Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bishop Gadsden Episcopal Health Care Center during CMS and state inspections, most recent first.
Two residents with urinary catheters had discrepancies between their physician orders and care plans regarding catheter balloon size. One resident with severe cognitive impairment had a care plan listing a different balloon size than ordered, while another resident with a history of cancer and chronic self-catheterization also had mismatched documentation. Facility policy requires care plans to reflect physician orders, and this inconsistency was confirmed by the Director of Clinical Excellence.
The facility failed to consistently monitor and document the use of a wander guard device for a resident with cognitive impairment and wandering behaviors, with inconsistent records and lack of required daily checks. Additionally, two residents with pain were administered PRN opioid and non-opioid medications without clear physician order parameters or documentation of non-pharmacological interventions, and the care plan did not address opioid use. The Director of Clinical Excellence confirmed these deficiencies in monitoring, documentation, and adherence to policy.
A resident with significant respiratory conditions was observed receiving oxygen at a lower flow rate than prescribed by the physician. Despite orders and care plan interventions specifying 4 L/min during ambulation and 2 L/min at rest, the oxygen concentrator was repeatedly set at only 1 L/min. This discrepancy was confirmed by the DCE during the survey.
The facility did not maintain and operate kitchens in a manner that minimizes the risk of foodborne illness for all 21 residents. Observations included improper food storage, such as unlabeled bags and uncovered mixer bowls, and moisture between stacked pans. Staff were seen handling ready-to-eat foods with contaminated gloves and not following proper handwashing procedures. Additionally, employees were observed without hair restraints, contrary to facility policy. The Certified Dietary Manager acknowledged issues with labeling and monitoring expiration dates, indicating inconsistent adherence to established protocols.
A facility failed to maintain a medication error rate below 5%, resulting in an error rate of 7.67%. An RN mistakenly prepared Fluticasone instead of Azelastine for a resident and administered an incorrect dosage of Azelastine. The resident had been admitted with acute respiratory failure and hypoxia, and the error was acknowledged by the RN after review.
The facility failed to ensure the Medical Director assessed a resident for unnecessary medications, specifically Seroquel, without proper rationale or indication for use. The resident's medical records lacked documentation for the use of the antipsychotic medication, and the Medical Director did not work with the facility to evaluate the continued use of the drug.
Failure to Individualize and Accurately Document Catheter Balloon Size in Care Plans
Penalty
Summary
The facility failed to individualize and accurately document comprehensive care plans for urinary catheter bulb size for two residents who required catheter care. For one resident with severe cognitive impairment and urinary retention, the physician order specified an 18 French catheter with a 5 cc balloon, but the care plan incorrectly listed a 10 cc balloon. For another resident with a history of prostate and bladder cancer, chronic self-catheterization, and intact cognition, the physician order specified a 16 French catheter with a 10 cc balloon, while the care plan referenced a 14 French catheter with a 10 ml balloon. These discrepancies were identified through clinical record review, policy review, and staff interview. Facility policy requires that all physician orders, including specific instructions such as catheter and balloon size, be accurately documented and reflected in the resident's care plan. The care plans are to be developed by an interdisciplinary team and must include measurable goals and timetables based on the comprehensive assessment. The Director of Clinical Excellence confirmed that the care plan should match the physician order for catheter balloon size, as this is a standard of care. The failure to ensure consistency between physician orders and care plans for catheter care was observed for both residents reviewed.
Failure to Monitor Wander Guard and Inadequate Pain Management Documentation
Penalty
Summary
The facility failed to monitor and document the use of a wander guard device according to professional standards for a resident assessed at risk for wandering. The resident, who had diagnoses including traumatic subarachnoid hemorrhage, dementia, and depression, was identified as severely cognitively impaired and exhibited wandering behaviors. Although the care plan and facility policy required daily checks for the placement and function of the wander guard, as well as skin checks for irritation, documentation was inconsistent. Clinical records showed alternating documentation of the device being present or absent on various days, and there was no evidence of daily checks or skin assessments as required. The Director of Clinical Excellence confirmed that the physician's order for the wander guard was not obtained in a timely manner and that documentation was inaccurate, with no evidence of adherence to policy or care plan interventions. The facility also failed to provide care and services consistent with professional standards for pain management for another resident with a history of fractures and malignancy, who was cognitively intact and reported frequent pain. The care plan included interventions for pain assessment and medication administration, but physician orders for both opioid (Tramadol) and non-opioid (Tylenol) pain medications lacked specific parameters for use. Nursing staff administered PRN Tramadol on most days, sometimes multiple times per day, and also administered Tylenol for similar pain scores, without clear guidance on which medication to use for specific pain levels. Documentation did not include non-pharmacological interventions prior to opioid administration, and the care plan did not address the use of opioid medication. Interviews with the Director of Clinical Excellence confirmed that the facility did not clarify physician orders for pain medications, did not document non-pharmacological interventions prior to opioid use, and did not follow facility policy or accepted standards of practice for pain management. The lack of clear parameters for medication administration and incomplete documentation contributed to the deficiencies identified in the management of both the wander guard device and pain control.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
A deficiency was identified when staff failed to follow physician orders for oxygen therapy for a resident with multiple respiratory diagnoses, including acute and chronic respiratory failure with hypoxia, COPD, acute pulmonary manifestations due to radiation, pneumonia, and influenza. The resident's care plan and physician orders specified oxygen administration via nasal cannula at 4 liters per minute during ambulation and 2 liters per minute at rest. However, during multiple observations, the resident was found sitting in a wheelchair in their room with the oxygen concentrator set at only 1 liter per minute, which was not consistent with the prescribed orders. These observations were confirmed on three separate occasions, including one in the presence of the Director of Clinical Excellence, who acknowledged that the physician's order for supplemental oxygen was not being followed. The clinical record and care plan documentation supported the need for specific oxygen settings, but staff did not adhere to these requirements during the survey period.
Kitchen Safety and Sanitation Deficiencies Identified
Penalty
Summary
The facility failed to ensure the kitchens were maintained and operated in a safe manner to minimize the chances for potential spread of foodborne illness to all 21 residents. Observations revealed various deficiencies, including improper food storage, handling ready-to-eat foods with contaminated gloves, failure to air dry pans and containers before storage, and lack of employee hair restraint in the kitchens. Policies related to storing staples, perishable food items, sanitary conditions, labeling, hair restraints, and food preparation and handling were found to be in place, but not consistently followed by staff. During kitchen tours, instances of improper food storage were noted, such as unlabeled bags of food, uncovered mixer bowls, and moisture between stacked pans and containers. Employees were observed not following proper handwashing procedures and using contaminated gloves to handle food. Additionally, staff members were seen without hair restraints while working in the kitchen, which is a violation of the facility's policy. The Certified Dietary Manager acknowledged deficiencies in labeling and expiration date monitoring of food items, indicating a lack of adherence to established protocols.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an error rate of 7.67% during a medication pass observation for one of three residents. Specifically, a registered nurse (RN1) was observed preparing to administer Azelastine Nasal Spray to a resident (R224) but mistakenly took a container of Fluticasone Nasal Spray from a pharmacy-labeled Azelastine vial. The surveyor intervened, and RN1 acknowledged the error, stating that the wrong medication had been placed in the vial by the pharmacy. Despite this, RN1 proceeded to administer the correct medication, Azelastine, but gave an incorrect dosage of two sprays per nostril instead of the prescribed one spray per nostril twice a day for allergic rhinitis, unspecified. The resident, R224, had been admitted to the facility with diagnoses including acute respiratory failure with hypoxia. During the medication reconciliation process, it was confirmed that the resident had orders for both Azelastine and Fluticasone nasal sprays, but the administration of Azelastine was not in accordance with the prescribed dosage. RN1 admitted to the error after reviewing the medication administration record and the medications for R224. This incident highlights a failure in the medication administration process, leading to a higher than acceptable medication error rate in the facility.
Failure to Assess Unnecessary Medications
Penalty
Summary
The facility failed to ensure the Medical Director worked with the facility to completely assess a resident for unnecessary medications. Specifically, an antipsychotic and psychoactive medication, Seroquel, was used without an attempted gradual dose reduction, proper medical rationale, or proper indication for use. The facility's policy requires the Medical Director to supervise medical care and ensure compliance with regulations, but this was not followed in the case of the resident. The resident's medical records did not indicate a psychiatric or mood diagnosis, nor did they document the physician's rationale for prescribing Seroquel or any behaviors or psychosis that would justify its use. The resident was admitted with diagnoses including pneumonia, normal pressure hydrocephalus, and unspecified dementia. Despite these conditions, the resident's Minimum Data Set did not indicate a need for psychotherapeutic agents. The facility's Administrator and Director of Nursing confirmed that the Medical Director did not work with the facility to assess the continued use of Seroquel, citing a reluctance to alter long-standing psychotherapeutic medication orders during a short-term stay. Attempts to contact the Medical Director were unsuccessful, and the resident's care plan did not reference the specific medication, highlighting a significant oversight in the resident's medical management.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 52 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Charleston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kempton Of Charleston | 4 mi | ★★★★★ | 0 | 0 |
| Ashley River Healthcare | 4.9 mi | ★★★★★ | 6 | 0 |
| Nhc Healthcare - Charleston | 6.6 mi | ★★★★★ | 5 | 1 |
| Johns Island Post Acute | 6.6 mi | ★★★★★ | 16 | 3 |
| Sandpiper Post Acute | 8.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bishop Gadsden Episcopal Health Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.