Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Lake Moultrie Nursing Home during CMS and state inspections, most recent first.
Medication Administration Error Rate Exceeded Threshold: A resident with Parkinson's disease, dysphagia, and a G-tube had oral orders for apixaban, carbidopa-levodopa, and lorazepam, but an RN crushed the medications and administered them via G-tube instead of following the ordered route. The RN stated she gave medications by mouth during the day and via G-tube at night, while the consultant pharmacist, DON, Administrator, and NP all confirmed the orders required administration by mouth, with lorazepam also allowed sublingually.
A facility failed to update a resident's code status from DNR to Full Code in the physician's orders, despite the resident's request for CPR. The discrepancy was found between the hard chart and EMR, with staff interviews revealing procedural lapses in updating and verifying code status changes. The facility was transitioning to a paperless system, contributing to the oversight.
A resident with dementia was found with a bruise on the chest after an incident with a family member during a meal. An LPN observed the family member pushing his fist into the resident's chest, but the incident was not reported or investigated as required by the facility's abuse policy. Interviews revealed that key staff were unaware of the bruise and the incident, leading to a failure to report potential abuse.
A resident with end-stage renal disease and moderate cognitive impairment was observed receiving oxygen at 3.5 LPM instead of the prescribed 2 LPM. The discrepancy was confirmed by a nurse, and the DON stated that oxygen should be administered as ordered by the physician.
Medication Administration Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent, with 3 medication errors out of 27 opportunities for an error rate of 11.11%, affecting 1 resident during medication administration observation. The cited resident had diagnoses including Parkinson's disease, dysphagia, a gastrostomy tube, a history of pulmonary embolism, and palliative care. The resident's record showed active orders for apixaban 5 mg by mouth twice daily, carbidopa-levodopa 25 mg-100 mg by mouth three times daily, and lorazepam 0.5 mg by mouth or sublingual every morning and at bedtime. During observation, the RN removed lorazepam, carbidopa/levodopa, and apixaban from packaging, crushed each medication, and placed them in separate cups. The RN stated she usually gave the resident's medications by mouth, but also said she could give them either route because the resident had a G-tube. She then administered the crushed medications via the resident's G-tube after adding water to the cups. The RN stated she did not know the ordered route and said she gave medications by mouth during the day and via G-tube at night because the resident was at high risk for aspiration. The RN later stated the medications should have been given according to the physician-ordered route and that she should have called for an order to administer them via G-tube. The consultant pharmacist, DON, Administrator, and NP all reviewed the orders and stated the medications were ordered for oral administration, with lorazepam ordered by mouth or sublingual, and that medications should be administered as ordered. The NP stated she was not aware the facility was giving daytime medications by mouth and nighttime medications via G-tube.
Failure to Update Resident's Code Status in Medical Records
Penalty
Summary
The facility failed to ensure that physician orders matched a resident's documented end-of-life wishes, specifically regarding code status. A resident, identified as R71, initially had a Do Not Resuscitate (DNR) status chosen by their representative. However, five days later, R71 personally chose to have a Full Code status, indicating a desire for cardiopulmonary resuscitation (CPR) in case of a medical emergency. Despite this change, the physician's orders were not updated to reflect the resident's new choice, leaving the resident at risk of not receiving CPR if needed. The discrepancy was discovered during a review of R71's records, which showed conflicting information between the hard chart and the electronic medical record (EMR). The hard chart contained a DNR request, while the EMR had orders for Full Code. Interviews with facility staff revealed that the process for updating and verifying code status was not consistently followed. The Social Services Director (SSD) had discussed the code status with R71 and obtained a signed Full Code request, but this was not properly communicated or documented in the EMR in a timely manner. Further interviews with the facility's nursing staff and administration highlighted gaps in the procedure for handling code status changes. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged that the facility was in the process of transitioning to a paperless system, which contributed to the oversight. The SSD and other staff members were aware of the need to ensure that the resident's wishes were accurately reflected in the medical records, but the failure to update the physician's orders in a timely manner led to the deficiency.
Removal Plan
- The Facility Medical Director was notified of the incident.
- The DON or designee completed a chart audit on every resident and compared the advance directives to the physician order for accuracy.
- The Social Worker, Director of Nursing (DON), and ADON went through each medical record separately. They compared the order to the advanced directive and reviewed the care plan to reflect the current code status.
- The ward secretary and Social Service director scanned the advanced directives into the EMR.
- Resident R71 was interviewed by the social worker to confirm the resident's wishes for his code status. The resident confirmed that he wished to have all possible measures taken to revive him. The resident's advance directive reflected his decision to be a Full Code. An order was obtained by LPN for the resident to be full code. The care plan was updated.
- The DON or designee educated all licensed nurses on duty in the facility on the facility's policy and procedure for initiating code status orders, the appropriate forms to be used for a full code or DNR, and the location of the code status for each resident in the EMR.
- The Administrator educated the social worker on the Advanced Directive policy and procedure.
- Licensed nurses will not be permitted to work a shift until education is completed on the resident's code status. Nurses on leave will receive education prior to their next scheduled shift.
- Code status will be reviewed during quarterly and annual care plan meetings to address residents' current preference of code status.
- A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented. DON to monitor code status compliance by interviewing licensed nurses about facility Advance Directive policy and procedure, as well as requesting return demonstration of Advance Directive process.
- DON or designee will audit new admissions to compare the residents' advanced directives to the physician orders for accuracy.
Failure to Report and Investigate Resident Injury
Penalty
Summary
The facility failed to report and investigate a bruise of unknown origin on a resident's chest, which was discovered during a review of the resident's electronic medical record. The resident, who was admitted with a diagnosis of dementia and had severe cognitive impairment, was observed by an LPN to have been involved in an incident with a family member during a meal. The family member was seen pushing his fist into the resident's chest, where bruising was noted. Despite this observation, there was no documentation or investigation into the cause of the bruise, and the incident was not reported to the appropriate authorities. Interviews with facility staff, including the Administrator and DON, revealed a lack of awareness of the bruise and the incident involving the family member. The LPN who witnessed the event reported it to the DON, but the details of the family member's actions were not communicated effectively, leading to a failure to report the incident as potential abuse. The facility's policy on reporting abuse was not followed, as the injury was not observed by any person or explained by the resident, and the location of the injury was suspicious. This oversight had the potential to affect other residents who might have unidentified injuries or be at risk of abuse.
Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
The facility failed to administer oxygen at the physician-prescribed rate for a resident, identified as R9, who was reviewed for oxygen therapy. R9 was admitted with diagnoses including end-stage renal disease, diabetes, and anxiety, and had moderate cognitive impairment. The resident's care plan and medication administration record indicated an order for oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation above 92%. However, during observations on two consecutive days, R9's oxygen concentrator was set at 3.5 liters per minute, which was not in accordance with the physician's order. During interviews, R9 was unable to recall the reason for the oxygen use or the setting, and a registered nurse confirmed the discrepancy between the ordered and administered oxygen levels. The Director of Nursing stated that oxygen should be delivered at the rate ordered by the physician and should not be adjusted without a physician's order. This failure to adhere to the prescribed oxygen rate had the potential to cause respiratory distress for the resident.
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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 Saint Stephen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth- Moncks Corner | 15.5 mi | ★★★★★ | 1 | 0 |
| Carlyle Senior Care Of Kingstree | 19.1 mi | ★★★★★ | 7 | 0 |
| Lake Marion Nursing Facility | 29.1 mi | ★★★★★ | 1 | 0 |
| Pocotaligo River Health And Rehab | 29.6 mi | ★★★★★ | 4 | 0 |
| Life Care Center Of Charleston | 29.9 mi | ★★★★★ | 4 | 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 July 2026) and official state health department websites.