Cycle 1
Health 2025-01-22 · Fire 2025-01-22
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Saint Stephen, SC
Lake Moultrie Nursing Home
2-star overall rating with 2-star inspections with $19,097 in total fines with 3 recent health deficiencies
1038 McGill Lane, Saint Stephen, SC
(843) 567-2307
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
88
Certified beds
Average residents
83
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.74
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.22 · national 2.35
Total nurse hours
3.53
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.36
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
0.53
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
3.85
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,849
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.44
Composite VBP score used to determine payment impact.
Payment multiplier
0.9954
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.93
Performance 20.54% · Measure score 1.93 · Achievement 1.93 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.38
Baseline 7.73% · Performance 6.83% · Measure score 3.38 · Achievement 3.38 · Improvement 2.82
Total nurse turnover
9.08
Baseline 28.17% · Performance 26.58% · Measure score 9.08 · Achievement 9.08 · Improvement 4.28
Adjusted total nurse staffing
2.59
Baseline 3.8 hours · Performance 3.81 hours · Measure score 2.59 · Achievement 2.59 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.99% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 7.27% · Lower 95% interval 6.35% |
| Discharge to community | 21.09% |
50.57%
29.5 pts worse
|
Worse than the National Rate · Eligible stays 34 · Observed rate 0% · Lower 95% interval 11.06% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 44 · Denominator 44 |
| Falls with major injury | 2.27% |
0.77%
1.5 pts worse
|
Numerator 1 · Denominator 44 |
| Discharge self-care score | 67.65% |
53.69%
14 pts better
|
Numerator 23 · Denominator 34 |
| Discharge mobility score | 58.82% |
50.94%
7.9 pts better
|
Numerator 20 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 2.27% |
2.29%
About the same
|
Numerator 1 · Denominator 44 · Adjusted rate 1.85% |
| Healthcare-associated infections requiring hospitalization | 6.83% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 6.06% · Lower 95% interval 3.58% |
| Staff COVID-19 vaccination coverage | 0.78% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 128 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 64.71% |
56.45%
8.3 pts better
|
Numerator 22 · Denominator 34 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 91.67% |
25.2%
66.5 pts better
|
Numerator 22 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.0
0.3 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.7 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.9
0.1 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
90.5%
6.6 pts better
|
93.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 96.1% · Q3 100.0% · Q4 96.2% · 4Q avg 97.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
90.6%
9.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.0%
0.4 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.6% · Q3 2.7% · Q4 2.5% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
2.9%
1.8 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.5% · Q3 0.0% · Q4 1.3% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
6.2%
2.6 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.4% · Q3 3.1% · Q4 6.9% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.7% |
20.4%
3.7 pts better
|
19.6%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 20.3% · Q3 13.2% · Q4 16.4% · 4Q avg 16.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.1% |
16.3%
9.2 pts better
|
16.7%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 6.7% · Q3 6.8% · Q4 6.3% · 4Q avg 7.1% · 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 | 14.7% |
14.9%
0.2 pts better
|
16.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 18.3% · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.1% |
12.4%
1.7 pts worse
|
14.9%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 14.9% · Q3 15.3% · Q4 10.2% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.7%
0.3 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
1.6%
0.4 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.6% · Q3 1.4% · Q4 1.3% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.8% |
17.2%
8.4 pts better
|
19.8%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 9.9% · Q3 14.0% · Q4 4.2% · 4Q avg 8.8% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
5.8%
3.5 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 0.0% · Q3 1.1% · Q4 1.9% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.4% |
79.8%
12.6 pts better
|
81.7%
10.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.7% · 4Q avg 92.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.7% |
14.1%
8.6 pts worse
|
12.0%
10.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 22.9% · Expected 11.3% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.5% |
24.7%
0.8 pts worse
|
23.9%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.5% · Observed 25.0% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-06 · Fire 2023-04-06
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-09-17 · Fire 2021-09-17
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
J · Immediate jeopardy
2025-01-22
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-01-23
D · Potential for more than minimal harm
2025-01-22
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 2025-02-10
D · Potential for more than minimal harm
2025-01-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-07
G · Actual harm
2023-04-06
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 2023-05-02
D · Potential for more than minimal harm
2023-04-06
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-05-02
D · Potential for more than minimal harm
2023-04-06
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-05-02
D · Potential for more than minimal harm
2023-04-06
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-05-02
D · Potential for more than minimal harm
2023-04-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-02
F · Potential for more than minimal harm
2021-09-17
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 2021-10-01
E · Potential for more than minimal harm
2021-09-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-10-08
Penalties and ownership
What sits behind the stars
$11,196
2025-01-22
Fine
Fine · fine $11,196
Fine
$7,901
2023-04-06
Fine
Fine · fine $7,901
Fine
Ownership
Browder, Christina
Corporate Officer · Individual
Clarendon Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Matthews, Robin
Operational/Managerial Control · Individual
Matthews, Robin
Corporate Officer · Individual
Stanley, Mathew
Operational/Managerial Control · Individual
Stanley, Mathew
Corporate Director · Individual
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#3
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