Based on review of facility policy, record review, interview, and observation, the facility failed to ensure a safe environment and failed to provide adequate supervision to prevent elopement for 1 of 5 residents reviewed for elopement risk (Resident (R)1), a cognitively impaired resident with dementia and an inactive wander guard in place. This failure allowed R1 to exit the facility unsupervised through an unlocked front entrance on 05/22/26. On 06/02/26 at 6:05 PM, the Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template and notified that the facility had failed to prevent Resident (R)1's elopement which occurred on 05/22/26, creating a reasonable expectation that serious injury, harm, impairment, or death could have occurred, constituting IJ. …
F689 citations in South Carolina
Accidents and supervision · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
South Carolina cites F689 more often than its own record predicts
1.33 times the share F689 takes of citations nationally.
Of every deficiency written in South Carolina in 2025, this is the portion that was F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Carolina surveyors wrote
F689 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 staff interview, record review, and policy review, the facility failed to provide adequate supervision and assistive devices for one of seven residents identified at risk for falls. Specifically, Resident (R)103, who was assessed as a fall risk, sustained a fall on 04/10/26 while an agency staff was providing care, resulting in a closed, displaced comminuted fracture of the right femur and a closed comminuted supracondylar fracture of the left femur.The findings include: Review of the facility's policy titled, Activity Daily Life, prepared and approved on 06/24/26, revealed that residents were to receive individualized assistance with activities of daily living in a manner that promoted safety, independence, quality of life, care, and dignity. …
Based on review of facility policy, observation, and interview, the facility failed to ensure that chemicals were secured and not accessible to residents in the hallway, for 1 of 1 housekeeping carts reviewed.Findings include:Review of the facility policy titled, Hazard Communication Program, implemented on 01/06/25, revealed, It is the policy of this facility to implement a hazard communication program to ensure that information about the dangers of all hazardous chemicals used in this facility is known by all affected employees.During an observation on 07/20/26 at 2:00 PM, revealed multiple chemical sanitation bottles were stored in the door compartment of the housekeeping cart and not secured. …
The short window
Recent years
| Year | Share of South Carolina citations | vs expected |
|---|---|---|
| 2023 | 6.62% | 1.34× |
| 2024 | 5.97% | 1.11× |
| 2025 | 7.35% | 1.33× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else South Carolina surveyors cite →
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