Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Heritage Post Acute during CMS and state inspections, most recent first.
A resident with a history of respiratory failure, who had been receiving supplemental O2 in the facility, was discharged home without discharge paperwork or supplemental O2. The responsible party had informed staff in advance of the planned discharge and was told paperwork would be ready, but when they arrived, no discharge documents were available and attempts by nursing staff to obtain them were unsuccessful. The resident left without discharge instructions, and the SW later confirmed that although the resident had received supplemental O2 in the facility, no O2 order was sent home. Discharge instructions were instead reviewed with the responsible party by phone several days after the resident had already left.
The facility did not follow its policy requiring weekly body audits and wound measurements for a resident admitted with an unstageable sacral pressure ulcer and severe cognitive impairment. Although staff, including LPNs, the wound care nurse, and the DON, stated that weekly skin audits and wound assessments were performed and documented in the EHR, the medical record contained only a single Skin & Wound Evaluation from admission with no subsequent documented skin checks or wound measurements during the resident’s stay.
Failure to Care Plan for Bed Enablers: A resident with MS and intact cognition was observed in bed with bilateral enabler bars used for mobility and positioning, but the care plan did not reference the enablers. An LPN, the MDS RN, the Administrator, and the DON each stated the resident should have a care plan for the enabler bars and confirmed one was not in place.
Care Plan Did Not Reflect Use of Fall Mats: A resident with muscle weakness, unsteadiness on feet, severe cognitive impairment, and a history of falls had three fall mats placed around the bed, but the care plan did not include this intervention. An LPN, MDS RN, DON, and Administrator all confirmed the fall mats were being used and were not documented in the resident’s care plan.
Failure to document an ordered nutritional supplement for a resident with severe protein-calorie malnutrition and severe cognitive impairment. The resident’s care plan identified a nutritional problem, and the MAR showed no evidence that the supplement was administered as ordered. The DON, an LPN, another LPN, and the Administrator all stated that nutritional supplements should be documented on the MAR when given.
A resident with urinary retention, severe cognitive impairment, and an indwelling catheter had the catheter drainage bag observed resting directly on the floor between the bed and the wall. Facility policy stated catheter tubing and drainage bags should be kept off the floor, and RN, DON, and the Administrator all stated the bag was not supposed to be on the floor.
The facility failed to remove expired medications from a medication cart and storage room, and did not secure the medication room properly, allowing unauthorized access by unlicensed personnel. Expired medications, including suppositories and Hydrocodone-Acetaminophen tablets, were found and verified by LPNs. Unauthorized access was observed when a CNA entered the medication room to use a microwave, a practice confirmed to be ongoing for years. The DON acknowledged that only licensed nurses should have access, but both licensed and unlicensed staff had the code to the room.
A resident with multiple diagnoses, including anemia and osteoporosis, did not receive the ordered House Shake supplement for weight gain, despite experiencing significant weight loss. Observations showed the resident received ice cream but not the House Shake. Interviews revealed communication and documentation lapses, as the supplement was not listed on meal tickets or the MAR, leading to the dietary staff not providing it.
A facility failed to ensure proper hand hygiene during wound care for a resident with a stage 4 pressure ulcer. The RN did not sanitize her hands between multiple glove changes, violating the facility's infection control policy. Interviews confirmed the lapse in protocol adherence, highlighting a deficiency in infection prevention practices.
Failure to Provide Discharge Instructions and Supplemental Oxygen at Discharge
Penalty
Summary
The facility failed to provide a discharge summary and supplemental oxygen at the time of discharge for one resident. Facility policy titled "Discharge Summary and Plan" required that, when discharge was anticipated, a discharge summary and post-discharge plan be developed and that a copy of the evaluation of discharge needs, the post-discharge plan, and the discharge summary be provided to the resident and receiving facility, with a copy filed in the medical record. The resident, who had a medical history including respiratory failure, was admitted on 11/07/2025 and discharged home with home health services on 11/27/2025. The resident’s responsible party reported notifying the Admissions Coordinator the day before discharge that the resident would be going home and was told discharge paperwork would be ready at pickup. When the responsible party arrived to take the resident home, the facility did not have the discharge paperwork available, and although a nurse attempted to contact someone to obtain it, they were unsuccessful. The responsible party left the facility with the resident without any discharge paperwork. The resident had been receiving supplemental oxygen while in the facility, but the responsible party stated the resident was discharged without supplemental oxygen. The Social Worker reported that her usual process at discharge was to set up home health, print durable medical equipment orders, and provide discharge paperwork at the time of discharge, but she was not working during the resident’s holiday-weekend discharge. She believed the discharge paperwork was mailed and confirmed that on 12/01/2025 she reviewed the discharge paperwork with the responsible party by phone, four days after discharge. The Social Worker stated that if a resident received supplemental oxygen in the facility, they would be discharged with an order for supplemental oxygen, and confirmed that this resident had received supplemental oxygen in the facility but had no orders for supplemental oxygen at discharge. Review of the Discharge Instruction Form showed it was signed by the Social Worker and dated 12/01/2025, with a handwritten note indicating the instructions were discussed verbally with the responsible party on that date. The DON and Administrator both stated their expectation that residents receive education, medications, post-discharge arrangements, and discharge paperwork at the time of discharge.
Failure to Perform and Document Weekly Skin Audits and Wound Measurements
Penalty
Summary
The facility failed to provide weekly body audits and wound measurements as required by its own policy and the resident’s care plan for a resident with an unstageable sacral pressure ulcer. The facility’s Pressure Injury/Wound/Skin Management policy dated 08/2016 required a licensed nurse to perform weekly body audits, wound measurements, and document findings in the medical record. The resident was admitted with an unstageable sacral pressure ulcer, documented on the admission record and baseline care plan, which identified impaired skin on the sacrum and directed staff to perform weekly skin checks. The admission MDS showed the resident had severe cognitive impairment with a BIMS score of 7/15 and one unstageable pressure ulcer present on admission. Record review showed only one Skin & Wound Evaluation dated on the admission date, documenting the sacral wound size and tissue characteristics, with no further documented skin checks or wound measurements for the remainder of the resident’s stay until discharge. Multiple LPNs, including the wound care nurse, reported in interviews that weekly skin audits were conducted and documented in the EHR, and that the wound nurse was responsible for weekly wound measurements with the wound physician. However, the wound care nurse acknowledged she did not know why this resident’s measurements were not documented, and the DON confirmed that the facility could not locate any wound documentation beyond the initial evaluation, despite her expectation that wounds be measured and documented weekly.
Failure to Care Plan for Bed Enablers
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for the use of enablers for one resident. The facility policy on care planning required a comprehensive, person-centered care plan with measurable objectives and timeframes that describes services to meet the resident’s physical, psychosocial, and functional needs, and the enablers policy required interventions to be recorded on the plan of care and staff informed. Review of the resident’s record showed admission on 02/14/2025 with a diagnosis of multiple sclerosis, and the Quarterly MDS with an ARD of 12/12/2025 showed a BIMS score of 15/15 and substantial/maximal assistance needed to roll left to right while lying on the back. During observation on 02/04/2026, the resident was found supine in bed with bilateral enabler bars attached to both sides of the bed in the elevated position and stated the bars were used to assist with mobility and positioning in bed. Review of the care plan report did not reference the resident’s use of enabler bars. During interviews, an LPN, the MDS RN, the Administrator, and the DON each stated the resident had enabler bars in place and should have a care plan for them, and each confirmed that the resident did not have a care plan for the enabler bars.
Care Plan Did Not Reflect Use of Fall Mats
Penalty
Summary
The facility failed to update the care plan to reflect a resident’s use of fall mats. The resident was admitted with diagnoses that included muscle weakness and unsteadiness on feet, had a BIMS score of 6 out of 15 indicating severe cognitive impairment, and had a fall with major injury since admission or reentry. The resident’s care plan had a focus area for a history of falls, but it did not include interventions for the use of fall mats at the bedside. Observations showed three fall mats placed around the resident’s bed, including at the foot of the bed and on each side. During interviews, an LPN stated the resident had three fall mats in place due to fall risk and that they needed to be care planned, but the resident was not care planned for them. The MDS RN, DON, and Administrator each stated that when fall mats were used as a fall intervention, the resident’s care plan should reflect that intervention, and all confirmed the resident’s care plan did not document the fall mats.
Failure to Document Ordered Nutritional Supplement
Penalty
Summary
The facility failed to document the administration of a nutritional supplement ordered for one resident, R137. R137 was admitted on 11/07/2025 and had a history that included severe protein-calorie malnutrition. The resident’s MDS with an ARD of 11/14/2025 showed a BIMS score of 7 out of 15, indicating severe cognitive impairment, and the resident required supervision or touching assistance with eating. The care plan identified a nutritional problem or potential for a nutritional problem, and an order dated 11/21/2025 directed that the resident receive a nutritional supplement with meals. Review of the MAR for 11/01/2025 through 11/30/2025 showed no evidence that staff documented administration of the nutritional supplement as ordered. During interviews, the DON stated that if a resident received a nutritional supplement, nurses had to document it on the MAR and monitor the amount consumed. An LPN stated she knew R137 received the supplement but did not know why it was not documented on the MAR, and another LPN stated she remembered the resident receiving the supplement but did not know why her initials were not on the MAR. The Administrator stated nutritional supplements should be signed out on the MAR and that nursing staff should sign the MAR when supplements were given.
Catheter drainage bag left on the floor
Penalty
Summary
The facility failed to ensure an indwelling catheter drainage bag was kept off the floor for one resident with urinary retention. The resident was admitted on 01/06/2026 with a history that included retention of urine, had a BIMS score of 5 out of 15 indicating severe cognitive impairment, was dependent on staff for toileting, and had an indwelling catheter documented on the MDS and care plan. The facility policy titled Catheter Care, Urinary, revised 08/2022, stated that catheter tubing and drainage bags should be kept off the floor. During an observation on 02/04/2026 at 12:17 PM, the resident’s urinary catheter drainage bag was observed resting directly on the floor between the bed and the wall. During interviews, RN1, the DON, and the Administrator each stated that catheter drainage bags were not supposed to be on the floor.
Expired Medications and Unauthorized Access in Medication Storage Room
Penalty
Summary
The facility failed to adhere to its medication storage policy, resulting in expired medications and biologicals being present in the medication storage room and on a medication cart. During observations, expired Rugby Hemorrhoidal Suppositories and BD Vacutainer Safety-Lok Blood Collection Sets were found in the Chestnut Medication Storage Room. Additionally, Hydrocodone-Acetaminophen tablets were found expired on the Chestnut Front Hall Cart. Licensed Practical Nurses verified the expiration of these items and removed them from their respective locations. The facility also failed to secure the medication storage room properly, allowing unauthorized access by unlicensed personnel. A Certified Nursing Assistant (CNA) was observed entering the medication storage room to use a microwave, which was confirmed to be a common practice. The CNA accessed the room using a code, which was known to other unlicensed staff, including housekeepers who entered the room to clean the microwave. This practice had been ongoing for several years, as confirmed by the staff. The Director of Nursing (DON) acknowledged that only licensed nurses should have access to the medication room. However, it was revealed that both licensed and unlicensed staff had the code to the room, and stock medications were stored in unlocked cabinets. The DON admitted to not considering the accessibility of stock medications and focused only on the requirement for narcotics to be double locked. The practice of storing stock medications in the room began after a pharmacy switch in 2020.
Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
The facility failed to provide a resident, identified as R50, with the ordered nutritional supplements, specifically the House Shake, as part of her dietary needs. R50, who was admitted with diagnoses including anemia, hyperlipidemia, cerebral infarction, anxiety, gastroesophageal reflux, and osteoporosis, experienced unintentional weight loss of 10.40% over 180 days. Her dietary plan included receiving nutritional supplements twice a day, including a House Shake at lunch and dinner. However, observations on multiple occasions revealed that R50 did not receive the House Shake as ordered, although ice cream was consistently provided. Interviews with facility staff, including the Dietary Manager and the Director of Nursing, revealed a lack of communication and documentation regarding the provision of the House Shake. The Dietary Manager noted that the House Shake was not listed on R50's meal ticket, which led to the dietary staff not providing it. The Director of Nursing confirmed that the House Shake was not recorded on the medication administration record (MAR) for nurses to verify its delivery. The Unit Manager stated that the order for the House Shake was placed, but it was not communicated effectively to ensure R50 received it.
Failure to Follow Hand Hygiene Protocols During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for a resident with a stage 4 pressure ulcer. The facility's policy on wound care and dressing change procedures requires hand hygiene to be performed after removing gloves and before applying new ones. However, during an observation of wound care for a resident, the registered nurse (RN) did not follow these procedures. The RN was observed performing wound care without sanitizing her hands between multiple glove changes, which is a violation of the facility's infection prevention and control program. The resident involved in this deficiency was admitted with multiple diagnoses, including dementia, depression, Alzheimer's disease, dysphagia, and hypertension. The resident had a treatment order to cleanse a sacral wound with normal saline, apply Medi-honey and calcium alginate, and cover it with a dry dressing. During the wound care observation, the RN cleaned the wound, applied treatments, and changed gloves several times without performing hand hygiene, despite the presence of a foul odor and a deep crater in the wound. Interviews with the RN, the Unit Manager, and the Director of Nurses confirmed the failure to adhere to hand hygiene protocols. The RN acknowledged that she should have sanitized her hands between glove changes, and both the Unit Manager and the Director of Nurses stated that hand hygiene is required after removing gloves during dressing changes. This deficiency highlights a lapse in following established infection control procedures, which are critical for preventing the spread of infection in long-term care settings.
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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) |
|---|---|---|---|---|
| Southland Health Care Center | 0.6 mi | ★★★★★ | 2 | 0 |
| Faith Healthcare Center | 0.9 mi | ★★★★★ | 5 | 1 |
| Veteran Village | 1.5 mi | ★★★★★ | 0 | 0 |
| Honorage Nursing Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Presbyterian Communities Of South Carolina-florenc | 4.3 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.