Inspection Reports for Oak Harbor Healthcare
921 BOWMAN RD, MOUNT PLEASANT, SC, 29464-3234
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% better than South Carolina average
South Carolina average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
121 residents
Based on a March 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 15, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding residents' rights to access contact information for state regulatory agencies and proper medication storage practices within the facility.
Complaint Details
The complaint investigation revealed that 10 of 10 residents at a resident council meeting were unaware of their rights to access contact information for state regulatory agencies and complaint filing procedures. Interviews with the Activity Director and Administrator confirmed lack of awareness and communication regarding this information.
Findings
The facility failed to ensure residents were informed of their right to access contact information for pertinent state regulatory and advocacy agencies, as confirmed by resident council minutes and interviews. Additionally, the facility failed to properly store medications in three medication room refrigerators, with temperature monitoring issues and expired vaccines found.
Deficiencies (2)
Failed to ensure residents were informed of their right to access names, addresses, and telephone numbers of pertinent state regulatory and informational agencies, resident advocacy groups, and information on filing complaints or reporting abuse violations.
Failed to ensure medications were properly stored in locked compartments with appropriate temperature controls in 3 of 3 medication rooms.
Report Facts
Expired vaccine syringes: 18
Medication rooms inspected: 3
Temperature readings: 32
Temperature readings: 17
Temperature readings: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activity Director | Interviewed regarding resident rights and complaint information awareness | |
| Administrator | Interviewed regarding facility communication with Ombudsman and medication refrigerator issues | |
| LPN1 | Licensed Practical Nurse | Confirmed expired vaccine storage |
| LPN2 | Licensed Practical Nurse | Confirmed refrigerator temperature reading of 32 degrees Fahrenheit |
| LPN3 | Licensed Practical Nurse | Confirmed refrigerator temperature reading of 17 degrees Fahrenheit |
| LPN4 | Unit Manager | Informed of refrigerator temperature reading of 17 degrees Fahrenheit and reviewed temperature logs |
| Consultant Pharmacist | Acknowledged expired vaccine was in active storage but intended for return to manufacturer | |
| Maintenance Director | Informed of refrigerator temperature concerns and directed to place new thermometers |
Inspection Report
Routine
Census: 121
Deficiencies: 5
Date: Mar 29, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, facility operations, and infection control at Oak Harbor Healthcare.
Findings
The facility was found deficient in multiple areas including inaccurate Minimum Data Set (MDS) assessments for residents receiving specialized care, failure to provide appropriate splint devices per care plans, inadequate dialysis medication administration, food safety and sanitation issues in the kitchen, and ineffective infection prevention practices including hand hygiene and laundry area contamination risks.
Deficiencies (5)
Failure to ensure accurate MDS assessments capturing hemodialysis treatments, pain interventions, and anticoagulant therapy for residents R17, R29, and R113.
Failure to provide a splint device for contracture per plan of care for resident R112.
Failure to ensure dialysis related medications were provided for resident R71.
Failure to ensure the kitchen was properly cleaned, food was properly handled, and the dish machine was working according to professional standards.
Failure to ensure effective hand hygiene during wound care and lack of physical barrier to separate dirty and clean laundry areas.
Report Facts
Residents sampled: 33
Census: 121
Dishwasher temperature: 90
Dishwasher temperature: 103
Dishwasher sanitizer concentration: 200
Dishwasher temperature: 100
Dishwasher temperature: 119
Dishwasher temperature: 112
Dishwasher temperature: 122
Dishwasher temperature: 100
Medication doses missed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | LPN | Provided care for resident R29 and confirmed pain medication effectiveness |
| Licensed Practical Nurse 2 | LPN | Observed and applied splint to resident R112's right hand |
| MDS Coordinator | MDSC | Confirmed inaccuracies in MDS assessments for residents R17 and R113 |
| Director of Therapy | Director of Therapy | Confirmed lack of policy on splint use and education provided to nursing staff regarding splint application |
| Director of Nursing | DON | Provided expectations on splint application, hand hygiene, and laundry handling |
| Unit Manager 2 | Unit Manager | Discussed dialysis medication administration timing for resident R71 |
| Nurse Practitioner | NP | Reviewed medication orders and confirmed missed doses of Renvela for resident R71 |
| Dietary Manager | DM | Observed food service practices and confirmed ongoing staff education on glove use and cleaning |
| Corporate Dining Consultant | CDC | Confirmed dishwasher temperature requirements and booster installation |
| Registered Dietician | RD | Confirmed dishwasher temperature requirements and booster installation |
| Wound Care Nurse | WCN | Observed performing wound care with inadequate handwashing technique |
| Laundry Staff 1 | Laundry Staff | Confirmed no physical barrier between clean and dirty laundry areas |
| Administrator | Administrator | Acknowledged lack of laundry barrier identified during mock survey |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 9, 2023
Visit Reason
The inspection was conducted following a complaint investigation regarding a resident fall incident on 09/01/2023, where a Certified Nursing Assistant improperly repositioned a resident resulting in a fall and injury.
Complaint Details
The complaint investigation was substantiated. The resident fell on 09/01/2023 during a bed bath when a CNA attempted to reposition her improperly, causing a fall with head injury and subsequent hospitalization. The facility conducted a self-reportable investigation and implemented staff education and care plan interventions.
Findings
The facility failed to maintain resident safety, resulting in actual harm to one resident who fell during care. The investigation revealed deficiencies in staff training and supervision, with corrective interventions implemented after the incident.
Deficiencies (1)
Failed to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, resulting in a resident fall and injury.
Report Facts
Residents Affected: 1
Date of fall incident: Sep 1, 2023
Date survey completed: Nov 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA1 | Certified Nursing Assistant | Named in fall incident for improper repositioning of resident |
| LPN1 | Licensed Practical Nurse | Witnessed and reported resident fall |
| Director of Nursing | Director of Nursing | Interviewed regarding staff training and expectations |
| Advanced Practice Nurse | Advanced Practice Nurse | Documented resident progress note after fall |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 4, 2023
Visit Reason
The inspection was conducted due to a complaint alleging that the facility failed to timely report an allegation of abuse involving Resident 2 within the required two-hour timeframe.
Complaint Details
The complaint investigation found that the facility did not notify the State Survey Agency of the abuse allegation within the required two-hour timeframe; notification occurred approximately 24 hours later. The Administrator acknowledged the delay and explained it was due to the nurse being an external agency staff and the allegation being identified during 24-hour chart audits the following day.
Findings
The facility failed to report an allegation of abuse to the Administrator and the State Survey Agency within the required two-hour timeframe, instead reporting approximately 24 hours after the allegation was made. The Administrator confirmed the delay was due to the nurse involved being an external agency nurse and the allegation was only discovered during the next day's chart audits.
Deficiencies (1)
Failed to report an allegation of abuse to the Administrator and State Survey Agency within the two-hour timeframe for 1 of 3 residents reviewed for abuse.
Report Facts
Residents reviewed for abuse: 3
Residents affected: 1
Time delay in reporting abuse allegation: 24
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 4
Date: Mar 16, 2022
Visit Reason
The inspection was conducted due to complaints regarding failure to provide quarterly financial statements to a resident's representative, failure to update the Pre-admission Screening and Resident Review (PASARR) Level I for a resident, failure to provide activities meeting residents' needs, and failure to provide appropriate care to maintain or improve range of motion for a resident.
Complaint Details
The complaint investigation revealed failures in financial management communication, PASARR screening updates, activity programming, and therapy services related to range of motion for specific residents.
Findings
The facility failed to provide quarterly financial statements to a resident's representative, failed to update PASARR Level I for one resident resulting in lack of appropriate evaluation, failed to provide ongoing activity programs aligned with residents' preferences for two residents, and failed to provide appropriate treatment and services to prevent further decline in range of motion for one resident with severe hand contractures.
Deficiencies (4)
Failed to provide quarterly financial statements in writing to the resident's representative within 30 days after the end of the quarter and upon request.
Failed to ensure the PASARR Level I was updated for one resident, resulting in no PASARR Level II evaluation to ensure appropriate care and services.
Failed to provide an ongoing program of activities in accordance with residents' comprehensive assessment, interests, and well-being for two residents, causing their activity preferences not to be honored.
Failed to provide appropriate treatment and services to increase and/or prevent further decrease in range of motion to a resident's severely contracted left hand, risking additional pain/discomfort and poor hygiene.
Report Facts
Residents in initial pool sample: 32
Residents reviewed for PASARR: 5
Residents sampled for activities: 7
BIMS score: 4
BIMS score: 13
BIMS score: 4
Contracture severity: 25
Therapy duration: 29
Splint wearing time: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Confirmed failure to provide quarterly financial statements to resident's representative |
| Social Services Director | Social Services Director | Acknowledged failure to update PASARR Level I and need to resubmit |
| Activity Director | Activity Director | Reported lack of music and appropriate activities for residents R33 and R105 |
| Licensed Practical Nurse 2 | Unit Manager | Unaware of residents' activity preferences and failure to ensure music was played |
| Rehabilitation Director | Rehabilitation Director | Provided therapy records and acknowledged lack of therapy recommendations for left hand contractures |
| Licensed Practical Nurse 1 | Unit Manager | Acknowledged absence of restorative nursing program and knowledge of contracture issues |
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