Conway, SC

Compass Post Acute Rehabilitation

5-star overall rating with 4-star inspections with 2 recent health deficiencies

2320 Highway 378, Conway, SC

(843) 397-2273

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

95

Certified beds

Average residents

81

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

The Ensign Group

Operator or chain grouping

Approved since

2009-08-20

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

329 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.62

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

0.91

Licensed practical nurse staffing · state 1.01 · national 0.87

Aide hours / resident day

1.84

Nurse aide staffing · state 2.22 · national 2.35

Total nurse hours

3.37

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.53

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

2.95

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.50

Weekend registered nurse coverage · state 0.40 · national 0.47

Physical therapist

0.22

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.61

CMS adjusted RN staffing hours

Adjusted total hours

3.31

CMS adjusted total nurse staffing hours

Case-mix index

1.39

Higher values indicate more complex resident acuity

RN turnover

60%

Annual RN turnover · state 44% · national 45%

Total nurse turnover

44%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,515

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

23.43

Composite VBP score used to determine payment impact.

Payment multiplier

0.9832

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 23.01% · Performance 25.46% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

3.36

Baseline 8.21% · Performance 6.97% · Measure score 3.36 · Achievement 2.90 · Improvement 3.36

Total nurse turnover

5.15

Baseline 45.16% · Performance 42.65% · Measure score 5.15 · Achievement 5.15 · Improvement 0.74

Adjusted total nurse staffing

0.86

Baseline 3.13 hours · Performance 3.32 hours · Measure score 0.86 · Achievement 0.86 · Improvement 0.23

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	14.4%	10.72% 3.7 pts worse	Worse than the National Rate · Eligible stays 319 · Observed rate 16.3% · Lower 95% interval 11.41%
Discharge to community	57.03%	50.57% 6.5 pts better	Better than the National Rate · Eligible stays 307 · Observed rate 52.12% · Lower 95% interval 51.78%
Medicare spending per beneficiary	1.1	1.02 0.1 pts worse
Drug regimen review with follow-up	94.04%	95.27% 1.2 pts worse	Numerator 205 · Denominator 218
Falls with major injury	0.46%	0.77% 0.3 pts better	Numerator 1 · Denominator 218
Discharge self-care score	60.16%	53.69% 6.5 pts better	Numerator 77 · Denominator 128
Discharge mobility score	46.09%	50.94% 4.8 pts worse	Numerator 59 · Denominator 128
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 218 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.97%	7.12% 0.2 pts better	No Different than the National Rate · Eligible stays 191 · Observed rate 6.81% · Lower 95% interval 4.39%
Staff COVID-19 vaccination coverage	1.68%	8.2% 6.5 pts worse	Numerator 2 · Denominator 119
Staff flu vaccination coverage	19.73%	42% 22.3 pts worse	Numerator 29 · Denominator 147
Discharge function score	54.69%	56.45% 1.8 pts worse	Numerator 70 · Denominator 128
Transfer of health information to provider	99.42%	95.95% 3.5 pts better	Numerator 170 · Denominator 171
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 23 · Denominator 23
Resident COVID-19 vaccinations up to date	2.06%	25.2% 23.1 pts worse	Numerator 2 · Denominator 97

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.9	2.0 1.1 pts better	1.9 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.6	1.9 0.3 pts better	1.8 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.0%	90.5% 8.5 pts better	93.4% 5.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 95.9% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.1%	90.6% 7.5 pts better	95.5% 2.6 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1%
Percentage of long-stay residents experiencing one or more falls with major injury	0.5%	3.0% 2.5 pts better	3.3% 2.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	3.8%	2.9% 0.9 pts worse	11.4% 7.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 2.2% · Q4 11.9% · 4Q avg 3.8%
Percentage of long-stay residents who lose too much weight	3.4%	6.2% 2.8 pts better	5.4% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.4% · Q3 2.3% · Q4 4.7% · 4Q avg 3.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	8.2%	20.4% 12.2 pts better	19.6% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 6.2% · Q3 6.7% · Q4 11.1% · 4Q avg 8.2%
Percentage of long-stay residents who received an antipsychotic medication	8.7%	16.3% 7.6 pts better	16.7% 8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 8.1% · Q3 10.5% · Q4 8.8% · 4Q avg 8.7% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	4.6%	14.9% 10.3 pts better	16.3% 11.7 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 4.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	4.3%	12.4% 8.1 pts better	14.9% 10.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.5% · Q3 2.5% · Q4 5.0% · 4Q avg 4.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	0.7% 0.3 pts better	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	1.6% 1.6 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	18.3%	17.2% 1.1 pts worse	19.8% 1.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 16.2% · Q3 12.4% · Q4 25.2% · 4Q avg 18.3%
Percentage of long-stay residents with pressure ulcers	1.5%	5.8% 4.3 pts better	5.1% 3.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.0% · Q3 2.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.1%	79.8% 19.3 pts better	81.7% 17.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 100.0% · Q3 99.3% · Q4 98.6% · 4Q avg 99.1%
Percentage of short-stay residents who had an outpatient emergency department visit	11.4%	14.1% 2.7 pts better	12.0% 0.6 pts better	Short Stay · 20240701-20250630 · Adjusted 11.4% · Observed 12.2% · Expected 12.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.6% 1.6 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	95.2%	78.0% 17.2 pts better	79.7% 15.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 95.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.2%	24.7% 0.5 pts better	23.9% 0.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 27.3% · Expected 26.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-10 · Fire 2025-04-10

2 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-03-26 · Fire 2024-03-26

1 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2022-05-20 · Fire 2022-05-20

0 health deficiencies

No concentrated health issue counts in this cycle.

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-04-10

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-05-01

D · Potential for more than minimal harm 2025-04-10

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2025-05-01

F · Potential for more than minimal harm 2024-03-26

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-04-12

Penalties and ownership