Cycle 1
Health 2025-04-03 · Fire 2025-04-03
1 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fort Mill, SC
The Lodge At Wellmore- Tega Cay
5-star overall rating with 3-star inspections with $39,971 in total fines with 1 recent health deficiencies
111 Wellmore Drive, Fort Mill, SC
(803) 835-7000
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
49
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2016-04-18
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
0.88
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.47
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.88
Nurse aide staffing · state 2.22 · national 2.35
Total nurse hours
5.23
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.35
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.78
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.86
CMS adjusted RN staffing hours
Adjusted total hours
5.12
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
474
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
69.20
Composite VBP score used to determine payment impact.
Payment multiplier
1.0220
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.08
Baseline 22.62% · Performance 18.94% · Measure score 6.08 · Achievement 5.38 · Improvement 6.08
Healthcare-associated infections
10
Baseline 7.77% · Performance 4.75% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
5.01
Baseline 49.30% · Performance 43.21% · Measure score 5.01 · Achievement 5.01 · Improvement 1.99
Adjusted total nurse staffing
6.59
Baseline 4.66 hours · Performance 4.95 hours · Measure score 6.59 · Achievement 6.59 · Improvement 2.14
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.7% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 418 · Observed rate 7.89% · Lower 95% interval 7.54% |
| Discharge to community | 64.69% |
50.57%
14.1 pts better
|
Better than the National Rate · Eligible stays 414 · Observed rate 61.84% · Lower 95% interval 60.4% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 77% |
95.27%
18.3 pts worse
|
Numerator 164 · Denominator 213 |
| Falls with major injury | 2.35% |
0.77%
1.6 pts worse
|
Numerator 5 · Denominator 213 |
| Discharge self-care score | 43.35% |
53.69%
10.3 pts worse
|
Numerator 75 · Denominator 173 |
| Discharge mobility score | 56.65% |
50.94%
5.7 pts better
|
Numerator 98 · Denominator 173 |
| Pressure ulcers or injuries, new or worsened | 0.47% |
2.29%
1.8 pts better
|
Numerator 1 · Denominator 213 · Adjusted rate 0.52% |
| Healthcare-associated infections requiring hospitalization | 4.75% |
7.12%
2.4 pts better
|
Better than the National Rate · Eligible stays 242 · Observed rate 2.48% · Lower 95% interval 2.84% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 2 |
| Staff flu vaccination coverage | 78.57% |
42%
36.6 pts better
|
Numerator 44 · Denominator 56 |
| Discharge function score | 63.01% |
56.45%
6.6 pts better
|
Numerator 109 · Denominator 173 |
| Transfer of health information to provider | 89.25% |
95.95%
6.7 pts worse
|
Numerator 83 · Denominator 93 |
| Transfer of health information to patient | 94.74% |
96.28%
1.5 pts worse
|
Numerator 90 · Denominator 95 |
| Resident COVID-19 vaccinations up to date | 47.47% |
25.2%
22.3 pts better
|
Numerator 47 · Denominator 99 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
2.0
1 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.3 · Expected 2.4 · 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 1.6 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
90.5%
8.4 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.7% · Q3 100.0% · Q4 100.0% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.7% |
90.6%
0.9 pts worse
|
95.5%
5.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.0%
0.4 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.3% · Q3 4.8% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
2.9%
1.7 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 2.0% |
6.2%
4.2 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
20.4%
4.4 pts better
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
16.3%
16.3 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 need for help with daily activities has increased | 14.9% |
12.4%
2.5 pts worse
|
14.9%
About the same
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.9% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
1.6%
1.8 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.3% · Q3 4.8% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.2% |
17.2%
1 pts better
|
19.8%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.2% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
5.8%
2.9 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.1% · Q3 0.0% · Q4 4.3% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.2% |
79.8%
11.4 pts better
|
81.7%
9.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.9% · Q2 90.4% · Q3 93.1% · Q4 89.4% · 4Q avg 91.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.3% |
14.1%
0.2 pts worse
|
12.0%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 13.6% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.6%
1 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.8% · Q4 0.8% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.7% |
78.0%
17.7 pts better
|
79.7%
16 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.1% |
24.7%
3.6 pts better
|
23.9%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 18.3% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-23 · Fire 2023-03-23
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-12-09 · Fire 2021-12-09
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-11
G · Actual harm
2025-02-20
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 2025-03-11
J · Immediate jeopardy
2024-07-25
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 2024-07-26
J · Immediate jeopardy
2023-10-16
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 2023-10-10
E · Potential for more than minimal harm
2023-03-23
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 2023-04-04
D · Potential for more than minimal harm
2023-03-23
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-04
D · Potential for more than minimal harm
2023-03-23
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 2023-04-04
Penalties and ownership
What sits behind the stars
$9,110
2025-02-20
Fine
Fine · fine $9,110
Fine
$16,801
2024-07-25
Fine
Fine · fine $16,801
Fine
$9,492
2023-10-16
Fine
Fine · fine $9,492
Fine
$2,470
2023-06-26
Fine
Fine · fine $2,470
Fine
$2,098
2023-06-20
Fine
Fine · fine $2,098
Fine
Ownership
Wellmore LLC
5% Or Greater Direct Ownership Interest · Organization
Thompson, Brenda
5% Or Greater Indirect Ownership Interest · Individual
Thompson, Donald
5% Or Greater Indirect Ownership Interest · Individual
Chp Tega Cay Sc Owner LLC
5% Or Greater Security Interest · Organization
Thompson, Donald
Operational/Managerial Control · Individual
Thompson, Donald
Corporate Officer · Individual
Wellmore LLC
Operational/Managerial Control · Organization
Nearby options
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#2
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#3
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