Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Opus Post Acute Rehabilitation during CMS and state inspections, most recent first.
A resident with significant physical and cognitive impairments, requiring staff assistance for all ADLs, was left without access to their call light after a CNA intentionally removed it and placed it out of reach. This action was confirmed by the DON and constituted neglect, as it violated facility policy and the resident's care plan, though no adverse outcomes were reported during the incident.
Staff did not remove plated food, utensils, and drinks from serving trays onto the table for three residents dining communally, and a CNA stood while assisting a dependent resident with a meal instead of sitting, contrary to facility policy and expectations for promoting dignity and a homelike environment.
Surveyors found that call lights were not within reach for multiple residents with varying cognitive and physical impairments, and one resident's wheelchair had damaged arms. These deficiencies were observed during the survey and confirmed by facility leadership as contrary to policy.
Surveyors identified that a fall mat was improperly positioned under a bed, creating a hazard, and that several bathroom floors were excessively slippery due to a greasy buildup, leading to resident falls. Additionally, a resident with severe cognitive impairment and a history of falls was left unsupervised in a geri-chair, resulting in a fall and injury. Staff and administration were unaware of these hazards, and improper cleaning practices were suggested as a contributing factor.
Staff did not assist or offer hand hygiene to four residents before or after meals, and bath basins for three residents were found uncovered and unlabeled under shared sinks. The DON confirmed that facility procedures require both hand hygiene assistance and proper labeling and covering of basins.
The facility failed to maintain proper infection control measures for aerosol drainage bags and a shared glucometer. Observations showed drainage bags on the floor and improper cleaning of the glucometer between residents. Staff lacked awareness of infection control protocols, posing a risk of cross-contamination and infection spread among residents with respiratory and diabetes care needs.
The facility failed to label, store, and discard food items according to expiration dates, as required by policy. During a survey, numerous items in the main kitchen were found without labels or expiration dates, including rice, croutons, marshmallows, noodles, cheeses, and bread products. Interviews with staff revealed inconsistencies in implementing the labeling and dating policy, with the Lead Cook and Regional Dietician acknowledging lapses in procedure.
The facility failed to provide a homelike environment for two residents. One resident, with multiple health issues, had to manage her own breakfast tray and move a trash can from her shower. Another resident's room was not cleaned properly, with chips scattered on the floor for days. Staff confirmed these conditions were not in line with facility policies.
A facility failed to obtain necessary lab orders for a repeat PT/INR test after adjusting a resident's Coumadin dose. The resident, with a history of atrial fibrillation and deep vein thrombosis, required close monitoring of INR levels. Despite expectations for nurses to ensure follow-up tests, the Director of Nursing could not find an order for the repeat test, leading to a deficiency in care standards.
A resident with multiple health issues, including diabetes and heart failure, did not receive prescribed nutritional supplements due to a failure in updating meal tickets. Despite a physician's order for fortified pudding to prevent malnutrition, the dietary department did not include it on the resident's meal tickets, resulting in the resident not receiving the supplements. The oversight was acknowledged by the dietary manager, and the issue was not known to the director of nursing or the administrator until it was brought to their attention.
A resident with chronic respiratory conditions was not provided the correct oxygen flow rate as per physician orders, receiving incorrect levels of 2.5 LPM and 1.5 LPM instead of the prescribed 2 LPM. The resident was unaware of how to adjust the machine, and staff had not verified the settings since the initial setup. The DON acknowledged the importance of adhering to physician orders to prevent health decline.
The facility failed to properly store drugs and biologicals in two treatment/medication carts, as observed during a survey. Items such as wound dressings and gauze were found opened and no longer sterile, and some were expired. A registered nurse confirmed that opened items should be discarded, but these items were only discarded after being observed by surveyors. The facility's policy requires routine inspection and proper storage of medications, which was not adhered to.
Call Light Removed from Resident's Reach by CNA
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) removed a resident's call light and placed it out of the resident's reach, resulting in the resident not having access to the call light. The facility's policy on the prevention of abuse requires staff to deliver care in a manner that respects residents' rights and ensures their safety, including access to assistance. The resident involved had multiple diagnoses, including muscle weakness, cognitive communication deficit, lack of coordination, and required staff assistance for all activities of daily living (ADLs), transfers, bed mobility, and personal care. The resident's care plan specifically indicated a need for staff assistance with toileting, transfers, and other ADLs due to physical and cognitive limitations. The incident was confirmed through interviews and record review. The resident recalled the incident and identified the CNA involved, stating that other staff members treated him well and that he felt safe in the facility. The Director of Nursing (DON) confirmed that the CNA admitted to removing the call light and placing it out of reach. The resident did not experience any negative or adverse outcomes during the period without the call light, but the removal itself constituted neglect of the resident's needs as outlined in the facility's policies and the resident's care plan.
Failure to Promote Homelike Dining Experience and Dignified Meal Assistance
Penalty
Summary
The facility failed to promote a homelike dining experience for its residents, as observed during meal service. Three residents who dined communally in the main dining room were served their meals on trays, with staff failing to remove the plated food, eating utensils, and drinks from the serving trays onto the table. One of the residents confirmed that staff do not move the trays, and the Director of Nursing acknowledged that it is the facility's expectation for staff to remove food from serving trays to encourage a homelike environment. Additionally, a dependent resident with quadriplegia and intact cognition was observed being assisted with a meal by a CNA who stood at the bedside rather than sitting, as is expected for feeding residents. The CNA confirmed her practice of standing while assisting this resident, stating it was easier for him, despite knowing the expectation to sit while feeding. These actions were inconsistent with the facility's policy to treat all residents with kindness, dignity, and respect.
Failure to Ensure Call Lights Within Reach and Wheelchair Maintenance
Penalty
Summary
The facility failed to ensure that call lights were within reach for six out of thirteen residents reviewed, as required by their own Call Light/Bell policy. Observations revealed that call bells for several residents were either hanging on the wall, on the floor, or off the bed, making them inaccessible. These residents had varying degrees of cognitive impairment and physical limitations, including severe dementia, muscle weakness, hemiplegia, and unsteadiness on their feet. The policy states that the call device should be placed within the resident's reach before staff leave the room, but this was not consistently followed. Additionally, the facility failed to maintain a resident's wheelchair in good repair, as one resident was observed with wheelchair arms that were tattered, peeling, and worn. Interviews with the DON and Administrator confirmed that call bells should always be within reach of residents, indicating awareness of the policy. The deficiencies were identified through direct observation and review of medical records, which documented the residents' medical conditions and cognitive status at the time of the incidents.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for several residents. One resident's fall mat was observed to be stuck under the wheel of the bed and protruding, creating an accident hazard. Additionally, the bathroom and shower room floors for four residents were found to have a buildup of a grey, greasy substance, making the floors excessively slippery. Multiple residents reported that the bathroom floors were very slippery when wet, and two residents stated they had fallen in the bathroom due to the slippery conditions. Staff interviews revealed that the maintenance director and administration were not aware of the slippery floors, and the maintenance director suggested improper cleaning practices could be the cause. In another incident, a resident with severe cognitive impairment, a history of repeated falls, and agitation was left unsupervised in a geri-chair while the assigned CNA left the room to retrieve supplies. The resident fell from the chair, resulting in a head laceration and requiring hospital evaluation. The CNA acknowledged that he should not have turned his back on the resident and should have gathered all necessary supplies beforehand. The DON confirmed that the resident was care planned for falls and that staff were expected to maintain supervision. The facility's policy required monthly environmental rounds to ensure a safe and functional environment, but observations and interviews indicated lapses in both environmental safety and staff supervision. The lack of awareness and failure to address known hazards, such as improperly placed fall mats and slippery bathroom floors, as well as inadequate supervision of high-risk residents, directly contributed to the deficiencies identified during the survey.
Failure to Provide Hand Hygiene and Properly Label Bath Basins
Penalty
Summary
Staff failed to assist or offer hand hygiene to four residents before and/or after meals, as observed during multiple meal times. These residents had varying degrees of cognitive impairment and physical limitations, including sequelae of cerebral infarction, spinal stenosis, dementia, diabetes, hemiplegia, traumatic brain injury, muscle wasting, and atrophy. Observations confirmed that staff did not provide or prompt hand hygiene for these residents during meal service. Additionally, bath basins used by three residents were found uncovered and unlabeled under shared vanity sinks. The Director of Nursing confirmed that facility procedure requires basins to be labeled and covered with plastic, and that staff are expected to assist residents with hand hygiene before and after meals. These lapses were directly observed and confirmed through staff interview.
Infection Control Deficiencies in Aerosol and Glucometer Practices
Penalty
Summary
The facility failed to ensure proper infection control measures were taken regarding aerosol drainage bags for two residents. Observations revealed that the aerosol drainage bags for these residents were found on the bedroom floor on multiple occasions. The Director of Nursing acknowledged that the drainage bags should not have been on the floor due to infection control concerns. Both residents had significant respiratory conditions requiring tracheostomy care and continuous aerosol therapy, which necessitated strict adherence to infection control protocols. Additionally, the facility did not properly clean and disinfect a blood glucose meter that was shared among multiple residents. Observations showed that staff did not follow the facility's policy or the manufacturer's recommendations for cleaning and disinfecting the glucometer between uses. Staff members were observed placing the glucometer on unclean surfaces and failing to use appropriate barriers or disinfectants. Interviews with staff revealed a lack of awareness and understanding of the proper procedures for cleaning the glucometer, which is critical to prevent cross-contamination and the spread of infections. The facility's failure to adhere to infection control protocols for both aerosol drainage bags and the glucometer was identified as a serious deficiency. The State Agency determined that these lapses in infection control posed a risk of serious harm to residents, leading to the identification of Immediate Jeopardy related to infection control practices. The facility's policies were not effectively implemented, resulting in potential exposure to infectious agents for residents requiring respiratory and diabetes management care.
Removal Plan
- Resident sample numbers #388, #45, #340 the licensed nurses on staff at that time were immediately in-serviced once notified by surveyor to prevent future occurrences, glucometer cleaned and disinfected, notifications of incident made to Medical Director and Nurse Practitioner with no new orders.
- All residents that require glucose monitoring by glucometer have the potential to be affected.
- Inservice initiated with all licensed nurses and completed prior to the nurses next scheduled shift by the Director of Nursing and/or clinical supervisors, staff were educated on equipment cleaning of the glucometer devices to include cleaning and disinfecting before and after each resident's use.
- Staff educated to clean with an EPA disinfectant for the wet time that is indicated by manufacturer guidelines that is effective against blood borne pathogens that meet OSHA's standards. Licensed nurses educated on utilizing a barrier between the glucometer device and in contact with surface areas to prevent cross contamination and the prevention of the spread of blood borne pathogens.
- Staff education reinforced at the Annual Skills Fair.
- All licensed nurses will be educated on the glucometer policy upon hire and during new hire orientation.
- The clinical nursing supervisors will complete audits to ensure that all staff remain in compliance with infection control procedure for glucometer cleaning and disinfecting of blood glucose devices.
- ADHOC QAPI meeting held to discuss alleged deficiencies and implementation of POC.
- Findings of the audit will be reported to the Administrator and Director of Nursing for compliance review.
- Failure to adhere to facility policy will be considered a violation. Violations will result in disciplinary action in accordance with the facility progressive disciplinary policy.
- A report of findings and subsequent disciplinary action, if applicable, will be reported to the facility Quality Assurance Committee consisting of Director of Nursing, Medical Director, Administrator, Pharmacy Consultant to review the need for continued intervention or amendment of and disposed of in accordance with the facility policies and procedures.
Failure to Label and Discard Expired Food Items
Penalty
Summary
The facility failed to ensure that food items in the main kitchen were labeled, stored, and discarded according to their expiration dates, as observed during a survey. The facility's policy requires all food items in storage areas to be labeled and dated, with specific guidelines for newly opened items. However, during an inspection of the dry storage, walk-in refrigerator, and deep freezer, numerous food items were found without labels or expiration dates. These included bags of rice, croutons, marshmallows, spaghetti noodles, and various cheeses, among others. Additionally, several items were found to be expired, such as grated Parmesan cheese, crinkle cut wedge potatoes, and various bread products. Interviews with the facility's staff revealed inconsistencies in the implementation of the labeling and dating policy. The Lead Cook acknowledged her responsibility for ensuring items are properly labeled and dated but admitted there was no way to determine when some items were opened. The Regional Dietician stated that deliveries are labeled with the delivery date and that monthly walkthroughs are conducted to check labeling and dating. However, the presence of expired and unlabeled items suggests a lapse in these procedures. The Kitchen Manager also mentioned that food items are dated per delivery date and that prepared items have a 48-72 hour usage window, but the findings indicate these practices were not consistently followed.
Failure to Maintain a Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for two residents, leading to deficiencies in their care. One resident, who was admitted with multiple diagnoses including chronic diastolic congestive heart failure and major depressive disorder, reported that her breakfast tray remained on her table until lunchtime, indicating a lack of assistance from staff. Additionally, a large trash can was observed in her shower, which she had to move herself to take a shower. A CNA confirmed that trash cans are not usually kept in showers and acknowledged that the trash can should not have been there. Another resident, admitted with conditions such as peripheral vascular disease and chronic kidney disease, had chips scattered across the floor of her room over several days. The Environmental Services Director confirmed that the room should have been swept and mopped daily, indicating a failure in maintaining cleanliness. The Director of Nursing also stated that trash cans should not be in residents' showers, further highlighting the facility's failure to ensure a safe and comfortable environment for its residents.
Failure to Obtain Follow-Up Lab Orders for Anticoagulant Therapy
Penalty
Summary
The facility failed to adhere to professional standards of practice by not obtaining lab orders for a repeat PT/INR test after adjusting the anticoagulant medication, Coumadin, for a resident. The resident, who was cognitively intact, had a history of proximal atrial fibrillation, Type 2 Diabetes, deep vein thrombosis, and hypertension. The resident's Coumadin dose was adjusted due to fluctuating INR levels, but the necessary follow-up lab orders to monitor the INR levels were not obtained, which is a critical step in managing anticoagulation therapy. Interviews with the Director of Nursing (DON) and the Nurse Practitioner (NP) revealed that there was an expectation for nurses to ensure follow-up PT/INR tests were ordered and conducted. However, the DON was unable to locate an order for a repeat INR test after the medication adjustment, and the NP stated that if she forgets to order a repeat PT/INR, the nurses should contact her. This oversight in obtaining the necessary lab orders after a medication adjustment led to a deficiency in the standard of care provided to the resident.
Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility failed to provide nutritional supplements to a resident, as prescribed by the physician, to prevent potential nutritional problems or further weight loss. The resident, who was admitted with multiple diagnoses including cerebral infarction, Type 2 Diabetes Mellitus, and heart failure, was observed to be weak and malnourished. Despite having a physician order for fortified pudding with lunch and dinner due to the risk of malnutrition, the resident reported not receiving any supplements since admission, only a meal tray and one drink due to fluid restrictions. The resident's electronic health record confirmed the physician's order for fortified pudding, which was not reflected on the meal tickets. The dietary aide and registered dietician confirmed that the meal tickets did not include the fortified pudding, indicating the resident had not been receiving the prescribed supplements. The dietary manager admitted to forgetting to manually update the meal ticket to include the fortified pudding, despite receiving the diet communication form from nursing staff. Interviews with the director of nursing and the administrator revealed a lack of awareness of the resident's weight loss and the failure to execute physician orders. The director of nursing, who had recently assumed the position, emphasized the expectation for staff to follow physician and dietary orders to prevent further decline in residents. The administrator, who was also unaware of the issue, planned to address the matter in an upcoming QAPI meeting.
Failure to Provide Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for a resident, identified as R140, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. The physician's order specified that R140 should receive oxygen at 2 liters per minute (LPM) via nasal cannula continuously. However, observations revealed that R140 was receiving oxygen at incorrect flow rates of 2.5 LPM and 1.5 LPM at different times, contrary to the physician's order. Interviews with R140 and the nursing staff indicated that the resident was not aware of how to adjust the oxygen machine, and the staff had not checked the oxygen settings since the initial setup. The Registered Nurse (RN1) confirmed the discrepancy in the oxygen flow rate and acknowledged that the resident had not been out of bed since admission, which required continuous oxygen therapy. The Director of Nursing (DON) stated that it was unacceptable for residents not to receive the correct flow rate, emphasizing the importance of following physician orders to prevent further decline in residents' health.
Improper Storage of Drugs and Biologicals
Penalty
Summary
The facility failed to ensure proper storage of drugs and biologicals in two of five treatment/medication carts, as observed during a survey. The facility's policy, dated 2014, mandates that medications and biologicals be stored safely, securely, and properly, following the manufacturer's or supplier's recommendations. It also requires nurses to routinely inspect medication storage facilities and discard any items that are no longer sterile or have expired. However, during observations, several items were found opened and no longer sterile, including wound dressings and gauze, and some items were expired. During interviews, a registered nurse (RN) confirmed that once a sterile item is opened, it should be discarded. Despite this, the survey revealed that opened and expired items were present in the Transitional Care Unit (TCU) and Continuing Care Unit (CCU) treatment carts. The RN was observed discarding these items only after the surveyor's observation. The RN also stated that each nurse is responsible for their own dressing changes, indicating a lack of adherence to the facility's policy on medication storage and inspection.
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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 West Columbia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Millennium Post Acute Rehabilitation | 0.9 mi | ★★★★★ | 9 | 0 |
| Nhc Healthcare - Lexington | 1.3 mi | ★★★★★ | 1 | 0 |
| Presbyterian Home Of South Carolina-columbia | 2.5 mi | ★★★★★ | 0 | 0 |
| Still Hopes Episcopal Retirement Community | 2.9 mi | ★★★★★ | 0 | 0 |
| St Andrews Operator, Llc | 4.4 mi | ★★★★★ | 0 | 0 |
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