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Complaint Investigation

Physical Rehabilitation And Wellness Center Of Spa

February 20, 2026 · Spartanburg, SC · 8020 White Avenue
Citations 1
CMS Rating 1/5
Beds 120
Provider ID 425175
Healthcare Facility
Physical Rehabilitation And Wellness Center Of Spa
Spartanburg, SC  ·  View full profile →
Inspection Summary

Physical Rehabilitation And Wellness Center Of Spa in Spartanburg, SC — inspection on February 20, 2026.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0689
Quality of Life and Care Deficiencies

and his brother was one of them. My brother took the snacks.

They called me that day, and told me he

jeopardy to resident health or on 02/07/26, after midnight going into 02/08/26. He states he received another call stating he was safety vomiting, and he had to get sent out. He is still in the hospital, in a coma, for the moment.During an interview with Certified Nursing Assistant (CNA)1 on 02/19/26 at 12:11 PM revealed that On the day

stated she removed it from his hand.

She notified the nurse.

She saw the visitors, not his usual visitors, but church members who do missionary work, which is common on weekends.During a phone interview with LPN2 on 02/19/26 at 1:00 PM, LPN2 states she was walking by and noticed a cereal bar (blue wrapper) and a Styrofoam cup.

She states she took what he had; he had some in his mouth and some in his hand.

Half of the bar was in his mouth, maybe 2 inches left, all smushed up.

All of the water was gone. He could not tell her who gave it to him.A phone interview with the Medical Director (MD) on 02/19/26 at 1:15 PM revealed his understanding that the incident occurred on 02/07/26 when an unknown church member or group came in and gave the resident a cereal/granola bar along with some water.A phone interview on 02/19/26 at 1:51 PM with the Nurse Practitioner (NP) revealed she received a call from the nurse that night stating R1 was NPO and that earlier that day, he had received a cereal bar and some water from a church group that visited.

The nurse reported symptoms of projectile vomiting and clamminess present; she gave the order for the resident to be sent out.

The NP stated that eating and drinking while on NPO (nothing by mouth) can lead to vomiting.

She also stated that his blood pressure at the time, 184/100, is considered critically high and an urgent situation.An interview with the Facility Administrator (FA) on 02/19/26 at 3:11 PM revealed that he first heard about the event with R1 on the following Monday, 02/09/26, during the morning meeting, which included a review of nurses' notes, clinical review, and all department heads. He explained that during the day on weekends, the facility has a receptionist present. If she is away from the desk, she informs the nurses so they can monitor visitors.

Accushield, the screening tool for visitors, is hit or miss when a group of people enters at the same time.

The last update on R1 is that he had a tracheostomy.

The expectation is that when he returns, he will be on the rehab side.

Immediate actions taken included speaking with staff, implementing bright pink signage to inform visitors not to offer food or drink without consulting nurses due to the resident's condition, and discussions with the clinical team.

The facility's removal plan included:The identified resident was assessed by the provider following the incident on 02/07/26 with orders implemented.

The resident was discharged to the hospital on [DATE].

Residents in-house who have orders for nothing by mouth were assessed for change in condition, including change in vital signs, respiratory distress, and gastrointestinal distress by the Director of Nursing/Designee on 02/09/26; no concerns identified. A sign was placed at the entrance of the facility for visitors and/or delivery drivers to consult with a nurse prior to delivering and/or providing food or drink to a resident.

Residents who have orders for nothing by mouth had signs posted in their rooms identifying them as nothing by mouth and to contact the nurse prior to providing any food or drink to the resident on 2/10/26.

Facility Staff were reeducated by the Administrator/Designee beginning 02/09/26 on the policy of food brought in from outside sources Including: Questioning visitors providing food/drink to a resident to check with the nurse first.

Requesting visitors to notify the nurse prior to providing food/drink to a resident.

The facility will complete audits of food distributed from outside sources, validating proper distribution 3x a week for 1 month, then randomly thereafter. Ad Hoc QAPI was held on 2/10/26.

The Medical Director was notified on 02/08/26 and updated with interventions completed.

Allegation of Compliance 2/10/26.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Spartanburg, SC, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Physical Rehabilitation And Wellness Center Of Spa or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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