Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Pruitthealth- Aiken during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including stroke-related deficits, was found unresponsive and pulseless, but CPR was not started because staff relied on conflicting EMR information showing DNR status. The active physician order still listed the resident as Full Code, and the chart did not contain a valid DNR order or POLST at the time of the event. Staff used different sources to determine code status, and the responding RN did not verify the physician order before calling time of death.
Spa 100 was found in disrepair, with residents reporting mildew on the walls. Observation showed missing wall and floor tiles, exposed plywood, a loose handrail, cracked tiles, and a black substance in the grout. The LPN did not know why repairs were not completed, the HM said the shower room was cleaned every other day and remained damp, and the Administrator stated shower one had previously been blocked off but was currently accessible and that there was no housekeeping policy or written process for cleaning the shower tiles.
Failure to Maintain Resident Dignity: Two residents with severe cognitive impairment were observed in situations that did not preserve dignity. One resident was left in a hospital gown and undressing in a public area near the nurse's station without immediate staff redirection or covering, and the DON stated he had no clothes at the facility. Another resident's room was used by a CNA to complete facility in-service training on a tablet, which the CNA acknowledged should have been done in a break area or at the nurse's station rather than in a resident's room without permission.
Failure to complete PASARR Level II evaluations for two residents with serious mental illness. One resident had diagnoses including bipolar disorder and major depression, and the record lacked evidence of a Level II PASARR before survey. Another resident had depression and later received a bipolar II diagnosis in a psychotherapy note, but the facility could not show a Level II PASARR request after the new diagnosis. Staff stated there was no process for notifying SW of significant mental health changes, and MDS nurses said the mental health provider was expected to notify the facility.
A facility binder labeled for survey results was kept in a hallway cabinet, but it did not include the most recent recertification survey or any plan of correction. The Administrator confirmed the missing survey results and stated the facility had no policy addressing survey results postings.
A resident's Diazepam medication was misappropriated when an LPN signed out additional doses without a physician's order or proper documentation. The resident, with an Anxiety Disorder, was prescribed Diazepam twice daily, but discrepancies in the Controlled Drug Record indicated extra doses were signed out at unauthorized times. The LPN involved could not recall administering these doses and failed to communicate during the investigation, leading to her termination. The facility's policies on medication management were breached, resulting in unaccounted Diazepam pills.
The facility failed to report an allegation of sexual abuse involving two residents to the Ombudsman, as required by state law. A social worker documented the incident and informed the Administrator and DON, and the police were called. However, the Administrator admitted to not reporting any allegations to the Ombudsman, which is a violation of the facility's policy and state requirements.
The facility failed to properly store and label food items in the main kitchen, as required by its policies. During a survey, several items were found undated and unlabeled, including sandwiches, a pureed item, and hard-boiled eggs. Expired milk cartons and a container of pork loin were also discovered. Interviews with staff revealed a lack of adherence to policies, with the Kitchen Manager and Administrator acknowledging the need for proper labeling and daily checks.
A resident experienced unmanaged severe pain due to the misappropriation of controlled medication. The facility failed to maintain accountability for Oxycodone, resulting in several doses being unavailable. Nursing staff reported issues with medication orders and communication with the pharmacy, contributing to the deficiency.
A facility failed to conduct a PASARR Level 1 for a resident before admission and did not refer them for a PASARR Level II after a new severe mental illness diagnosis. The resident, with moderate cognitive impairment and psychotic symptoms, was on antipsychotic medication, yet the PASARR assessment was not updated to reflect their mental health status.
A resident with specific dietary restrictions was served fish despite clear instructions to avoid it. The resident, who is cognitively intact, reported that such errors occur frequently. The kitchen staff and CNAs are responsible for ensuring meal tickets reflect dietary preferences, but this oversight led to a deficiency.
A facility failed to coordinate care for a resident with complex psychiatric needs, resulting in missed medication recommendations. The resident, under the care of a Psychiatric NP and an outside PCP, had a care plan that included various psychiatric medications and recommendations for adjustments. However, the facility did not communicate these recommendations to the outside PCP, leading to a lack of coordination. The facility lacked a policy for handling orders for residents with an outside PCP, resulting in the resident not receiving a recommended mood stabilizer.
A resident with bipolar disorder and depression, who was cognitively intact, experienced verbal abuse from a CNA. The incident involved a verbal altercation where the CNA used profanity in response to the resident's belligerent behavior. The CNA was immediately terminated following the incident.
Failure to Initiate CPR When Code Status Was Not Validly Documented
Penalty
Summary
The facility failed to ensure CPR was initiated for one resident who did not have a valid DNR order in place at the time she was found unresponsive and pulseless. The resident had been admitted and readmitted from an acute care hospital with diagnoses including UTI, type 2 diabetes mellitus, CKD stage 3, acute on chronic systolic CHF, and hemiplegia/hemiparesis following a stroke. Her EMR contained conflicting code status information: the face sheet and care plan reflected DNR/palliative care or Full Code in different areas, while the physician orders listed her as Full Code and the EMR also contained notes indicating she had not executed an advance directive and did not have a DNR order in place. When the resident was found in her room, staff documented that she was flat on the bed, warm, soft to touch, with eyes closed, not breathing, and without a pulse. The nurse who responded documented that no resuscitation was done because the resident was listed as DNR on file, and time of death was called. The record also showed that the resident did not have a South Carolina EMS DNR Order form or POLST on file during her stay, and the facility’s physician orders still reflected Full Code. The hospital discharge summary and later physician progress note referenced DNR or palliative care, but those statements were not reflected on the active physician order page at the time of the event. Interviews showed that staff relied on different sources to determine code status, including the EMR banner, care plan, face sheet, DNR binder, and physician orders, and their responses varied on which source they would follow if information conflicted. The nurse who responded to the event stated he checked the EMR banner, which showed DNR, and did not look at the physician order because he did not have time. Another nurse later verified the resident had expired based on the banner and physical assessment. The facility’s own investigation concluded that the active orders page had not been updated to reflect current code status information, and the record also showed that the facility did not have a valid DNR order in place in the chart at the time CPR was not initiated.
Spa 100 Shower Room in Disrepair
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment in Spa 100, the shower room used by residents on Hall 100. During the Resident Council Meeting, residents reported that the shower room was in disrepair and had mildew on the walls. On observation, shower one had a two-foot by two-foot wall area with numerous missing tiles, additional missing tiles on the opposite wall, a loose handrail held by one screw, and exposed plywood where tiles should have been. Shower two had several cracked wall tiles and a black substance in the grout in the right back corner. The shower room floor also had several missing ceramic tiles where water collected and made the area difficult to clean. During interviews, the LPN stated she did not know why repairs had not been completed and referred questions about the black substance to housekeeping. The HM stated the shower room was cleaned every other day and did not know whether the black substance had been present longer than two days, adding that the room remained damp because many resident showers were completed daily. The Administrator and MD confirmed the missing tiles, cracked tiles, and black substance, and the MD stated he had tried to repair the missing floor tiles but they would not stay down. The Administrator stated shower one had previously been blocked off but was currently accessible for use, and also stated the building was older and had not been remodeled. He further stated there was no housekeeping policy or written process regarding cleaning of the shower tiles.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to provide two residents with dignity. R9, who was admitted with diagnoses including cerebral infarction, speech and language deficits following cerebral infarction, adult failure to thrive, and anxiety disorder due to a known physiological condition, had severe cognitive impairment with a BIMS score of 5 and required substantial to maximal assistance with upper body dressing and was dependent on staff for lower body dressing. He was care planned for attention-seeking behaviors, including yelling, cursing, crawling or rolling on the floor in his room, and fixation on food. During observation, R9 was seen near the nurse's station in a green hospital gown and undressing himself in a public area around other residents and staff, and no staff initially redirected him or covered him with appropriate clothing or blankets. RN1 only placed a blanket over him after being prompted by the surveyor. The DON stated that R9 had no specific care plan intervention for undressing in public and that he had no clothes at the facility. R10, who had diagnoses including Alzheimer's disease, muscle weakness, unsteadiness on feet, and restlessness and agitation, also had severe cognitive impairment with a BIMS score of 3. During observation, CNA1 was found sitting in R10's room completing facility in-service training on a facility tablet with the resident's bedside table in front of her. CNA1 stated she was not providing one-to-one supervision and acknowledged that she should have completed the in-service in a break area or at the nurse's station rather than in a resident's room without permission. The Administrator and DON later stated that staff should show respect and dignity in residents' rooms and agreed that the CNA's behavior did not meet their expectations related to dignity.
Failure to Complete PASARR Level II Evaluations for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to refer two residents diagnosed with serious mental illness for PASARR Level II evaluation. One resident was admitted with diagnoses including major depression, bipolar disorder, and mood disorder, and had a quarterly MDS showing a BIMS score of 10 out of 15, indicating moderate cognitive impairment. The resident’s record contained a PASARR Level I completed years earlier that identified bipolar disorder and recommended no further evaluation, but no Level II PASARR was available in the record, and the facility could not provide evidence that one had been completed before the survey. The second resident was admitted with diagnoses including personality disorders, dementia, adjustment disorder with depressed mood, and depression. The resident’s quarterly MDS showed a BIMS score of 14 out of 15, indicating cognitive intactness. The record contained a PASARR Level I completed earlier that identified depression and recommended no further evaluation, but a psychotherapy note later added a diagnosis of bipolar II disorder. The facility could not provide evidence of a request for a Level II PASARR after that diagnosis was added. During interviews, Social Work staff stated they were not aware of the new bipolar diagnosis until recently and had no process for being notified of significant mental health changes, and MDS nurses stated the mental health provider should notify the facility when a new significant diagnosis was added.
Survey Results Not Publicly Available
Penalty
Summary
The facility failed to provide public access to the most recent survey results and any plan of correction. During an observation in the main hallway, a small brown cabinet with a sign reading "Annual Survey Results Inside" was found containing a blue binder labeled "Survey Results." The binder included complaint survey results dated 06/18/25, 03/24/25, 02/22/25, 01/23/25, 12/31/24, 11/21/24, 07/26/24, 05/02/24, 11/02/23, and 08/02/23, but it did not contain the facility's previous recertification survey conducted on 09/12/24. The Administrator confirmed that the binder lacked the results of that recertification survey and also confirmed that the facility did not have a policy addressing survey results postings.
Misappropriation of Resident's Diazepam Medication
Penalty
Summary
The facility failed to protect a resident's medications from misappropriation, specifically involving Diazepam, a Schedule IV controlled substance. The resident, who has an Anxiety Disorder and an intact cognitive status, was prescribed Diazepam to be administered twice daily at 9 AM and 9 PM. However, discrepancies were found in the Controlled Drug Record, indicating that additional doses were signed out and potentially administered at 2 AM and 6 AM without a corresponding physician's order or documentation in the Medication Administration Record (MAR). The investigation revealed that an LPN signed out the additional doses of Diazepam, but there was no documentation or recollection of administering these doses to the resident. The resident confirmed receiving her regular dose at 9 PM and denied receiving any additional doses. The LPN involved could not provide a reason for the additional doses and did not respond to the facility's attempts to contact her during the investigation. The Director of Nursing and Administrator confirmed that the facility's policy requires adherence to physician orders and proper documentation of medication administration. The LPN's actions were in breach of these policies, leading to her suspension and eventual termination. The investigation concluded with the two missing Diazepam pills being unaccounted for, highlighting a failure in medication management and safeguarding resident property.
Failure to Report Allegation of Sexual Abuse to Ombudsman
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving two residents to the Ombudsman, as required by state law. The facility's policy, revised on 07/29/19, mandates compliance with federal and state requirements for reporting abuse, neglect, exploitation, mistreatment, and misappropriation of property, including notifying the Ombudsman. However, during an interview, the Ombudsman confirmed that they had not received a self-report from the facility regarding this incident, and the last report received was over six months ago. The incident involved a resident who was reported by a social worker to have been approached by his roommate with inappropriate sexual comments. The social worker documented that the charge nurse informed them of the incident, and the social worker subsequently informed the Administrator and the DON. The police were called, and the responsible party was contacted. Despite these actions, the Administrator admitted during an interview that they had not been reporting any allegations to the Ombudsman, which constitutes a failure to adhere to the facility's policy and state requirements.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to ensure proper storage and labeling of food items in the main kitchen, as observed during a survey. The facility's policy requires all opened refrigerator items to have a use-by date and mandates that all items be dated upon arrival. Additionally, leftovers must be covered, labeled, dated, and stored appropriately. However, during a tour of the kitchen, several items were found undated and unlabeled, including six sandwiches, a container of an unknown orange pureed item, and five hard-boiled eggs. Furthermore, a container of pork loin was found with an expired use-by date, and nine milk cartons were past their expiration date. Interviews with staff revealed a lack of adherence to the facility's policies. A kitchen aid stated that produce should be dated and labeled immediately upon entering the refrigerator, and if not, it should be discarded. The Kitchen Manager confirmed that all open foods should be labeled and dated for three days, after which they should be discarded. The Administrator also acknowledged that items should be labeled and discarded if not, and that kitchen staff should check dates daily. Despite these policies, the expired milk was only discarded after the surveyors' visit, indicating a lapse in daily monitoring and compliance with food safety standards.
Misappropriation of Controlled Medication
Penalty
Summary
The facility failed to prevent the misappropriation of controlled medication for a resident, identified as R99, who was on a scheduled pain medication regimen. R99, who was cognitively intact, suffered from severe pain due to multiple medical conditions, including trigeminal neuralgia, chronic pain, and extensive burns. The resident was prescribed Oxycodone and Morphine to manage pain, but discrepancies were found in the administration records, indicating that doses of Oxycodone were not given due to the medication being unavailable. The facility's policy required reconciliation of controlled substances at the end of each shift, but a card containing 30 Oxycodone pills was missing. Interviews with nursing staff revealed that the medication was not available for several scheduled doses, causing the resident to experience severe pain. The LPN and RN involved reported issues with medication orders and communication with the pharmacy, which contributed to the unavailability of the medication. The Director of Health Services confirmed the missing medication and conducted interviews and drug tests with the nursing staff. Despite efforts to monitor the resident's pain and communicate with the physician, the facility's failure to maintain accountability for controlled substances resulted in the resident experiencing unmanaged pain for several days.
Failure to Conduct PASARR Level II for Resident with Severe Mental Illness
Penalty
Summary
The facility failed to conduct a Preadmission Screening and Resident Review (PASARR) Level 1 for a resident prior to their admission. Additionally, the facility did not refer the resident for a PASARR Level II after a new diagnosis of a severe mental illness was made. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, tachycardia, and osteoarthritis, was later diagnosed with a psychotic disorder. This diagnosis was not included in the resident's PASARR Level 1, and no PASARR Level II was recommended. The resident's medical records indicated moderate cognitive impairment and potential indicators of psychosis, such as delusions and hallucinations. Despite these indicators and the use of antipsychotic medications, the facility did not update the PASARR assessment to reflect the resident's mental health status. The Social Worker acknowledged missing the diagnosis and had not taken the necessary steps to refer the resident for a PASARR Level II review.
Failure to Adhere to Resident's Dietary Preferences
Penalty
Summary
The facility failed to ensure that a resident, identified as R25, received meals according to her dietary preferences and physician-prescribed diet orders. R25, who was admitted to the facility with multiple diagnoses including diabetes mellitus, cognitive communication deficit, and morbid obesity, had a specific diet order dated 06/28/24 for a consistent carbohydrate diet with special instructions to avoid oatmeal and fish, and to have milk with breakfast. Despite these instructions, during an observation on 09/12/24, R25 was served fish for lunch, contrary to her dietary restrictions and preferences. R25, who is cognitively intact with a BIMS score of 15, expressed that she has never eaten fish and that this error occurs frequently, as noted on her lunch ticket which clearly stated "NO FISH." Interviews with the Kitchen Manager and the Director of Nursing revealed that the kitchen staff and CNAs are responsible for ensuring that meal tickets are checked and that residents' dietary preferences and restrictions are adhered to. However, the oversight in serving R25 fish indicates a lapse in following these procedures, leading to the deficiency noted in the report.
Lack of Coordination in Resident's Psychiatric Care
Penalty
Summary
The facility failed to ensure a process for reviewing provider recommendations and maintaining continuity of care for a resident with complex psychiatric and medical needs. The resident, who had a history of bipolar disorder, PTSD, schizoaffective disorder, and other mental health conditions, was under the care of a Psychiatric Nurse Practitioner (NP) and an outside primary care physician (PCP). The resident's care plan included various psychiatric medications and recommendations for monitoring and adjustments, including the addition of Tegretol as a mood stabilizer. However, the facility did not effectively communicate these recommendations to the resident's outside PCP, leading to a lack of coordination in the resident's care. The resident's Medication Administration Record (MAR) showed that certain medications were discontinued, but there was no transcription of an order for Tegretol, as recommended by the Psychiatric NP. Interviews revealed that the facility's Director of Health Services (DHS) was aware of the medication changes but did not ensure that the Psychiatric NP's recommendations were communicated to the outside PCP. The DHS admitted that the facility lacked a policy for handling orders for residents with an outside PCP and that the recommendations for Tegretol were missed. The facility's failure to coordinate care was further compounded by the resident's refusal to see the facility's primary care physician, leading to a disconnect between the Psychiatric NP's recommendations and the actions of the outside PCP. The Psychiatric NP was unaware that the resident was seeing an outside PCP, and the facility did not have a process in place to ensure that recommendations were communicated and acted upon. This lack of communication and coordination resulted in the resident not receiving the recommended mood stabilizer, potentially impacting their mental health management.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to ensure that a resident was free from verbal abuse by a CNA. The facility's policy on abuse prevention, last revised on 10/27/20, mandates that all residents be protected from various forms of abuse, including verbal abuse. Despite this policy, an incident occurred involving a resident with a diagnosis of bipolar disorder and depression, who was cognitively intact with a BIMS score of 15 out of 15. The resident's care plan noted issues related to mood and behavior, including swearing and impatience. During an interview, the resident mentioned that the incident was a misunderstanding and felt the issue was resolved after returning from a doctor's visit. The Director of Nursing (DON) confirmed that there was a verbal altercation between the resident and CNA1, during which CNA1 admitted to using profanity. Witnesses also heard the CNA curse. The DON stated that CNA1 was immediately terminated for this behavior. CNA1 explained that the resident was belligerent and cursing at her because his roommate had not received a shower. CNA1 responded by cursing back at the resident, which led to her termination from the facility.
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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 Aiken
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carlyle Senior Care Of Aiken | 0.6 mi | ★★★★★ | 8 | 2 |
| Aiken Rehabilitation And Care Center | 2.4 mi | ★★★★★ | 8 | 0 |
| Anchor Post Acute | 4.8 mi | ★★★★★ | 7 | 0 |
| Nhc Healthcare - North Augusta | 12.8 mi | ★★★★★ | 2 | 0 |
| Pruitthealth- North Augusta | 14.1 mi | ★★★★★ | 2 | 0 |
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