Cycle 1
Health 2025-03-11 · Fire 2025-03-11
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Pawleys Island, SC
Lakes At Litchfield
5-star overall rating with 5-star inspections with $5,244 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
120 Lakes At Litchfield Drive, Pawleys Island, SC
(843) 235-9393
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
24
Certified beds
Average residents
15
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Senior Living Communities
Operator or chain grouping
Approved since
2003-08-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 4 overall / 4 health / 5 staffing / 3 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
1.34
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.18
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.81
Nurse aide staffing · state 2.22 · national 2.35
Total nurse hours
5.33
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.52
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.80
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
1.06
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.13
CMS adjusted RN staffing hours
Adjusted total hours
4.49
CMS adjusted total nurse staffing hours
Case-mix index
1.62
Higher values indicate more complex resident acuity
RN turnover
50%
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
12,416
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.54% · Performance 23.22% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.25% · Performance 8.55% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.72
Baseline 52.94% · Performance 48.48% · Measure score 3.72 · Achievement 3.72 · Improvement 1.09
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.77% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 126 · Observed rate 11.9% · Lower 95% interval 8.41% |
| Discharge to community | 40.49% |
50.57%
10.1 pts worse
|
Worse than the National Rate · Eligible stays 124 · Observed rate 37.1% · Lower 95% interval 33.59% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.98% |
95.27%
3.7 pts better
|
Numerator 97 · Denominator 98 |
| Falls with major injury | 1.02% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 98 |
| Discharge self-care score | 55.88% |
53.69%
2.2 pts better
|
Numerator 38 · Denominator 68 |
| Discharge mobility score | 70.59% |
50.94%
19.7 pts better
|
Numerator 48 · Denominator 68 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 98 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.55% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 88 · Observed rate 9.09% · Lower 95% interval 5.72% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 28 |
| Staff flu vaccination coverage | 21.43% |
42%
20.6 pts worse
|
Numerator 6 · Denominator 28 |
| Discharge function score | 79.41% |
56.45%
23 pts better
|
Numerator 54 · Denominator 68 |
| Transfer of health information to provider | 94.59% |
95.95%
1.4 pts worse
|
Numerator 35 · Denominator 37 |
| Transfer of health information to patient | 96.49% |
96.28%
0.2 pts better
|
Numerator 55 · Denominator 57 |
| Resident COVID-19 vaccinations up to date | 1.64% |
25.2%
23.6 pts worse
|
Numerator 1 · Denominator 61 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.7% |
79.8%
7.9 pts better
|
81.7%
6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 62.9% · Q2 92.0% · Q3 100.0% · Q4 95.7% · 4Q avg 87.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 27.9% |
14.1%
13.8 pts worse
|
12.0%
15.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 27.7% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.6%
0.5 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.5% · Q3 1.4% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.3% |
78.0%
12.3 pts better
|
79.7%
10.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.0% |
24.7%
7.3 pts worse
|
23.9%
8.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.0% · Observed 28.7% · Expected 21.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-18 · Fire 2023-05-18
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-12-15 · Fire 2021-12-15
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-11
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-11
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-03-19
D · Potential for more than minimal harm
2023-11-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-07-26
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 2023-07-27
D · Potential for more than minimal harm
2023-07-26
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 2023-07-27
F · Potential for more than minimal harm
2021-12-15
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 2022-02-10
E · Potential for more than minimal harm
2021-12-15
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-01-13
D · Potential for more than minimal harm
2021-12-15
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-01-13
D · Potential for more than minimal harm
2021-12-15
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-02-10
D · Potential for more than minimal harm
2021-12-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-10
Penalties and ownership
What sits behind the stars
$5,244
2023-06-05
Fine
Fine · fine $5,244
Fine
Ownership
Senior Living Commuities LLC
5% Or Greater Direct Ownership Interest · Organization
Brenda U. Thompson 2020 Irrevocable Trust Dated December 30, 2020
5% Or Greater Indirect Ownership Interest · Organization
Maxwell Group, Inc.
Operational/Managerial Control · Organization
Thompson, Benjamin
5% Or Greater Indirect Ownership Interest · Individual
Thompson, Benjamin
Operational/Managerial Control · Individual
Thompson, Benjamin
Corporate Officer · Individual
Thompson, Donald
5% Or Greater Indirect Ownership Interest · Individual
Thompson, Donald
Corporate Director · Individual
Thompson, Joshua
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
NHC Healthcare - Garden City
Garden City, SC
3-star overall rating with 3-star inspections with $6,380 in total fines with 4 recent health deficiencies
#2
Oak Hollow of Georgetown Rehabilitation Center LLC
Georgetown, SC
2-star overall rating with 2-star inspections with $14,892 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Prince George Healthcare Center
Georgetown, SC
3-star overall rating with 3-star inspections with 4 recent health deficiencies
Jump out