Retreat at Wellmore of Daniel Island

Inspectors wroteBased on a review of facility policy, manufacturers' recommendations, observations, and interviews, the facility failed to: 1. Ensure that food items were stored, prepared, distributed, and or served in accordance with professional standards of practice in one of one main kitchen and four of four satellite kitchenettes. 2. Ensure that staff adequately monitored and documented the sanitation levels of all facility dishwasher machines. Specifically, on 03/18/26, the facility was made aware of concerns with the main kitchen's dishwasher following a service repair by Ecolab and continued to prepare and serve meals using dishware that was not properly sanitized in five of five dishwashers reviewed. [...]

Inspectors wroteBased on observations, record reviews, interviews, review of the facility policy and South Carolina Board of Nursing regulations, the facility failed to ensure that no significant medication errors occurred for 1 (Resident (R) 45) of 3 residents observed during medication pass. (Cross reference F550, F759 and F880.)

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure meals were served according to the prescribed diets during two lunch meals for Resident (R) 33. Findings Include:Review of the facility policy titled, Tray Identification, with a revised date of 04/07, revealed, 2. The Food Services Manager will check trays for correct diets before the food carts are transported to their designated areas. 3. Nursing staff shall check each food tray for the correct diet before serving the residents. Review of R33's face sheet revealed he was admitted to the facility on [DATE]. His diagnoses included, but were not limited to, cerebral infarction (stroke), cerebellar stroke syndrome, dementia, and dysphagia (difficulty swallowing). [...]

Inspectors wroteBased on observations, record reviews and interviews the facility failed to ensure that privacy was maintained while intravenous medications were being administered to 1 (Resident (R) 45) of 3 residents observed during medication pass. (Cross reference F759, F760 and F880.)

Inspectors wroteBased on observations, record reviews, interviews and facility policy, the facility failed to ensure that medications were administered pursuant to physician orders for 1 (Resident (R) 45) of 3 residents observed during medication pass. The medication error rate was 8 percent. (Cross reference F550, F760 and F880.)

Inspectors wroteBased on observations, record reviews, interviews, and review of manufacturer labeling, the facility failed to ensure that medications were properly stored in 1 of 4 treatment carts. Findings Include: During an observation on 04/15/26 at approximately 11:32 AM, the [NAME] treatment cart contained one opened container of [NAME] Normal Saline 0.9 percent (0.9%), 100 milliliters (100 mL). The container was dated by the facility as opened on 04/10/2026. The manufacturer's labeling on the container stated Do Not Reuse and Contents STERILE in unopened.package. During a follow-up interview on 04/15/26 at approximately 11:37 AM, Licensed Practical Nurse 3 (LPN 3) inspected the [NAME] Normal Saline container, read the manufacturer's labeling, and stated that it should have been discarded after use rather than being returned to the treatment cart.

Inspectors wroteBased on observations, record reviews, interviews and review of the facility policy, the facility failed to ensure enhanced barrier precautions were followed for 1 (Resident (R) 45) of 3 residents observed during medication pass. (Cross reference F550, F759 and F760). Findings Include:Review of the facility policy titled, Enhanced Barrier Precautions, last revised August 2022, states, Policy Interpretation and Implementation: 1. Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: . g. [...]

Inspectors wroteBased on review of facility policy, record review, video footage and interviews, the facility failed to prevent accidents/hazards for 1 of 3 residents reviewed. Specifically, on 8/30/25, Resident (R)1 had a successful elopement from the facility. R1 was placed at an increased risk of being struck by a vehicle and/or suffering a heat related and inclement illness. On 09/11/25 at 2:22 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 09/11/25 at 2:22 PM, the Executive Director (ED) was notified that the failure to protect R1 from having a successful elopement from the facility constituted Immediate Jeopardy (IJ) at F689. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure items in the refrigerator, freezer, and dry storage were properly sealed, labeled, and dated. The facility also failed to discard expired items in dry storage. These failures had the potential to affect all 51 residents who consumed food from the kitchen.

Inspectors wroteBased on review of the facility policy, observations, and interviews, the facility failed to ensure that: 1. Staff practiced proper hand hygiene during meal tray preparation and 2. Prepared food was being held at regulatory temperatures on the serving line for hot and cold foods, in 2 of 4 satellite kitchens. Findings Include: Review of the facility policy titled, Preventing Foodborne Illness- Employee Hygiene Sanitary Practices, with a revision date of November 2022 states, Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. 6. Employees must wash their hands: g. during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. 9. [...]

Inspectors wroteBased on staff interviews, facility Registered Nurse (RN) coverage postings, and facility policy review, the facility failed to post RN coverage on daily staffing posted for March 2024 to the current date in April.

Inspectors wroteBased on review of the facility policy titled, Administering Medications, observations and interviews, the facility failed to ensure a medication administration error rate of less than 5 percent. The medication error rate was 7.69 percent for 2 out of 26 opportunities for error. Specifically medications for Resident (R)8 that were clearly labeled as, Do Not Crush or Chew, were crushed by Licensed Practical Nurse (LPN)2 and administered.

Inspectors wroteBased on the facility policy titled, Administering Medications, observations and interviews, the facility failed to ensure medications that were not supposed to be crushed were crushed and administered in applesauce. Specifically medications for Resident (R)8 that were clearly labeled as, Do Not Crush or Chew, were crushed by Licensed Practical Nurse (LPN)2 and administered.

Inspectors wroteBased on the facility policy titled, Medication Labeling and Storage, observations and interviews, the facility failed to ensure medications that were outdated/expired or incorrectly labeled were removed from storage and not stored with other medications and biologicals used for residents in 2 of 4 medication carts and 1 of 3 treatment carts.

Inspectors wroteBased on review of the facility policy titled, Hand Washing/Hand Hygiene, and Food Preparation and Service, observations, and interview, the facility failed to ensure proper hand washing during the lunch meal service on 04/15/2024. The facility failed to ensure staff were adhering to safe meal service to residents related to hand hygiene, and enhanced barrier precautions on the [NAME] Hall for 1 of 4 halls observed during the lunch meal service.

Inspectors wroteBased on observation and interviews, the facility failed to ensure commercial dryers were free from lint buildup, which could increase the likelihood of causing the unit to overheat or combust in fire.

Inspectors wroteBased on record reviews, interviews, observations and review of facility policy, the facility failed to ensure that a member of the nursing staff had renewed her Licensed Practical Nurse (LPN) license in a timely manner for 1 of 3 licensed practical nurses reviewed.