Charleston Rehab and Nursing

Inspectors wroteBased on interview and record review the facility failed to complete initial and weekly pressure ulcer assessments, initiate timely wound treatments, failed to provide pressure ulcer treatments, and failed to use the physician ordered treatment for one of three residents (R5) reviewed for Quality of Care on the sample list of five. These failures resulted in R5 developing one facility acquired pressure wound which deteriorated and became infected causing R5 to be hospitalized and treated for Sepsis related to a severe wound infection. Findings Include: The facility's Skin Prevention, Assessment and Treatment policy dated 5/2/25 documents the facility's policy is in place to promote a systemic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown as well as to promote the healing of existing pressure ulcers. [...]

Inspectors wroteBased on interview and record review the facility failed to accurately document medication administration for one of three residents (R1) reviewed for pharmacy records on the sample list of five. Findings Include: R1's Physician Order dated 4/9/26 documents R1 was prescribed Ertapenem Sodium (antibiotic) one gram intramuscularly once per day for a Urinary Tract Infection for seven doses. R1's Medication Administration Record dated April 2026 documents R1 received the Ertapenem starting on 4/11/26 and ending on 4/18/26 for a total of eight documented doses. On 5/13/26 at 3:00 PM R1 stated he was not given one dose of his antibiotic back in April. He complained about it and the nurse on duty reported it. [...]

Inspectors wroteBased on interview and record review the facility failed to accurately transcribe and administer multiple medications per physician order. This failure affected two of three residents (R1, R2) reviewed for pharmaceuticals on the sample list of nine. This failure included multiple missed doses of an antiepileptic medication resulting in R2 having a seizure and subsequently being sent to the emergency room. Findings Include:1. R2's Hospital Discharge Instructions dated 2/24/26 documents R2 was discharged to the facility on 2/24/26 after a hospital admission for elevated phenytoin level, altered mental status and urinary tract infection. R2's previous Phenytoin medication order was discontinued and R2 was to start taking Phenytoin 300 milligrams daily at bedtime. R2's Medical Diagnoses List dated March 2026 documents R2 is diagnosed with Epilepsy. [...]

Inspectors wroteBased on interview and record review the facility failed to implement physician's orders for one of three residents (R1) reviewed for following plans of care on the sample list of nine. Findings Include:R1's Medical Diagnoses List dated April 2026 documents Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Hypertension, Atrial Fibrillation, and Type II Diabetes Mellitus. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. R1's Physician Medication Order Sheet dated April 2026 documents a physician order for nursing to wrap R1's bilateral legs with elastic compression bandages from dorsum feet to below the knee every morning and remove at bedtime. R1's Treatment Administration Record (TAR) dated April 2026 documents between 4/1/26 - 4/23/26 there were seven missed treatments for R1's leg wraps. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to recognize and respond to a significant change in condition and delayed treatment for one resident (R1) with a known Covid diagnosis and a history of Atrial Fibrillation. This failure affects one (R1) of three residents reviewed for Resident/Patient/Client Neglect. As a result of the delayed response, R1 was sent to the local hospital and diagnosed with Acute Renal Failure, Elevated Troponin, Hyperkalemia, Dehydration, and Atrial Fibrillation with Rapid Ventricular Response.

Inspectors wroteBased on record review, and interview, the facility failed to identify appropriate targeted intervention post previous fall, for a resident (R1) with severe cognitive impairment, failed to maintain a mobility device within R1's reach to prevent an unwitnessed fall, failed to initiate neurological and physical assessments post the unwitnessed fall. These failures affected one of three residents (R1) reviewed for falls on the sample list of 18. These failures resulted in a severe head injury and untreated pain.

Inspectors wroteBased on interview and record review the facility failed to complete a thorough investigation, by failing to interview other residents/staff (R16) resident (R17), and R3 and R4 alleged verbal abuse and failed to remove the alleged perpetrator (R16) from a resident shared dining room post witnessed verbal abuse. These failures affected three of four residents, ( R3, R4, and R17) reviewed for abuse, and two additional resident (R7 and R14) on the sample list of 18.

Inspectors wroteBased on interview and record review the facility failed repeatedly to provide the receiving supportive living facility complete and accurate personal identity, residents fund, Medicare and Social Security documents, and proof of purchase for a mobility device to ensure a resident continuity of care, and discharge occurred in a timely manner. This failure affected one of four residents (R2) reviewed for resident rights/discharge on the sample list of 18.

Inspectors wroteBased on observation, interview and record review the facility repeatedly failed to ensure transportation and nursing preparation for dental appointments which resulted in a delay in dental extractions. These failures affected one of four residents (R7) reviewed for resident rights/quality of care on the sample list of 18.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's family, physician and Hospice after a change in residents' condition, post traumatic fall. This failure affected one of three residents (R1) reviewed for falls/change in conditon, on a sample list of 18.

Inspectors wroteBased on interviews and record review, the facility failed to ensure R17 was free from witnessed resident to resident emotional and verbal abuse. R17 is one of four residents reviewed for abuse on the sample list of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to obtain and arrange for a wheelchair replacement for a dependent resident. This failure resulted in R2's prolonged use of a wheelchair in disrepair. R2 is one of three residents reviewed for quality care and service on the sample list of 18.

Inspectors wroteBased on record review and interviews, the facility failed to maintain complete and accurate medical records for two of 18 residents (R7 and R17) reviewed for accuracy of medical records on the sample list of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to assess, provide timely treatment, provide complete urinary catheter care, prevent cross contamination during wound care for one (R10) resident out of four residents reviewed for Urinary Tract Infections (UTI) in a sample list of 17 residents. These failures resulted in R10 obtained a Penile wound at facility which caused pain, additional medicated treatment and additional specialty physician appointments.

Inspectors wroteBased on interview and record review the facility failed to ensure the dignity of one (R8) resident out of three residents reviewed for resident rights in a sample list of 17 residents.

Inspectors wroteBased on interview and record review the facility failed to protect the rights of the residents to be free from verbal/emotional abuse from staff and other residents. This failure affected seven of eight residents (R2, R4, R5, R6, R7, R9, R13) reviewed for abuse on the sample list of 17. Findings Include: 1. R2's Medical Diagnosis List dated August 2025 documents R2 is diagnosed with Epilepsy. R2's Care Plan dated 7/26/25 documents R2 has a diagnosis of Seizure Disorder. Staff are to administer medications, protect from onlookers, provide post seizure treatment, and take vital signs and do neuro checks post seizure. R2's Minimum Data Set, dated [DATE] documents R2 is cognitively intact. On 8/29/25 at 12:15 PM, R2 stated V13 Licensed Practical Nurse (LPN) often tells others that he is faking his seizures. R2 stated this makes him feel upset and mad. [...]

Inspectors wroteBased on interview and record review the facility failed to report allegations of mental abuse on two separate occasions affecting one (R8) resident from staff interactions to the State Agency timely out of three residents reviewed for Abuse in a sample list of 17 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively supervise an unalarmed and unlocked facility exit door. This failure resulted in R3, a resident with a diagnosis of Dementia, eloping unnoticed from the facility and exiting through the facility courtyard towards the facility parking lot area. The facility also failed to identify and document any root-cause for R3's elopement in their elopement investigation. R3 is one of three residents reviewed for supervision in the sample of 17.

Inspectors wroteBased on interview and record review, the facility failed to document a resident (R3) elopement and subsequent investigation in the resident's medical record. This failure affects one resident (R3) of three reviewed for elopement in the sample of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to wear the proper Personal Protective Equipment (PPE) for one (R8) resident on Enhanced Barrier Precautions (EBP) out of three residents reviewed for Urinary Tract Infections (UTI) in a sample list of 17 residents.

Inspectors wroteBased on interview and record review the facility failed to check their medical equipment on a timely basis to ensure the medical equipment is in good working condition. The failure of maintaining the Automated External Defibrillator (AED) prevented the use of the AED during an episode of Cardiac Failure for one resident (R1) reviewed for Cardiac Failure in a sample of one.

Inspectors wroteBased on record review and interview the facility failed to maintain a professional standard of conduct, by working under the influence of alcohol. This failure had the potential to affect all 54 residents that reside in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect a resident's right to privacy by posting a video of R1 in the facility, on social media. The facility also failed to protect a resident's right to privacy during wound care for R10. This failure affects two of five residents (R1 and R10) reviewed for privacy on the sample list on 17.

Inspectors wroteBased on observations, interviews and record review, the facility failed to protect the resident's right to be free from mental abuse of (R1) by V6 and V7, Agency Certified Nursing Assistants (CNA's). This failure affected one of four residents (R1) reviewed for abuse on the sample list of 17.

Inspectors wroteBased on interview and record review the facility failed to correctly identify a resident prior to administering medications resulting in a resident receiving another resident's medications. This failure affects one of 12 residents reviewed for medication administration in the sample list of 14.

Inspectors wroteBased on interview and record review the facility failed to ensure required personnel attended the quarterly Quality Assessment and Assurance (QAA) committee meetings and failed to hold (QAA) committee meetings quarterly. This failure has the potential to affect all 60 residents residing in the facility. Findings Include: The facility QA (Quality Assessment & Assurance) Meeting Members list documents the required facility leadership and staff except there is no required Infection Preventionist on the QA member list. The facility QAPI (Quality Assurance Performance Improvement) Policy plan updated January 2024 documents the following: The QAPI Program takes a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality while involving all caregivers in practical and creative problem solving. The community QAPI Program achieves the following: [...]

Inspectors wroteBased on interview and record review the facility failed to have an operational Legionella water management plan. This failure has the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure the Infection Preventionist completed specialized training in infection prevention. This failure has the potential to affect all 60 residents in the facility. Findings Include: The facility's Infection Control Manual dated 2019 documents, the facility will designate an Infection Preventionist, the Infection Preventionist will have completed specialized training in infection prevention and control. On 9/04/24 at 11:06 AM, V2 (Director of Nursing) states V14 (Regional Infection Preventionist) is acting as the facility Infection Preventionist until a facility nurse is trained to take over the role and is educated. On 9/04/24 at 2:16 PM, V14 stated she is the facility's Infection Preventionist, and she does not currently have a copy of her training certificate and she will try and bring it tomorrow. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure staff were provided the required abuse prevention education. This has the potential to affect all 60 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that call lights were in reach for four (R28, R32, R6, and R29) of 24 residents reviewed in a sample list of 39. Findings Include: The facility's Certified Nursing Assistant's Guidebook dated 2021 documents to ensure the call light is in reach before leaving the room. 1.) On 9/03/2024 at 9:52 AM, R28 was laying in the bed. R28's call light was not in R28's reach. The call light cord was laying on the floor at the foot of R28's bed. R28's care plan dated 3/13/2023, documents R28 is a high risk for falls. This care plan includes an intervention to ensure that the call light is within reach and to encourage R28 to use it as needed for assistance. 2.) On 9/03/2024 at 10:03 AM, R32 was laying in bed. R32's call light was not in R32's reach. A bedside table was positioned up against R32's head of the bed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dependent residents timely assistance to eat. This failure affected seven out of seven residents (R1, R3, R29, R34, R37, R40, and R51) reviewed for dining assistance on the sample list of 39.

Inspectors wroteBased on interview and record review, the facility failed to hold administration of a resident's blood pressure medication per medical provider's orders. This failure resulted in R14 receiving unordered medication for an additional 23 days. This failure affects one resident (R14) of five reviewed for unnecessary medications in the sample list of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect residents' right to be free from physical abuse by another resident. This failure affected two of two residents (R44, R58) reviewed for abuse on the sample list of 39.

Inspectors wroteBased on interview and record review the facility failed to complete a thorough physical abuse investigation related to a resident-to-resident altercation. This failure affects two of two residents (R44, R58) reviewed for abuse on the sample list of 39.

Inspectors wroteBased on interview and record review the facility failed to request a new Level 1 PASARR within 30 days of admission for one (R32) of one resident reviewed for PASARR in a sample list of 39.

Inspectors wroteBased on interview and record review, the facility failed to identify a residents' specific behaviors necessitating anti-psychotic medication use. The facility also failed to develop, implement, and care plan non-pharmacological interventions prior to use of anti-psychotic medication. These failures affect one resident (R20) of five reviewed for unnecessary medications in the sample list of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to apply treatments as ordered by the physician and care plan interventions for two (R34 and R12) of two residents reviewed for skin condition in a sample list of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide catheter care in a manner that prevented cross contamination, ensure urinary collection bags were placed up off the floor, secure a residents catheter tubing, and failed to develop a catheter care plan for residents. This failure affects three (R28, R6, R29) of three residents reviewed for catheters on the sample list of 39.

Inspectors wroteBased on interview and record review, the facility failed to prevent unnecessary use of anti-psychotic medication (Risperidone) by failing to identify and document an approved diagnosis for anti-psychotic use and failing to identify and track targeted behaviors or persistent psychiatric distress necessitating the use of anti-psychotic medication. These failures affect one resident (R20) of five reviewed for unnecessary medications in the sample list of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to honor food preferences for one of seven residents (R34) reviewed for food preferences on the sample list of 39.

Inspectors wroteBased on interview and record review the facility failed to offer influenza vaccinations for one (R6) of five residents reviewed for immunizations on a sample list of 39.

Inspectors wroteBased on interview and record review the facility failed to offer a vaccination booster for Covid-19 for one (R36) of five residents reviewed for immunizations in a sample list of 39. Findings Include: On 9/03/24 at 10:40 AM R36 states he has not been offered any vaccinations since admitted to the facility. R36 states he would like to receive the Covid-19 booster immunization. R36's immunization record documents R36 has not received a Covid-19 vaccination since 4/01/21. On 9/06/24 at 8:26 AM, V8 (Registered Nurse) stated the facility had a Covid-19 vaccination clinic from an outside organization in June of 2024. V8 stated R36 should have been offered a Covid-19 vaccine during the vaccination clinic, but his name was not placed on the list for the clinic. V8 stated R36 should have been on this list to receive the Covid-19 vaccination.

Inspectors wroteBased on interview and record review the facility failed to notify the physician of a new diabetic foot ulcer, obtain a treatment order, and complete wound assessments for multiple days after the wound was found for one of three residents (R1) reviewed for diabetic ulcers in a sample list of six.

Inspectors wroteBased on interview and record review the facility failed to notify the Physician and the Power of Attorney when changes were identified for R1 relating to diabetic ulcers of R1's right great toe. R1 is one of three residents reviewed for diabetic ulcers in a sample list of six residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's (R2) right to be free from physical abuse by another resident (R1). R1 and R2 are two of three residents reviewed for abuse in the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin/source for one (R1) of three residents reviewed for abuse in the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to complete and document a thorough investigation into a resident's (R1) hand injury of unknown source. R1 is one of three residents reviewed for abuse in the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to supervise a resident (R1) with known aggression and other inappropriate behaviors towards others while in the facility dining room. This failure resulted in R1 pulling another resident (R2) and the resident's (R2) wheelchair onto the floor.

Inspectors wroteBased on observation, interview and record review the facility failed to document three compartment sink temperatures and sanitizer levels, failed to properly store and label perishable foods, and failed to maintain a sanitary kitchen environment. These failures have the potential to affect all 64 residents residing in facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen tubing was kept off of the floor, failed to clean and store bilevel positive airway pressure (BIPAP) and continuous positive airway pressure (CPAP) machines/tubing/masks in a sanitary manner, failed to change and label oxygen tubing weekly and failed to administer the accurate amount of oxygen for seven of seven residents (R5, R13, R19, R31, R1, R28, R57) reviewed for respiratory care on the sample list of 39.

Inspectors wroteBased on interview and record review the facility failed to complete psychotropic medication assessments, identify and monitor/track targeted behavioral interventions and nonpharmacological interventions, document clinical rational and orders to continue PRN (as needed) antianxiety medication, complete AIMS (Abnormal Involuntary Movement Scale) assessments, and follow up on pharmacy recommendations to attempt gradual dose reductions of psychotropic medications for five (R9, R21, R4, R54, R31) of five residents reviewed for unnecessary medications in the sample list of 39.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the dignity of one (R25) resident out of one resident reviewed for Dignity in a sample list of 39 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to have a physician order to keep medications at bedside, identify which medications were safe to keep at bedside, and develop a plan of care for self-administration of medications for one of one residents (R57) reviewed for self-administration on the sample list of 39.

Inspectors wroteBased on interview and record review the facility failed to provide Advance Beneficiary Notices to two of three residents (R54, R57) reviewed for reviewed for Beneficiary Protection Notifications on the sample list of 39.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a clean, orderly, homelike environment for two of three residents (R8, R19) reviewed for Environment on the sample list of 39.

Inspectors wroteBased on observation, interview and record review the facility failed to attempt to reduce the use/form of a physical restraint for one (R6) out of one resident reviewed for restraints in a sample list of 39 residents.

Inspectors wroteBased on interview and record review the facility failed to timely report an allegation of staff to resident abuse to the administrator and to the state survey agency for one of one residents (R21) reviewed for abuse in the sample list of 39.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate and thoroughly document an abuse allegation for one (R21) of one resident reviewed for abuse in the sample list of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a care plan for smoking, anticoagulants and the use of psychotropic medications for three (R57, R21, and R9) of 24 residents reviewed for care plans on the sample list of 39.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's record identified the hospice company, included active hospice orders, and included hospice in the care plan for one (R1) of one residents reviewed for hospice in the sample list of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received foot care including toenail care for one of one resident (R8) reviewed for Foot Care on the sample list of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to report a fall to the resident representative, implement post fall interventions, document post fall interventions on the care plan, complete fall risk assessments, and investigate a bruise to identify root cause and interventions. These failures affect two (R28, R49) of seven residents reviewed for accidents in the sample list of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's urinary catheter bag was stored off the floor, failed to obtain orders for a resident's urinary catheter and failed to document urinary catheter care for two of three residents (R8, R21) reviewed for urinary catheters on the sample list of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to date an insulin pen and bottle when opened for two (R26, R15) of 12 residents reviewed for insulin on the sample list of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide routine dental care for one of one resident (R13) reviewed for dental services on the sample list of 39.

Inspectors wroteBased on observation, interview and record review the facility failed to serve palatable food for three of three residents (R59, R50, R12) reviewed for palatability of food on the sample list of 39 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain residents' rights to receive unopened packages delivered to residents in the facility. This failure has the potential to affect all 63 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide Transfer and Discharge Notices to residents (R316, R26, R23) and their representatives when being discharged to the hospital. R316, R26 and R23 are three of three residents reviewed for hospitalizations in the sample list of 23.

Inspectors wroteBased on record review and interview, the facility failed to provide written Bed Hold Notices to residents (R316, R26, R23) and their representatives when being transferred to the hospital. R316, R26 and R23 are three of three residents reviewed for Hospitalizations in the sample list of 23. Findings Include: 1.) R316's Facility Census Sheet's dated July 2022, September 2022 and October 2022 document R316 being in the hospital on the following three occasions: 7/27/22 through 7/29/22 and returning to the facility on 7/30/22, 9/23/22 through 10/2/22 and returning to the facility on [DATE] and again hospitalized [DATE] through 10/6/22, returning to the facility on [DATE]. R316's Medical Record does not contain Bed Hold Notices for R316's admittance to the hospital on 7/27/22, 9/23/22 and 10/5/22, nor is there documentation a Bed Hold Notice was given. [...]

Inspectors wroteBased on record review, observation and interview the facility failed to obtain Physician orders for diagnosis, care and changes for R53's Urinary Catheter for one (R53) resident out of two residents reviewed for Urinary Catheters in a sample list of 23 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor residents' right to examine survey results by failing to place the survey book in a location readily accessible to residents. This failure affects all 56 residents residing in the facility.