Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Retreat At Wellmore Of Daniel Island during CMS and state inspections, most recent first.
A resident with cognitive impairment and a known risk for wandering successfully exited the facility unsupervised after staff failed to respond to the Roam Alert system due to not wearing pagers while on break. The resident was found outside by a passerby and returned to the facility without injury. The incident was attributed to staff inattention and non-compliance with established monitoring protocols.
Surveyors identified that dietary staff failed to properly label, date, and store multiple food items in the kitchen, refrigerator, freezer, and dry storage areas. Items were found unlabeled, undated, not properly covered, or past their use-by dates, and these issues were confirmed by the Director of Diet and Executive Chef. Staff interviews revealed a lack of awareness and adherence to facility policy regarding food storage and labeling.
Two out of four satellite kitchens were found to have deficiencies in hand hygiene and food temperature control. Staff did not consistently wash hands with soap when unavailable, failed to clean and calibrate thermometers before use, and did not change gloves after touching potentially contaminated surfaces. Additionally, temperature checks revealed that food items such as cole slaw, apple juice, fried tator tots, and steamed carrots were held outside the safe temperature range, increasing the risk of foodborne illness.
The facility failed to post RN coverage on daily staffing logs from March 2024 to April 2024. The current system does not differentiate between RN and LPN hours, and a new HR system, UKG, is being implemented to address this issue. The facility has 3 RNs working 8-hour shifts each day and an RN night shift supervisor, with the DON and ADON always on call.
The facility failed to ensure a medication administration error rate of less than 5 percent, resulting in a 7.69 percent error rate. An LPN crushed medications labeled 'Do Not Crush or Chew' for a resident, citing the resident's preference and choking risk. Medication reconciliation confirmed the error.
A facility failed to ensure medications labeled 'Do Not Crush or Chew' were administered correctly. An LPN crushed and administered these medications in applesauce to a resident, despite the label and physician's orders. The LPN stated the resident is a choking risk, but another RN confirmed that not all medications could be crushed, indicating a significant medication error.
The facility failed to remove expired and incorrectly labeled medications from storage, as observed in 2 of 4 medication carts and 1 of 3 treatment carts. Expired medications such as Acetaminophen, Vitamin D3, and Lemon Glycerine Swabs were found, and a blister pack of Trazodone had an incorrect expiration date label. These findings were confirmed by the nursing staff and the Director of Nursing.
The facility failed to ensure proper hand hygiene during the lunch meal service on the [NAME] Hall. A CNA did not cleanse their hands while delivering meal trays, handled items that had fallen on the floor without subsequent hand hygiene, and donned and doffed PPE without washing their hands. The CNA confirmed they had not followed the facility's hand hygiene policy.
The facility failed to ensure commercial dryers were free from lint buildup, which could increase the likelihood of overheating or fire. Observations revealed lint in dryer trays and disorganized laundry areas. CNA2 and the Administrator acknowledged the issue, but there was no specific policy for lint cleaning.
Elopement Due to Staff Failure to Respond to Roam Alert System
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease and dementia, who was identified as being at risk for wandering and elopement, successfully exited the facility without staff knowledge or intervention. The resident, who had a BIMS score of 4 out of 15 indicating cognitive impairment, was able to leave the skilled nursing facility (SNF) through the main exit while in a wheelchair. Video footage confirmed that the resident propelled himself to the elevator, traveled to the first floor, and exited the building without being stopped or supervised by staff. The incident was only discovered when a former employee, passing by the facility, noticed the resident outside and contacted the facility to alert them. At the time of the incident, staff responsible for monitoring the resident were not wearing their pagers, as they were on break, and did not respond to the Roam Alert system. The facility's policy required staff to use pagers and respond to alarms generated by the Roam Alert system, which is designed to notify staff when a resident at risk for wandering approaches a monitored exit. However, the staff failed to adhere to these protocols, resulting in the resident leaving the premises unsupervised. The resident was found outside the facility, near garages of an adjoining community, on a hot and humid day, and was returned to the facility by a staff member after being located by the former employee. Interviews with staff confirmed that the resident was last seen in the dining room and that his wandering behavior was known to staff. The main exit doors and alarm systems were in place, but the lack of staff supervision and failure to carry and respond to pagers directly contributed to the resident's elopement. The facility's own investigation and review of camera footage established that the resident was unattended when he left the SNF unit, and the alarm system notifications were not acted upon due to staff inattention and non-compliance with established safety protocols.
Removal Plan
- Member [R1] was returned to his apartment and immediately assessed by the Registered Nurse (RN)1 for any injury. No injuries were identified. Skin checks were initiated, and no injuries were noted. The family was notified. Medical Director was notified, and provider team completed an assessment.
- Safety checks were completed for the Member.
- The Community implemented 1:1 sitter immediately following the event.
- The Pharmacy consultant completed a medication review that was provided to the Medical Provider.
- The Administrator met with the family and updated the Member's care plan.
- Pending room availability and appropriateness, the Community has made the recommendation to move to Memory Care Assisted Living when appropriate.
- New elopement screening conducted for all residents by Unit Nurse.
- Residents assessed by Unit Nurse for ambulatory status and BIMS (Behavioral Interview for Mental Status) level of 5 or below. Roam Alert tags and corresponding physician orders obtained for qualifying residents.
- RN and C.N.A. assigned to Member [R1] were given immediate education on pager and call bell system use by the DON.
- DON (Director of Nursing) completed immediate reeducation to SNF staff and all community staff reeducated by CSA on Roam Alert and Pager Policy.
- Working pagers and radios verified for all staff.
- Maintenance staff assessed all exit points to ensure they were in proper working order.
- Elopement binders updated by ADON for all service lines.
- Maintenance increased the sound frequency on squealers at all SNF exit points.
- Maintenance reviewed [NAME]-Tone monitor volumes and ordered external speakers to increase sound of call bells/roam alerts.
- VP of Construction ordered Desk Top pagers that will be secured in hallways to provide additional alert of call bells/roam alerts.
- Upon admission, each resident will undergo elopement screening, including evaluation of ambulatory status by Unit Nurse, to then be reviewed by DON and/or ADON.
- Nursing staff will complete daily Roam Alert Tag audits to verify device functionality, proper placement, and skin integrity monitoring once per shift. Documentation will be maintained in the medical record and Roam Alert List.
- CSA, DON, and/or Designee will conduct audits daily, weekly, and monthly or longer until 100% compliance is met to ensure Roam Alert tags are functioning and in proper use. All negative findings will be corrected immediately.
- Involved Team Members will be reeducated immediately.
- Audit results will be reviewed in monthly Quality Assurance (QA) meetings for further recommendations.
- The facility's assessment will be updated to incorporate specific Roam Alert system requirements.
- All staff re-educated by DON and CA on elopement prevention policies, including the proper use of Roam Alert tags, immediate response protocols, and the importance of timely supervision.
- New hires will receive elopement training during orientation, and annual refresher training will be conducted for all staff by Administrative Nurse Staff.
- Family input will be incorporated into individualized care plans to enhance elopement prevention strategies at start of admission and will be carried out by the IDT.
Failure to Properly Label, Date, and Store Food Items in Dietary Department
Penalty
Summary
Surveyors found that the facility failed to ensure proper food storage, labeling, and dating practices in the kitchen, refrigerator, freezer, and dry storage areas. Multiple food items in the walk-in cooler, such as noodles, sauces, spreads, and meats, were observed to be either unlabeled, undated, or not properly covered. Additionally, several items in the dry storage, including various types of noodles, cereals, cocoa powder, and baking soda, were found opened without open dates or were past their use-by dates. In the walk-in freezer, bags of food were not in their original packaging and lacked proper labeling and dating. Bread products in a mobile cabinet were also found with expired use-by dates. These observations were confirmed by the Director of Diet and the Executive Chef. Interviews with facility staff revealed that dietary staff are responsible for spot-checking and ensuring all food items are properly labeled and free from expiration, with leftovers requiring both the date placed in the container and a discard date within three days. The Director of Nursing was unaware of the findings but expected dietary staff to follow regulations regarding food storage and labeling. The Facility Administrator indicated that, to her knowledge, dietary staff had addressed the concerns and planned to review relevant policies.
Hand Hygiene and Food Temperature Control Issues Identified in Satellite Kitchens
Penalty
Summary
The facility failed to ensure proper hand hygiene during meal tray preparation and appropriate holding temperatures for prepared food in two out of four satellite kitchens. Observations on 04/16/24 revealed instances where staff did not follow proper hand hygiene practices, such as not washing hands with soap when soap was unavailable, not cleaning and calibrating thermometers before use, and not changing gloves after touching potentially contaminated surfaces. Temperature checks during meal preparation showed food items like cole slaw, apple juice, fried tator tots, and steamed carrots were being held at temperatures outside the safe range, posing a risk for foodborne illness.
Failure to Post RN Coverage on Daily Staffing Logs
Penalty
Summary
The facility failed to post Registered Nurse (RN) coverage on daily staffing postings from March 2024 to the current date in April. The facility policy requires the posting of the type and category of nursing staff working each shift, including RNs, Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs). However, a review of the facility's staff postings revealed that 8-hour RN coverage was not posted. The Director of Nursing (DON) explained that the current system does not differentiate between RN and LPN hours on daily posting logs. The facility has recently implemented a new Human Resource system called Ultimate Kronos Group (UKG), which will designate RN hours, but it is still in the process of being fully operational. Interviews with the DON and the Facility Administrator revealed that the facility has 3 RNs working 8-hour shifts each day from Monday to Friday, and an RN night shift supervisor working four times a week. The DON and Assistant DON (ADON) are always on call. The DON stated that the facility meets the required number of staff hours but acknowledged that it is not clear to others whether an RN or LPN is on duty unless they ask for credentials. The facility is working towards meeting the proposed CMS requirement for 24/7 RN coverage. The Administrator confirmed that the UKG system started on April 1, 2024, and the facility is currently running both the old and new systems until UKG is fully operational and can post leadership nursing positions accurately.
Medication Administration Error
Penalty
Summary
The facility failed to ensure a medication administration error rate of less than 5 percent, resulting in a medication error rate of 7.69 percent for 2 out of 26 opportunities for error. Specifically, medications for Resident 8 that were clearly labeled as 'Do Not Crush or Chew' were crushed by an LPN and administered. The facility policy titled 'Administering Medications' states that medications should be administered in a safe and timely manner and as prescribed, including checking the label three times to verify the right resident, medication, dosage, time, and method of administration before giving the medication. However, this policy was not followed in this instance. During an observation and interview, the LPN stated that Resident 8 liked her medications crushed and placed in applesauce. Medication reconciliation revealed that the prescribed medications observed to be crushed were not supposed to be crushed, according to the medication label. The LPN justified her actions by stating that Resident 8 is a choking risk. Another RN confirmed that while she crushes the medications she can, some of Resident 8's medications cannot be crushed. This discrepancy in medication administration practices led to the identified deficiency.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure that medications labeled as 'Do Not Crush or Chew' were administered correctly. Specifically, a Licensed Practical Nurse (LPN) crushed and administered these medications in applesauce to a resident (R8) during a medication pass. The facility's policy on administering medications clearly states that medications should be administered as prescribed and that the individual administering the medication should verify the right method of administration. However, during an observation, it was noted that LPN2 crushed all of R8's medications despite the label and physician's orders indicating that they should not be crushed. During an interview, LPN2 stated that she crushed all of R8's medications because R8 is a choking risk and prefers her medications in applesauce. However, another Registered Nurse (RN2) confirmed that while some of R8's medications could be crushed, others could not. This discrepancy indicates a failure to adhere to the prescribed method of medication administration, leading to a significant medication error. The facility's policy also requires that each nurse's station have a current Physician's Desk Reference (PDR) and other medication references available, which should have been consulted to prevent such errors.
Failure to Remove Expired and Incorrectly Labeled Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals that were outdated, expired, or incorrectly labeled were removed from storage and not stored with other medications and biologicals used for residents. This deficiency was observed in 2 of 4 medication carts and 1 of 3 treatment carts. Specifically, expired medications such as Acetaminophen and Vitamin D3 were found in the Folly Hall medication cart, and expired Lemon Glycerine Swabs were found in the [NAME] Hall treatment cart. Additionally, a blister pack of Trazodone with an incorrect expiration date label was found in the [NAME] Hall medication cart. These findings were confirmed by the nursing staff present during the observations. During an interview, the Director of Nursing confirmed that the label on the blister card for Trazodone was incorrectly applied by the pharmacy, and no one had questioned the label nor the expiration date. The facility policy titled 'Medication Labeling and Storage' outlines that medications and biologicals should be stored in their original packaging and that only the issuing pharmacy is authorized to transfer medications between containers. The policy also states that the dispensing pharmacy should be contacted for instructions regarding the return or destruction of discontinued, outdated, or deteriorated medications. However, these procedures were not followed, leading to the observed deficiencies.
Failure to Ensure Proper Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene during the lunch meal service on the [NAME] Hall. Observations revealed that a Certified Nursing Assistant (CNA) did not cleanse their hands while delivering meal trays to residents. The CNA was seen placing meal trays on a cart, going in and out of resident rooms without washing or sanitizing their hands, and handling items that had fallen on the floor without subsequent hand hygiene. Additionally, the CNA donned and doffed personal protective equipment (PPE) without washing their hands before and after, and continued to serve meal trays with bare hands, including opening a straw and placing it in a cup of tea for a resident without hand hygiene. During an interview, the CNA confirmed that they had not washed or cleansed their hands before and after each resident interaction, despite being aware of the facility's hand hygiene policy. The facility's policies on Handwashing/Hand Hygiene and Food Preparation and Service were reviewed, which emphasize the importance of hand hygiene in preventing the spread of healthcare-associated infections and safe food handling practices. The CNA's actions were inconsistent with these policies, leading to the deficiency observed during the survey.
Failure to Maintain Commercial Dryers Free from Lint Buildup
Penalty
Summary
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. During an observation of the Central Laundry Room, lint was found in the trays of commercial dryers #1 and #2, along with clothing thrown in cubie cubes alongside the wall, plastic bins in the middle of the floor, and laundry sitting in the washer. CNA2 acknowledged the lint buildup but was unaware of the specific process for maintaining the laundry room. Further observation the next day revealed more lint accumulation in the dryers. The Administrator and DON confirmed that laundry is completed at night by CNAs and acknowledged the lint in the trays, despite the lint logbook indicating that the trays were cleaned. The Administrator later informed that there is no specific policy for lint cleaning of the dryers.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Charleston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverside Health And Rehab | 4.7 mi | — | 4 | 0 |
| Oak Harbor Healthcare | 4.7 mi | — | 0 | 0 |
| Sandpiper Post Acute | 5 mi | — | 0 | 0 |
| Franke Health Care Center | 6 mi | — | 0 | 0 |
| Kempton Of Charleston | 6.1 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.