Cycle 1
Health 2025-08-28 · Fire 2025-08-28
1 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Georgetown, SC
Oak Hollow of Georgetown Rehabilitation Center LLC
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
2715 South Island Road, Georgetown, SC
(843) 546-4123
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1974-10-01
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
0.28
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.21
Nurse aide staffing · state 2.22 · national 2.35
Total nurse hours
3.46
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.24
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
2.88
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.14
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
3.80
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,719
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.66
Baseline 55.10% · Performance 56.90% · Measure score 1.66 · Achievement 1.66 · Improvement 0
Adjusted total nurse staffing
0.52
Baseline 2.77 hours · Performance 3.08 hours · Measure score 0.52 · Achievement 0 · Improvement 0.52
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.17% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 19.15% · Lower 95% interval 7.62% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 18 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 57.58% |
8.2%
49.4 pts better
|
Numerator 38 · Denominator 66 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · 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 | 2.0 |
2.0
About the same
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.9
0.4 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.0% |
90.5%
6.5 pts worse
|
93.4%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.6% · Q2 78.1% · Q3 83.1% · Q4 91.0% · 4Q avg 84.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 76.1% |
90.6%
14.5 pts worse
|
95.5%
19.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 76.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.0%
1.5 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 1.5% · Q4 1.5% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
2.9%
2.5 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 10.8% |
6.2%
4.6 pts worse
|
5.4%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 12.2% · Q3 6.5% · Q4 2.0% · 4Q avg 10.8% |
| 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 8.2% · Q2 2.2% · Q3 10.6% · Q4 11.1% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.0% |
16.3%
10.3 pts better
|
16.7%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 5.9% · Q3 5.3% · Q4 4.8% · 4Q avg 6.0% · 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 | 49.3% |
14.9%
34.4 pts worse
|
16.3%
33 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 49.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.0% |
12.4%
7.6 pts worse
|
14.9%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 22.0% · Q3 15.9% · Q4 15.2% · 4Q avg 20.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.7%
0.1 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.6%
0.8 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.6% |
17.2%
0.4 pts worse
|
19.8%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 24.9% · Q3 21.0% · Q4 14.6% · 4Q avg 17.6% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
5.8%
3.6 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.0% · Q3 1.0% · Q4 1.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 64.6% |
79.8%
15.2 pts worse
|
81.7%
17.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 44.0% · Q2 51.4% · Q3 75.0% · Q4 92.0% · 4Q avg 64.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.7% |
14.1%
2.6 pts worse
|
12.0%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.7% · Observed 16.7% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.0% |
1.6%
3.4 pts worse
|
1.6%
3.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 31.4% |
78.0%
46.6 pts worse
|
79.7%
48.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 31.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.1% |
24.7%
10.6 pts better
|
23.9%
9.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.1% · Observed 13.3% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-15 · Fire 2024-08-15
8 health deficiencies
Top issue: Administration (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-09-02 · Fire 2022-09-02
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-08-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-08-28
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-28
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-09-25
D · Potential for more than minimal harm
2024-08-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-08
D · Potential for more than minimal harm
2022-09-02
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-09-29
D · Potential for more than minimal harm
2022-09-02
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-09-29
D · Potential for more than minimal harm
2022-09-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-09-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-15
J · Immediate jeopardy
2024-08-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-15
J · Immediate jeopardy
2024-08-15
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-09-15
J · Immediate jeopardy
2024-08-15
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-09-15
F · Potential for more than minimal harm
2024-08-15
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-09-15
E · Potential for more than minimal harm
2024-08-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-15
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-15
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 2024-09-15
D · Potential for more than minimal harm
2024-08-15
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-09-15
D · Potential for more than minimal harm
2022-09-02
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 2022-10-02
D · Potential for more than minimal harm
2022-09-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-02
Penalties and ownership
What sits behind the stars
$5,156
2024-08-15
Fine
Fine · fine $5,156
Fine
$5,156
2024-08-15
Fine
Fine · fine $5,156
Fine
$4,580
2023-03-20
Fine
Fine · fine $4,580
Fine
Ownership
2014 Hud Master Tenant, LLC
5% Or Greater Mortgage Interest · Organization
Craven, Robert
Operational/Managerial Control · Individual
Flansburg, Christine
Operational/Managerial Control · Individual
Morrison, Brent
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Georgetown, SC
3-star overall rating with 3-star inspections with 4 recent health deficiencies
#2
Lakes At Litchfield
Pawleys Island, SC
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
#3
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
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