Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chandler Creek Post Acute during CMS and state inspections, most recent first.
An LPN pre-poured medications for more than one resident and failed to follow required resident-identification and "five rights" checks, resulting in a resident with dementia and multiple comorbidities receiving another resident’s ordered regimen, including oxycodone 30 mg, multiple antihypertensives, an antiarrhythmic, and gabapentin, none of which were prescribed for her. After receiving the wrong medications mixed in pudding, the resident developed hypotension, bradycardia, somnolence, and hypoxia, with documented very low BP and HR, and was transferred to the hospital where she required IV fluids, naloxone, atropine, and vasopressor support and was diagnosed with drug-induced hypotension, accidental drug overdose, bradycardia, respiratory insufficiency, sepsis with acute hypoxic respiratory failure, and pneumonia. Surveyors found that this failure to adhere to the facility’s medication administration policy and to ensure residents were free from significant medication errors constituted non-compliance at F760, rising to Immediate Jeopardy.
The facility failed to report a serious medication error that led to a resident’s hospitalization to the Administrator and State Agency within the required two-hour timeframe. An LPN pre-pulled medications for more than one resident, became distracted, and administered another resident’s medications, including multiple cardiac and pain medications, to a resident with dementia, atrial fibrillation, dysphagia, and depression. The resident subsequently developed hypotension, bradycardia, and decreased respirations and was transferred to the hospital. Although the LPN notified supervisory nursing staff and the NP, the incident was not entered on the reportable incident log, the Administrator was not promptly informed, and the State Agency was not notified, in part because the ADON was unaware of the reporting requirement and the DON was on leave.
A resident did not receive her prescribed medication, Restoril, for several days due to issues with insurance coverage and pharmacy refills. The MAR indicated the medication was not administered, and interviews revealed that the facility was informed of insurance issues, which were later confirmed to be incorrect. The resident and her daughter were involved in resolving the issue, but the medication was not given as prescribed.
The facility failed to assess a resident for self-administration of medications before allowing an inhaler to be left at the bedside. The resident, who had intact cognition and a diagnosis of COPD, was found with an inhaler that belonged to his roommate. The facility's policy requires an assessment and documentation for self-administration, which was not followed.
The facility failed to notify the responsible party of a severely cognitively impaired resident about the bed hold policy when the resident was sent to the ER. Although the resident signed the bed hold form, there was no documentation indicating that the responsible party was informed, which could affect the resident's return to the facility.
Significant Medication Error When Wrong Resident Received Another Resident’s Medications
Penalty
Summary
The deficiency involves a failure to ensure that a resident was free from significant medication errors when an LPN administered another resident's medications. Facility policy required that medications be administered safely and as prescribed, including verifying the resident's identity before administration using methods such as checking an identification band, reviewing a photograph on the medical record, and, if necessary, confirming identity with other staff. The policy also required the person administering medications to check the label three times to verify the right resident, medication, dosage, time, and route, and prohibited administering medications ordered for one resident to another. Despite these requirements, the LPN pre-poured medications for more than one resident at a time and did not correctly verify the resident's identity before administration. The resident who received the wrong medications, identified as R2, had been admitted with diagnoses including cognitive communication deficit, dementia with mild anxiety, atrial fibrillation, dysphagia, and major depressive disorder. Another resident, identified as R3, had diagnoses including heart failure, high blood pressure, chronic pain syndrome, and lumbar spondylosis, and had active orders for multiple medications: oxycodone 30 mg three times daily, amlodipine 5 mg (two tablets once daily), losartan 50 mg twice daily, dofetilide 250 mcg twice daily, gabapentin 600 mg four times daily, and metoprolol 50 mg once daily. R2 did not have physician orders for these medications. On the morning of the incident, the LPN labeled a medication cup with a resident's name, poured medications into the cup, mixed whole pills in pudding, and administered them to R2 in her room. The LPN later discovered that R2's medication cup was still on the cart and realized that the medications given to R2 were actually those prescribed for R3. Following the administration error, staff documented that R2 had received oxycodone 30 mg, amlodipine 5 mg, losartan 50 mg, dofetilide 250 mcg (also documented once as 520 mcg), gabapentin 600 mg, and metoprolol 50 mg, none of which were ordered for her. Progress notes and vital sign records showed that R2 subsequently experienced low blood pressure and slow heart rate, with multiple blood pressure readings in the 70s and 80s systolic and 40s diastolic, and heart rates in the 40s and 50s. A nurse practitioner assessed R2 shortly after the error and initially noted no acute distress, but within an hour R2 became symptomatic. Later documentation indicated that R2 was transferred to the hospital, where she was evaluated for somnolence, hypotension, bradycardia, and hypoxia after receiving the incorrect medications. Hospital records described that she required interventions including IV fluids, naloxone, atropine, and vasoactive medications due to persistent hypotension over several days, and she was diagnosed with hypotension due to drugs, drug overdose (accidental or unintentional), confusion caused by a drug, bradycardia, respiratory insufficiency, sepsis with acute hypoxic respiratory failure, and pneumonia. The state survey agency determined that the facility's non-compliance with pharmacy services requirements caused or was likely to cause serious injury, harm, impairment, or death, and cited the facility at F760.
Removal Plan
- The Administrator notified the Medical Director of the Immediate Jeopardy.
- R2 was assessed by the Nurse Practitioner, and new orders were written for vital signs every 30 minutes and Midodrine stat.
- R2 was sent to the emergency department for a higher level of care.
- The Assistant Director of Nursing began the investigation into the medication error.
- The Assistant Director of Nursing counseled LPN1 related to the medication error and failure to follow the five rights of medication pass, including prepulling medication that resulted in the medication error; the licensed nurse was placed on a process improvement plan.
- The Assistant Director of Nursing provided 1:1 education with LPN1 related to types of medication errors, causes, and prevention.
- The Assistant Director of Nursing began a medication pass in-service related to the 5 rights of medication administration.
- The Assistant Director of Nursing or designee began education with the licensed nurses on the 5 rights of medication pass and medication administration.
- The Assistant Director of Nursing or designee began education on the medication administration policy to include how to verify the medications are correct for all licensed nurses on or before their next scheduled shift.
- The Assistant Director of Nursing or designee began competency checks on medication pass on all licensed nurses.
- The Administrator, the Director of Nursing, and the Assistant Director were re-educated on Medication Pass, including medication errors, by the Regional Assistant Director of Clinical Services.
- The Director of Nursing completed a review of hospitalizations to determine if any were related to medication error.
- The Director of Nursing completed a medication error review to ensure proper documentation, appropriate corrective action, and reporting compliance.
- Nurse management will randomly select each nurse daily to observe medication passes for 7 days, then weekly for 4 weeks, then monthly for 2 months.
- The nurse involved in the deficiency will complete medication pass competency daily for 7 days, weekly for 4 weeks, monthly for 2 months, and quarterly for 2.
Failure to Report Serious Medication Error Resulting in Resident Hospitalization
Penalty
Summary
The facility failed to timely report a significant medication error that resulted in serious bodily injury to the Administrator and the State Agency within two hours, as required by its own abuse, neglect, exploitation, and misappropriation reporting policy. The policy, last revised in September 2022, states that suspicions of abuse, neglect, exploitation, misappropriation, or injury of unknown source must be reported immediately to the Administrator and appropriate authorities, defining "immediately" as within two hours for allegations involving abuse or resulting in serious bodily injury. Despite this, the medication error involving Resident 2, which led to hospitalization, was not entered on the facility’s reportable incident log and was not reported to the State Agency or Administrator as required. Resident 2 was admitted with diagnoses including cognitive communication deficit, dementia with mild anxiety, atrial fibrillation, dysphagia, and major depressive disorder. On the morning of 12/04/25, LPN1 pre-pulled medications for more than one resident at a time and prepared medications for Resident 2 and Resident 3. When Resident 3 requested pain medication, LPN1 retrieved oxycodone for Resident 3 but then became distracted and administered Resident 3’s medications to Resident 2 instead. Witness statements from the Unit Manager and ADON documented that Resident 2 received multiple medications not prescribed for them, including oxycodone 30 mg, amlodipine 5 mg, losartan 50 mg, dofetilide, gabapentin 600 mg, and metoprolol 50 mg. Progress notes show that Resident 2’s blood pressure remained low despite ordered midodrine and fluids, with documented hypotension, bradycardia, and decreased respirations, and the resident was ultimately transferred to the hospital for further evaluation. Following the error, LPN1 reported the incident to her supervisor, and the ADON and NP were notified; however, the Administrator and State Agency were not notified as required by policy. The DON, who was on maternity leave at the time, later stated that the incident should have been reported to the State Agency but confirmed that no report was submitted and that the ADON was unaware the incident needed to be reported. The ADON stated she was unsure if the Administrator had been notified and acknowledged she did not know she was required to report the incident to the State Agency. The Facility Administrator reported that he only became aware of the medication error recently, after speaking with another resident, and confirmed that no report had been sent to the State Agency and that he had not been informed of the incident when it occurred.
Failure to Administer Prescribed Medication Due to Insurance and Pharmacy Issues
Penalty
Summary
The facility failed to administer the prescribed medication, Restoril, to a resident for several days, despite having a physician's order for its administration to treat insomnia. The resident, who was cognitively intact with a BIMS score of 15 out of 15, did not receive the medication on multiple occasions as indicated by the Medication Administration Record (MAR). The MAR showed initials with numbers instead of check marks, indicating the medication was not given. The numbers corresponded to codes for 'hold/see nurses notes' and 'other/see nurses notes,' but the notes did not consistently document the medication's status. Interviews with the resident, her daughter, and facility staff revealed that the medication was not administered due to issues with insurance coverage and pharmacy refills. The resident and her daughter were informed that the insurance would not cover the medication, although the insurance company later confirmed there was no issue. The Director of Nurses acknowledged that the absence of check marks on the MAR suggested the medication was not administered, and the facility should have requested a hold or discontinuation of the medication. This series of events led to the resident not receiving her prescribed medication for insomnia over a period of several days.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed for self-administration of medications before allowing medications to be left at the bedside. Specifically, Resident 8, who had a diagnosis of chronic obstructive pulmonary disease and an intact cognition score of 15 out of 15, was found with an Albuterol Sulfate inhaler on his bedside table. The resident stated that the staff had always allowed him to keep the inhaler in his possession, although there was no order for self-administration or documentation in his care plan indicating that he had been assessed for this capability. The facility's policy requires an interdisciplinary team assessment and documentation in the medical record and care plan for residents to self-administer medications, which was not followed in this case. During an interview, an LPN confirmed that the resident did not have an order for the inhaler and should not have had it in his possession. The Director of Nursing later clarified that the inhaler belonged to the resident's roommate, who had an order to self-administer medications. However, the inhaler should not have been accessible to Resident 8, who had neither a prescription for it nor an assessment for self-administration. This oversight indicates a failure to adhere to the facility's policy on medication self-administration and secure storage of medications.
Failure to Notify Responsible Party of Bed Hold Policy
Penalty
Summary
The facility failed to issue a bed hold notice to the responsible party of a resident (R123) who was sent to the emergency room. R123, who was severely cognitively impaired with a BIMS score of one out of 15, was sent to the ER for an evaluation of a laceration to her left cheek area. Although the resident signed the bed hold form with an X, there was no documentation in the electronic medical record (EMR) indicating that her responsible party, her son, had been informed of the bed hold policy. The facility's investigation and progress notes confirmed that the responsible party was notified about the transfer to the ER but not about the bed hold policy. During interviews, the Administrator provided the facility's Bed Hold Policy and an additional Bed Holds and Returns policy, which stated that written information about bed holds should be given to residents and their representatives prior to a transfer or as timely as possible. The Administrator acknowledged that a resident with severe cognitive impairment, like R123, should not have signed the form and that the responsible party should have been notified. This failure to inform the responsible party of the bed hold policy had the potential to affect the resident's return to the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Greer
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brushy Creek Post Acute | 2.2 mi | — | 7 | 2 |
| Nhc Healthcare - Greenville | 6.6 mi | — | 0 | 0 |
| The Gables Of Pelham Skilled Nursing & Rehab | 7.8 mi | — | 0 | 0 |
| Rolling Green Village | 7.9 mi | — | 0 | 0 |
| Patewood Post Acute | 9 mi | — | 0 | 0 |
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