Edisto Post Acute
For profit - Limited Liability company
113 Beds
PACS GROUP
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
38/100
#110 of 186 in SC
Photo by Edisto Post Acute
Photo by Edisto Post-Acute, Formerly: Edisto Rehabilitation and Healthcare Center
Photo by nuk C ourt
1 / 5 photos
Last Inspection: June 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Edisto Post Acute holds a Trust Grade of F, indicating significant concerns about the quality of care provided. It ranks #110 out of 186 nursing homes in South Carolina, placing it in the bottom half of facilities in the state, and is #3 out of 4 in Orangeburg County, meaning only one local option is better. Although the facility is showing some improvement, with issues decreasing from 4 in 2024 to 1 in 2025, there are still serious weaknesses. Staffing is a major concern with a low rating of 1 out of 5 stars and a turnover rate of 52%, which is higher than average, indicating a lack of stability among caregivers. Recent inspector findings revealed critical issues, including a resident developing maggots at the site of a PEG tube due to inadequate care and another resident being left soiled for hours due to insufficient staffing, suggesting severe lapses in care quality.
- Trust Score
- F
- In South Carolina
- #110/186
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 52% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $33,280 in fines. Lower than most South Carolina facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 16 minutes of Registered Nurse (RN) attention daily — below average for South Carolina. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ○ Average
- 10 deficiencies on record. Average for a facility this size. Mostly minor or procedural issues.
38/100
Bottom 41%
Review needed
4 → 1 violations
★★☆☆☆
2.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 4 issues
2025: 1 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below South Carolina average (2.8)
Below average - review inspection findings carefully
Staff Turnover: 52%
Near South Carolina avg (46%)
Higher turnover may affect care consistency
Federal Fines: $33,280
Below median ($33,413)
Moderate penalties - review what triggered them
Chain: PACS GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 10 deficiencies on record
1 life-threatening 1 actual harm
Feb 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, record review, and interviews, the facility failed to complete fall risk assessments in ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, record review, and interviews, the facility failed to complete fall risk assessments in a timely manner for 1 of 1 resident (Resident (R)1).
Findings include:
Review of facility policy titled, Quarterly Assessments revealed, 2. Three Quarterly assessments are completed in each 12-month period, assuming the resident does not have a Significant Change in Status Assessment (SCSA) or Significant Correction to Prior Comprehensive Assessment (SCPA) completed and was not discharged from the nursing home.
Record review of R1's Face Sheet revealed, R1 was admitted to the facility on [DATE] with diagnoses including but not limited to; fracture of right femur, subsequent encounter for closed fracture with routine healing, repeated falls, osteoarthritis, and abnormalities of gait and mobility.
Record review of R1's Care Plan dated 12/20/24 revealed, Focus: Resident is at risk for falls related to medication regimen, anxiety, Depression, HX falls. Fall 12/5/2024. Revision on 1/15/2025. GOAL- Resident will not have any major injuries with falls. Resident will not have any major injuries with falls and resident will be compliant with fall interventions through next review. INTERVENTIONS-Cancelled:12/5/2024 two people assist with bed mobility. Cancelled 12/5/2024: Two staff members present for all bed mobility .
Record review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/24 revealed, under section J1700- A. Did the resident have a fall any time in the last month prior to admission/entry or reentry? YES
C. Did the resident have any fracture related to a fall in 6 months prior to admission/entry or reentry? Yes. J2510. Repair fractures of the pelvis, hip, leg, knee, or ankle (not foot).
Record review of R1's Quarterly Fall Risk assessment dated [DATE] revealed, a score of 12 indicating she was a moderate risk for assessment. No other Fall risk assessment in EHR (Electronic Health Record).
During an interview on 02/20/25 at 2:50 PM, Registered Nurse (RN)1 stated, she was familiar with the resident. RN1 stated, Assessments are done quarterly and confirmed R1 missed 2 assessments in 2024. Floor nurses are responsible for conducting those assessments. RN1 states, She is not sure why the resident didn't have it done. Orders are to be put in for 3 days prior to charting. [Another order would get put in the day of the assessment id to be done], and it would then populate on the [Electronic Medication Administration Record] EMAR when it was due. RN1 Stated, Her expectation is for residents to have assessments done within the required time frame.
During an interview on 2/25/25 at 4:45 PM, the Assistant Director of Nursing (ADON) confirmed, There was no updated assessments found for R1.
Jun 2024
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and facility policy review, the facility failed to treat residents with respect and dignity for two sampled residents (Resident (R)28 and R64) as evidence by staff st...
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Based on observation, interviews, and facility policy review, the facility failed to treat residents with respect and dignity for two sampled residents (Resident (R)28 and R64) as evidence by staff standing over the residents while assisting them with eating their meals.
Findings include:
Review of the facility's policy titled Assistance with Meals revealed:
2. Facility staff will serve resident trays and will help residents who require assistance with eating.
3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example:
a. Not standing over residents while assisting them with meals;
b. keeping interactions with other staff to minimum while assisting residents with meals;
c. avoiding the use of labels when referring to residents (e.g., feeders); and
d. avoiding the use of bibs or clothing protectors instead of napkins, unless requested by the resident.
Observation during lunch meal on 6/18/24 at 12:34 PM showed Certified Nurse Aide (CNA)1 was observed feeding R64, while she was standing over the resident.
Further observations on 06/18/24 at 12:39 PM showed CNA1 was then observed feeding a second resident, R28, in addition to R64, and was standing up in between the residents, while feeding both of them.
On 6/20/24 at 12:4 PM, during an interview with the Director of Nursing (DON), the DON stated, The protocol for just somebody that needs assistant with feeding, they have to feed the patient. They deliver the tray. They've used their hands; of course, they should have already used their hand sanitizer. They, you know, shouldn't touch the food. If they have to cut it up or anything like that after they're done, they need to wash their hands before they move on to the next person. They need to sit down when they're feeding the resident.
On 6/20/24 at 12:51 PM, the DON further stated, Training? The last time was probably today, but I guess yesterday they did, but probably today. Now they know they need to wash their hands before and after helping a resident. The training probably didn't go in depth with not feeding two patients at the same time, but as far as standing while feeding the residents, they (the staff) know they need to sit down.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on record review, interview with facility staff and review of facility policy, the facility failed to ensure the comprehensive assessment for one (1) of 21 residents reviewed was completed accur...
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Based on record review, interview with facility staff and review of facility policy, the facility failed to ensure the comprehensive assessment for one (1) of 21 residents reviewed was completed accurately (Resident (R)77).
Findings include:
Review of facility policy titled Electronic Transmission of the MDS revealed the Policy Interpretation and Implementation stated 8. The MDS coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data and that feedback and validation reports from each transmission are maintained for historical purposes and for tracking.
Review of the medical record for R77 revealed an admission date of 5/28/24. Diagnoses included metabolic encephalopathy, dementia and depression.
Review of the Physician's Orders for R77 revealed Physician's Orders for Quetiapine Fumarate (Seroquel-an antipsychotic) 25 mg (milligrams) at bedtime, and Escitalopram Oxalate (Lexapro-an antidepressant) 10 mg by mouth daily.
Review of the Medication Administration Record for R77 for the months of May 2024 and June 2024 revealed R77 received Seroquel and Lexapro from 5/28/24 through 6/18/24.
Review of the admission MDS assessment for R77, with an Assessment Reference Date of 6/4/24, revealed that R77 had not been coded for the use of antipsychotic and antidepressant medications.
On 6/19/24 at 1:35 PM, during an interview with the MDS Coordinator 5, s/he stated s/he must have missed coding those medications and the MDS would need a modification.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and interview with facility staff the facility failed to ensure a comprehensive person-centered care plan for each resident identified services to be provided to attain or maint...
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Based on record review and interview with facility staff the facility failed to ensure a comprehensive person-centered care plan for each resident identified services to be provided to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being by not initiating a care plan for the use of antipsychotic medications for one (1) of 21 residents whose care plans were reviewed (Resident (R)77).
The findings include:
Review of the medical record for R77 revealed an admission date of 5/28/24. Diagnoses included Metabolic Encephalopathy, Dementia and Depression.
Review of the Physician's Orders for R77 revealed Physician's Orders for Quetiapine Fumarate (Seroquel-an antipsychotic) 25 mg (milligrams) at bedtime, and Escitalopram Oxalate (Lexapro-an antidepressant) 10 mg by mouth daily.
Review of the Medication Administration Record for R77 for the months of May 2024 and June 2024 revealed R77 received Seroquel and Lexapro from 5/28/24 through 6/18/24.
Review of the admission Minimum Data Set (MDS) assessment for R77, with an Assessment Reference Date (ARD) of 6/4/24, revealed that R77 had not been coded for the use of antipsychotic and antidepressant medications.
Review of the Care Plan for R77 revealed no Care Plan for the use of the antipsychotic medication, Seroquel.
On 6/19/24 at 1:35 PM, during an interview with the MDS Coordinator 5, s/he stated s/he must have missed coding those medications and the MDS would need a modification. The MDS Coordinator 5 stated since R77 had not been coded on the admission MDS for the use of antipsychotic medications, a Care Plan for the use of Seroquel had not been developed as it should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and facility policy review, the facility failed to ensure that food was served to residents in a manner that would ensure the prevention and spread of disease or pot...
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Based on observations, interviews, and facility policy review, the facility failed to ensure that food was served to residents in a manner that would ensure the prevention and spread of disease or potential infection for two (2) sampled residents (R28 and R64) during meals observation.
The findings include:
Review of the facility's policy titled Handwashing/Hand Hygiene revealed:
This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. The policy further revealed,
Administrative Practices to Promote Hand Hygiene
1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.
2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.
Observation during lunch meal on 6/18/24 at 12:34 PM showed Certified Nursing Assistant (CNA)1 was observed feeding R64. Observed CNA2 setting up R28 meal on the food tray while he/she was still feeding R64 without washing his/her hands.
On 6/18/24 at 12:39 PM, CNA1 was observed to simultaneously feeding two residents, R28 and R64, without performing any hand hygiene in between assisting one to the other.
On 6/18/24 at 3:15 PM, Licensed Practical Nurse (LPN)1, stated that the facility is definitely under staffing. LPN1 then stated, They have at least 15 Feeders (residents who need assistant with eating) and only three (3) CNAs to help. LPN1 then stated that the CNAs were doing the best they could to attend all of the residents. S/he stated, You know, now we have more residents and less staffing. On this wing right now, we have 2 CNAs I think, but we have several feeders. How can they attend all of them .
On 6/20/24 at 12:49 PM, during an interview with the Director of Nursing (DON), the DON stated, Every delivery of trays, they have to wash their hands with hand sanitizer. Of course, they already wash their hands before delivery of trays. They can use hand sanitizer three times, and they have to wash their hands if they're going to feed a patient, you know. They should wash their hands after even before they go to the next person not hand sanitizer. No, not washing their hands and helping 2 patients at the same time, that will not be appropriate. They should wash their hands before they move to the next person .
On 6/20/24 at 12:51 PM, the DON further stated, Training? The last time was probably today, but I guess yesterday they did but probably today. Now they know they need to wash their hands before and after helping a resident. The training probably didn't go in depth with not feeding two patients at the same time, but as far as standing while feeding the residents, they (the staff) know they need to sit down.
Jun 2023
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Tube Feeding
(Tag F0693)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and review of the facility's policy, the facility failed to provide Resident (R)2 with appr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and review of the facility's policy, the facility failed to provide Resident (R)2 with appropriate care to her percutaneous endoscopic gastronomy (PEG) tube. This failure resulted in the development of maggots at the site of the PEG tube.
On 06/12/23 at approximately 4:00 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death.
On 06/13/23 at 1:15 PM, the Administrator was notified that the failure to provide appropriate care to the site of R2's PEG tube , resulting in the development of maggots, constituted Immediate Jeopardy (IJ) at F693 with a start date of 05/21/23.
On 06/14/23 at 9:40 AM the facility presented an acceptable plan of removal for the IJ at F693. The survey team validated the removal of immediacy following the facility's implementation of the plan of removal. However, the facility remained out of compliance at a lower scope and severity level of D.
An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F693, constituting substandard quality of care.
Findings include:
Facility policy titled Enternal Feedings - Safety Precautions, last revised November 2018 documents: Observe for signs of skin breakdown, infection and irritation.
Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE] from an acute care hospital, with diagnosis that included but was not limited to; muscle weakness, dysphagia, dementia, and bacterial infection.
Review of R2's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/20/22 revealed, R2 had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating R2 was not cognitively intact.
Review of R2's undated Care Plan revealed, .at nutritional risk due to NPO, CHF, dementia, significant dysphagia, weight loss, abnormal labs, weight loss, need for PEG tube to meet 100% of Est needs, and malnutrition. [R2] at high risk for nutritional decline due to failure to thrive and overall decline. R2's goal was to, . maintain her weight once edema is resolved, she will have improved skin integrity, her skin integrity, and she will tolerate her tube feeding through the next review date. Further review of R2's Care Plan revealed an intervention, Administer medications as ordered. Monitor/Document for side effects and effectiveness. However, there were no interventions that included maintaince/cleaning of the PEG tube.
Review of R2's Physician Orders revealed an order dated 05/21/23, Clean stoma area with hydrogen peroxide and apply BID [twice a day] for 7 days 5/21/23 -5/28/23 every shift for Monitoring for 7 days. Note Text: Mupirocin External Ointment 2%.
Review of R2's Discharge Progress Note dated 05/26/23 revealed, 5/24/2023, Follow-up scheduled due to noted maggot infestation on the stoma of the PEG. I was called by the nurse on Sunday at home that this was noted during a dressing change. I immediately ordered hydrogen peroxide twice daily to kill the maggots and Bactroban ointment to apply twice daily. RN notified family. I sent an email to the admin and DON that we needed to review protocols on Monday. We had a meeting Monday to review cleaning and possible initiation of blood lights in the area. There have been flies noted in the halls and it is summertime so they are coming through the doors on occasion. 5/26 - [R2] is medically cleared for discharge on hospice with stable vital signs on exam today. Note Text: This nurse met with MD concerning new orders for treatment of maggots. this nurse also spoke with hospice nurse who provided care for [R2] today and states no issues noted at this time. [R2] assessed by this nurse at this time, no issues noted. no distress noted at this time. will continue to follow up with IDT team and resident's family.
During an interview on 06/12/23 at 1:15 PM, the former Director of Nursing (DON) revealed, he had received a call from Licensed Practical Nurse (LPN)1 and another nurse who stated that R2 had maggots in her G-tube. The former DON revealed the facility has a lot of flies and further revealed that LPN1 did not describe or say how many maggots she saw but she did tell him that R2 did not have any orders in the system to care for her G-tube. The former DON concluded that he was working on a quality improvement audit to ensure that all residents in the facility get an order to receive G-tube care.
During an interview on 06/12/23 at 1:29 PM, LPN1 revealed, during a body audit on R2, the Friday before, LPN1 removed R2's G-tube dressing. The dressing contained an abnormal discharge that was dark brown, with a moderate amount of fluid, and no odor. On this day LPN1 further revealed that R2 did not have orders for peg tube care. LPN1 stated the next day the g-tube dressing was saturated, and upon removal of the dressing, there was a ball of maggots under the dressing. Some of the maggots were trying to get into her G-tube. It looked like they had just hatched, so I cleaned the g-tube and some were on me.
During a phone interview on 06/12/23 at 3:50 PM, Registered Nurse (RN)1 revealed R2 would get wound care from hospice when in the building and for facility staff to provide wound care the other times. RN1 further revealed she was notified that R2 had maggots on 05/21/23 and she called the family to notify them.
During an interview on 6/12/23 at 4:43 PM, RN2 revealed that R2 was not care planned for the maggots in her wound because, It is not something I encountered before. We care plan infections. We handled this in a grievance form.
During an interview on 6/14/23 at 8:30AM, the DON stated, all staff are supposed to follow all physician orders for wound care and the same for infection control.
The facility's removal plan with a included the following:
MD notified and new orders obtained and initiated.
Site was cleaned per order and all maggots were removed.
Local Pest Control notified numerous times and treatments discussed and initiated.
100% Audit complete on 6-13-23 on all residents with ostomy/stomas/ feeding tube sites to
ensure that all stoma sites are clean and bug free.
100% Audit complete on 6-13-23 on all residents with ostomy/stomas/feeding tube sites to
ensure that all of these residents have orders to cleanse site Q shift and to monitor site q shift.
Education provided to all licensed nurses in person or via phone by RDCS and DON/designees on 6-13-23 related to non-sterile dressing change procedure and orders for cleansing and monitoring of all ostomy/stoma and feeding tube sites q shift.
Education will be provided to all newly hired staff and or agency staff as well as facility staff not reached by phone prior to next shift scheduled.
AdHoc QA Meeting Held 6-13-23
Root cause of issue related to maggots noted on resident R2 identifed as flies in facility and lack of orders for monitoring and cleansing the gtube site qshift.
Audits of all residents with Stomas/ostomies/feeding tube sites complete to ensure all sites are clean and maggot free.
Audits of all residents with Stomas/ostomies/feeding tube sites complete to ensure all of the residents with these sites have orders in place for monitoring and cleansing sites q shift.
Education initiated for all licensed nurses to include monitoring all stoma/ostomy/feeding tube sites q shift as well as cleansing q shift. Education provided as well for non-sterile dressing
change procedure.
The above components have been implemented as of 6-13-23 by 8pm.
May 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0725
(Tag F0725)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide sufficient staffing to its residents, resulting in deficie...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide sufficient staffing to its residents, resulting in deficient quality of care for 6 of 10 residents. Resident (R)5 was left soiled for several hours waiting for staff, and R6 fell trying to use the restroom after waiting for staff to come help her.
Findings include:
R5 was admitted to the facility on [DATE] with diagnoses including, but not limited to, nontraumatic intracerebral hemorrhage, type 2 diabetes mellitus, and hemiplegia and hemiparesis. Review of R5's 5 day Minimum Data Set (MDS) with an assessment reference date (ARD) on 03/23/2023 revealed R5 scored a 12 out of15 on his Brief Interview for Mental Status (BIMS) indicating moderately impaired cognition.
R6 was admitted to the facility on [DATE] with diagnoses including, but not limited to, pneumonia, malignant neoplasm, muscle weakness, and repeated falls. Review of R6's admission MDS with an ARD of 03/07/2023 revealed R6 scored an 11 out of 15 on her BIMS indicating moderately impaired cognition.
R7 was admitted to the facility on [DATE] with diagnoses including, but not limited to, epileptic seizures, contractures, and legal blindness.
R8 was admitted to the facility on [DATE] with diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarct and gait abnormalities.
R9 was admitted to the facility on [DATE] with diagnoses including, but not limited to, end stage renal dialysis, hyperlipidemia, and requiring dialysis.
R10 was admitted to the facility on [DATE] with diagnoses including, but not limited to, cerebral infarction, muscle weakness, and type 2 diabetes mellitus.
Review of facility grievances revealed a 03/20/2023 grievance from R7 that staff did not get her out of bed daily as she preferred.
Review of facility grievances revealed a 03/20/2023 grievance from R8 that staff do not check on her often enough.
Review of facility grievances revealed a 03/21/2023 grievance from R9 indicating that she had not been changed since the previous evening. The Director Of Nursing followed up on the grievance, and review of his email revealed that she was left soiled for some time but could not remember the specific length of the time. Staff would be educated on rounding and anticipating resident needs.
Review of facility grievances revealed a 03/22/2023 grievance from R6 that staff did not respond to her call light in a timely manner.
Review of facility grievances revealed a 03/24/2023 grievance from R10 that he had not been changed since 3 AM, and he fell trying to get up to go to the bathroom.
Interview with Licensed Practical Nurse (LPN)1 on 05/08/2023 at 2:02 PM revealed the nursing aides often had to ask for help, and that management would have to assist them during resident meals.
During an interview with Certified Nursing Aide (CNA)1 on 05/08/2023 at 2:10 PM, she revealed she usually works 7 AM - 7 PM. She stated, The number of residents she has had on her assignment is 14. There is not enough time to complete her tasks. The other day she, and an unnamed coworker, couldn't assist R5 in a timely manner. His lights had been ringing from 8-11, and he hadn't been touched at all. The staffing is terrible because the aides are overworked. They have too many residents for too few workers.
During an interview with Registered Nurse (RN)1 on 05/08/2023 at 2:19 PM, she revealed the facility had staffing concerns -- specifically relating to the patient to CNA ratio. She stated she often had to assist CNAs with their tasks.
During an interview with CNA2 on 05/08/2023 at 2:26 PM, she revealed she had 13 residents that shift. She stated she usually has 13-14 residents on day shift. She also indicated there is not enough time to complete all tasks, and she will routinely pass what could not be done to the next CNA.
During an interview with CNA3 on 05/08/2023 at 2:29 PM, she revealed she had 12-13 residents to care for on her 7 AM-7 PM shift. Because of staffing concerns, some residents don't get changed when they should, or they don't get the wash care (bath/shower) they should get. R6 slipped because she was trying to get to the bathroom after waiting for someone to respond to her call light.
During an interview with CNA4 on 05/08/2023 at 2:33 PM, she revealed she had 14 residents on the day shift. There is not enough time to complete all tasks, and CNAs need help badly.
During an interview with CNA5 on 05/08/2023 at 2:36 PM, she revealed she had 14 residents on her 7 AM-7 PM shift. She stated, There is not enough time to complete all her tasks. Often, staff can't wash or bathe the residents as they should and just do perineal care and go to the next resident. On weekends, it's possible for CNAs to have 18-20 residents during the day shift. She believed that increasing staff would cut down on falls and fall injuries because if a resident falls at the bottom of the hall, she might not realize until the next hour. It's also impossible to meet the 2 hour rounds standard because there are too many residents she has to provide care for.
During an interview with LPN2 on 05/08/2023 at approximately 2:40 PM, she revealed that she was the wound nurse. She stated, Even as the facility's wound nurse, she often had to help CNAs because there weren't enough nursing aides. Furthermore, she has had trouble finding an aide to assist with wound care. She has mentioned the staffing concerns to the facility several times, and they say that they're coming up with an action plan but have yet to present one.
During an interview with the DON on 05/08/2023 at 2:48 PM, she revealed the facility had no plans to correct staffing concerns. The DON stated, the facility uses central supply, the schedular, and activities assistants to assist when callouts occur. Department heads do compliance rounds where they round and check on residents. They might assist with resident meals, but this is usually only lunch since department heads are not usually present for breakfast or dinner.
During an interview with CNA6 on 05/08/2023 at 3 PM, she revealed she usually has 14-15 residents on her 7 AM-7 PM shifts. She stated, There is not enough time to complete tasks with such a workload, especially activities of daily living (ADLs), showers, hygiene, and toileting.
During an interview with R5 on 05/08/2023 at approximately 3:24 PM, he confirmed the incident where he waited several hours soiled before staff came to answer his call light.
During an interview with R6 on 05/08/2023 at approximately 4 PM, she confirmed concerns with delayed staffing. R6 stated, There are not enough CNAs to provide care. She did confirm an incident where she waited a long time for someone to help her after pushing her call light before getting up and falling - resulting in a broken tooth.
Observation confirmed that R6 had a broken tooth.
Review of R6's Change in Condition Evaluation with effective date 4/12/2023 revealed the resident had a change in condition related to a fall on 04/12/2023. The resident was found on the floor of the bathroom sitting on buttocks. The call light near the shower was on. The resident fell while getting up off the commode and fell on her face, resulting in a broken tooth.
Review of February staff postings revealed that the facility assigned more than 9 residents to a CNA on a first shift (defined as 7 AM - 3 PM) for 21 days.
Review of March staff postings revealed that the facility assigned more than 9 residents to a CNA on a first shift (defined as 7 AM - 3 PM) for 23 days.
Review of April staff postings revealed that the facility assigned more than 9 residents to a CNA on a first shift (defined as 7 AM - 3 PM) for 30 days.
May 2022
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to provide an individualized ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to provide an individualized activity program for two Resident (R) 88 and R296 of 29 sampled residents. This had the potential for the residents to feel isolated and not promote their quaility of life.
Findings include:
Review of the facility policy titled Activity Programs revised 08/06 revealed 1. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs .6. Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board (e.g., bed bound or visually impaired residents) . 7. Individualized and group activities are provided that: a. reflect the schedules, choices and rights of the residents; b. Are offered at hours convenient to the residents, including evenings, holidays and weekends .
1. Review of R88's undated admission Record found in R88's electronic medical record (EMR) under the Profile tab indicated he was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris.
Review of R88's document Baseline Care Plan Person-Centered Care Planning dated 04/27/22, located in the EMR under the Evaluations tab revealed the resident and/or Resident Representative (RR) participated in Baseline Care Plan Meeting .Section V: Activities: A.1. Daily Routine N/A 2. Activities and Hobbies: Resident enjoys watching television .
Review of R88's document titled Activity Assessment - V2.1 dated 04/27/22 located in the EMR under the evaluations tab stated resident was not able to communicate and an interview for daily and activity preferences should not be conducted. The document also revealed activities should be done in R88's room.
Review of R88's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/01/22, found in the resident's EMR under the MDS tab revealed R88 did not have a Brief Interview for Mental Status (BIMS) assessment. The MDS section F revealed staff were interviewed regarding R88's daily and activity preferences to reflect the resident had no preferences and he should not be evaluated individually.
Review of R88's Activities and Activities Participation Note located in EMR under the Progress Notes tab was empty as of 05/12/22.
Observation and interview on 05/10/22 at 9:08 AM with R88 revealed the resident said he could not see. Signs were posted to the bedroom door indicating droplet and contact precautions were in place. R88 stated he did not participate in any activities.
Interview on 05/11/22 at 1:25 PM with R88's daughter revealed her sister came to visit at least one to two times per day and she came to visit daily. She said she was concerned that she had not seen her father participating in any activities since he was admitted on [DATE]. The daughter stated he loved to talk to people and have interaction with them. She further revealed the only interaction staff had with R88 was noted to be nursing assessments and the Certified Nursing Assistants (CNAs) providing care.
Interview on 05/11/22 at 1:30 PM with CNA1 revealed she had not seen R88 participating in or being offered any activities.
Interview on 05/11/22 at 3:58 PM with the Activities Director (AD) revealed R88 liked watching TV, reading books, and music therapy. The AD confirmed neither himself nor the Activities Assistant (AA) had performed one to one activities with R88 since he was admitted to the facility on [DATE].
Interview on 05/11/22 at 4:28 PM with Licensed Practical Nurse (LPN)8 revealed she had not seen R88 participating in activities and that he was primarily in his bed either eating, sleeping, or just sitting there.
Interview on 05/11/22 at 4:33 PM with CNA4 revealed she was not sure what activities R88 liked to participate in because he stays to himself, liked his door closed, liked it quiet, and calm. CNA4 also stated that R88 had no difficulties communicating with staff.
2. Review of R296's undated admission Record found in R296's EMR under the Profile tab indicated he was admitted to the facility on [DATE].
Review of R296's quarterly MDS with an ARD of 05/01/22, found in the resident's EMR under the MDS tab revealed the resident had a BIMS score of eight out of 15 indicating the resident was moderately cognitively impaired.
Review of R296's document Baseline Care Plan Person-Centered Care Planning dated 05/04/22, located in the EMR under the Evaluations tab revealed the resident and/or Resident Representative (RR) participated in Baseline Care Plan Meeting .A. Activity Preferences 1. Daily Routine patient will participate in therapy program and attend activities of choice .2. Activities and Hobbies: tbd [to be determined] 3. Other notes: pt [patient] to be provided w [with] activity schedule; all activities held with any isolation protocol in place .
Review of R296's document Care Plan dated 05/09/22, located in the EMR under the Care Plan tab revealed the resident had an alteration in psychosocial well-being related to visitor restrictions to limit risk for exposure to Coronavirus per protocol .Allow resident to voice feelings and frustrations as indicated .assist resident to communicate with family and friends via alternative methods such as: phone calls, video calls, and email .
Review of R296's documents located in the EMR under the evaluations tab revealed he did not have an activity assessment performed upon admission.
Review of R296's Activities and Activities Participation Note located in EMR under the Progress Notes tab was empty as of 05/12/22.
Observations on 05/10/22 at 9:00 AM, 1:31 PM, and 5:13 PM revealed R296 was resting in bed with his eyes closed.
Interview on 05/10/22 at 9:00 AM with LPN9 confirmed R296 was on contact precautions and resting in bed with his eyes closed. LPN9 stated she had not seen R296 participating in any activities or the activities department in his room during any of her shifts.
Interview on 05/11/22 at 4:15 PM with the AD revealed he was not aware that R296 was located downstairs and on transmission-based precautions (TBP). AD stated he met the resident at the end of his admission care conference and had limited information about R296 and had not created an individualized baseline care plan reflecting the resident's activity preferences. AD confirmed no formal activities had been offered to the resident and that neither himself, nor the AA had visited with R296.
Interview on 05/11/22 at 4:30 PM with LPN8 revealed she had not seen anyone from the activities department visiting with R296.
Interview on 05/11/22 at 4:33 PM with CNA4 revealed R296 liked to watch TV and occasionally had visitors on the evening shift. CNA4 stated she had not seen anyone from the activities department conducting visits on the [NAME] hall.
Interview on 05/11/22 at 5:01 PM with the Director of Nursing (DON) revealed it was her expectation and understanding that the AD performs an assessment upon admission and then develops a baseline care plan related to activities. The DON stated she was not aware that R88 or R296 did not have an individualized care plan or that they had not been provided activities while on TBP.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that a resident's ph...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that a resident's physician orders for emergency respiratory equipment was kept at the bedside for one of one (Resident (R) 45) reviewed for respiratory care. This failed practice placed the resident at risk for respiratory distress.
Findings include:
Review of the facility's policy titled Tracheostomy Care revised 08/13 revealed, .A replacement tracheostomy tube must be available at the bedside at all times .
Review of R45's admission Record found in the electronic medical record (EMR) under the Profile tab, revealed R45 was originally admitted to the facility on [DATE] with a primary diagnosis of esophageal obstruction.
Review of R45's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 06/13/21 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating resident had moderate cognitive impairment. R45's diagnoses included esophageal obstruction, history of malignant neoplasm of larynx, dysphagia, and disturbances of salivary secretion. R45 required special treatments and programs to include tracheostomy care.
Review of R45's undated Care Plan located in the EMR under the Care Plan tab revealed the resident had a communication deficit related to a history of cognitive communication deficit with laryngectomy (portion of larynx/throat surgically removed) and aphonia (without voice). Resident noted with a history of removing laryngeal tube and sitting it in a cup of water .Resident was also at risk for altered respiratory status related to having larynx tube (larytube)/tracheostomy related to esophageal obstruction, absence of larynx, history of shortness of breath, and history of swelling to larynx tube. Nursing staff to provide .Larytube care as ordered and as needed .Resident is to use the Heat and Moisture Exchanger (HME) Cassette in Larytube as ordered .
Review of R45's active Physician's Orders dated 04/19/22 located in the EMR under the Orders tab included Remove and provide care (clean) #10 LaryTube Q [every] shift and reinsert; Change HME on larytube every 24 hours.
An observation on 05/10/22 at 12:44 PM revealed R45 with tracheostomy/larytube (artificial opening to larynx).
An interview and observation on 05/11/22 at 11:21 AM with Licensed Practical Nurse (LPN)8 confirmed she was assigned to the care of R45 on 05/11/22. When asked where the emergency trach/inner cannula was located for R45's larytube, LPN8 stated she did not know where the replacement inner cannula was located other than at the bottom of the nursing cart or in the supply room. Additionally, LPN8 stated if R45 were to go into respiratory arrest she would call 911(emergency services) and use the ambu bag to provide artificial respirations and the resident would be sent to the emergency department (ED) due to not being able to locate a replacement laryngeal tube.
An interview on 05/11/22 at 11:44 AM with LPN9 revealed she worked at the facility through a staffing agency. LPN9 confirmed she had been assigned to the care of R45 on 05/10/22. LPN9 further revealed she was unable to locate a 10mm laryngeal tube, and the only cannula she was able to find was a 7.6mm 8DIC replacement tube located in the supply storage room on the South wing.
An interview on 05/11/22 at 12:10 PM with the Unit Manger (UM) revealed she checked R45's room daily and just replaced the resident's laryngeal tube yesterday. The UM showed this surveyor a box labeled Atos provox larytube 10/155 brand laryngeal tube that she stated she keeps in her office. The UM confirmed that a replacement tube should be at R45's bedside at all times and she was not aware that the resident did not have one available or that LPN8 was unable to locate one.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on document review, interview, and review of facility policy, the facility failed to ensure two Licensed Practical Nurses (LPN8 and LPN9) were completely trained on tracheal care and safety meas...
Read full inspector narrative →
Based on document review, interview, and review of facility policy, the facility failed to ensure two Licensed Practical Nurses (LPN8 and LPN9) were completely trained on tracheal care and safety measures for one of one (Resident (R) 45) reviewed for trach status.
Findings include:
Review of the facility's undated policy titled Edisto Post Acute Facility Assessment 2021 revealed §483.95 Training Requirements. A facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. A facility must determine the amount and types of training necessary based on a facility assessment as specified at §483.70(e) .
Review of an undated document titled Long Term Care Essential Clinical Assessment provided by the facility indicated LPN8 and LPN9 did not receive trach care training.
An interview on 05/11/22 at 11:21 AM with LPN8 revealed she worked at the facility through a staffing agency and was not sure when she last had trach care training. When asked where the emergency trach/inner cannula was located for R45's larytube (laryngeal tube in place related to history of esophageal cancer and collapse). LPN8 stated she did not know where the replacement inner cannula was located other than at the bottom of the nursing cart or in the supply room. LPN8 reviewed R45's physician orders and was unable to determine what size cannula R45 required; LPN8 was unable to locate a replacement inner cannula on the nursing cart. Additionally, LPN8 was not able to state what was meant by the order reading Change HME [heat moisture exchanger] on cannula .check and confirm HME is in place every shift related to encounter for attention to tracheostomy.
An interview on 05/11/22 at 11:44 AM with LPN9 revealed she worked at the facility through a staffing agency was not sure when she last had trach care training. LPN9 further stated she was unable to locate a 10mm laryngeal tube, and the only cannula she was able to find was a 7.6mm 8DIC replacement tube located in the supply storage room on the South wing.
An interview on 05/12/22 at 11:39 AM with the Director of Staff Development (DSD) confirmed that LPN8 and LPN9 had not received trach care training by the staffing agency or the facility but should have. During the interview the surveyor requested a copy of trach care training required by the facility. The document was not provided to the surveyor.
An interview on 05/12/22 at 11:54 AM with the Assistant Director of Nursing (ADON) revealed it was the expectation of the facility that all nurses providing care to residents with a trach appliance receive trach care education. ADON confirmed LPN8 and LPN9 had not received trach care training from the staffing agency or the facility but should have. ADON further stated that LPN8 told her she had not received formal trach care training from the staffing agency or the facility; ADON was unable to get in touch with LPN9 to obtain a statement.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s), $33,280 in fines, Payment denial on record. Review inspection reports carefully.
- • 10 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $33,280 in fines. Higher than 94% of South Carolina facilities, suggesting repeated compliance issues.
- • Grade F (38/100). Below average facility with significant concerns.
Bottom line: Trust Score of 38/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Edisto Post Acute's CMS Rating?
CMS assigns Edisto Post Acute an overall rating of 2 out of 5 stars, which is considered below average nationally. Within South Carolina, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Edisto Post Acute Staffed?
CMS rates Edisto Post Acute's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 52%, compared to the South Carolina average of 46%.
What Have Inspectors Found at Edisto Post Acute?
State health inspectors documented 10 deficiencies at Edisto Post Acute during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 8 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Edisto Post Acute?
Edisto Post Acute is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PACS GROUP, a chain that manages multiple nursing homes. With 113 certified beds and approximately 108 residents (about 96% occupancy), it is a mid-sized facility located in Orangeburg, South Carolina.
How Does Edisto Post Acute Compare to Other South Carolina Nursing Homes?
Compared to the 100 nursing homes in South Carolina, Edisto Post Acute's overall rating (2 stars) is below the state average of 2.8, staff turnover (52%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Edisto Post Acute?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Edisto Post Acute Safe?
Based on CMS inspection data, Edisto Post Acute has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in South Carolina. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Edisto Post Acute Stick Around?
Edisto Post Acute has a staff turnover rate of 52%, which is 6 percentage points above the South Carolina average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Edisto Post Acute Ever Fined?
Edisto Post Acute has been fined $33,280 across 2 penalty actions. This is below the South Carolina average of $33,412. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Edisto Post Acute on Any Federal Watch List?
Edisto Post Acute is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.