Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Faith Healthcare Center during CMS and state inspections, most recent first.
Failure to Provide Written Transfer Notice and Bed-Hold Information: The facility did not ensure that a resident with dementia, psychosis, and severe cognitive impairment, or the resident’s RP, received a written notice of transfer or a bed-hold notice when the resident was transferred to the hospital for ongoing behavioral disturbances and psychosis. Record review found no evidence of either notice, and the Administrator stated there was no bed-hold policy or written transfer notice provided to the RP.
Uncovered nebulizer equipment was left on a resident’s nightstand, with the mask and tubing not labeled or dated to show when they were last replaced. The resident had pneumonia, moderate cognitive impairment, and an order for PRN nebulizer treatments, but MAR/TAR review showed no treatments had been given since admission. An LPN said the equipment was normally stored in a bag in the resident’s drawer, but the resident had removed it; the DON stated nebulizers, masks, and tubing are expected to be cleaned and stored properly.
Failure to assess and document bed rail use led to side rails being raised on two residents’ beds without the required physician order, informed consent, or current evaluation. One resident had poor cognition and disorganized thinking, and the other had moderate cognitive impairment with cancer diagnoses and needed extensive help with bed mobility and transfers. The record showed side rails in use, but the chart lacked evidence of assessment, alternatives, consent, and, for one resident, a current order or care plan.
Bed rails were not inspected and maintained per facility policy for two residents. One resident with a hx of stroke and dementia and another with frontotemporal neurocognitive disorder were observed in bed with raised side rails, but record review found no documentation that maintenance had assessed the beds or attached rails for safety. The MD stated beds were not specifically checked when rails were applied and that neither bed had been inspected for safety.
A resident with dementia and a history of wandering exited the facility through a door with disabled mag locks and alarms, remaining undetected until found by a passerby across a busy street. Staff interviews and records confirmed the door's security systems were not re-engaged after maintenance, and the resident was not wearing identification or monitored with a wander guard device.
The facility failed to maintain proper sanitation in the main kitchen and did not adhere to food labeling and expiration policies. Observations revealed dirty kitchen equipment, improperly labeled and expired foods, and unsanitary conditions. The Dietary Manager acknowledged the issues, citing high staff turnover as a contributing factor. The DON was unaware of the deficiencies and stated that the Dietary Manager is responsible for kitchen cleanliness.
The facility failed to maintain the dignity of two residents by not addressing unwanted facial hair and not covering a foley catheter bag. Two residents were observed with facial hair, which was not addressed despite personal care being provided. Another resident's catheter bag was left uncovered, compromising their dignity. Staff interviews confirmed these oversights, highlighting deficiencies in personal care and privacy measures.
A facility failed to ensure resident safety by leaving unlabeled medicinal substances at a resident's bedside, contrary to its medication management policy. Observations revealed two small clear medicine cups with a white creamy substance in the resident's nightstand and on a soap dispenser. Interviews with staff, including a CNA and the DON, confirmed that medications should be stored securely and not left at the bedside. The Facility Administrator emphasized the importance of labeling medications to prevent improper use and ensure resident health and wellness.
The facility failed to ensure call lights were within reach for two residents, impacting their ability to call for help. Observations showed call lights were placed approximately 5 feet away, and both residents expressed concerns about their inability to reach them. Staff interviews revealed that a CNA forgot to reposition the call lights after attending to the residents, despite facility policy requiring call lights to be accessible.
A facility failed to check the placement of a resident's gastrostomy (g) tube before administering medications. An LPN administered a mixture of medications through the g-tube without verifying its placement, despite the resident having a traumatic brain injury. The LPN acknowledged the oversight, and the Director of Nursing confirmed that checking g-tube placement is standard practice.
The facility failed to administer oxygen according to physician's orders for three residents, leading to deficiencies in respiratory care. One resident's oxygen was set at 1 liter per minute instead of the ordered 2 liters, another's was at 3 liters instead of 5, and a third's was at 2.5 liters instead of 2. The DON and Administrator emphasized the importance of verifying orders and ensuring correct flow rates, while an LPN admitted to not routinely checking the flow rate.
A facility failed to maintain a medication error rate below 5%, resulting in a 14.29% error rate during a medication pass for a resident with a traumatic brain injury. An LPN did not fully administer a mixture of medications through the resident's g-tube, leaving approximately 15 ml of the medication slurry in the cup. The LPN acknowledged the error, and the DON confirmed that all medications should be administered unless there is a valid reason not to do so.
The facility failed to secure medications as required by policy, leaving them unattended on top of a locked cart in a common area. An LPN confirmed leaving the medications unattended, and the DON stated that unattended medications should be locked.
A resident's foley catheter bag was improperly stored above bladder level, leading to a deficiency in infection control. The catheter bag was folded and tucked into the bed rail, causing potential obstruction of urine flow, as evidenced by cloudy urine with debris. Facility policy and CDC guidelines require the catheter bag to be below the bladder to prevent backflow and infection. Observations showed the catheter lacked a privacy covering, and the tubing was not kink-free. Interviews with staff confirmed the importance of proper catheter care, but revealed gaps in adherence to procedures.
Failure to Provide Written Transfer Notice and Bed-Hold Information
Penalty
Summary
The facility failed to ensure that the resident and/or the resident’s responsible party were provided with a written notice of transfer and a written bed hold for one of three residents reviewed for hospitalizations, Resident 105. The record review, interview, and policy review showed that the facility’s Discharge/Transfer policy dated 10/23/19 stated the facility would obtain a discharge/transfer order from the physician and notify the patient/resident, legal representative, or interested family member and document the discharge. Resident 105’s record showed diagnoses including dementia, severe psychotic disturbance, hallucinations, paranoia, major depressive disorder, and anxiety disorder. The admission MDS showed a BIMS score of 6 out of 15, indicating severe cognitive impairment. A progress note by the NP dated 01/28/26 stated the resident was seen for follow-up evaluation to assess the need for transfer to a higher level of care due to ongoing severe behavioral disturbances and psychosis related to schizophrenia, and the resident was transferred to the hospital that day. Review of the archived paper medical record found no evidence that the resident and/or the responsible party was issued a written notice of transfer or a bed hold upon or soon after the transfer. During interview, the Administrator stated there was no bed-hold policy or written notice of transfer provided to the resident’s responsible party.
Uncovered nebulizer equipment left on resident’s nightstand
Penalty
Summary
Respiratory care was not provided with proper equipment storage for one resident who was reviewed for respiratory care. The resident was admitted with diagnoses that included pneumonia and had a BIMS score of 8, indicating moderate cognitive impairment. During observation, a nebulizer machine, mask, and tubing were seen on the resident’s nightstand uncovered, and the mask and tubing were not labeled or dated to show when they were last replaced. The resident stated the nebulizer belonged to him and believed he had recently received a treatment because he had been feeling congested. The resident had a physician’s order for Ipratropium/Albuterol nebulizer treatments every six hours as needed for pneumonia, with tubing to be changed weekly on Sunday. Review of the MARs and TARs for January, February, and March showed the resident had not received a nebulizer treatment since admission. On follow-up observation, the nebulizer equipment remained uncovered on the nightstand. An LPN stated the equipment was normally stored in a bag in the resident’s drawer, but the resident had removed it. The DON stated that nebulizers, masks, and tubing are expected to be cleaned and stored properly, and that when mask and tubing are replaced, they should be labeled with the replacement date or documented in a log.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess residents for the use of bed rails, obtain physician orders, and obtain informed consent before side rails were installed on the beds of two residents. The facility’s policy stated that alternatives should be attempted before installing side rails, that qualified staff should assess continued use at least quarterly, annually, and with a significant change, and that the risks and benefits should be reviewed with the resident and/or responsible party before consent and a physician order were obtained. One resident, admitted to the facility and documented as having poor cognition and disorganized thinking on the annual MDS, was observed in bed with a 1/3 side rail raised on multiple occasions. The resident required partial to moderate assistance to roll in bed and was dependent for transfers. The physician order report showed bilateral half side rails were ordered, and the care plan stated side rails were used to promote independence with bed mobility. However, the record contained no documented evidence that the resident had been assessed for side rail use, that alternatives had been attempted, or that informed consent had been obtained. A second resident, admitted with kidney cancer, liver cancer, and frontotemporal neurocognitive disorder, was also observed in bed with bilateral side rails raised on multiple occasions. The resident’s significant change MDS showed a BIMS score of 8 out of 15, indicating moderate cognitive impairment, and the resident required assistance to roll and substantial to maximal assistance to transfer. The physician order report contained no order for side rails, the care plan did not address side rail use, and the record showed no documented evaluation recommending side rails beyond an evaluation dated about 10 months earlier. During interview, the UM/LPN confirmed the side rails were raised and stated residents were to have physician orders; the DON confirmed side rail use should be assessed quarterly and stated there was no order, no care plan, and no evidence of assessment or informed consent for the first resident, and no current order or care plan for the second resident.
Bed rails were not inspected or documented as safe for two residents
Penalty
Summary
The facility failed to ensure bed rails were inspected and maintained per its policy for two residents, R11 and R14, who were reviewed for accidents. The facility policy titled "Bed Rails and Side Rails, Installation and Use Policy," revised 05/05/23, stated that residents would be evaluated for entrapment risk before bed rails were installed and that the facility would ensure bed dimensions were appropriate based on the resident's size to minimize entrapment potential. R11's paper record showed a history of stroke and dementia with psychotic disturbance, and R14's record showed frontotemporal neurocognitive disorder. During observation, R11 was lying in bed with one side of the bed against the wall and 1/3 side rails raised in the middle of the bed, and R14 was lying in bed with 1/3 bilateral side rails raised in the middle of the bed. Review of both residents' records and the facility's bed maintenance documentation found no documented evidence that maintenance had assessed either bed to confirm the side rails were safe and functioning properly. The Maintenance Director stated that beds were not specifically checked by maintenance for each resident when rails were applied and that neither R11's nor R14's bed and attached side rails had been inspected or checked for safety.
Failure to Prevent Elopement Due to Disabled Door Alarms and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's dementia, confusion, and a history of wandering and falls was able to exit the facility unsupervised and was found across a busy street by a passerby. The resident, who was at significant risk for elopement and injury due to her cognitive impairment and physical limitations, left the building through a door on D hall. This door was equipped with mag locks and alarms, but both systems were found to be disengaged at the time of the incident, allowing the resident to leave without staff awareness. Interviews and record reviews revealed that the mag lock and alarm on the D hall door had been disabled, reportedly due to recent maintenance work. The Maintenance Director admitted to working on the door days prior and forgetting to reactivate the alarm system. Staff members, including those responsible for deliveries and supply, described procedures for unlocking and relocking the door, but on the day of the incident, the door was left unsecured and unalarmed. Multiple staff members confirmed that the red indicator light, which signals a locked door, was not on, and the door could be opened without triggering an alarm. The resident was not wearing any identification and was not immediately missed by staff, despite being seen walking the halls earlier in the day. The facility did not utilize wander guard devices for residents at risk of elopement. The incident was only discovered after emergency services contacted the facility, having been alerted by a passerby who found the resident outside. The facility's elopement policy required prompt investigation and search for missing residents, but the lack of functioning door alarms and supervision allowed the resident to leave undetected.
Removal Plan
- Resident evaluated at emergency room. No injuries indicated.
- Each Exit door was checked and secured by Manager on Duty.
- Resident returned to facility and placed on 15-minute checks.
- Physical Assessment Completed by Licensed Nurse with no injuries identified.
- Upon Resident return, Elopement Risk Assessment Updated to reflect current status by Licensed Nurse.
- Care Plan and resident profile updated by licensed Nurse.
- Maintenance Director was reeducated by the Administrator on validating doors are engaged and secure after any repair to door.
- Residents residing in the facility had an Elopement Risk Assessments updated by Director of Nursing/Designee.
- Residents identified as elopement risk were placed in the elopement binder and had care plans and profiles updated by Director of Nursing/Designee.
- Facility Staff were reeducated by the Director of Nursing/Designee on Elopement Policy and Process.
- Designated doors were set for facility staff to enter and exit the building.
- Any keys to disable door locks or alarms were placed with the Administrator.
- The identified side door will remain locked and alarmed at all times.
- Facility Staff were reeducated by the Administrator/Designee on the use of the designated doors for entry and exit.
- Any staff not receiving this education will receive prior to their next scheduled shift.
- Doors will be checked daily validating they are secure and properly functioning by Administrator/Designee for 3 months.
- Maintenance Director will validate exit doors are secure and functioning properly weekly.
- Elopement Drills will be completed with facility staff three times a month for 3 months.
- The Medical Director was notified of the contents of this plan and the Immediate Jeopardy.
- Ad Hoc QAPI was held.
Deficiencies in Kitchen Sanitation and Food Labeling
Penalty
Summary
The facility failed to ensure proper sanitation of kitchen equipment and overall cleanliness in the main kitchen, as well as proper labeling and discarding of expired foods. During an initial walkthrough, surveyors observed various deficiencies, including a visibly dirty industrial double-door oven, a deep fryer with accumulated old food crumbs and grease, and a stove with heavy accumulation of old food and grease debris. Additionally, the large window above the three-compartment sinks was covered with dried grease and grime, and all kitchen doors leading outside and to the main dining room were dirty with chipped paint and built-up dirt and grime. The facility's dietary policies require that food be stored in its original packaging if clean, dry, and intact, or in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. However, the surveyors found multiple instances of improperly labeled and expired foods in the main kitchen's walk-in cooler, freezer, and dry storage areas. Items such as jars of jam, bags of hot dogs, steaks, chicken, muffins, and bread loaves were either not in their original packaging or lacked proper labeling with use-by dates. The Dietary Manager confirmed these findings and acknowledged the high turnover rate as a contributing factor to the oversight in checking for expired foods and maintaining cleanliness. Interviews with the Dietary Aide/Cook and the Director of Nursing (DON) revealed that leftovers are supposed to be labeled with a preparation date and use-by date, and discarded after a certain number of days. The DON was unaware of the kitchen's condition and stated that mock surveys are conducted annually. The DON also mentioned that the Dietary Manager is responsible for overseeing dietary staff and ensuring kitchen cleanliness. Despite the facility's policy of daily cleaning and weekly deep cleaning, the kitchen remained in the same unsanitary condition during subsequent walkthroughs.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of two residents, R39 and R74, by not addressing unwanted facial hair. R39, who has a BIMS score of 99, indicating cognitive impairment, was observed multiple times with facial hair on her chin. Despite receiving personal care from a hospice aide, the facial hair was not addressed, and the responsibility fell to a CNA who acknowledged the oversight. Similarly, R74, with a BIMS score of 6, indicating severe cognitive impairment, was observed with facial hair on several occasions. Both a CNA and an LPN confirmed the presence of facial hair and agreed it was unacceptable for female residents. The DON stated that facial hair should be removed if the resident allows, but there was uncertainty about whether R74 would permit shaving. Additionally, the facility failed to ensure the dignity of R2 by not covering the resident's foley catheter bag. R2, who has an intact cognition with a BIMS score of 15, was observed with an uncovered catheter bag at the bedside. An LPN confirmed the need for a privacy bag, and it was later observed that the catheter was placed inside a privacy bag. The ADON stated that catheter care education includes ensuring dignity by covering catheter bags, and this was reinforced during staff orientation. The facility's policy on resident rights emphasizes treating each resident with respect and dignity, which was not upheld in these instances. The observations and interviews with staff highlighted lapses in personal care and privacy measures, leading to deficiencies in maintaining the residents' dignity and quality of life.
Unlabeled Medicinal Substances Left at Resident's Bedside
Penalty
Summary
The facility failed to ensure that residents were free from hazards by leaving unlabeled medicinal substances at the bedside of a resident, identified as R79, who was reviewed for accidents and self-administration of medication. The facility's policy on medication management clearly states that medications should not be left in a resident's room without an order to do so, and unused doses should be destroyed following facility policy. However, during observations, it was found that two small clear medicine cups with a white creamy substance were left in R79's nightstand drawer and on top of the soap dispenser in his room, accessible to both residents. R79's physician orders did not include any orders for self-administration of medication, indicating a breach of protocol. Interviews with facility staff, including a CNA and the DON, revealed that medications should be stored in the medication cart or drug room for safety, and there is no appropriate time for medication to be left or stored at the bedside. The DON mentioned that protective cream could be stored at the bedside, but not medicated cream, and if a cream is needed for one-time use, it should be disposed of after use. The Facility Administrator confirmed that medications should not be left at the bedside unless they are non-toxic and labeled for identification. The presence of unlabeled medicinal substances at the bedside posed a risk of improper use, as noted by the CNA and the Administrator, who emphasized the importance of ensuring the health and wellness of residents.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, R50 and R33, which could potentially impact their physical and emotional well-being by limiting their access to call for help in emergencies. The facility's policy requires that call lights be placed within the resident's reach when leaving the room. However, during observations, it was noted that R50's call light was approximately 5 feet away on the nightstand, and R33's call light was similarly out of reach. Both residents expressed concerns about their inability to reach the call lights, with R50 stating that he could not receive assistance until a CNA returned, and R33 expressing frustration about having to wait to voice his needs. R50 has a medical history that includes cerebral infarction, hemiplegia, and cognitive communication deficits, requiring substantial assistance with mobility and personal care. R33 has a history of cognitive communication deficit, hemiplegia, and dementia, also requiring significant assistance. Interviews with staff revealed that CNA3, responsible for the unit, acknowledged forgetting to place the call lights back within reach after changing the residents' briefs. LPN6 and the DON emphasized the importance of ensuring call lights are accessible, with the DON stating it is a standard practice for residents to call for help.
Failure to Check G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to adhere to standard nursing practice by not checking the placement of a resident's gastrostomy (g) tube before administering medications. This deficiency was observed during a medication pass for a resident who was admitted with a diagnosis of traumatic brain injury. On the specified date, an LPN prepared a mixture of medications, including Haldol Oral Solution, gabapentin, amlodipine, and thiamine, and administered them through the resident's g-tube without verifying its placement. During an interview, the LPN admitted to not checking the g-tube placement prior to medication administration. The Director of Nursing confirmed that checking g-tube placement is a standard practice that should always be followed before administering medications.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to administer oxygen according to physician's orders for three residents, leading to deficiencies in respiratory care. For one resident, the physician's order specified oxygen at 2 liters per minute via nasal cannula, but observations revealed the oxygen was set at 1 liter per minute. The Licensed Practical Nurse (LPN) verified the discrepancy and adjusted the rate after checking the Medication Administration Record (MAR). The Director of Nursing (DON) stated that it is the nurse's responsibility to verify the oxygen order and check the flow rate every shift. Another resident, who was admitted with diagnoses including acute respiratory failure and hypoxia, had a physician's order for oxygen at 5 liters per minute. However, observations showed the oxygen was initially set at 3 liters per minute. The resident confirmed the correct setting should be 5 liters per minute, and the LPN adjusted it accordingly after being notified of the error. The DON emphasized the importance of verifying oxygen orders and ensuring the correct flow rate is administered. A third resident, with severe cognitive impairment and a history of respiratory issues, had a physician's order for oxygen at 2 liters per minute. Observations indicated the oxygen was set at 2.5 liters per minute, which was not in accordance with the order. The DON and the Administrator both stated that staff are expected to follow physician's orders and verify the correct oxygen flow rate every shift. The LPN admitted to not routinely checking the flow rate, focusing instead on the humidifier and oxygen saturation levels.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 14.29% error rate during a medication pass for one resident. The incident involved a resident with a traumatic brain injury who was admitted to the facility with a gastrostomy tube. During the medication administration, an LPN prepared a mixture of Haldol Oral Solution, gabapentin, amlodipine, and thiamine to be administered through the resident's g-tube. However, after the administration, the surveyor found approximately 15 ml of the medication slurry left in the cup, indicating that not all medications were administered. The LPN acknowledged the oversight, and the Director of Nursing confirmed that all medications should be administered unless there is a valid reason not to do so.
Unattended Medications Found on Top of Locked Cart
Penalty
Summary
The facility failed to ensure that medications were securely locked when not in use or being observed by licensed staff, as required by their policies. During an observation, a medication cart on Skilled East was found unattended with approximately four medication cards containing medications placed on top of the locked cart. This occurred near a common area where a wandering resident in a wheelchair was passing by. The facility's policy, revised on April 1, 2022, mandates that medications and biologicals be stored safely and securely in locked compartments, accessible only to authorized personnel. Additionally, the Medication Management Program policy, revised on May 5, 2023, specifies that no medications should be left on top of the cart. The Licensed Practical Nurse (LPN) confirmed leaving the medications unattended, and the Director of Nursing (DON) stated that her expectation is for unattended medications to be locked.
Improper Foley Catheter Management Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to adhere to proper foley catheter procedures for a resident, leading to a deficiency in infection control. The resident, who has a history of traumatic subdural hemorrhage, gastrostomy, dysphasia, and urinary retention, was observed with a foley catheter bag improperly stored above the bladder level, folded and tucked into the bed rail. This improper positioning of the catheter bag could obstruct urine flow, as evidenced by the cloudy urine with debris and sedimentation in the tubing. The facility's policy and CDC guidelines require that the catheter bag be kept below the bladder to prevent backflow and potential infection. Observations revealed that the catheter bag lacked a privacy covering, and the tubing was not free from kinks, which are necessary to maintain unobstructed urine flow. Interviews with the LPN and DON confirmed the importance of proper catheter care to prevent infections and maintain resident dignity. The LPN acknowledged the catheter was not dated and planned to replace it and obtain a privacy covering. The DON was unsure of the policy regarding privacy bags when the resident is in the room, indicating a lack of clarity in the facility's procedures. The Administrator emphasized the importance of timely catheter care and staff training, although the deficiency suggests a gap in adherence to these standards.
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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 Florence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Post Acute | 0.9 mi | ★★★★★ | 7 | 0 |
| Southland Health Care Center | 1.2 mi | ★★★★★ | 2 | 0 |
| Honorage Nursing Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Veteran Village | 2 mi | ★★★★★ | 0 | 0 |
| Presbyterian Communities Of South Carolina-florenc | 3.6 mi | ★★★★★ | 0 | 0 |
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