Cycle 1
Health 2025-05-08 · Fire 2025-05-08
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lancaster, SC
Lancaster Health and Rehabilitation
2-star overall rating with 3-star inspections with 2 recent health deficiencies
2044 Pageland Hwy, Lancaster, SC
(803) 285-7907
Overall
2 / 5
CMS overall stars
Health inspections
3 / 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
142
Certified beds
Average residents
131
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Fundamental Healthcare
Operator or chain grouping
Approved since
1986-02-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
69 facilities
Chain averages 2 overall / 2 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
0.29
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
1.67
Nurse aide staffing · state 2.22 · national 2.35
Total nurse hours
2.87
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
2.54
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.28
CMS adjusted RN staffing hours
Adjusted total hours
2.86
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,974
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.15
Composite VBP score used to determine payment impact.
Payment multiplier
0.9863
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.37
Baseline 16.36% · Performance 20.80% · Measure score 1.37 · Achievement 1.37 · Improvement 0
Healthcare-associated infections
8.74
Baseline 5.92% · Performance 5.22% · Measure score 8.74 · Achievement 8.74 · Improvement 7.03
Total nurse turnover
2.35
Baseline 41.82% · Performance 54.05% · Measure score 2.35 · Achievement 2.35 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.48 hours · Performance 3.05 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.66% |
10.72%
2.1 pts better
|
No Different than the National Rate · Eligible stays 155 · Observed rate 5.81% · Lower 95% interval 6.13% |
| Discharge to community | 46.47% |
50.57%
4.1 pts worse
|
No Different than the National Rate · Eligible stays 114 · Observed rate 36.84% · Lower 95% interval 36.52% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 98.72% |
95.27%
3.5 pts better
|
Numerator 154 · Denominator 156 |
| Falls with major injury | 0.64% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 156 |
| Discharge self-care score | 49.11% |
53.69%
4.6 pts worse
|
Numerator 55 · Denominator 112 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 56 · Denominator 112 |
| Pressure ulcers or injuries, new or worsened | 5.77% |
2.29%
3.5 pts worse
|
Numerator 9 · Denominator 156 · Adjusted rate 4.11% |
| Healthcare-associated infections requiring hospitalization | 5.22% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 114 · Observed rate 2.63% · Lower 95% interval 2.83% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 132 |
| Staff flu vaccination coverage | 58.06% |
42%
16.1 pts better
|
Numerator 90 · Denominator 155 |
| Discharge function score | 56.25% |
56.45%
0.2 pts worse
|
Numerator 63 · Denominator 112 |
| Transfer of health information to provider | 89.74% |
95.95%
6.2 pts worse
|
Numerator 35 · Denominator 39 |
| Transfer of health information to patient | 88.68% |
96.28%
7.6 pts worse
|
Numerator 47 · Denominator 53 |
| Resident COVID-19 vaccinations up to date | 14.29% |
25.2%
10.9 pts worse
|
Numerator 11 · Denominator 77 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.0
0.5 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.9
0.5 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 75.7% |
90.5%
14.8 pts worse
|
93.4%
17.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 68.8% · Q2 68.1% · Q3 86.1% · Q4 79.5% · 4Q avg 75.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.1% |
90.6%
3.5 pts worse
|
95.5%
8.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.0%
1.7 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.8% · Q3 0.9% · Q4 1.7% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.2% |
2.9%
2.7 pts better
|
11.4%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
6.2%
0.2 pts better
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 6.2% · Q3 6.9% · Q4 6.6% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.2% |
20.4%
2.8 pts worse
|
19.6%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 23.0% · Q3 19.8% · Q4 22.4% · 4Q avg 23.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.5% |
16.3%
2.8 pts better
|
16.7%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 11.6% · Q3 13.2% · Q4 14.6% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.2% |
0.2%
About the same
|
0.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% |
| Percentage of long-stay residents whose ability to walk independently worsened | 29.1% |
14.9%
14.2 pts worse
|
16.3%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 19.5% · Q4 22.2% · 4Q avg 29.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.0% |
12.4%
10.6 pts worse
|
14.9%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 20.0% · Q3 24.5% · Q4 24.2% · 4Q avg 23.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.7%
0.2 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.6% · Q3 0.6% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.6%
1.2 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.6% |
17.2%
0.6 pts better
|
19.8%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 19.9% · Q3 5.8% · Q4 15.5% · 4Q avg 16.6% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.8%
1.4 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 6.6% · Q3 3.9% · Q4 1.9% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 49.6% |
79.8%
30.2 pts worse
|
81.7%
32.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 35.2% · Q2 56.6% · Q3 65.9% · Q4 40.6% · 4Q avg 49.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
14.1%
4.9 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 10.2% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.6%
1.2 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 60.4% |
78.0%
17.6 pts worse
|
79.7%
19.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 60.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.3% |
24.7%
4.6 pts worse
|
23.9%
5.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.3% · Observed 31.8% · Expected 25.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-04 · Fire 2024-04-04
10 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-05-20 · Fire 2022-05-20
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-04-04
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2024-05-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-19
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 2025-12-12
E · Potential for more than minimal harm
2025-05-08
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-05-16
E · Potential for more than minimal harm
2024-12-11
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-01-02
F · Potential for more than minimal harm
2024-04-04
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 2024-04-26
D · Potential for more than minimal harm
2024-04-04
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-04-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-04-04
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-04-04
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 2024-04-26
D · Potential for more than minimal harm
2024-04-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-04-04
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-04-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-04-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-26
E · Potential for more than minimal harm
2022-05-20
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-06-15
D · Potential for more than minimal harm
2022-05-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-06-15
D · Potential for more than minimal harm
2022-05-20
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-06-15
Penalties and ownership
What sits behind the stars
Ownership
Thi Of South Carolina, LLC
5% Or Greater Direct Ownership Interest · Organization
Forman, Murray
5% Or Greater Indirect Ownership Interest · Individual
Hunt Valley Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Skinner, Jeff
Corporate Officer · Individual
Skinner, Jeff
W-2 Managing Employee · Individual
Thi Of Baltimore, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
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White Oak Manor - Lancaster
Lancaster, SC
4-star overall rating with 3-star inspections with 4 recent health deficiencies
#2
White Oak of Waxhaw
Waxhaw, NC
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
#3
Monroe Rehabilitation Center
Monroe, NC
2-star overall rating with 2-star inspections with abuse icon flag with $76,381 in total fines with 13 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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