Retreat at Wellmore of Lexington

Lexington, SC · 60 beds · For profit - Limited Liability company

62 Trust Score
Grade: C MEDIUM Risk → Stable

Red Flags

  • 1 citation(s) at the highest severity level — immediate risk to residents

Green Flags

  • 4-star health inspection rating
  • 4-star staffing rating
  • Below-average deficiency count (1 vs 4 state avg)

Quick Facts

★★★★☆
CMS Overall
★★★★☆
Health Inspection
1
0.3x state avg
Deficiencies
$16,153
Fines (3-yr)
★★★★☆
Staffing

Violation Timeline

May 21, 2025

2 deficiencyies
F0760 Immediate Jeopardy Scope/Severity: J

Pharmacy Service Deficiencies

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Ensure that residents are free from significant medication errors.

F0760 Immediate Jeopardy Scope/Severity: J

Pharmacy Service Deficiencies

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Ensure that residents are free from significant medication errors.

January 30, 2024

8 deficiencyies
F0695 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide safe and appropriate respiratory care for a resident when needed.

F0761 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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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.

F0812 Potential Harm Scope/Severity: F

Nutrition and Dietary Deficiencies

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Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

F0880 Potential Harm Scope/Severity: D

Infection Control Deficiencies

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Provide and implement an infection prevention and control program.

F0695 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide safe and appropriate respiratory care for a resident when needed.

F0761 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

Show details

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.

F0812 Potential Harm Scope/Severity: F

Nutrition and Dietary Deficiencies

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Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

F0880 Potential Harm Scope/Severity: D

Infection Control Deficiencies

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Provide and implement an infection prevention and control program.

February 2, 2022

10 deficiencyies
F0578 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

F0584 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

F0644 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

F0656 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

F0686 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide appropriate pressure ulcer care and prevent new ulcers from developing.

F0725 Potential Harm Scope/Severity: D

Nursing and Physician Services Deficiencies

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Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

F0726 Potential Harm Scope/Severity: D

Nursing and Physician Services Deficiencies

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Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

F0758 Potential Harm Scope/Severity: E

Pharmacy Service Deficiencies

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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.

F0759 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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Ensure medication error rates are not 5 percent or greater.

F0761 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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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.

See full violation history →

Staffing

0.84
RN hrs/res/day
1.10
LPN hrs/res/day
2.52
CNA hrs/res/day
4.13
Weekend hrs/res/day
40%
Total nurse turnover
42%
RN turnover

A nurse checks on each resident roughly every 5.4 hours on average.

Fines & Penalties

  • Fine May 21, 2025
    $16,153
Total $16,153

Ownership

For profit - Limited Liability company Independent (not part of a chain)
  • WELLMORE LLC

    5% OR GREATER DIRECT OWNERSHIP INTEREST

    Since since 01/21/2015

    100% Organization
  • THOMPSON, BENJAMIN

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 01/01/2021

    25% Individual
  • THOMPSON, DONALD

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 01/21/2015

    50% Individual
  • THOMPSON, JOSHUA

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 01/01/2021

    25% Individual
  • MAXWELL GROUP, INC.

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 09/01/2016

    Organization
  • THOMPSON, BENJAMIN

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 07/01/2022

    Individual

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