Inspection Reports for
Cooper River Post Acute
1049 ANNA KNAPP BLVD, MOUNT PLEASANT, SC, 29464-3133
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
357% worse than South Carolina average
South Carolina average: 3.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Census: 151
Deficiencies: 16
Date: Apr 10, 2025
Visit Reason
Routine inspection conducted to assess compliance with regulatory requirements including resident care, environment, medication administration, infection control, and documentation.
Findings
The facility was found deficient in multiple areas including failure to maintain accessible survey results, unsafe and unhomelike environment, incomplete and inaccurate resident assessments and care plans, medication administration errors, inadequate infection control practices, inaccurate dialysis care documentation, incomplete narcotic counts, menu and dietary deficiencies, and failure to offer recommended pneumococcal vaccinations.
Deficiencies (16)
F577: The facility failed to ensure previous three years of surveys, complaint investigations, and plans of correction were made accessible to residents and visitors.
F584: The facility failed to maintain a safe and homelike environment; bedroom walls were scraped and bathroom doors were jammed, affecting eight residents.
F637: The facility failed to complete a significant change Minimum Data Set assessment when a resident revoked hospice services, affecting one resident.
F641: The facility failed to accurately code Minimum Data Set assessments for prognosis and mental status for two residents.
F655: The facility failed to develop an accurate baseline care plan within 48 hours of admission for one resident, omitting care plans for gastrostomy tube and CPAP.
F656: The facility failed to implement a comprehensive care plan with measurable goals; a resident with pressure ulcers was not provided a wheelchair cushion as ordered.
F657: The facility failed to revise the comprehensive care plan when a resident revoked hospice services, had a gastrostomy tube removed, and enhanced barrier precautions discontinued.
F692: The facility failed to investigate significant weight loss and assess a resident before using a psychotropic drug for appetite stimulation.
F698: The facility failed to ensure dialysis residents received care with Enhanced Barrier Precautions and lacked physician orders and accurate care plans for dialysis treatments.
F757: The facility failed to ensure one resident's blood pressure medications were administered with proper monitoring of vital signs as ordered.
F759: The facility failed to maintain medication error rates below 5%, with two medication errors in 30 opportunities (6.67% error rate).
F761: The facility failed to ensure narcotic counts were properly documented and initialed by on-coming and off-going nurses at shift changes for eight medication carts.
F803: The facility failed to have and follow menu spreadsheets for portion sizes and therapeutic diets for three residents, risking choking and weight loss.
F842: The facility failed to ensure accurate documentation of dialysis site care; documented presence of bruit and thrill for residents with central venous catheters instead of arteriovenous fistulas.
F880: The facility failed to post Enhanced Barrier Precautions signage for 13 residents with wounds, catheters, or dialysis, risking infection spread.
F883: The facility failed to offer pneumococcal vaccination updates according to CDC recommendations for five residents, increasing pneumonia risk.
Report Facts
Residents affected: 8
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Medication error rate: 6.67
Medication carts: 8
Residents affected: 3
Residents affected: 2
Residents affected: 13
Residents affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 8 | Licensed Practical Nurse | Acknowledged medication error with iron supplements for Resident 20 |
| LPN 1 | Licensed Practical Nurse | Administered incorrect Vitamin D dose for Resident 80 |
| RD | Registered Dietitian | Discussed menu discrepancies and weight loss concerns |
| DON | Director of Nursing | Confirmed multiple deficiencies including medication errors, narcotic count issues, and infection control |
| IP | Infection Preventionist/Unit Manager | Confirmed infection control deficiencies and dialysis care documentation errors |
| RN 3 | Registered Nurse | Confirmed dialysis catheter care and documentation practices |
| LPN 3 | Licensed Practical Nurse | Verified gentamicin order and dialysis catheter removal for Resident 412 |
| LPN 12 | Licensed Practical Nurse | Acknowledged narcotic count documentation mistake |
| LPN 15 | Licensed Practical Nurse/Unit Manager | Discussed vital sign monitoring and medication administration parameters |
| NP | Nurse Practitioner | Discussed weight loss and medication use for Resident 51 |
| RDCS | Regional Director of Clinical Services | Explained pneumovax vaccination follow-up failure |
Inspection Report
Deficiencies: 1
Date: Jan 28, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the protection of residents' personal and medical records.
Findings
The facility failed to protect residents' private health information for 3 of 8 residents when a nurse left a medication cart unattended with the Electronic Medication Administration Record open on the computer screen. Interviews confirmed the nurse did not secure the screen as required by facility policy.
Deficiencies (1)
F 0583: The facility failed to keep residents' personal and medical records private and confidential. A nurse left the medication cart unattended with the EMAR screen open, exposing multiple residents' information.
Report Facts
Residents affected: 3
Residents reviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)1 | Licensed Practical Nurse | Named in relation to failure to secure computer screen during medication administration |
| Director of Nursing | Director of Nursing | Provided interview regarding expectations for protecting patient information |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Apr 18, 2024
Visit Reason
Annual recertification survey and extended survey conducted to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity, notification of room changes, prevention of abuse and neglect, timely reporting of incidents, provision of activities of daily living (ADL) care, smoking safety protocols, catheter care, pain management, staff performance reviews, medication storage and labeling, meal provision, and food safety practices.
Deficiencies (12)
F0550: Facility failed to provide dignity to Resident 129 by not knocking prior to entering the resident's room.
F0580: Facility failed to notify Resident 273's representative of a room change.
F0600: Facility failed to prevent resident-to-resident altercation and neglected care for Resident 58, including failure to document care and timely report incidents.
F0609: Facility failed to timely report a resident-to-resident altercation and neglect allegation to the state agency.
F0677: Facility failed to provide Resident 60 with assistance for activities of daily living, including grooming and oral care.
F0689: Facility failed to assess, supervise, and provide proper safety protocols for residents who smoke, constituting Immediate Jeopardy which was later removed.
F0690: Facility failed to properly position the catheter bag for Resident 163, leaving it on the floor.
F0697: Facility failed to assess and provide pain medication as prescribed to Resident 60 in a timely manner.
F0730: Facility failed to ensure annual performance reviews for 3 certified nursing assistants.
F0761: Facility failed to ensure medications were properly stored, labeled, and not expired in multiple medication carts and rooms.
F0803: Facility failed to provide Resident 3 with a dinner meal tray after returning from hospital.
F0812: Facility failed to ensure kitchen staff wore beard/hair restraints and failed to properly store, label, and discard expired foods in the kitchen.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 1
Certified Nursing Assistants: 3
Expired medications: 20
Expired food items: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN8 | Registered Nurse | Confirmed medication cart findings |
| RN1 | Registered Nurse | Confirmed medication cart findings |
| LPN3 | Licensed Practical Nurse | Confirmed medication cart findings |
| LPN8 | Licensed Practical Nurse | Confirmed medication cart findings |
| LPN9 | Licensed Practical Nurse | Confirmed medication cart findings |
| LPN10 | Licensed Practical Nurse | Confirmed medication cart findings |
| Regional Director | Regional Director of Clinical Services | Interviewed about CNA performance reviews |
| Administrator | Facility Administrator | Interviewed about CNA performance reviews and pain management |
| Director of Nursing | Director of Nursing | Interviewed about pain management and catheter care |
| Dietary Manager | Dietary Manager | Interviewed about meal provision and kitchen staff attire |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 5, 2024
Visit Reason
The inspection was conducted following a complaint investigation triggered by an incident involving a resident's death related to bedrail entrapment and failure to report the incident timely to the State Agency.
Complaint Details
The complaint investigation was substantiated. The facility failed to report a resident death involving bedrail entrapment within the required two-hour timeframe. The resident died by asphyxiation due to head entrapment in the bedrail. The facility also failed to develop appropriate care plans, assessments, consents, and monitoring related to bedrail use.
Findings
The facility failed to timely report a resident death involving bedrail entrapment to the State Agency. The facility also failed to develop a comprehensive care plan addressing bedrail use, failed to properly assess and obtain consent for bedrail use, and failed to monitor the use of bedrails. Immediate jeopardy was identified but later removed after corrective actions.
Deficiencies (3)
F0609: The facility failed to timely report an incident involving a resident's death to the State Agency within two hours as required.
F0656: The facility failed to develop and implement a comprehensive person-centered care plan related to the resident's use of bedrails, including measurable objectives and risk interventions.
F0700: The facility failed to properly assess the resident for safety risks related to bedrail use, failed to obtain informed consent, and failed to monitor and maintain bedrails according to policy.
Report Facts
Time to report incident: 2
Number of residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Interviewed regarding failure to report incident and care plan for bedrail use |
| Director of Nursing | Director of Nursing | Interviewed regarding lack of care plan and consents for bedrail use |
| LPN1 | Licensed Practical Nurse | Provided witness statement about resident found with head entrapped in bedrail |
| Administrator | Administrator | Interviewed regarding failure to report incident and monitoring of bedrail use |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 16, 2023
Visit Reason
The inspection was conducted due to a complaint investigation following a resident elopement incident on 08/10/2023, where the facility failed to provide adequate supervision to prevent accidents and hazards.
Complaint Details
The complaint investigation was substantiated with immediate jeopardy identified due to failure to prevent a resident elopement on 08/10/2023. The immediate jeopardy was removed by 08/11/2023 following the facility's corrective actions.
Findings
The facility was found to have immediate jeopardy for failing to prevent a resident from eloping on 08/10/2023. The resident was found outside the facility without injury. The facility implemented a removal plan including audits, staff education, revised door locking procedures, and increased monitoring to address the issue.
Deficiencies (1)
F 0689: The facility failed to ensure adequate supervision to prevent accidents and hazards, resulting in a resident elopement on 08/10/2023. Immediate jeopardy was identified but removed by 08/11/2023 after corrective actions were implemented.
Report Facts
BIMS score: 2
Temperature: 85
Audit frequency: 2
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 19, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide ordered antibiotic medication to a resident after hospital discharge.
Complaint Details
The complaint was substantiated. The resident did not receive several doses of ordered antibiotics between 04/29/23 and 05/02/23 due to medication access issues and delayed communication with the primary physician.
Findings
The facility failed to ensure that one resident received ordered antibiotic medication for four days after returning from the hospital due to an incorrectly documented allergy and pharmacy supply issues. Interviews confirmed the delay and lack of timely notification to the resident's primary physician.
Deficiencies (1)
F0684: The facility failed to provide ordered antibiotic medication to one resident for four days after hospital discharge due to an incorrectly documented allergy and pharmacy supply issues.
Report Facts
Residents reviewed in sample: 36
Resident affected: 1
Dates of missed medication administration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and confirmed the medication administration failure and issues with allergy documentation |
Inspection Report
Routine
Deficiencies: 14
Date: May 19, 2023
Visit Reason
Routine inspection of Sandpiper Post Acute nursing home to assess compliance with regulatory requirements including medication self-administration, mail delivery, Medicaid/Medicare notices, hospital transfer notifications, PASARR assessments, care planning, ADL assistance, medication administration, smoking safety, urinary catheter care, dietary services, waste disposal, and infection control.
Findings
The facility had multiple deficiencies including failure to assess and document medication self-administration, inconsistent mail delivery, late notification of Medicare benefit termination, lack of written hospital transfer notices, inaccurate PASARR screening, incomplete care plans for PTSD, inadequate oral and personal hygiene care, delayed antibiotic administration, unsafe smoking practices, improper urinary drainage bag positioning, medication administration errors, failure to follow planned menus, improper garbage disposal, and lapses in infection control precautions.
Deficiencies (14)
F 0554: The facility failed to ensure one resident was appropriately assessed and documented for self-administration of medication and lacked physician orders for medication found at bedside.
F 0576: The facility failed to ensure mail delivery on Saturdays for nine residents, with no policy or mechanism to guarantee weekend mail delivery.
F 0582: The facility failed to notify a Medicare resident's representative timely about therapy service termination, with notification delayed by three days.
F 0623: The facility failed to provide written notification of hospital transfers to residents, representatives, or ombudsman for three residents.
F 0644: The facility failed to ensure accuracy of a Level 1 PASARR screening for one resident exhibiting significant behavioral symptoms and psychotropic medication use.
F 0656: The facility failed to develop a care plan addressing PTSD diagnosis and triggers for one resident.
F 0677: The facility failed to provide adequate oral and personal hygiene care for two residents dependent on staff, resulting in skin breakdown and dry cracked lips.
F 0684: The facility failed to ensure timely availability and administration of ordered antibiotic medication for one resident, resulting in a four-day delay.
F 0689: The facility failed to assess and supervise a resident's smoking safety, with the resident smoking unescorted and lighter confiscated without proper supervision.
F 0690: The facility failed to properly position a resident's urinary drainage bag, which was observed lying flat on the floor, risking urinary tract infection.
F 0759: The facility had a medication error rate of 18% during observed medication pass, including incorrect medication administration route for one resident.
F 0800: The facility failed to follow preplanned menus and provide nutritionally equivalent food substitutions for many residents, causing dissatisfaction and nutritional concerns.
F 0814: The facility failed to properly dispose of garbage and refuse, with uncovered dumpsters and construction debris present.
F 0880: The facility failed to adhere to infection control precautions for one resident on Contact Isolation, including failure to perform hand hygiene and don protective equipment properly.
Report Facts
Residents affected by mail delivery issue: 9
Residents reviewed for PASARR: 36
Medication error rate: 18
Residents in facility: 163
Residents affected by dietary issues: 153
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN3 | Licensed Practical Nurse | Named in medication self-administration and smoking supervision findings |
| Director of Nursing | Director of Nursing | Named in multiple findings including medication self-administration, smoking supervision, antibiotic administration, and medication error expectations |
| CNA16 | Certified Nursing Assistant | Named in mail delivery findings |
| Social Services Director | Social Services Director | Named in PASARR and Medicare notification findings |
| Recruiter | Recruiter | Named in Medicare notification and hospital transfer notification findings |
| LPN4 | Licensed Practical Nurse | Named in PTSD care plan and urinary drainage bag findings |
| CNA17 | Certified Nursing Assistant | Named in oral hygiene care findings |
| LPN2 | Licensed Practical Nurse | Named in medication administration error findings |
| Dietary Manager | Dietary Manager | Named in dietary menu and food substitution findings |
| Assistant Dietary Manager | Assistant Dietary Manager | Named in dietary menu and food substitution findings |
| Registered Dietician | Registered Dietician | Named in dietary menu and food substitution findings |
| Maintenance Director | Maintenance Director | Named in garbage disposal findings |
| CNA18 | Certified Nursing Assistant | Named in infection control and isolation precaution findings |
| Unit Manager | Unit Manager | Named in urinary drainage bag and infection control findings |
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