Cycle 1
Health 2025-09-11 · Fire 2025-09-11
2 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.
Rock Hill, SC
Rock Hill Post Acute Care Center
5-star overall rating with 4-star inspections with 2 recent health deficiencies
159 Sedgewood Dr, Rock Hill, SC
(803) 329-6565
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1987-05-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 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
0.53
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.22 · national 2.35
Total nurse hours
3.50
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
2.90
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.65
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
46%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,758
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.12
Composite VBP score used to determine payment impact.
Payment multiplier
0.9889
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.35
Baseline 20.63% · Performance 19.42% · Measure score 4.35 · Achievement 4.35 · Improvement 2.87
Healthcare-associated infections
1.67
Baseline 6.93% · Performance 7.33% · Measure score 1.67 · Achievement 1.67 · Improvement 0
Total nurse turnover
6.77
Baseline 40.32% · Performance 36.00% · Measure score 6.77 · Achievement 6.77 · Improvement 2.29
Adjusted total nurse staffing
1.26
Baseline 3.27 hours · Performance 3.44 hours · Measure score 1.26 · Achievement 1.26 · Improvement 0.16
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.3% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 225 · Observed rate 13.78% · Lower 95% interval 9.53% |
| Discharge to community | 54.75% |
50.57%
4.2 pts better
|
No Different than the National Rate · Eligible stays 221 · Observed rate 48.87% · Lower 95% interval 48.72% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.66% |
95.27%
2.4 pts better
|
Numerator 125 · Denominator 128 |
| Falls with major injury | 0.78% |
0.77%
About the same
|
Numerator 1 · Denominator 128 |
| Discharge self-care score | 40.59% |
53.69%
13.1 pts worse
|
Numerator 41 · Denominator 101 |
| Discharge mobility score | 69.31% |
50.94%
18.4 pts better
|
Numerator 70 · Denominator 101 |
| Pressure ulcers or injuries, new or worsened | 0.79% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 127 · Adjusted rate 0.69% |
| Healthcare-associated infections requiring hospitalization | 7.33% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 144 · Observed rate 7.64% · Lower 95% interval 4.9% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 138 |
| Staff flu vaccination coverage | 18.24% |
42%
23.8 pts worse
|
Numerator 31 · Denominator 170 |
| Discharge function score | 59.41% |
56.45%
3 pts better
|
Numerator 60 · Denominator 101 |
| Transfer of health information to provider | 97.62% |
95.95%
1.7 pts better
|
Numerator 82 · Denominator 84 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 7.14% |
25.2%
18.1 pts worse
|
Numerator 4 · Denominator 56 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
2.0
0.9 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.9
1.6 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
90.5%
8.8 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 100.0% · Q3 100.0% · Q4 98.6% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
90.6%
8 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
3.0%
2.6 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
2.9%
1.4 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 5.2% · 4Q avg 1.5% |
| Percentage of long-stay residents who lose too much weight | 8.0% |
6.2%
1.8 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 3.2% · Q3 8.2% · Q4 10.6% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.3% |
20.4%
7.9 pts worse
|
19.6%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 29.7% · Q3 27.4% · Q4 25.8% · 4Q avg 28.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.9% |
16.3%
10.4 pts better
|
16.7%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 7.3% · Q3 5.7% · Q4 3.5% · 4Q avg 5.9% · 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 | 0.0% |
14.9%
14.9 pts better
|
16.3%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.1% |
12.4%
9.3 pts better
|
14.9%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 5.4% · Q4 5.2% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.7%
0.4 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · 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 1.5% · Q2 0.0% · Q3 0.0% · 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 | 24.4% |
17.2%
7.2 pts worse
|
19.8%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.5% · Q2 22.5% · Q3 20.7% · Q4 23.8% · 4Q avg 24.4% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
5.8%
2.1 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 2.0% · Q3 2.8% · Q4 4.5% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.1% |
79.8%
9.3 pts better
|
81.7%
7.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 79.5% · Q2 89.3% · Q3 93.5% · Q4 94.8% · 4Q avg 89.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.8% |
14.1%
3.3 pts better
|
12.0%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 10.5% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.6%
0.3 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 2.5% · Q3 1.9% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.5% |
78.0%
0.5 pts worse
|
79.7%
2.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.2% |
24.7%
8.5 pts better
|
23.9%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 15.8% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-15 · Fire 2024-08-15
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-08-09 · Fire 2022-08-09
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-11
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-10-11
D · Potential for more than minimal harm
2025-09-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-11
D · Potential for more than minimal harm
2024-08-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-14
D · Potential for more than minimal harm
2024-08-15
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 2024-09-14
D · Potential for more than minimal harm
2022-08-09
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 2022-09-01
D · Potential for more than minimal harm
2022-08-09
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 2022-09-01
D · Potential for more than minimal harm
2022-08-09
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 2022-09-01
Penalties and ownership
What sits behind the stars
Ownership
Hopewell Healthcare, Inc.
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Fitch, Craig
Corporate Officer · Individual
Powell, Steven
Operational/Managerial Control · Individual
Powell, Steven
Corporate Officer · Individual
Thatcher, Brent
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Magnolia Manor - Rock Hill
Rock Hill, SC
1-star overall rating with 1-star inspections with $128,214 in total fines with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Westminster Health & Rehab Center
RockHill, SC
3-star overall rating with 3-star inspections with $16,997 in total fines with 3 recent health deficiencies
#3
PruittHealth- Rock Hill
Rock Hill, SC
3-star overall rating with 3-star inspections with $23,989 in total fines with 1 recent health deficiencies
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