Cycle 1
Health 2025-05-22 · Fire 2025-05-22
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lexington, SC
Retreat at Wellmore of Lexington
4-star overall rating with 4-star inspections with $16,153 in total fines with 1 recent health deficiencies
200 Wellmore Drive, Lexington, SC
(803) 520-1200
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
48
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2018-04-20
CMS approved date
Coverage
Medicare
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
0.83
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.52
Nurse aide staffing · state 2.22 · national 2.35
Total nurse hours
4.44
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.93
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.12
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.49
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
0.84
CMS adjusted RN staffing hours
Adjusted total hours
4.45
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,047
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9944
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.31% · Performance 21.26% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
8.20
Baseline 4.27% · Performance 5.38% · Measure score 8.20 · Achievement 8.20 · Improvement 0
Total nurse turnover
3.27
Baseline 70.71% · Performance 53.42% · Measure score 3.27 · Achievement 2.51 · Improvement 3.27
Adjusted total nurse staffing
5.14
Baseline 5.09 hours · Performance 4.54 hours · Measure score 5.14 · Achievement 5.14 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.62% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 308 · Observed rate 9.74% · Lower 95% interval 7.92% |
| Discharge to community | 46.8% |
50.57%
3.8 pts worse
|
No Different than the National Rate · Eligible stays 307 · Observed rate 42.35% · Lower 95% interval 40.26% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.54% |
95.27%
2.3 pts better
|
Numerator 238 · Denominator 244 |
| Falls with major injury | 1.23% |
0.77%
0.5 pts worse
|
Numerator 3 · Denominator 244 |
| Discharge self-care score | 69.77% |
53.69%
16.1 pts better
|
Numerator 120 · Denominator 172 |
| Discharge mobility score | 51.74% |
50.94%
0.8 pts better
|
Numerator 89 · Denominator 172 |
| Pressure ulcers or injuries, new or worsened | 2.05% |
2.29%
0.2 pts better
|
Numerator 5 · Denominator 244 · Adjusted rate 2.3% |
| Healthcare-associated infections requiring hospitalization | 5.38% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 201 · Observed rate 3.48% · Lower 95% interval 3.12% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 359 |
| Staff flu vaccination coverage | 2.47% |
42%
39.5 pts worse
|
Numerator 9 · Denominator 364 |
| Discharge function score | 68.02% |
56.45%
11.6 pts better
|
Numerator 117 · Denominator 172 |
| Transfer of health information to provider | 85.71% |
95.95%
10.2 pts worse
|
Numerator 120 · Denominator 140 |
| Transfer of health information to patient | 95.29% |
96.28%
1 pts worse
|
Numerator 81 · Denominator 85 |
| Resident COVID-19 vaccinations up to date | 22.03% |
25.2%
3.2 pts worse
|
Numerator 26 · Denominator 118 |
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 2.7 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.9
0.9 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.1 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.3% |
90.5%
3.8 pts better
|
93.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 95.7% · Q3 96.3% · Q4 93.1% · 4Q avg 94.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.3% |
90.6%
1.3 pts worse
|
95.5%
6.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.0%
0.2 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q3 0.0% · Q4 6.9% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.9%
2.9 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
6.2%
1.4 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.2% |
20.4%
10.8 pts worse
|
19.6%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 31.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.1% |
16.3%
1.2 pts better
|
16.7%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.1% · 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 need for help with daily activities has increased | 15.4% |
12.4%
3 pts worse
|
14.9%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.7% |
1.6%
5.1 pts worse
|
1.7%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 8.7% · Q3 11.1% · Q4 0.0% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.6% |
17.2%
9.4 pts worse
|
19.8%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.9% · Q3 37.0% · Q4 15.7% · 4Q avg 26.6% |
| Percentage of long-stay residents with pressure ulcers | 10.3% |
5.8%
4.5 pts worse
|
5.1%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 12.2% · Q3 15.1% · Q4 3.5% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.4% |
79.8%
8.6 pts better
|
81.7%
6.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 91.6% · Q3 89.9% · Q4 81.4% · 4Q avg 88.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.0% |
14.1%
1.9 pts worse
|
12.0%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 15.2% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.6%
1.3 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.6% |
78.0%
6.6 pts better
|
79.7%
4.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.5% |
24.7%
5.8 pts worse
|
23.9%
6.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.5% · Observed 27.1% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-31 · Fire 2024-01-31
4 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-02-03 · Fire 2022-02-03
12 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
2024-01-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-16
Inspection history
Recent health citations
J · Immediate jeopardy
2025-05-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-13
F · Potential for more than minimal harm
2024-01-31
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 2024-02-23
D · Potential for more than minimal harm
2024-01-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-31
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 2024-02-23
D · Potential for more than minimal harm
2024-01-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-23
F · Potential for more than minimal harm
2022-02-03
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 2022-03-04
E · Potential for more than minimal harm
2022-02-03
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 2022-03-04
D · Potential for more than minimal harm
2022-02-03
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 2022-03-04
D · Potential for more than minimal harm
2022-02-03
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 2022-03-04
D · Potential for more than minimal harm
2022-02-03
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 2022-03-04
D · Potential for more than minimal harm
2022-02-03
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 2022-03-04
D · Potential for more than minimal harm
2022-02-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-03-04
D · Potential for more than minimal harm
2022-02-03
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 2022-03-04
D · Potential for more than minimal harm
2022-02-03
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 2022-03-04
D · Potential for more than minimal harm
2022-02-03
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-03-04
D · Potential for more than minimal harm
2022-02-03
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 2022-03-04
D · Potential for more than minimal harm
2022-02-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-04
Penalties and ownership
What sits behind the stars
$16,153
2025-05-22
Fine
Fine · fine $16,153
Fine
Ownership
Wellmore LLC
5% Or Greater Direct Ownership Interest · Organization
Thompson, Donald
5% Or Greater Indirect Ownership Interest · Individual
Thompson, Benjamin
5% Or Greater Indirect Ownership Interest · Individual
Thompson, Joshua
5% Or Greater Indirect Ownership Interest · Individual
Maxwell Group, Inc.
Operational/Managerial Control · Organization
Thompson, Benjamin
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
L.M.C.- Extended Care
Lexington, SC
1-star overall rating with 1-star inspections with $43,752 in total fines with 5 recent health deficiencies
#2
Presbyterian Home Of South Carolina-Columbia
Lexington, SC
5-star overall rating with 4-star inspections with 3 recent health deficiencies
#3
NHC Healthcare - Lexington
West Columbia, SC
3-star overall rating with 2-star inspections with 4 recent health deficiencies
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