Greenwood, SC

Wesley Commons Health And Rehabilitation Center

4-star overall rating with 4-star inspections with $14,521 in total fines

1110 Marshall Road, Greenwood, SC

(864) 227-7250

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

80

Certified beds

Average residents

72

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1980-12-01

CMS approved date

Coverage

Medicare + Medicaid

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

0.98

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

0.68

Licensed practical nurse staffing · state 1.01 · national 0.87

Aide hours / resident day

2.49

Nurse aide staffing · state 2.22 · national 2.35

Total nurse hours

4.15

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.66

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

3.66

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.65

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

1.02

CMS adjusted RN staffing hours

Adjusted total hours

4.33

CMS adjusted total nurse staffing hours

Case-mix index

1.31

Higher values indicate more complex resident acuity

RN turnover

31%

Annual RN turnover · state 44% · national 45%

Total nurse turnover

47%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,900

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

34.66

Composite VBP score used to determine payment impact.

Payment multiplier

0.9885

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.95

Baseline 18.96% · Performance 20.53% · Measure score 1.95 · Achievement 1.95 · Improvement 0

Healthcare-associated infections

3.61

Baseline 4.94% · Performance 6.75% · Measure score 3.61 · Achievement 3.61 · Improvement 0

Total nurse turnover

3.48

Baseline 58.09% · Performance 49.47% · Measure score 3.48 · Achievement 3.48 · Improvement 2.09

Adjusted total nurse staffing

4.83

Baseline 4.54 hours · Performance 4.45 hours · Measure score 4.83 · Achievement 4.83 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.71%	10.72% About the same	No Different than the National Rate · Eligible stays 201 · Observed rate 8.96% · Lower 95% interval 8.08%
Discharge to community	56.1%	50.57% 5.5 pts better	No Different than the National Rate · Eligible stays 193 · Observed rate 53.89% · Lower 95% interval 48.96%
Medicare spending per beneficiary	0.76	1.02 0.3 pts better
Drug regimen review with follow-up	99.6%	95.27% 4.3 pts better	Numerator 249 · Denominator 250
Falls with major injury	1.2%	0.77% 0.4 pts worse	Numerator 3 · Denominator 250
Discharge self-care score	52.76%	53.69% 0.9 pts worse	Numerator 105 · Denominator 199
Discharge mobility score	63.32%	50.94% 12.4 pts better	Numerator 126 · Denominator 199
Pressure ulcers or injuries, new or worsened	2%	2.29% 0.3 pts better	Numerator 5 · Denominator 250 · Adjusted rate 2.78%
Healthcare-associated infections requiring hospitalization	6.75%	7.12% 0.4 pts better	No Different than the National Rate · Eligible stays 117 · Observed rate 5.13% · Lower 95% interval 3.8%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 152
Staff flu vaccination coverage	28.87%	42% 13.1 pts worse	Numerator 56 · Denominator 194
Discharge function score	71.36%	56.45% 14.9 pts better	Numerator 142 · Denominator 199
Transfer of health information to provider	95.74%	95.95% 0.2 pts worse	Numerator 45 · Denominator 47
Transfer of health information to patient	98.84%	96.28% 2.6 pts better	Numerator 171 · Denominator 173
Resident COVID-19 vaccinations up to date	25.62%	25.2% 0.4 pts better	Numerator 31 · Denominator 121

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.2	2.0 1.2 pts worse	1.9 1.3 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 2.8 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.7	1.9 0.8 pts worse	1.8 0.9 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.4 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	90.5% 9.5 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	90.6% 9.4 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	2.3%	3.0% 0.7 pts better	3.3% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.9% · Q3 2.0% · Q4 3.7% · 4Q avg 2.3% · 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	10.4%	6.2% 4.2 pts worse	5.4% 5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 12.2% · Q3 8.3% · Q4 2.1% · 4Q avg 10.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	36.0%	20.4% 15.6 pts worse	19.6% 16.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 36.2% · Q2 37.2% · Q3 35.4% · Q4 35.4% · 4Q avg 36.0%
Percentage of long-stay residents who received an antipsychotic medication	27.8%	16.3% 11.5 pts worse	16.7% 11.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 29.3% · Q3 29.3% · Q4 23.8% · 4Q avg 27.8% · 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	16.4%	14.9% 1.5 pts worse	16.3% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 16.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	11.4%	12.4% 1 pts better	14.9% 3.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 12.8% · Q3 9.5% · Q4 15.9% · 4Q avg 11.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.3%	0.7% 0.6 pts worse	1.0% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 1.6% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	3.3%	1.6% 1.7 pts worse	1.7% 1.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 3.9% · Q3 2.0% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.7%	17.2% 7.5 pts worse	19.8% 4.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 21.9% · Q3 30.1% · Q4 20.2% · 4Q avg 24.7%
Percentage of long-stay residents with pressure ulcers	2.2%	5.8% 3.6 pts better	5.1% 2.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.5% · Q3 3.0% · Q4 1.1% · 4Q avg 2.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.3%	79.8% 19.5 pts better	81.7% 17.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.5% · Q3 99.3% · Q4 99.3% · 4Q avg 99.3%
Percentage of short-stay residents who had an outpatient emergency department visit	15.0%	14.1% 0.9 pts worse	12.0% 3 pts worse	Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 12.8% · Expected 9.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.2%	1.6% 0.6 pts worse	1.6% 0.6 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 3.1% · Q3 3.0% · Q4 1.1% · 4Q avg 2.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	93.6%	78.0% 15.6 pts better	79.7% 13.9 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 93.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	29.6%	24.7% 4.9 pts worse	23.9% 5.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 29.6% · Observed 23.9% · Expected 19.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-11-27 · Fire 2024-11-27

0 health deficiencies

No concentrated health issue counts in this cycle.

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2023-04-14 · Fire 2023-04-14

2 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2021-09-30 · Fire 2021-09-30

3 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

J · Immediate jeopardy 2023-10-19

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 2023-10-03

D · Potential for more than minimal harm 2023-04-14

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2023-05-05

D · Potential for more than minimal harm 2023-04-14

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 2023-05-05

D · Potential for more than minimal harm 2021-09-30

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 2021-10-11

D · Potential for more than minimal harm 2021-09-30

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 2021-10-11

Penalties and ownership

What sits behind the stars

$14,521 2023-10-19

Fine

Fine · fine $14,521

Fine