Based on interviews and record reviews, the facility failed to revise the comprehensive care plan for 1 of 3 residents reviewed for accident hazards/ supervision/ devices. On [DATE] at 8:00 AM, Resident (R)1 was found unresponsive by facility staff in the dining area. Specifically, the facility failed to monitor R1, who had known behaviors of taking others food to eat, while on pureed diet. This failure resulted in Immediate Jeopardy (IJ) to resident health or safey. On [DATE] at approximately 8:24 AM, Emergency Medical Services (EMS) arrived at the facility and pronounced R1 deceased at approximately 8:30 AM. Based on full and/or limited record reviews and interviews, it was determined on [DATE] at 2:29 PM that an Immediate Jeopardy existed. …
F657 citations in South Carolina
Care plan timing and revision · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
South Carolina cites F657 less often than its own record predicts
0.85 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 F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Carolina surveyors wrote
F657 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 facility policy, observations, record review, and staff interviews, the facility failed to adequately implement care plan interventions for one resident (R) 6 out of 3 reviewed for accidents. Specifically, R6 had an unwitnessed fall, sustained a facial fracture, which required sutures, and was readmitted to the facility with interventions related to falls. The failure to ensure the interventions in place were properly recorded and monitored by staff, placed the resident at risk for avoidable reoccurring injuries. Findings include: Review of the facility's policy titled Care Planning, effective July 2017, revealed I. …
Based on facility policy review, record review, and interviews, the facility failed to revise Resident (R)7's care plan from Full Code to Do Not Resuscitate (DNR) after the DNR order was written. This failure had the potential to cause harm if resuscitative measures were taken unnecessarily and against the Resident's and/or Family's wishes in the event of cardiopulmonary arrest. Findings include:Review of the facility policy titled, Advanced Directives with a revision date of [DATE], revealed, 5. …
The short window
Recent years
| Year | Share of South Carolina citations | vs expected |
|---|---|---|
| 2023 | 1.89% | 0.88× |
| 2024 | 1.77% | 0.93× |
| 2025 | 1.60% | 0.85× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else South Carolina surveyors cite →
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