Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Greenville Post Acute during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease and hypertension, treated with Benazepril and enrolled in PACE, had multiple significantly elevated BP readings over two consecutive days. Facility policy required prompt physician notification for significant changes in condition, and the care plan directed staff to contact PACE for medical needs. However, there was no documentation in nursing notes that the physician or PACE was notified, and the patient liaison and weekend supervisor reported not being informed. A CNA stated she reported the elevated BP to an RN, but the RN later indicated that if no progress note existed, the notification was not documented, resulting in a failure to notify the physician of the resident’s elevated blood pressures.
A resident with epilepsy, paranoid schizophrenia, and dementia did not receive 11 ordered doses of Lacosamide 100 mg, prescribed as 1.5 tablets PO BID for seizures, because the facility failed to obtain and administer the medication and did not develop a care plan addressing epilepsy, seizure risk, or seizure medications. Review of the MAR showed repeated omissions, and interviews revealed that although there was a protocol for handling missing medications—requiring nurses to call the pharmacy, notify the MD for alternatives, and check Omnicell—this process was not effectively followed or documented. The DON reported being unaware that there was no prescription for the medication, and the PCP stated she was never notified of the missed doses and that any missing medication should have been communicated to the NP and then to her by direct, immediate means.
The facility did not follow menu requirements for serving sizes during a meal service, resulting in inconsistent portions of turkey being served to residents. The meat slicer was broken, leading to hand-cutting and variable slice sizes, and portions were not weighed to ensure accuracy. This affected nearly all residents receiving meals from the kitchen.
Two residents reported that food was served cold, with one also noting that bread was consistently soaked by vegetables. A test tray confirmed that the food temperature was below standard, and the Dietary Manager acknowledged that both the plate warmers and pellet warmer were broken. The RD was not aware of the equipment issues, which contributed to food being served at improper temperatures.
A resident who was cognitively intact was not allowed to receive visitors of her choosing at any time, as facility staff enforced posted visitation hours that limited in-room visits and required visitors to leave by specific times. Family members reported being asked to leave the resident's room and expressed difficulty accommodating the restricted hours, despite the facility's policy stating residents could have 24-hour access to visitors. Staff interviews confirmed that exceptions to these hours required administrative approval, and the restrictions were enforced to address concerns from the resident's roommate.
A resident with moderate cognitive impairment reported that a CNA used abusive language about his mother, which was corroborated by the resident's cognitively intact roommate. The resident's son discussed the incident with the Administrator, but the facility failed to report the abuse allegation to the state agency within the required timeframe, and no documentation of such a report was found.
A resident with moderate cognitive impairment reported that a CNA used abusive language toward his mother, an incident corroborated by another resident. The resident's family member also reported the event to the Administrator, but the allegation was not documented or formally investigated, and the Administrator was unaware of the verbal abuse claim. The investigation remained incomplete, with no contact made with the accused CNA and no entry in the grievance log.
A resident with multiple comorbidities and significant mobility needs fell and was hospitalized after a side rail detached from the bed due to missing securing pins. Although regular inspections were documented, staff did not specifically check for the presence of the pins, leading to the side rail becoming unattached during care and causing the resident to fall and sustain injuries.
The facility did not adequately explain its Binding Arbitration Agreement to three residents with moderate to severe cognitive impairment, nor did it inform them or their representatives of the right to rescind the agreement. Despite policy requirements, the agreement was signed by residents who could not demonstrate understanding, and staff were unable to clearly explain key terms or the rescission period.
Failure to Notify Physician of Resident’s Elevated Blood Pressures
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of significantly elevated blood pressures as required by facility policy. The facility’s policy on Change in a Resident’s Condition or Status, revised February 2021, states that the nurse will promptly notify the attending or on-call physician when there is a significant change in the resident’s physical condition, defined as a major decline or improvement that will not normally resolve without intervention. The resident was admitted with diagnoses including Alzheimer’s disease, essential hypertension, and hypothyroidism, and had an active order for Benazepril 5 mg daily for hypertension with instructions to hold the medication if systolic blood pressure (SBP) was less than 110. The admission MDS showed the resident was unable to complete the BIMS interview and had an active diagnosis of hypertension. Blood pressure records showed multiple elevated readings, including 172/102 and 172/101 on one day and 171/119 on the following day. Review of the nurse’s notes revealed no documentation that the physician or PACE program was notified of these elevated blood pressures. The care plan indicated the resident was a PACE participant and directed staff to contact PACE for any medical needs. During interviews, the UM stated all medication orders came from PACE, and the DON acknowledged that 171/119 was an elevated blood pressure and that a call should have been made to the on-call PACE medical director, with family also to be notified of the change in condition. The patient liaison and weekend supervisor both reported not being informed of the elevated blood pressures, and CNA staff reported notifying an RN of the elevated readings but was unsure what occurred afterward. The RN stated she did not recall the patient but indicated that if there was no progress note, the notification would not have been documented anywhere else.
Failure to Obtain and Administer Ordered Seizure Medication
Penalty
Summary
The facility failed to obtain and administer Lacosamide, an ordered seizure medication, for one resident, resulting in 11 missed doses over the period from 1/7 to 1/13. The resident was admitted with diagnoses including epilepsy, paranoid schizophrenia, and dementia. Review of the care plan showed no care plan addressing epilepsy, seizure risk, or seizure medications. Review of the MAR for 1/7/26 through 1/14/26 showed that the resident did not receive Lacosamide 100 mg, ordered as 1.5 tablets by mouth twice daily for seizures, for a total of 11 missed doses. The facility’s policy on Adverse Consequences and Medication Errors defined a medication error to include omissions when a drug is ordered but not administered. During interviews, an LPN stated that if a progress note about Lacosamide not being given was scratched out, it meant the medication was administered, and that when waiting for a medication, the nurse keeps a running list and calls the pharmacy for status updates. The Staff Development Coordinator reported that the protocol for missing medications requires nurses to call the pharmacy and document the call, notify the MD for alternatives, and check the Omnicell if the medication is not a narcotic. The DON stated that on admission, floor nurses should send all prescriptions to the pharmacy and, if a prescription is missing, contact onsite/on-call providers to obtain one so the pharmacy can send the medication stat, and reported being unaware that there was no prescription for Lacosamide. The resident’s PCP stated she had no memory of being notified about any missed Lacosamide doses and explained that the NP should be notified first and work with the pharmacy, and if issues persist, the PCP should be contacted; she also stated that missing medication should be communicated immediately by direct means, not by a note left in a book.
Failure to Ensure Consistent Portion Sizes During Meal Service
Penalty
Summary
The facility failed to ensure that menus were followed in regard to serving sizes, specifically with the portioning of turkey during a meal service. Observations of the kitchen serving line revealed that turkey slices varied in size and were not weighed to confirm the correct portion was being served, as required by residents' meal tickets, which specified portions ranging from two to six ounces. Toward the end of the serving line, residents were served broken pieces of turkey rather than uniform slices. The facility's policy required tray cards to be checked for accuracy and proper portions to be served according to menu extensions. Interviews with the Dietary Manager indicated that the meat slicer was broken, necessitating hand-cutting of the turkey, which resulted in inconsistent slice sizes. The Dietary Manager described portion sizes in terms of the number of slices rather than weight, and was unable to confirm the actual amount of turkey being served to residents. The Registered Dietician was unaware of the equipment issue and stated that there should be a method to measure portion sizes. The deficiency had the potential to affect 120 of 124 residents who consumed meals from the facility's kitchen.
Failure to Serve Palatable and Properly Heated Food
Penalty
Summary
The facility failed to provide food that was palatable and at the proper temperature, as evidenced by observations, resident interviews, and a test tray sample. One resident with moderate cognitive impairment reported that food was served cold, while another cognitively intact resident stated that food was usually cold and bread was consistently soaked by vegetables. During a test tray sample, the mechanical turkey was measured at 94.5°F, and both the Dietary Manager and surveyor confirmed the food was cold. The Dietary Manager acknowledged that both the plate warmers and pellet warmer were broken, and the Registered Dietitian was unaware of these equipment failures, noting that serving food on cold plates would result in cold meals.
Failure to Honor Resident's Right to Unrestricted Visitation
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of her choosing at the time of her choosing, as required by both federal regulations and the facility's own visitation policy. The policy states that residents are permitted 24-hour access to visitors with the resident's consent, but posted signs throughout the facility indicated restricted visitation hours for patients in semi-private rooms, limiting in-room visits to between 8:00 AM and 7:00 PM, with public area visitation allowed until 9:00 PM. Interviews with the resident and her family members revealed that they were required to leave the resident's room by 7:00 PM and could only stay in common areas until 9:00 PM, unless special approval was obtained from a physician or hospice. The resident, who was cognitively intact with a BIMS score of 13, expressed dissatisfaction with these restrictions, stating that her parents and friends had been asked to leave and that the limited hours negatively impacted her quality of life. Staff interviews confirmed enforcement of these visitation hours, with the Social Service Director and DON explaining that exceptions required administrative approval and that the restrictions were in place to protect the rights of other residents, particularly in shared rooms. The DON noted that the resident's family was frequently present, sometimes from early morning until late at night, and that the roommate had expressed concerns about privacy and receiving adequate care during these times. Despite the facility's policy allowing for 24-hour visitation, the posted and enforced restrictions resulted in the resident and her family being unable to visit freely according to their wishes.
Failure to Timely Report Alleged Verbal Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of staff-to-resident verbal abuse was reported to the state agency within two hours of knowledge, as required by facility policy. Specifically, a resident with moderate cognitive impairment reported that a CNA used abusive language about his mother. The resident informed his son, who then discussed the incident with the Administrator. The resident's roommate, who was cognitively intact, corroborated the incident, stating that the CNA responded to the resident's offensive language with similar inappropriate language about the resident's mother. The son also reported the incident to the Administrator during a meeting, along with other concerns. Despite these reports, a review of the facility's records showed no documentation of the abuse allegation being reported to the state agency. Interviews with the Administrator and DON revealed that neither was aware of the specific verbal abuse allegation until it was brought to their attention during the survey. The Administrator confirmed that, upon learning of the allegation, he did not report it to the state agency as required by policy, nor had he done so as of the following day.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident verbal abuse involving one resident. The resident, who was moderately cognitively impaired, reported that a CNA used abusive language directed at his mother. Another resident, who was cognitively intact, corroborated the incident, stating that the CNA responded to the resident's offensive term by using inappropriate language about the resident's mother. The resident's family member also reported the incident to the Administrator, along with concerns about the resident being left unattended in the shower room. Despite these reports, the Administrator stated there was no documentation of the verbal abuse allegation, and the concern was not entered into the formal grievance log. The Administrator also indicated he was not previously aware of the verbal abuse allegation. Interviews with facility leadership revealed that the investigation into the allegations was incomplete and ongoing, with attempts to contact the accused CNA still pending. The DON and a Unit Manager interviewed the resident in private, during which the resident described the CNA's behavior, including verbal abuse, kicking the door, and bumping his chair, but could not identify the CNA by name. The DON also stated that the family member's initial report focused on the resident being left in the shower, which was later found to be unsubstantiated upon video review. The lack of thorough investigation and documentation of the verbal abuse allegation constituted the deficiency.
Failure to Secure Bed Side Rail Results in Resident Fall and Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a side rail was securely attached to a resident's bed, resulting in a fall that required hospitalization. The resident involved had significant medical conditions, including congestive heart failure, chronic kidney disease, respiratory failure, morbid obesity, and was dependent on staff for mobility and activities of daily living. The care plan specified the use of 1/4 side rails on both sides of the bed to assist with mobility and positioning, and the facility's policy required regular inspection and maintenance of bed systems, including side rails. On the day of the incident, the resident was being assisted by a CNA for personal care. As the resident turned and held onto the left side rail, the rail detached from the bed frame, causing the resident to fall to the floor and sustain a bruise and pain to the right leg. Interviews and documentation revealed that the pins securing the side rail to the bed frame were missing at the time of the fall, which allowed the side rail to become unattached. The maintenance staff confirmed that the absence of these pins was a safety risk and directly contributed to the incident. Routine monthly inspections of beds and side rails were documented, and the most recent inspection prior to the incident did not identify any issues. However, the staff responsible for weekly checks of side rails did not specifically assess whether the securing pins were in place, only checking for general stability. The failure to ensure the side rail was properly secured with the required pins led to the resident's fall and subsequent hospitalization for evaluation and treatment of injuries.
Failure to Properly Explain and Obtain Informed Consent for Binding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that its Binding Arbitration Agreement (BAA) was explained to residents in a manner they could understand, and did not inform residents or their representatives of their right to rescind the agreement within 30 days. This was identified through record review, interviews, and policy review, and affected three residents out of a sample of 31. The facility's policy required that the terms and conditions of the BAA be explained in a way that ensures understanding, taking into account language, literacy, and cognitive status, and that a signature alone is not sufficient to demonstrate understanding. For the three residents involved, documentation showed that two had moderate cognitive impairment and one had severe cognitive impairment at the time they signed the BAA without a representative. Specifically, one resident had a BIMS score of nine, another had a BIMS score of ten, and the third had severe cognitive impairment with no BIMS score recorded. Interviews revealed that at least one resident did not recall signing the BAA or having it explained, and another was unable to verbalize or demonstrate understanding of the agreement. The Director of Admissions stated that she used BIMS scores to determine capacity, but admitted to not knowing the required rescission period and was unable to fully explain the BAA contents. The facility's BAA documentation included a section stating that the agreement had been explained in a form and manner the resident understood, but interviews and record reviews indicated this was not consistently the case. The Director of Admissions also stated that residents were sometimes asked to sign the BAA more than once, as directed by corporate policy, and that she considered residents with a BIMS of 12 or lower as incapable of understanding the agreement, yet residents with lower scores still signed without a representative. The Administrator was also unclear about the terms of the BAA, including its duration.
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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 Greenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Magnolia Manor - Greenville | 2.6 mi | ★★★★★ | 0 | 0 |
| Heartland Health Care Center - Greenville East | 3.3 mi | ★★★★★ | 2 | 2 |
| West Village Post Acute | 3.5 mi | ★★★★★ | 7 | 0 |
| Patewood Post Acute | 5 mi | ★★★★★ | 0 | 0 |
| The Arboretum At The Woodlands | 5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.