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 St George Healthcare Center during CMS and state inspections, most recent first.
Unclean kitchen equipment and storage areas were observed in the dietary department. A large manual can opener had dried, sticky residue on the blade and base, the oven and stove top spill pan had dried and burned food buildup, and four drawers storing serving utensils and adaptive eating items had dried substances and loose food debris. The DM confirmed the items were unclean and stated the drawers, oven, and spill pan should be cleaned weekly or as needed, while the can opener should be cleaned after each use.
Controlled substance shift-change counts were not properly verified and signed, and multiple medication carts had controlled meds stored in blister packs with punched, ripped, torn, or taped foil. An LPN, RN, and DON interviews confirmed missing signatures on narcotic count sheets and damaged packaging for meds such as chlordiazepoxide, oxycodone, tramadol, lorazepam, and hydrocodone/APAP, with staff acknowledging the potential for drug diversion when seals were broken.
Failed Transmission of Annual MDS Assessment: A resident with type II DM, CKD, and altered mental status had an annual MDS signed as complete but marked Production Rejected and not transmitted to CMS. MDS staff confirmed the assessment was not sent, and the Administrator stated the facility expected timely MDS transmission but had no MDS policies, relying on the RAI Manual for procedures.
Staff competency for GT management was not validated before direct care was provided to a resident with a GT, dysphagia, GERD, and hospice status. An LPN attempted to flush the GT without first verifying placement by checking residuals, then left the room after the water would not infuse; later, the DON replaced the GT at bedside. Personnel files did not contain documentation of GT management or GT replacement training or competency validation for the LPN, DON, or ADON.
The facility failed to provide written notification of the reason for transfer or discharge to two residents and their representatives, as required by policy. One resident, cognitively intact, was admitted to the hospital with viral gastroenteritis and acute kidney injury, while another, moderately cognitively impaired, was admitted following syncope. Staff interviews revealed a misunderstanding of the requirement, with reliance on a bed hold notice instead of a written discharge notice.
The facility failed to provide complete Bed Hold notifications for two residents transferred to the hospital. One resident's notice was incomplete due to a missing daily rate, while the other resident's notice was not sent because there was no representative. Staff interviews revealed gaps in the notification process, with the Business Office Manager and Administrator acknowledging the deficiencies.
A resident with cognitive impairments and a history of wandering eloped from the facility due to inadequate supervision and lack of appropriate interventions in their care plan. Despite previous exit-seeking behavior, the resident did not have a wander guard, and the facility's cameras were not operational, complicating the investigation. The deficiency was related to the quality of care regulation.
Unclean kitchen equipment and storage areas
Penalty
Summary
The facility failed to keep the kitchen's large manual can opener, a kitchen oven, the stove top spill pan, and four kitchen drawers clean while they were stored and ready for use. During the initial kitchen inspection, the can opener was observed with dried and sticky substances on its blade and table base attachment, the oven had accumulated dried and burned food spills in its inner cooking compartment, the stove top spill pan had a heavy accumulation of dried food and burned food spills, and the inner storage compartments of four kitchen drawers had accumulated dried substances and loose food debris while holding serving scoops, serving spoons, spatulas, ladles, tongs, adaptive eating utensils, and measuring cups. The Dietary Manager was shown the unclean equipment and confirmed that the four kitchen drawers, kitchen oven, stove top spill pan, and the can opener's blade and table base attachment were unclean. During interview, the Dietary Manager stated the kitchen drawers, oven, and stove top spill pan should be cleaned weekly or as needed, and that the large manual can opener and its table base attachment should be cleaned after each use. The facility policy titled Sanitation & Food Safety in Food and Nutrition Services stated that the Certified Dietary Manager is responsible for food safety and sanitation, that infection control and sanitation practices are followed to minimize contamination, and that the CDM monitors food safety and sanitation daily and develops, implements, and monitors a cleaning schedule.
Controlled Substance Counts Not Signed and Blister Packs Found Damaged
Penalty
Summary
The facility failed to implement processes to ensure that controlled substance counts were verified and signed at each shift change and that controlled medications were maintained in a safe and secure manner. Review of the facility policy on controlled substances showed that a scheduled reconciliation of controlled substance inventory was to be completed at every nursing shift change and documented by both the off-going and oncoming staff members. The report identified this deficient practice in four of four medication carts observed on two units. On the [NAME] Unit, Medication Cart #1 had a missing signature from the oncoming LPN on the controlled substance shift change sheet. During the controlled drug count, multiple blister cards containing controlled substances were found with punched, ripped, torn, or taped foil on the back of the card, including chlordiazepoxide 25 mg capsules, oxycodone IR 5 mg tablets, tramadol 50 mg tablets, and lorazepam 0.5 mg tablets. The LPN stated she was required to sign the inventory count sheet after the narcotics were counted and said the exposed pills could be less effective, could fall out, or someone could take them for personal use. On the [NAME] Unit, Medication Cart #2 also had a missing oncoming nurse signature on the shift change sheet, and controlled substance blister cards were found with punched, ripped, torn, or taped foil, including hydrocodone/APAP 5/325 mg tablets and tramadol 50 mg tablets. On Stone Unit, Medication Cart #1 had a missing oncoming nurse signature and two tramadol blister cards with damaged foil, and Medication Cart #2 had three blister cards with damaged foil, including lorazepam 0.5 mg tablets and oxycodone/APAP 5/325 mg tablets. Staff interviews showed that one LPN forgot to sign the narcotic inventory sheet, another said she did not check the back of the cards when counting, and an RN stated that any broken seal was a risk of drug diversion. The DON stated that nurses and the Unit Manager were responsible for overseeing procedures that prevented drug diversion by monitoring the inventory log sheets and actual narcotic count.
Failed Transmission of Annual MDS Assessment
Penalty
Summary
The facility failed to ensure that an MDS assessment was transmitted to the State within the required timeframe for one resident. Review of the RAI Manual 3.0 showed that comprehensive assessments require completion of both the MDS and CAA process, and that the MDS completion date must be no later than 14 days from the ARD and no later than 14 days after the determination that criteria for an SCSA were met. The resident involved had an admission date of 04/24/23 and diagnoses that included type II diabetes mellitus, chronic kidney disease, and altered mental status. Review of the resident’s annual MDS with an ARD of 01/10/26 showed it was signed by an MDSC as completed on 01/16/26, but the assessment status was Production Rejected. The resident’s most recent successfully transmitted assessment was a quarterly MDS with an ARD of 10/10/25. During interviews, both MDSCs reviewed the annual MDS and confirmed it had not been transmitted to CMS. One MDSC stated she rejected the annual MDS and failed to transmit it, while the other MDSC stated she signed it as complete but did not know why it was rejected. The Administrator stated she expected MDS assessments to be transmitted on time and said the facility did not have MDS policies, using the RAI Manual for MDS procedures.
Staff Competency for GT Management Not Validated
Penalty
Summary
The facility failed to ensure nursing staff were competent in gastric tube (GT) management, including verifying tube placement before flushing and performing GT replacement, for one resident with a GT. The resident had diagnoses including dysphagia following cerebral infarction, gastroesophageal reflux disease without esophagitis, and gastrostomy status, and was receiving hospice services. The resident’s care plan directed staff to check placement and patency of the feeding tube before each feeding or medication administration, and the physician orders included checking residuals and flushing the tube with water before and after medication administration. During observation, an LPN disconnected the formula tubing from the resident’s GT feeding port and did not verify placement by checking gastric residual as ordered before attempting to flush the tube. The LPN poured approximately 30 cc of water into a syringe connected to the feeding port, but the water did not infuse, indicating the GT was not patent. The LPN then poured the water into a cup, detached the syringe, replaced the cap on the feeding port, and left the room. In a later interview, the LPN stated she had been told by the DON to use the syringe plunger to push the water through the GT and said she would verify tube placement by pushing air into the GT while listening with a stethoscope, which she said was the method she learned in school. Later the same day, the LPN again assessed the GT, withdrew gastric contents to check residual, returned the residual, and then poured approximately 30 cc of water into the syringe, which infused by gravity without difficulty after the DON had replaced the gastric tube. The DON confirmed he had replaced the resident’s GT and stated he had received training and been checked off for competence. Review of personnel files showed the LPN had competency validation only for isolation, handwashing, and perineal care, with no documentation of GT management or GT replacement training or competency. The DON’s file also lacked documentation of training or competency validation for gastric tube management or replacement, and the ADON’s file did not include documentation of training or competency validation for gastric tube management or replacement.
Failure to Provide Written Notification of Transfer Reasons
Penalty
Summary
The facility failed to provide written notification of the reason for transfer or discharge to two residents, their representatives, and the ombudsman, as required by their policy. This deficiency was identified during a review of the facility's records and interviews with staff. The facility's policy, revised on June 9, 2023, mandates that residents and their representatives be notified in writing and in a language and manner they understand. However, for two residents reviewed, there was no documentation of the reason for discharge provided in writing. Resident 58, who was cognitively intact with a BIMS score of 15, was admitted to the hospital with viral gastroenteritis and acute kidney injury on chronic kidney disease. Resident 70, who was moderately cognitively impaired with a BIMS score of 8, was admitted to the hospital following an episode of syncope. Interviews with the Social Services Director and the Director of Nurses revealed a misunderstanding of the requirement to provide written reasons for transfer or discharge, as they believed a bed hold notice sufficed. The Administrator was unaware of the lack of written discharge/transfer notices.
Incomplete Bed Hold Notifications for Hospital Transfers
Penalty
Summary
The facility failed to provide complete Bed Hold notifications to residents or their representatives upon discharge to the hospital for two residents reviewed for transfer and discharge. Resident 58, who was cognitively intact and required supervision for activities of daily living, was admitted to the hospital for viral gastroenteritis and acute kidney injury. The Bed Hold notice for Resident 58 was incomplete as it lacked the daily rate for the room charge. Resident 70, who was moderately cognitively impaired and also required supervision for activities of daily living, was admitted to the hospital following an episode of syncope. The Bed Hold notice for Resident 70 was not sent because the resident did not have a representative. Interviews with facility staff revealed that the Social Services Director sent a list of transfers and discharges to the ombudsman monthly, and the Business Office Manager was responsible for sending Bed Hold notifications to families and residents. However, the Business Office Manager admitted that the Bed Hold for Resident 58 was incomplete and that the notice for Resident 70 was not sent due to the absence of a resident representative. The Director of Nurses provided a checklist used during resident transfers, but it did not ensure the completion of Bed Hold notifications. The Administrator acknowledged the oversight in sending the Bed Hold notice for Resident 70 and the incomplete notice for Resident 58.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide appropriate supervision for a resident, resulting in the resident successfully eloping from the facility. The resident, who was admitted with diagnoses including Huntington's disease, major depressive disorder, restlessness, agitation, and insomnia, was found to be severely impaired in cognitive skills for daily decision-making. Despite this, the resident's care plan did not include interventions related to wandering or elopement prior to the incident. An elopement risk observation conducted earlier had noted the resident's confusion and history of wandering, but no interventions were listed. On the day of the incident, a door alarm was triggered, and the resident was found outside in a company van. The resident was combative and had to be assisted back into the facility. Interviews with staff revealed that the resident had exhibited exit-seeking behavior in the past, but a wander guard was not in place at the time of the incident. The Director of Nursing was unaware of the resident's exit-seeking behavior, and the facility's cameras were not operational, which hindered the investigation. The facility's policy on elopement risk assessment required interventions to be added to the care plan after analyzing the information obtained, but this was not done for the resident in question. The lack of a wander guard and the failure to update the care plan with appropriate interventions contributed to the resident's ability to elope. The facility was notified of the immediate jeopardy status due to this deficiency, which was related to the quality of care regulation under 42 CFR 483.25.
Removal Plan
- Resident #1 without injury and elopement risk evaluation repeated with interventions in place per care plan.
- Director of Nursing and Administrator will be reeducated on the Elopement Policy and Process by the Clinical Consultant including: Completing the elopement risk evaluation thoroughly and implementing interventions based on risk identified. Documentation of exit seeking behavior and completing elopement risk evaluation for increased exit seeking behaviors.
- Elopement risk Assessments will be reviewed for completion and accuracy by the Director of Nursing/Designee on current residents in facility to identify residents at risk for elopement. Those residents identified at risk will have interventions initiated and care plan updated.
- Licensed Nurses will be reeducated on the Elopement Policy and Process by the Director of Nursing/Designee including: Completing the elopement risk evaluation thoroughly and implementing interventions based on risk identified. Documentation of exit seeking behavior and completing elopement risk evaluation for increased exit seeking behaviors.
- Licensed Nurses not receiving this education will receive prior to their next scheduled shift.
- Facility Activity Report and 24hour report will be reviewed in clinical morning meeting to validate elopement assessments completed. The Director of Nursing/Designee will review completed elopement assessments in clinical morning meeting to validate accuracy and interventions have been implemented accordingly.
- Ad hoc QAPI held.
- Medical Director was notified of the Immediate Jeopardy and the contents of this plan.
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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 Saint George
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth- Walterboro | 19.7 mi | ★★★★★ | 1 | 0 |
| Veterans Victory House | 21.4 mi | ★★★★★ | 0 | 0 |
| The Oaks Post Acute | 22.5 mi | ★★★★★ | 8 | 0 |
| Presbyterian Communities Of South Carolina-summerv | 24.3 mi | ★★★★★ | 2 | 0 |
| Jolley Acres Healthcare Center | 25.7 mi | ★★★★★ | 1 | 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.