Based on record reviews, interviews, and facility policy reviews, the facility failed to develop and implement a baseline care plan that included instructions needed to maintain hydration for 1 (Resident #3) of 7 residents reviewed. Specifically, the facility failed to develop and implement a baseline care plan for Resident #3 that included administration of water with bolus enteral feedings and failed to update the baseline care plan with Registered Dietitian (RD) #4's recommendations to increase fluids to maintain hydration. This failure resulted in Resident #3 passing away in the facility due to dehydration. …
F655 citations in South Carolina
Baseline care plan · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
South Carolina cites F655 less often than its own record predicts
0.73 times the national share — cited less often here than elsewhere.
Of every deficiency written in South Carolina in 2025, this is the portion that was F655.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Carolina surveyors wrote
F655 findings written in South Carolina, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on record review and staff interview, the facility failed to ensure the Baseline Care Plan included required information related to the resident's tracheostomy status for 1 of 1 residents,(R)1 reviewed for baseline care planning. In addition, the facility did not have a policy or procedure addressing the development of baseline care plans. This failure had the potential to result in unmet care needs.Findings include:Review of R1's face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to: acute and chronic respiratory failure with hypoxia, tracheostomy status, dysphagia, gastrostomy status, and dementia.Review of R1's order summary report revealed physician orders for an NPO [nothing by mouth] diet with a start date… …
The short window
Recent years
| Year | Share of South Carolina citations | vs expected |
|---|---|---|
| 2024 | 0.65% | 0.94× |
| 2025 | 0.48% | 0.73× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else South Carolina surveyors cite →
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