Cycle 1
Health 2025-03-07 · Fire 2025-03-07
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Greenville, SC
Southpointe Healthcare and Rehabilitation
2-star overall rating with 2-star inspections with $25,603 in total fines with 4 fire-safety deficiencies in the latest cycle
35 Southpointe Drive, Greenville, SC
(864) 288-1415
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
111
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Fundamental Healthcare
Operator or chain grouping
Approved since
1998-07-10
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
0.19
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
1.78
Nurse aide staffing · state 2.22 · national 2.35
Total nurse hours
3.05
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
2.72
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.11
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.21
CMS adjusted RN staffing hours
Adjusted total hours
3.31
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,654
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
2.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9804
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.34% · Performance 25.29% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.71% · Performance 7.76% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.9
Baseline 49.40% · Performance 60.00% · Measure score 0.9 · Achievement 0.9 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.67 hours · Performance 3.20 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.06% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 9.33% · Lower 95% interval 7.03% |
| Discharge to community | 47.71% |
50.57%
2.9 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 36.96% · Lower 95% interval 34.29% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.11% |
95.27%
2.8 pts better
|
Numerator 52 · Denominator 53 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 53 |
| Discharge self-care score | 54.84% |
53.69%
1.2 pts better
|
Numerator 17 · Denominator 31 |
| Discharge mobility score | 54.84% |
50.94%
3.9 pts better
|
Numerator 17 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 53 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.76% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 10.26% · Lower 95% interval 4.44% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 113 |
| Staff flu vaccination coverage | 26.72% |
42%
15.3 pts worse
|
Numerator 31 · Denominator 116 |
| Discharge function score | 54.84% |
56.45%
1.6 pts worse
|
Numerator 17 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 8 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.0
0.9 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 1.9 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
1.9
1 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.2 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
90.5%
5.5 pts better
|
93.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 94.1% · Q3 99.1% · Q4 97.2% · 4Q avg 96.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.5% |
90.6%
4.9 pts better
|
95.5%
About the same
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.0%
0.8 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.0% · Q3 2.8% · Q4 5.6% · 4Q avg 3.8% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
6.2%
2.5 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 4.5% · Q3 5.1% · Q4 4.1% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.3% |
20.4%
8.9 pts worse
|
19.6%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 30.1% · Q3 31.0% · Q4 28.3% · 4Q avg 29.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.5% |
16.3%
0.2 pts worse
|
16.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 16.2% · Q3 17.6% · Q4 16.7% · 4Q avg 16.5% · 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 | 1.1% |
14.9%
13.8 pts better
|
16.3%
15.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 3.5% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.2% |
12.4%
8.2 pts better
|
14.9%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 2.3% · Q3 2.2% · Q4 4.4% · 4Q avg 4.2% · 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% · Q2 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 | 0.0% |
1.6%
1.6 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.2% |
17.2%
9 pts better
|
19.8%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 2.2% · Q3 8.5% · Q4 11.6% · 4Q avg 8.2% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
5.8%
0.7 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 7.5% · Q3 4.0% · Q4 5.6% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 59.6% |
79.8%
20.2 pts worse
|
81.7%
22.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 66.7% · Q3 76.7% · Q4 54.9% · 4Q avg 59.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.4% |
14.1%
8.3 pts worse
|
12.0%
10.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 24.4% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.6%
1.6 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.9% |
78.0%
2.9 pts better
|
79.7%
1.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.7% |
24.7%
About the same
|
23.9%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.7% · Observed 26.7% · Expected 25.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-12 · Fire 2023-07-12
13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-08-26 · Fire 2021-08-26
10 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-03-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-03-07
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-03-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-27
F · Potential for more than minimal harm
2023-07-12
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-08-06
D · Potential for more than minimal harm
2023-07-12
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-08-06
D · Potential for more than minimal harm
2023-07-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-08-06
D · Potential for more than minimal harm
2023-07-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-09-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-14
J · Immediate jeopardy
2024-04-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-02-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-05
K · Immediate jeopardy
2023-07-12
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 2023-08-11
F · Potential for more than minimal harm
2023-07-12
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 2023-08-11
E · Potential for more than minimal harm
2023-07-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-12
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 2023-08-11
D · Potential for more than minimal harm
2023-07-12
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 2023-08-11
D · Potential for more than minimal harm
2023-07-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-12
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 2023-08-11
D · Potential for more than minimal harm
2023-07-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-12
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-11
F · Potential for more than minimal harm
2021-08-26
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 2021-09-24
E · Potential for more than minimal harm
2021-08-26
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2021-09-24
E · Potential for more than minimal harm
2021-08-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-24
D · Potential for more than minimal harm
2021-08-26
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 2021-09-24
D · Potential for more than minimal harm
2021-08-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-09-24
D · Potential for more than minimal harm
2021-08-26
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-09-24
D · Potential for more than minimal harm
2021-08-26
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2021-09-24
D · Potential for more than minimal harm
2021-08-26
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2021-09-24
C · Minimal harm
2021-08-26
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-09-24
Penalties and ownership
What sits behind the stars
$14,433
2024-04-12
Fine
Fine · fine $14,433
Fine
$11,170
2023-07-12
Fine
Fine · fine $11,170
Fine
Ownership
Thi Of South Carolina, LLC
5% Or Greater Direct Ownership Interest · Organization
Carroll, Ravaun
Operational/Managerial Control · Individual
Forman, Murray
5% Or Greater Indirect Ownership Interest · Individual
Hunt Valley Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Thi Of Baltimore, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Thi Of South Carolina, LLC
Operational/Managerial Control · Organization
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#2
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5-star overall rating with 5-star inspections
#3
Promedica Skilled Nursing And Reh- Greenville West
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4-star overall rating with 4-star inspections with 1 recent health deficiencies
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