he reported seeing other CNAs do similar things in other resident rooms. The DON stated that staff should not be on their cellphones during work hours and should treat resident rooms and spaces with respect.
Failure to Secure EMR During Medication Pass
Penalty
Summary
The facility failed to provide Resident 89 the right to privacy by not adequately securing her EMR. Resident 89’s face sheet information was visible on the laptop mounted to a medication cart on the South Unit during an observation, and no staff members were present at that time. Resident 89’s record showed she was admitted with diagnoses including contracture of the left hand, type 2 diabetes, weakness, and major depressive disorder, and her MDS indicated a BIMS score of 4 out of 15, showing she was not cognitively intact. During the observation and interview, an LPN stated she had stepped away to give Resident 89 her morning medication and believed the resident was secured because the laptop screen was pulled out of line of sight, adding that because she is taller the laptop appeared to be secured. The LPN also stated the privacy screen in the EMR should have been used. The DON stated the expectation was for staff to provide privacy when handling residents’ PHI and that the EMR has a built-in privacy screen for use when staff step away from the medication cart or laptop. The Administrator also stated staff are expected to provide privacy when handling residents’ PHI and to follow HIPAA guidelines.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the state agency within the required time frame. Facility policy stated that suspected abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source must be reported immediately to the administrator and to the appropriate authorities, with "immediately" defined as within 2 hours for allegations involving abuse or serious bodily injury, or within 24 hours for allegations that do not involve abuse or serious bodily injury. The deficiency was identified for 1 of 3 residents reviewed for alleged abuse. The resident involved was admitted with diagnoses including fracture of the upper end of the right humerus, cognitive communication deficit, type 2 diabetes mellitus with hyperglycemia, morbid obesity, thyroid disorder, and pain. The resident's MDS showed a BIMS score of 15 of 15, indicating cognitive intactness, and dependence for several activities of daily living including toileting hygiene, lower body dressing, footwear, showering/bathing, and personal hygiene. During an interview, the resident stated that CNAs wiped back to front and reported that on the prior Thursday or Friday during day shift, a CNA dug her rectum and vagina out so hard with a rough washcloth that it caused pain and soreness the next day. The resident said she did not know who to tell until she told her therapist on Monday. The Director of Therapy later confirmed he was made aware of the resident's care concerns and notified the DON, while the DON stated she was unaware until later and then initiated an investigation. The DON later stated that a 24-hour report was faxed to DHEC and the employee in question was identified and suspended pending the investigation.
Failure to Update Care Plan After Suicidal Ideations
Penalty
Summary
The facility failed to revise and update a resident’s care plan in a timely manner after he expressed suicidal ideations and experienced a significant change in mood status. The resident, who was admitted with diagnoses including cerebral palsy, bipolar disorder, muscle spasm, and lack of coordination, had an annual MDS showing a BIMS score of 14 out of 15, indicating he was cognitively intact. Review of the EMR showed that on 09/11/25 the resident left the facility via stretcher related to suicidal ideations and was sent for psychiatric evaluation after telling Social Services that he felt the need to speak with a mental health professional about his emotions. The record also showed that the resident reported depression, suicidal ideation for several days, thoughts of cutting his wrist, and seeing and hearing things during the hospital encounter. Despite these events, the care plan contained no interventions related to the resident’s recent suicidal ideations. During interview, the SSD stated the care plan had not yet been revised to reflect the resident’s significant change in mood status and that no interventions were in place related to suicidal ideations. The DON also stated the care plan should have been revised after the resident’s most recent changes in mood and suicidal ideations.
Failure to Assess and Provide Resident Activities
Penalty
Summary
The facility failed to assess and provide activities to meet the interests and needs of a resident with cognitive communication deficit, dementia without behaviors, muscle weakness, and epilepsy. The resident’s Quarterly MDS showed a BIMS score of 5 out of 15, indicating severe cognitive impairment. The facility policy stated that activity programs are designed to meet each resident’s interests and support physical, mental, and psychosocial well-being, and that activities are based on the comprehensive resident-centered assessment and preferences of each resident. The resident stated that staff do not provide activities in her room. Review of the resident’s activity notes showed no documentation related to activities until notes were entered later, and those entries reflected participation in Bingo, bible study, social hour, music, and wandering in and out of activities. The admission activity assessment showed the resident said it was somewhat important to have books, newspapers, and magazines to read, but no other activity assessments were found after admission. The Activity Director stated that activity documentation was kept on paper Attendance Participation Records, that she had been told to document in the EMR, and that the EMR activity notes were completed that day. She also stated that the last activity assessment was completed on 01/16/25 and that quarterly activity assessments for the resident could not be located.
Failure to Complete Timely Fall Risk Assessments
Penalty
Summary
The facility failed to complete fall risk assessments in a timely manner for a resident, leading to a deficiency in ensuring the area was free from accident hazards and providing adequate supervision to prevent accidents. The facility's policy requires three quarterly assessments within a 12-month period unless there is a significant change in status or discharge. However, the resident, who was admitted with a history of falls and a fracture, did not receive the required assessments. The resident's care plan indicated a risk for falls due to various factors, including medication regimen and previous falls, but the necessary assessments were not conducted. Interviews with facility staff revealed that the resident missed two assessments in 2024, and the floor nurses responsible for conducting these assessments did not complete them. The registered nurse confirmed the oversight and stated that orders for assessments should be entered three days prior to charting, which would then appear on the EMAR when due. Despite this process, the assessments were not completed, and the Assistant Director of Nursing confirmed the lack of updated assessments for the resident.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect during meal assistance, as evidenced by staff behavior observed during meal times. Specifically, a Certified Nurse Aide (CNA) was seen standing over two residents while assisting them with eating, which is contrary to the facility's policy that emphasizes feeding residents with attention to safety, comfort, and dignity. The policy explicitly states that staff should not stand over residents while assisting them with meals, yet this was not adhered to during the observed incidents. During interviews, the Director of Nursing (DON) acknowledged the protocol requiring staff to sit while feeding residents and confirmed that staff are aware of this requirement. However, the DON admitted that recent training may not have thoroughly covered the importance of not feeding two residents simultaneously or the necessity of sitting while assisting residents with meals. This oversight in training and adherence to policy contributed to the deficiency in maintaining the residents' dignity during meal times.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure an accurate comprehensive assessment for one of the residents reviewed. The resident, who was admitted with diagnoses including metabolic encephalopathy, dementia, and depression, had physician's orders for Quetiapine Fumarate (Seroquel) and Escitalopram Oxalate (Lexapro). Despite receiving these medications from late May to mid-June, the Admission MDS assessment did not reflect the use of antipsychotic and antidepressant medications. During an interview, the MDS Coordinator acknowledged missing the coding for these medications, indicating a need for modification of the MDS.
Failure to Develop Care Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan for a resident, identified as R77, who was prescribed antipsychotic medication. The medical record review revealed that R77 was admitted with diagnoses including Metabolic Encephalopathy, Dementia, and Depression. Physician's orders included Quetiapine Fumarate (Seroquel) and Escitalopram Oxalate (Lexapro), which were administered from late May to mid-June 2024. However, the Admission Minimum Data Set (MDS) assessment for R77 did not reflect the use of these medications, and consequently, a care plan for the antipsychotic medication was not developed. During an interview, the MDS Coordinator acknowledged the oversight in coding the medications, which led to the absence of a necessary care plan for the use of Seroquel.
Inadequate Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during meal service, as observed with two residents. During a lunch meal observation, a Certified Nursing Assistant (CNA) was seen feeding one resident and then setting up another resident's meal without washing hands in between. Additionally, the same CNA was observed feeding two residents simultaneously without performing hand hygiene between assisting each resident. This action was contrary to the facility's hand hygiene policy, which emphasizes handwashing as the primary means to prevent the spread of healthcare-associated infections. Interviews with facility staff revealed challenges related to understaffing, which may have contributed to the observed deficiencies. A Licensed Practical Nurse (LPN) mentioned that the facility had a high number of residents requiring assistance with eating but insufficient CNAs to provide adequate support. The Director of Nursing (DON) confirmed the hand hygiene policy, stating that staff should wash their hands before and after assisting each resident. However, the DON acknowledged that recent training might not have covered the specifics of not feeding two patients simultaneously, indicating a potential gap in staff education on infection control practices.
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Orangeburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jolley Acres Healthcare Center | 0.7 mi | ★★★★★ | 1 | 0 |
| Pruitthealth- Orangeburg | 1.2 mi | ★★★★★ | 0 | 0 |
| The Oaks Post Acute | 4.2 mi | ★★★★★ | 8 | 0 |
| Calhoun Convalescent Center | 13.5 mi | ★★★★★ | 9 | 1 |
| Pruitthealth- Bamberg | 15.1 mi | ★★★★★ | 1 | 0 |
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