Deficiencies (last 4 years)
Deficiencies (over 4 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
34% better than South Carolina average
South Carolina average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Deficiencies: 2
Aug 20, 2025
Visit Reason
The inspection was conducted to assess compliance with medication storage policies, specifically ensuring that drugs and biologicals are labeled and stored according to professional standards.
Findings
The facility failed to ensure that an insulin pen in use was labeled with the open and expiration dates, and an expired nasal allergy spray was found on a medication cart. Both items were removed upon discovery.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to label an insulin pen with open and expiration dates. | Level of Harm - Minimal harm or potential for actual harm |
| Expired nasal allergy spray found on medication cart. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)1 | Confirmed the insulin pen findings and removed it from storage. | |
| Licensed Practical Nurse (LPN)2 | Confirmed the expired nasal spray and removed it from the medication cart. |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 22, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following a fall incident involving Resident 4 (R4) on 05/06/25, where staff failed to adhere to the resident's individualized transfer plan as recommended by Physical Therapy.
Findings
The facility failed to ensure staff used the required sit-to-stand lift during transfers for R4, resulting in a fall and fractured arm requiring surgical intervention. Interviews, policy reviews, and medical records confirmed the improper transfer and subsequent injury.
Complaint Details
The complaint investigation was substantiated. Resident 4 fell on 05/06/25 during a transfer by Licensed Practical Nurse 1 (LPN1) who did not use the required sit-to-stand lift. The fall caused a fractured arm requiring surgical intervention. Multiple staff interviews and documentation confirmed the failure to follow the transfer protocol.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff adhered to a resident's individualized transfer plan, resulting in a fall and fractured arm. | Level of Harm - Actual harm |
Report Facts
Date of fall incident: May 6, 2025
Pain rating: 3
Date of surgical intervention: May 14, 2025
Assessment Reference Date: Mar 10, 2025
Date of Care Plan initiation: Oct 20, 2023
Date of Physical Therapy Discharge Summary: Jul 4, 2024
Date of Educational/Counseling/Warning Notice: May 9, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Transferred Resident 4 without using required sit-to-stand lift, resulting in fall and injury |
| CNA2 | Certified Nurse Aide | Assisted with transfer after fall and observed resident's injured arm |
| NP9 | Nurse Practitioner | Evaluated Resident 4 after fall and noted arm injury |
| Therapy Director | Provided information on Resident 4's transfer requirements | |
| Medical Director | Stated nurse should have used sit-to-stand lift and sought assistance | |
| DON | Director of Nursing | Completed investigation and confirmed transfer protocol was not followed |
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 11, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at White Oak Manor - Charleston.
Findings
No health deficiencies were found during the inspection, indicating full compliance with applicable standards.
Inspection Report
Annual Inspection
Deficiencies: 2
Jun 22, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to pressure ulcer care and infection prevention and control at White Oak Manor - Charleston.
Findings
The facility failed to prevent a pressure ulcer from developing in one resident and did not follow infection control protocols by failing to wear required personal protective equipment during care for another resident. The facility lacked a specific wound prevention policy and had incomplete documentation for skin condition monitoring.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to prevent a pressure ulcer from developing in one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow infection control protocol by not wearing designated PPE when providing care to a resident with an open wound. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Pressure ulcer size: 7.8
Pressure ulcer size: 6
Pressure ulcer size: 2
Pressure ulcer size: 3
Pressure ulcer size: 2.7
Pressure ulcer size: 1
Pressure ulcer size: 1
MDS Assessment Reference Date: Apr 26, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wound Care Nurse (WCN) | Interviewed regarding pressure ulcer and infection control findings | |
| Director of Nursing (DON) | Interviewed regarding wound prevention policy and reporting | |
| Infection Control Nurse (ICN) | Confirmed PPE requirements for residents on Enhanced Barrier Precautions | |
| Staff Development Coordinator | Confirmed staff PPE use during perineal care |
Inspection Report
Complaint Investigation
Deficiencies: 4
Oct 13, 2022
Visit Reason
The inspection was conducted based on complaints regarding failure to notify residents of medication changes, failure to provide timely assistance with activities of daily living (ADLs), improper administration of enteral feedings, failure to maintain proper head of bed elevation during tube feedings, and inadequate cleaning and storage of nebulizer equipment.
Findings
The facility failed to notify a resident of medication changes, provide timely incontinent care and repositioning for dependent residents, administer enteral feedings as ordered, maintain appropriate head of bed elevation during tube feedings to prevent aspiration, and properly clean and store nebulizer equipment after use.
Complaint Details
The complaint investigation revealed failures in resident notification of medication changes, timely ADL assistance, proper enteral feeding administration, head of bed elevation during tube feedings, and nebulizer equipment maintenance.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure a resident was notified of changes to the medication regimen. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to promptly assist residents with activities of daily living, including timely incontinent care and repositioning. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure enteral feedings were administered continuously as ordered and maintain head of bed elevation during feedings. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe and appropriate respiratory care by not cleaning and storing nebulizer equipment properly after each use. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for notification of changes: 7
Residents affected by medication notification deficiency: 1
Residents reviewed for ADL assistance: 4
Residents affected by ADL assistance deficiency: 2
Residents reviewed for enteral feedings: 4
Residents affected by enteral feeding deficiency: 2
Residents reviewed for respiratory therapy: 2
Residents affected by respiratory therapy deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN3 | Licensed Practical Nurse | Interviewed regarding medication notification and ADL care deficiencies |
| UM1 | Unit Manager | Interviewed regarding medication notification and ADL care deficiencies |
| DON | Director of Nursing | Interviewed regarding medication notification, ADL care, enteral feeding, head of bed elevation, and nebulizer equipment deficiencies |
| LPN2 | Licensed Practical Nurse | Interviewed regarding enteral feeding administration and head of bed elevation |
| LPN6 | Licensed Practical Nurse | Interviewed regarding enteral feeding administration |
| LPN1 | Licensed Practical Nurse | Observed administering medication with improper head of bed elevation |
| CNA7 | Certified Nursing Assistant | Interviewed regarding head of bed elevation during tube feedings |
| CNA2 | Certified Nursing Assistant | Interviewed regarding head of bed elevation during tube feedings |
| CNA4 | Certified Nursing Assistant | Interviewed regarding head of bed elevation during tube feedings |
| CNA5 | Certified Nursing Assistant | Interviewed regarding head of bed elevation during tube feedings |
| CNA6 | Certified Nursing Assistant | Interviewed regarding head of bed elevation during tube feedings |
| CNA11 | Certified Nursing Assistant | Observed feeding resident and interviewed regarding ADL care |
| CNA12 | Certified Nursing Assistant | Interviewed regarding ADL care |
| CNA13 | Certified Nursing Assistant | Interviewed regarding ADL care |
| CNA14 | Certified Nursing Assistant | Interviewed regarding ADL care |
| LPN2 | Licensed Practical Nurse | Interviewed regarding enteral feeding administration and head of bed elevation |
| RD | Registered Dietitian | Interviewed regarding enteral feeding administration |
| SLP | Speech Language Pathologist | Interviewed regarding aspiration precautions for tube-fed resident |
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