Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Oak Hollow Of Sumter Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, contractures, and dependence for care developed a red, swollen arm that was reported to the UM, but no assessment was documented when the change in condition was first identified. Staff later observed the resident grabbing the arm, with swelling, warmth, and facial grimacing, and imaging ultimately showed a displaced humerus fracture. Interviews and records showed confusion about the initial report, but the resident was not assessed when the concern was first raised.
A facility failed to maintain a safe, clean, and functional environment in 2 rooms. One resident’s bathroom had a broken ceramic soap dish with jagged edges, and another resident’s bathroom sink was clogged and not draining. An LPN said the broken soap dish could pose a hazard, while a housekeeper reported the sink issue had been told to the Maintenance Director weeks earlier but remained unresolved. Records showed no documented work orders or repairs for either issue.
Failure to maintain and service oxygen concentrators: The facility did not clean an oxygen concentrator filter weekly for a resident with COPD, dementia, sleep apnea, and continuous O2 therapy, and the filter was observed covered with dirt and lint on multiple occasions. Staff said night shift was responsible for cleaning the concentrators, but there was no documentation that the filter was cleaned. The facility also could not provide records showing preventative maintenance or servicing for two DeVilbiss concentrators, and leadership gave conflicting information about who was responsible for the equipment.
Incomplete Dialysis Assessment and Communication Documentation: A resident with ESRD, DM, and other chronic conditions received scheduled HD, but the record lacked required pre-dialysis progress notes on several treatment days and lacked post-dialysis assessments on multiple returns. Staff interviews showed nurses were expected to document vital signs, meds, assessments, and communication with the dialysis center in the EMR and on the dialysis communication form, but documentation was often kept only in the binder, and several forms were undated, incomplete, or not completed by the dialysis center.
Expired house stock medications were found in a medication cart available for resident use, including naproxen and Orajel toothache rinse past the manufacturer expiration date. An LPN confirmed both items were expired, while staff stated medication carts were audited weekly and expired meds were supposed to be destroyed. The UM said she placed the naproxen in the cart without checking the expiration date, and the ADM and DON stated expired meds should not have been in the cart.
Staff failed to use the correct test strips to monitor sanitation concentrations in the kitchen, resulting in inaccurate records of chlorine levels for both the dishwashing machine and the three-compartment sink. Observations also revealed a trash bin without a lid and dust and debris on top of the dishwashing machine, with the Certified Dietary Manager confirming these sanitation lapses.
The facility did not maintain an effective infection prevention and control program, as evidenced by staff failing to perform hand hygiene, missing signage for Enhanced Barrier Precautions, empty hand sanitizer dispensers, and improper use of PPE. A resident with a suprapubic catheter did not have required precaution signage, and staff were not consistently educated on infection control protocols. Plumbing issues led to shared bathrooms, further impacting infection control efforts.
A resident with a physician's order for TED hose was not provided with the prescribed compression stockings, resulting in red, swollen legs, while another resident with incontinence and mobility issues experienced significant delays in receiving incontinent care. Staff were unaware of care orders due to reliance on verbal handoff and did not follow care plans or the facility's No Pass Zone policy, leading to unmet care needs.
The facility did not have a full-time certified dietary manager or food service manager overseeing the food and nutrition service, as required. Staff reported working without supervision, and the CDM confirmed he was responsible for multiple buildings and had not been present to train or manage the dietary staff. The administrator was unable to confirm the CDM's schedule, and the job description indicated the need for full-time, on-site management, which was not being met.
The facility did not develop or implement a QAPI action plan to address environmental hazards, including damaged fall mats, nail holes in walls, and non-functioning toilets. A resident reported ongoing bathroom access issues, and leadership confirmed awareness of these problems without initiating a Performance Improvement Plan.
A resident using an alternating pressure mattress experienced discomfort and had to relocate to the lobby due to a malfunctioning mattress. The facility lacked a policy for maintaining patient care electrical equipment and did not have documentation of inspection or maintenance for the mattress. The Maintenance Director was unaware of the requirement for electrical testing, leading to the deficiency.
Surveyors identified multiple environmental deficiencies, including cracked drywall, peeling paint, damaged furniture, and black residue in resident rooms and bathrooms. Staff and residents reported ongoing plumbing issues that required shared bathroom use, and a resident described long-standing poor wall conditions with incomplete painting. A corporate executive confirmed that unresolved maintenance concerns persisted after the facility owner left the property.
A resident with a history of aggression physically abused two other residents in the facility. Despite having a care plan in place, the facility failed to prevent the assaults, resulting in one resident sustaining a black eye and experiencing pain. The incidents highlight the facility's inability to manage the aggressive behavior of the resident effectively.
A resident with a history of traumatic brain injury and hemiplegia experienced two falls from a mechanical lift due to broken straps. The first fall resulted in a concussion, and although some staff received re-education, not all involved were retrained. The second fall led to a bruise and skin tear, with no documented investigation conducted. The facility failed to adhere to its policies requiring thorough investigations and proper staff training.
A resident with severe cognitive impairment and multiple diagnoses developed several pressure ulcers due to the facility's failure to follow wound care and repositioning protocols. Despite physician orders and family wishes for comprehensive care, treatments were inconsistently administered, and the resident was not regularly turned, leading to multiple untreated wounds.
A resident with severe cognitive impairment successfully eloped from the facility despite having a care plan indicating a risk for elopement. The resident was found outside the facility, and staff interviews revealed that the resident frequently exhibited exit-seeking behavior. The facility's failure to provide adequate supervision and timely response to the alarm resulted in Immediate Jeopardy and substandard quality of care.
The facility failed to ensure that four CNAs received the minimum 12 hours of annual training as required. The new Administrator was unable to provide documentation supporting the completion of the required training for the CNAs.
The facility failed to complete weekly body audits on all residents and did not ensure weekly treatment audits were completed as per the plan of correction. No documentation was found to confirm that these audits were reviewed by the QAPI Committee. Interviews with the Administrator, Administrator in Training, and DON confirmed these deficiencies.
Failure to Assess Resident After Change in Condition
Penalty
Summary
The facility failed to complete an assessment for a resident after a change in condition was identified. On 03/27/26, a CNA noticed the resident had a red, swollen left arm and reported the finding to the UM. The resident had significant baseline impairments, including severe intellectual disability, vascular dementia, contractures, muscle weakness, and dependence on staff for most activities of daily living. The resident was also nonverbal, had a feeding tube, and was documented as needing staff to observe nonverbal cues. Although the arm swelling was reported on 03/27/26, there was no documented evidence that the resident’s arm was assessed that day. The record showed pain assessments were completed every shift and were usually 0, with two later episodes of moderate pain relieved by acetaminophen. On 03/29/26, acetaminophen was given for pain, but there was no documentation that the location of the pain was assessed. On 03/30/26, the resident was observed grabbing the left arm, with swelling from the elbow to the shoulder, slight warmth, and facial grimacing with range of motion. Orders were then obtained for imaging and a venous doppler, and x-ray testing revealed a displaced fracture of the left humerus. Witness statements and interviews showed confusion about which resident had been reported initially, but staff later confirmed that R67 was the resident with the swollen arm. The UM stated that once the correct resident was identified, the NP was told the resident would be monitored and assessed later, and the UM was unsure whether the assigned nurse completed an assessment. The DON stated that when a resident has a change in condition, an instant assessment should be completed and the findings reported to the NP. The deficiency was based on the lack of assessment after the initial report of arm swelling and the delay until the fracture was identified.
Unsafe and Unrepaired Bathroom Conditions
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment in 2 of 7 rooms observed. In one room, the ceramic soap dish in the resident’s bathroom was broken in half and left with jagged, sharp edges. The broken soap dish was observed on 04/28/26 and was still broken on 04/30/26. An LPN stated the broken soap dish had the potential to pose a hazard to any resident who used it and did not know whether a work order had been entered for the repair. In another room, the bathroom sink was clogged and water was not draining. The clogged sink was observed on 04/28/26 and again on 04/30/26. A housekeeper stated he had told the Maintenance Director about the sink two to three weeks earlier, and the Maintenance Director had poured de-clogging solution into it, but the problem was not resolved. Facility records reviewed showed no documented concerns or repairs for either the broken soap dish or the clogged sink, and no completed work orders for either issue during the reviewed timeframe. The Maintenance Director stated staff were supposed to log work orders in a binder at the nursing stations, but staff did not always follow up after verbal notification, and he was not aware of the broken soap dish or that the sink was clogged again.
Failure to Maintain and Service Oxygen Concentrators
Penalty
Summary
The facility failed to maintain oxygen concentrators consistent with professional standards of practice for 2 residents who used oxygen, specifically by not cleaning one resident’s oxygen concentrator filter weekly and by not ensuring preventative maintenance or servicing was completed for two oxygen concentrators. The Director of Nursing stated the facility did not have a policy related to preventative maintenance or cleaning for oxygen concentrators. An undated DeVilbiss 515 Series Instruction Manual stated the air filter and connector should be cleaned at least once a week. One resident was admitted with diagnoses including COPD, vascular dementia with anxiety, sleep apnea, and hypertension. The resident’s MDS showed moderate cognitive impairment, shortness of breath when lying flat, and continuous oxygen therapy. The care plan identified the resident as at risk for respiratory complications related to COPD, sleep apnea, and hypercapnia, and the resident had an order for 3 liters of oxygen via nasal cannula for oxygen saturation less than 90%. Although staff documented changing and dating the oxygen tubing and humidifier bottle weekly, there was no documented evidence that the oxygen concentrator air filter or connector had been cleaned. Observations on multiple dates showed the concentrator filter was dislodged and covered with visible dirt and lint, including thick grayish white lint that could not be pulled off with the fingers. Staff interviews confirmed the filter was dirty and needed cleaning or replacement, and staff stated night shift was responsible for cleaning the concentrators and changing tubing. The facility also failed to provide documentation showing preventative maintenance or servicing for the two DeVilbiss oxygen concentrators used by the residents. The Maintenance Director stated the oxygen concentrator company was responsible for maintenance and servicing, but he could not provide records showing the machines had been serviced. The DON stated he did not know when the concentrators were last serviced and did not know who to call for servicing, and he was unable to provide documentation of maintenance. Later, the DON stated the oxygen provider company maintained the concentrators, but the oxygen provider company’s customer service representative stated they did not provide DeVilbiss Healthcare concentrators to the facility. The Administrator stated the expectation was for the facility to follow protocol and was not aware of any timeframe or schedule for cleaning or maintenance of the oxygen concentrators.
Incomplete Dialysis Assessment and Communication Documentation
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care for a resident with ESRD, dependence on renal dialysis, type 2 diabetes, hypocalcemia, hypertension, hyperkalemia, and hypomagnesemia. The resident was admitted with an order for dialysis chair time on Monday, Wednesday, and Friday, with a requirement that a progress note be completed prior to the visit. The facility’s policy required residents with ESRD to be cared for according to recognized standards of care, and the charting policy required all services provided and changes in condition to be documented in the medical record so the interdisciplinary team could communicate about the resident’s condition and response to care. The resident’s dialysis binder contained a guide for documenting arrival from dialysis, assessment findings, dialysis-related symptoms, access site condition, weight and fluid status, medications and treatments, safety measures, and the resident’s response. The binder also contained a dialysis communication record intended to be completed by both the facility and the dialysis center, including pre-dialysis vital signs, medications administered or held, meal provision, condition alert, and post-dialysis information such as weights, incidents, vital signs, and recommendations. Although the resident was transferred to dialysis multiple times during the month, the record showed no pre-dialysis notes on several dialysis days and no post-dialysis assessments documented on multiple return dates. Staff interviews confirmed that nurses were expected to complete pre-dialysis assessments, document vital signs and medications on the communication form, complete post-dialysis assessments when the resident returned, and enter progress notes in the electronic medical record. However, staff also stated that they often relied on the dialysis binder forms rather than documenting in the electronic record, and several communication forms were undated, incomplete, or not completed by the dialysis center. The unit manager and DON stated that progress notes and communication forms should be completed and reviewed, but the resident’s record still lacked documented pre-dialysis notes for several dialysis visits and lacked documented post-dialysis assessments for multiple returns from dialysis.
Expired Medications Found in Medication Cart
Penalty
Summary
Expired medications were available for resident use in Medication Cart #3, which served Hall 300 and Hall 400. During observation, surveyors found a bottle of naproxen 220 mg with an opened date of 04/29/26 and a manufacturer expiration date of 03/26, along with a half-empty bottle of Orajel 2X Medicated Toothache Rinse with an expiration date of 10/2024. LPN6 confirmed both items were house stock medications and stated they were expired. The facility policies reviewed stated that expired medications are to be promptly destroyed and that medication storage conditions are to be monitored routinely. Facility staff reported that medication carts were audited weekly for expired medications, and weekly audit forms for Hall 400 documented no expired medications in the cart on multiple dates. During interviews, LPN5 and LPN2 stated that expired medications were not effective and that expired or undated medications were to be reported for destruction. The UM stated she was responsible for weekly medication cart audits and said she had bought the naproxen that day and placed it in the cart without checking the expiration date. The ADM and DON stated that expired medications should not have been in the cart and were expected to be disposed of.
Failure to Maintain Proper Kitchen Sanitation and Monitoring
Penalty
Summary
Facility staff failed to follow proper sanitation protocols in the kitchen, as evidenced by the use of incorrect test strips to check the sanitation concentrations for both the dishwashing machine and the three-compartment sink. During observations, the test strips used by dietary staff consistently read zero, indicating that the sanitation levels were not being properly monitored. Additionally, a trash bin without a lid was found in front of the refrigerator doors, and dust and debris were observed on top of the dishwashing machine, further indicating lapses in maintaining a clean and sanitary environment. The Certified Dietary Manager confirmed that the wrong test strips were used, which resulted in inaccurate readings for chlorine concentration. The daily dish machine log showed that staff had been recording appropriate chlorine levels, but these readings were not accurate due to the use of incorrect test strips. The CDM also acknowledged the need for cleaning in the kitchen, specifically noting the unclean area on top of the dishwashing machine and the uncovered trash bin.
Failure to Maintain Effective Infection Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program across all three units, the kitchen, and the main dining room. Observations revealed multiple lapses in hand hygiene practices, including staff not performing hand sanitization before and after resident contact, and residents not being provided hand hygiene before meals. Several wall-mounted hand sanitizer dispensers were found empty for extended periods, and staff did not consistently ensure their availability. Additionally, staff entered dietary areas without proper hair coverings or hand hygiene, and some staff admitted to forgetting these protocols due to being busy. Signage for Enhanced Barrier Precautions was missing outside rooms where it was required, and staff were observed providing care to residents on such precautions without wearing appropriate personal protective equipment (PPE). One resident with a suprapubic catheter, a condition requiring strict infection control, did not have the necessary signage posted, and the agency CNA providing care was not instructed on Enhanced Barrier Precautions. The Infection Control Nurse acknowledged gaps in the implementation of precaution signage and hand hygiene for residents receiving meals in their rooms. Interviews with staff, including the DON and Infection Control Nurse, revealed inconsistent understanding and application of infection control policies, particularly regarding when to use PPE and Enhanced Barrier Precautions. Plumbing issues led to shared bathrooms among residents and staff, further complicating infection control efforts. The Infection Control Nurse also stated that there were no infection control systems in place when assuming the role three months prior, and surveillance did not always catch missing signage or empty sanitizer dispensers.
Failure to Follow Physician's Orders and Provide Timely Incontinent Care
Penalty
Summary
The facility failed to follow physician's orders and provide appropriate care for two residents. One resident, who had a physician's order for daily use of TED hose due to vascular insufficiency and hematoma, was observed with red, swollen legs and was not wearing the prescribed compression stockings. The resident reported not having worn TED hose for two weeks because their pair was destroyed in the washing machine. Agency staff assigned to the resident were unaware of the order, having relied on verbal handoff rather than reviewing the resident's care plan or Kardex. The Director of Nursing confirmed there was no policy in place regarding adherence to physician's orders. Another resident, with diagnoses including anxiety disorder, depression, schizophrenia, and hemiparesis, and who was consistently incontinent of bowel and bladder, did not receive timely incontinent care. The resident and their family reported extended waits for assistance, including an incident where the resident waited up to three hours for care after returning from church. Staff interviews revealed that delays were due to the need for two staff members to assist with mechanical lifts and a practice of waiting for the assigned CNA rather than seeking help from available staff. The LPN involved acknowledged instructing the resident to wait for care due to being busy and the assigned CNA being unavailable. The facility's care plans for both residents included interventions to anticipate and meet care needs, maintain cleanliness, and ensure comfort. However, staff failed to follow these plans, resulting in unmet care needs and non-compliance with physician's orders. The facility's No Pass Zone policy, which required all staff to respond to call lights, was not effectively implemented, contributing to the deficiencies observed.
Lack of Full-Time Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) or certified food service manager (CFSM) to oversee the food and nutrition service, as required. During an initial kitchen tour, it was observed that only two staff members were present, and both confirmed that there was no dietary manager or supervisor on site. Staff reported working independently without direct supervision or guidance from a qualified manager. Interviews with the CDM and facility administration revealed inconsistencies regarding the CDM's presence and role. The CDM stated he was responsible for three buildings and had not been present at the facility for the previous week, as he was assisting at other locations. He acknowledged that he had not had time to train or work closely with the dietary staff at this facility. The administrator initially claimed the CDM was full-time and present for 40 hours the previous week but later admitted uncertainty about the CDM's actual schedule after being informed of conflicting information from the CDM. Review of the job description for the dietary manager confirmed that the position was intended to be full-time and responsible for managing the dining services program, including staff supervision, training, and compliance with federal and state requirements. However, the CDM's own account and staff interviews indicated that these responsibilities were not being fulfilled due to the CDM's absence and divided attention across multiple facilities. This lack of consistent, qualified oversight had the potential to affect all residents receiving food and nutrition services.
Failure to Implement QAPI Action Plan for Environmental Repairs
Penalty
Summary
The facility failed to develop and implement an action plan to address and repair environmental deficiencies, impacting the safety and quality of life for all residents. Observations included fall mats with edges sticking up and significant rips, as well as nail holes in the wall next to a window. These environmental hazards were not addressed through the facility's Quality Assurance and Performance Improvement (QAPI) process, despite being identified. Additionally, a resident reported having to use a bathroom down the hall for several months due to non-functioning toilets. Interviews with facility leadership confirmed that the QAPI Committee was aware of the issue with the toilets but had not developed a Performance Improvement Plan (PIP) to address it. The Corporate Executive acknowledged that repairs had been attempted but had not been discussed with the QAPI Committee, indicating a lack of coordinated action through the established quality assurance processes.
Failure to Maintain and Document Safe Operation of Patient Care Electrical Equipment
Penalty
Summary
The facility failed to maintain patient care electrical equipment in safe operating condition for a resident using an alternating pressure mattress. The facility did not have a policy regarding the maintenance of patient care electrical equipment, and there was no documentation available for the inspection or maintenance of the mattress. On observation, the resident was found lying in bed with the mattress, and reported having to sit in the lobby the previous day due to the mattress malfunctioning and feeling uncomfortable. The Corporate Executive confirmed that the Maintenance Director was unaware of the electrical testing requirement for the mattress, resulting in the absence of maintenance records.
Environmental Deficiencies and Poor Maintenance
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable homelike environment for residents and staff, as evidenced by multiple environmental deficiencies observed during the survey period. Specific findings included cracked and exposed drywall, extensive paint chipping, unpainted patched holes, peeling paint in various colors, and black residue on ceilings and around air vents in several resident rooms and bathrooms. Furniture was also found to be in poor condition, such as a chest of drawers with extensive paint chipping, a deteriorated blue chair with worn fabric, and a bed footboard with a longitudinal crack. Additionally, a resident's manual wheelchair was observed with torn and damaged foam on the armrest. Bathrooms were noted to have thick black substances in the corners, peeling walls, and cracked door jams. Interviews with staff and residents confirmed ongoing issues, including unresolved plumbing problems that required staff and residents to share bathroom facilities. One resident reported that the poor wall conditions had persisted for a long time, with incomplete painting in their room. A corporate executive disclosed that the facility's owner had left the property, resulting in numerous unresolved concerns, including the ongoing plumbing issues. These observations and interviews collectively demonstrate the facility's failure to provide a safe, clean, and comfortable environment for its residents and staff.
Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, specifically involving two residents, R5 and R6, who were physically abused by R4. R4, who had a history of physical aggression and severe cognitive impairment, was admitted to the facility with diagnoses including paranoid schizophrenia and violent behavior. Despite having a care plan that identified R4's potential for physical aggression, the facility did not effectively prevent R4 from physically assaulting R5 and R6. R5, who had moderate cognitive impairment and a history of Alzheimer's disease and vascular dementia, was struck in the face by R4 over a misunderstanding regarding a wheelchair. This incident resulted in R5 sustaining a black eye and experiencing pain, which required medical attention. The facility's staff, including CNAs and an LPN, were present during the incident but were unable to prevent the assault. R5 expressed fear and discomfort following the incident, indicating a failure in the facility's ability to ensure a safe environment. R6, who had severe cognitive impairment and a history of hemiplegia and vascular dementia, was also physically assaulted by R4. This incident occurred after R6 allegedly called R4 a derogatory name, prompting R4 to punch R6 in the face. Although R6 did not sustain visible injuries, the incident highlights the facility's inability to manage R4's aggressive behavior effectively. The facility's failure to adequately monitor and address R4's known behavioral issues contributed to these incidents of resident-to-resident abuse.
Failure to Investigate Mechanical Lift Incidents
Penalty
Summary
The facility failed to conduct a complete and thorough investigation for a resident who experienced two falls from a mechanical lift. The first incident occurred when the sling strap broke during a transfer from the bed to a wheelchair, resulting in the resident hitting their head on the wheelchair arm. This incident led to a concussion and cervical strain, as confirmed by an emergency department visit. Although staff involved in this incident received re-education on mechanical lift safety, there was no evidence that all relevant staff, including those involved in the second incident, received similar training. The second incident involved the same resident falling when the shower harness strap broke during a transfer from a shower chair to the bed. The CNA involved attempted to brace the resident with their leg to prevent injury. Despite this effort, the resident sustained a bruise and a skin tear. There was no documented investigation for this incident, and the CNA involved had not received re-education on mechanical lift safety following the first incident. The resident involved had a medical history of traumatic brain injury, hemiplegia, and muscle weakness, which increased their risk of falls. The facility's policies required that all injuries be investigated and that only trained personnel operate mechanical lifts. However, the facility did not adhere to these policies, as evidenced by the lack of a documented investigation for the second incident and incomplete staff re-education following the first incident.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide treatment and services to prevent and/or heal a resident's pressure ulcers, resulting in the resident acquiring multiple pressure ulcers. The resident, who had severe cognitive impairment and was receiving hospice care, was admitted with diagnoses including vascular dementia, chronic obstructive pulmonary disease, and hyperlipidemia. Despite being at high risk for skin breakdown due to immobility and incontinence, the facility did not adhere to its own policies for skin and wound management and repositioning, leading to the development of multiple pressure ulcers on the resident's body. The facility's records revealed that the resident had several deep tissue injuries and unstageable wounds that were not properly treated as per physician orders. The Medication Administration Record and Treatment Administration Record indicated that wound care treatments were not consistently administered. Interviews with the Director of Nursing and other staff members revealed a lack of proper documentation and execution of turning and repositioning protocols. Additionally, there was a discrepancy between the facility's claim that the family had refused wound care and the family's statement that they wanted all comfort measures, including wound care, to be provided. The hospice staff also reported that the resident was not being turned regularly and that they were not in the facility daily to change dressings as ordered. This neglect was reported to various authorities, leading to the discovery of the resident's untreated wounds. The facility's failure to follow its own policies and physician orders for wound care and repositioning directly contributed to the resident's deteriorating condition and the development of multiple pressure ulcers.
Removal Plan
- The CEO/Nurse met with the Agape Nurse to ensure treatments for residents under their care were being documented in the hospice notes and the staff of the facility will complete on days they are not in the facility.
- All residents had a head-to-toe assessment completed by licensed nurses. All identified areas were provided treatment if warranted. The attending physician and resident's representative were notified.
- All residents will have a head-to-toe skin assessment upon admission and weekly skin assessment thereafter. All current residents will have a weekly skin assessment completed to ensure the skin remains intact.
- All licensed and certified staff will be educated on ensuring residents preventative measures are in place for wound care to include: 1. Weekly Skin Assessment and prevention. 2. Shower Skin Audit (completed by C.N.A.). 3. New Admission Skin Assessment and prevention. 4. Turning and repositioning. 5. Abuse and Neglect.
- Licensed nurses were educated on the protocol for identifying risk and wounded residents and ongoing to include notifying the MD and RR.
- The Director of Nursing or designee will audit the treatments weekly to ensure the residents have been provided proper wound care treatment per the MD order.
- The Director of Nursing will review the audit with the administrator to ensure the protocol is being followed.
- The Administrator and DON will review the completed weekly skin audits with the monthly QAPI Committee for further follow-up and recommendations.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident with severe cognitive impairment. The resident, who had a history of exit-seeking behavior and was at risk for elopement, successfully left the facility. The incident occurred when door exit alarms were triggered, and the resident was found outside the facility, approximately 200 feet away, ambulating with a rollator walker. The resident was appropriately dressed for the weather and was returned to the facility without injuries. However, the resident continued to exhibit exit-seeking behavior and required constant redirection and 15-minute checks to ensure safety. The resident's care plan indicated a risk for elopement due to cognitive impairment, but the interventions in place were insufficient to prevent the elopement. The care plan had been updated multiple times, but the resident's exit-seeking behavior persisted. The facility's policy on wandering and unsafe residents aimed to prevent elopement while maintaining a least restrictive environment, but the staff failed to adequately supervise the resident and prevent the elopement. Interviews with staff revealed that the resident frequently exhibited exit-seeking behavior and required constant reminders and redirection. On the day of the elopement, staff initially thought the alarm was from a different door, leading to a delay in locating the resident. The Director of Nursing was informed, and the resident was placed on 15-minute checks. The facility's failure to provide adequate supervision and timely response to the alarm resulted in the resident's successful elopement, constituting Immediate Jeopardy and substandard quality of care.
Removal Plan
- Resident 1 was escorted back into the facility and assessed without injury, placed on 15-minute checks, MD and RP notified. The elopement assessment was revised with a score of 4 indicating at risk for elopement and the care plan was updated with the new assessment information.
- All egress doors were checked by the Maintenance Director after the elopement and all doors were working properly.
- The DON and Unit Coordinator are completing the wandering and elopement assessment on all residents. Any change in elopement status will be care planned, and the MD and RR notified.
- The Director of Nursing and Administrator were educated on the Elopement Resource manual and Elopement Policy and Procedure by the CEO who is a licensed nurse, Social Worker and LNHA.
- All departments will be educated on the Elopement Resource manual and Elopement Policy and Procedure by the Administrator and Director of Nursing.
- The Elopement Resource Manual and Elopement Policy and Procedure Education will be included in the new hire orientation.
- The maintenance or designee will audit the door daily and Manager on Duty on the weekend to ensure the egress doors are in good repair and enunciate correctly. The Administrator will review the completed audits for further follow-up if warranted.
- The Plan of Correction for F689 was reviewed with the QAPI Committee to include the Medical Director without changes.
- The completed audits and identified listing of residents that are at risk of elopement will be reviewed monthly in the QAPI committee for further follow-up and recommendations.
Failure to Ensure Annual CNA Training
Penalty
Summary
The facility failed to ensure that four Certified Nursing Assistants (CNAs) received the minimum 12 hours of annual training as required. The facility's policy mandates that nurse aides must undergo a state-approved training program and participate in a state-approved training and competency evaluation program. During an interview, the Administrator, who was new to the facility, was unable to provide documentation supporting that the four CNAs had completed the required training. Despite efforts to contact the agency for supporting training documents, the necessary documentation was not available at the time of the survey.
Failure to Complete and Review Weekly Body and Treatment Audits
Penalty
Summary
The facility failed to ensure weekly body audits were completed on all residents and further failed to ensure the weekly treatment audits were completed as stated in the plan of correction. No documentation was found to confirm that the weekly skin and treatment audits were reviewed by the QAPI Committee. During interviews with the Administrator, Administrator in Training, and the Director of Nursing, it was confirmed that the weekly body audits were not being completed, and there was no documentation to ensure the treatments were audited and completed as required.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 16 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sumter
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare - Sumter | 5.4 mi | ★★★★★ | 1 | 0 |
| Sumter East Health & Rehabilitation Center | 6 mi | ★★★★★ | 10 | 0 |
| Pocotaligo River Health And Rehab | 13.1 mi | ★★★★★ | 4 | 0 |
| Lake Marion Nursing Facility | 17.5 mi | ★★★★★ | 1 | 0 |
| Calhoun Convalescent Center | 25.5 mi | ★★★★★ | 9 | 1 |
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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.