Inspection Reports for Bishop Gadsden Episcopal Retirement Community
1 BISHOP GADSDEN WAY, CHARLESTON, SC, 29412-3506
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than South Carolina average
South Carolina average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Routine
Deficiencies: 4
Date: Apr 25, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards related to catheter care, wander guard monitoring, pain management, and respiratory care at Bishop Gadsden Episcopal Health Care Center.
Findings
The facility failed to individualize comprehensive care plans for urinary catheter bulb size for two residents, failed to monitor and document the use of a wander guard device properly for one resident, failed to provide consistent and appropriately documented pain management for one resident, and failed to follow physician orders for oxygen therapy for one resident.
Deficiencies (4)
Failed to individualize comprehensive plans for urinary catheter bulb size for two residents.
Failed to monitor and document the use of a wander guard device according to standards of practice for one resident.
Failed to provide care and services consistent with professional standards for pain management related to frequent opioid medication requests and inconsistent administration for one resident.
Failed to follow physician orders for oxygen therapy prescribed for one resident.
Report Facts
Deficiencies cited: 4
Pain medication doses: 14
Pain medication administration days: 9
Pain medication multiple doses days: 5
Pain scale range: 8
Pain scale range: 4
Oxygen flow rate: 1
Oxygen flow rate ordered: 4
Oxygen flow rate ordered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Clinical Excellence | Interviewed and confirmed deficiencies related to catheter care, wander guard monitoring, pain management, and oxygen therapy. |
Inspection Report
Routine
Census: 21
Deficiencies: 3
Date: Mar 18, 2024
Visit Reason
The inspection was conducted to assess compliance with medication administration safety, food safety and handling practices, and medical director oversight of psychotropic medication use in the facility.
Findings
The facility failed to maintain a medication error rate below 5%, with a 7.67% error rate observed in medication administration. Food safety violations were noted including improper food storage, failure to use hair restraints, and improper drying of pans. Additionally, the Medical Director did not adequately assess the use of psychotropic medications for one resident, lacking proper rationale and documentation.
Deficiencies (3)
Medication error rate exceeded 5% due to administration errors involving nasal sprays for one resident.
Food safety violations including improper food storage, handling ready-to-eat foods with contaminated gloves, failure to air dry pans and containers, and lack of employee hair restraints in kitchens.
Medical Director failed to ensure complete assessment and proper oversight of psychotropic medication use for one resident.
Report Facts
Medication error rate: 7.67
Residents affected by food safety violations: 21
Seroquel dosage: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Named in medication administration error involving nasal sprays |
| Executive Chef | Executive Chef | Observed without hair restraint and confirmed food safety violations |
| Certified Dietary Manager | Certified Dietary Manager | Provided information on food handling expectations and observed violations |
| Director of Nursing | Director of Nursing | Confirmed number of rehab residents receiving meals and discussed medical director oversight |
| Administrator | Administrator | Confirmed issues with medical director oversight of psychotropic medication use |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 25, 2023
Visit Reason
The inspection was conducted as an annual survey of the Bishop Gadsden Episcopal Health Care Center to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 4
Date: Feb 17, 2022
Visit Reason
The inspection was conducted to assess compliance with regulations related to medication use, medication storage, infection control, food safety, and COVID-19 screening procedures at Bishop Gadsden Episcopal Health Care Center.
Findings
The facility failed to ensure appropriate use of psychotropic medications for one resident, failed to remove expired medications from storage, failed to properly label and store food items, and failed to maintain an effective COVID-19 screening process, including inaccurate temperature measurements and inadequate staff training. Immediate jeopardy was identified related to COVID-19 screening but was removed after corrective actions.
Deficiencies (4)
Failure to ensure one resident received psychotropic medication without proper clinical risk assessment, indication, gradual dose reduction, and monitoring.
Expired medications were not removed from active storage in the medication room.
Expired food items were not removed and open food items were not labeled with open dates or resealed; food splatter was present on microwave; trash receptacle missing at hand washing sink in Bistro.
Failure to maintain an effective infection prevention and control program by inadequately monitoring COVID-19 screening logs, improper temperature screening, lack of thermometer calibration, and insufficient staff training, resulting in immediate jeopardy to resident health or safety.
Report Facts
Deficiencies cited: 4
Temperatures measured under 97 F: 266
Temperatures measured over 99.5 F without rechecks: 29
Total screenings: 2663
Error rate: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| R10 | Resident | Resident reviewed for psychotropic medication use deficiency. |
| LPN 1 | Licensed Practical Nurse | Interviewed regarding resident R10's behavior and medication. |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding resident R10's behavior and medication. |
| CNA 2 | Certified Nursing Assistant | Interviewed regarding resident R10's behavior and medication. |
| Consulting Pharmacist | Pharmacist | Provided pharmacy consultation reports and medication recommendations for resident R10. |
| Medical Doctor | Physician | Interviewed regarding resident R10's medication and mental health treatment. |
| Registered Nurse 1 | Registered Nurse | Confirmed expired medication findings and COVID-19 screening procedures. |
| Director of Nursing | Director of Nursing | Provided physician assessment progress notes and confirmed medication findings. |
| Screening Gate Attendant 1 | Screening Gate Attendant | Interviewed regarding COVID-19 screening process and thermometer use. |
| Assistant Director of Environmental Services | Assistant Director | Interviewed regarding COVID-19 screening process and thermometer calibration. |
| Director of Operations | Director of Operations | Interviewed regarding COVID-19 screening process and temperature rechecks. |
| Administrator | Administrator | Interviewed regarding COVID-19 screening deficiencies and corrective actions. |
| Transportation Staff 1 | Transportation Staff | Interviewed regarding COVID-19 screening training. |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Designated to take oral temperatures for COVID-19 screening and received training. |
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