Cycle 1
Health 2025-09-18 · Fire 2025-09-18
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Orangeburg, SC
Edisto Post Acute
1-star overall rating with 1-star inspections with $33,280 in total fines with 8 recent health deficiencies
575 Stonewall Jackson Boulevard, Orangeburg, SC
(803) 534-7771
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
113
Certified beds
Average residents
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1978-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 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
0.20
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.14
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
3.18
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
2.76
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.11
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.19
CMS adjusted RN staffing hours
Adjusted total hours
3.14
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,974
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9849
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
6.63
Baseline 11.57% · Performance 6.88% · Measure score 6.63 · Achievement 3.19 · Improvement 6.63
Total nurse turnover
1.83
Baseline 57.01% · Performance 56.18% · Measure score 1.83 · Achievement 1.83 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.79 hours · Performance 3 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.98% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 12.82% · Lower 95% interval 7.95% |
| Discharge to community | 58.96% |
50.57%
8.4 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 51.11% · Lower 95% interval 42.75% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 31 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | 39.13% |
53.69%
14.6 pts worse
|
Numerator 9 · Denominator 23 |
| Discharge mobility score | 47.83% |
50.94%
3.1 pts worse
|
Numerator 11 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 12.9% |
2.29%
10.6 pts worse
|
Numerator 4 · Denominator 31 · Adjusted rate 8.84% |
| Healthcare-associated infections requiring hospitalization | 6.88% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 6.9% · Lower 95% interval 3.58% |
| Staff COVID-19 vaccination coverage | 35.34% |
8.2%
27.1 pts better
|
Numerator 47 · Denominator 133 |
| Staff flu vaccination coverage | 37.74% |
42%
4.3 pts worse
|
Numerator 60 · Denominator 159 |
| Discharge function score | 47.83% |
56.45%
8.6 pts worse
|
Numerator 11 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.2 |
2.0
1.2 pts worse
|
1.9
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.9
About the same
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 79.2% |
90.5%
11.3 pts worse
|
93.4%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 87.8% · Q2 83.9% · Q3 71.1% · Q4 74.7% · 4Q avg 79.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.0% |
90.6%
6.6 pts worse
|
95.5%
11.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.0%
1 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.2% · Q3 1.1% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
2.9%
0.1 pts worse
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 3.4% · Q3 4.8% · Q4 0.0% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
6.2%
3.2 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 0.0% · Q3 3.7% · Q4 2.4% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.8% |
20.4%
7.6 pts better
|
19.6%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 13.0% · Q3 13.4% · Q4 10.7% · 4Q avg 12.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.8% |
16.3%
4.5 pts worse
|
16.7%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 25.9% · Q3 22.4% · Q4 17.7% · 4Q avg 20.8% · 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 | 9.8% |
14.9%
5.1 pts better
|
16.3%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.9% |
12.4%
3.5 pts better
|
14.9%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 8.8% · Q3 10.1% · Q4 2.7% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.7%
0.5 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.6%
1.3 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.4% |
17.2%
3.2 pts worse
|
19.8%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 24.4% · Q3 18.3% · Q4 21.4% · 4Q avg 20.4% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
5.8%
0.9 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 10.5% · Q3 3.6% · Q4 5.1% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 51.4% |
79.8%
28.4 pts worse
|
81.7%
30.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 66.1% · Q2 48.3% · Q3 37.3% · Q4 54.6% · 4Q avg 51.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.1% |
14.1%
3 pts better
|
12.0%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.1% · Observed 11.1% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.6%
0.2 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 1.3% · Q4 1.1% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 52.0% |
78.0%
26 pts worse
|
79.7%
27.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 52.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.5% |
24.7%
0.2 pts better
|
23.9%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.5% · Observed 27.8% · Expected 27.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-21 · Fire 2024-06-21
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-05-12 · Fire 2022-05-12
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-05-12
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-05-31
D · Potential for more than minimal harm
2022-05-12
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2022-05-31
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-09-18
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-10-15
F · Potential for more than minimal harm
2025-09-18
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 2025-10-15
F · Potential for more than minimal harm
2025-09-18
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-18
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-18
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-18
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 2025-10-15
D · Potential for more than minimal harm
2025-09-18
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-02-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-07
D · Potential for more than minimal harm
2024-06-21
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-06-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-17
J · Immediate jeopardy
2023-06-14
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-06-15
G · Actual harm
2023-05-08
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-06-07
D · Potential for more than minimal harm
2022-05-12
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-06-12
D · Potential for more than minimal harm
2022-05-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-06-12
D · Potential for more than minimal harm
2022-05-12
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2022-06-12
Penalties and ownership
What sits behind the stars
$12,155
2023-05-08
Fine
Fine · fine $12,155
Fine
$21,125
2023-05-08
Fine
Fine · fine $21,125
Fine
$0
2023-05-08
Payment Denial
Payment Denial · denial start 2023-05-31 · 15 days
15 day denial
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Jennings, Mark
W-2 Managing Employee · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Newlands, Frank
Contracted Managing Employee · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Jolley Acres Healthcare Center
Orangeburg, SC
4-star overall rating with 4-star inspections with 2 recent health deficiencies
#2
PruittHealth- Orangeburg
Orangeburg, SC
3-star overall rating with 3-star inspections with $3,728 in total fines with 2 recent health deficiencies
#3
The Oaks Post Acute
Orangeburg, SC
1-star overall rating with 1-star inspections with $122,296 in total fines with 9 recent health deficiencies
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