Cycle 1
Health 2025-11-20 · Fire 2024-10-24
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Greenville, SC
The Arboretum At The Woodlands
5-star overall rating with 5-star inspections
50 Arboretum Way, Greenville, SC
(864) 371-3100
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
28
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2009-11-25
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
1.43
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
3.24
Nurse aide staffing · state 2.22 · national 2.35
Total nurse hours
5.55
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.31
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
5.30
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.97
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
1.53
CMS adjusted RN staffing hours
Adjusted total hours
5.95
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,126
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.68
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.8
Baseline 20.39% · Performance 21.06% · Measure score 0.8 · Achievement 0.8 · Improvement 0
Healthcare-associated infections
0
Baseline 7.23% · Performance 7.83% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.45
Baseline 58.82% · Performance 53.66% · Measure score 2.45 · Achievement 2.45 · Improvement 1.02
Adjusted total nurse staffing
6.62
Baseline 4.83 hours · Performance 4.96 hours · Measure score 6.62 · Achievement 6.62 · Improvement 0.85
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.23% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 213 · Observed rate 11.74% · Lower 95% interval 8.39% |
| Discharge to community | 78.94% |
50.57%
28.4 pts better
|
Better than the National Rate · Eligible stays 182 · Observed rate 79.67% · Lower 95% interval 71.55% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 96.7% |
95.27%
1.4 pts better
|
Numerator 88 · Denominator 91 |
| Falls with major injury | 2.2% |
0.77%
1.4 pts worse
|
Numerator 2 · Denominator 91 |
| Discharge self-care score | 50.67% |
53.69%
3 pts worse
|
Numerator 38 · Denominator 75 |
| Discharge mobility score | 52% |
50.94%
1.1 pts better
|
Numerator 39 · Denominator 75 |
| Pressure ulcers or injuries, new or worsened | 2.2% |
2.29%
0.1 pts better
|
Numerator 2 · Denominator 91 · Adjusted rate 2.77% |
| Healthcare-associated infections requiring hospitalization | 7.83% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 92 · Observed rate 7.61% · Lower 95% interval 4.67% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 264 |
| Staff flu vaccination coverage | 23.27% |
42%
18.7 pts worse
|
Numerator 64 · Denominator 275 |
| Discharge function score | 61.33% |
56.45%
4.9 pts better
|
Numerator 46 · Denominator 75 |
| 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 | 96.83% |
96.28%
0.5 pts better
|
Numerator 61 · Denominator 63 |
| Resident COVID-19 vaccinations up to date | 28.26% |
25.2%
3.1 pts better
|
Numerator 13 · Denominator 46 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.0
0.6 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 0.8 · Expected 1.1 · 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 1.0 · Expected 1.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
90.5%
6 pts better
|
93.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 95.2% · Q3 100.0% · Q4 95.8% · 4Q avg 96.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.4% |
90.6%
4.2 pts worse
|
95.5%
9.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
3.0%
1.7 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 4.8% · Q3 4.5% · Q4 8.3% · 4Q avg 4.7% · 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 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
6.2%
0.3 pts better
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.9% |
20.4%
14.5 pts better
|
19.6%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.3% |
16.3%
6 pts better
|
16.7%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.3% · 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 · 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 | 18.2% |
12.4%
5.8 pts worse
|
14.9%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.2% · 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 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
1.6%
1.9 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 4.5% · Q4 4.2% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.8% |
17.2%
17.6 pts worse
|
19.8%
15 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 37.8% · 4Q avg 34.8% |
| Percentage of long-stay residents with pressure ulcers | 0.6% |
5.8%
5.2 pts better
|
5.1%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.0% |
79.8%
10.2 pts better
|
81.7%
8.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.1% · Q2 94.4% · Q3 97.6% · Q4 78.6% · 4Q avg 90.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.1% |
14.1%
1 pts worse
|
12.0%
3.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.1% · Observed 14.5% · Expected 10.7% · 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 | 71.4% |
78.0%
6.6 pts worse
|
79.7%
8.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 71.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.2% |
24.7%
2.5 pts worse
|
23.9%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 24.6% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-24 · Fire 2023-07-14
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.
Cycle 3
Health 2023-07-14 · Fire 2022-01-07
1 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.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-24
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 2024-11-23
D · Potential for more than minimal harm
2024-10-24
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 2024-11-23
D · Potential for more than minimal harm
2024-02-02
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 2024-03-01
Penalties and ownership
What sits behind the stars
Ownership
Brackett, James
Operational/Managerial Control · Individual
Brackett, James
Corporate Officer · Individual
Cannaday, Troy
Operational/Managerial Control · Individual
Cannaday, Troy
Corporate Officer · Individual
Todd, Kelly
Corporate Officer · Individual
Upstate Senior Living, Inc.
Operational/Managerial Control · Organization
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#3
West Village Post Acute
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3-star overall rating with 3-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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