State inspectors found Charleston Healthcare Center failed to follow its own care requirements for Resident #153 during a complaint investigation completed October 16. The facility houses 143 residents.
The resident's care plan specified they needed complete assistance from one staff member for all meals. But documentation showed no feeding help was recorded for entire days at a time between July and September 2025.
From July 17 through July 19, no meals were documented as requiring assistance. The same pattern continued July 21, then July 23 through July 25, then July 27 through July 31. In August, the resident went without documented feeding help for 22 of the month's 31 days.
On August 1, 2, 3, and 5 through 18, all three daily meals lacked documentation of the required assistance. The pattern continued into September.
The Director of Nursing confirmed to inspectors on October 15 that meals were not documented as dependent and the care plan was not implemented.
Beyond the feeding failures, the facility also ignored skin protection measures until after an injury occurred. Resident #153 developed a deep tissue injury to their right heel on August 18. Only then did staff add interventions to the care plan.
The belated measures included floating the resident's heels "as resident allows" and establishing a turning and repositioning schedule. Both are standard preventive care practices typically implemented before injuries develop.
The Director of Nursing acknowledged to inspectors that skin integrity interventions were not added to the care plan until August 18, after the deep tissue injury was discovered. She confirmed the care plan had not been developed and implemented regarding skin protection beforehand.
Deep tissue injuries represent serious wounds that begin beneath the skin surface and can progress to full-thickness wounds requiring extensive treatment. They typically result from sustained pressure that damages tissue and blood vessels.
The inspection focused on one resident among 18 reviewed during the survey process. Federal regulations require nursing homes to develop complete care plans that meet all resident needs, with specific timetables and measurable actions for implementation.
Care plans serve as roadmaps for daily resident care, detailing everything from medication schedules to mobility assistance to feeding requirements. When facilities fail to follow these plans, residents face increased risks of malnutrition, weight loss, pressure injuries, and other preventable complications.
For residents marked as totally dependent for eating, consistent feeding assistance becomes critical for maintaining nutrition and preventing choking. The three-month documentation gap at Charleston Healthcare Center left unclear whether Resident #153 received necessary help during dozens of meals.
The timing of the skin injury interventions raised additional concerns about the facility's approach to preventive care. Standard nursing practice calls for implementing pressure relief measures before injuries develop, particularly for residents at risk due to mobility limitations or other factors.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm, affecting few residents. The facility must submit a plan of correction detailing how it will address the care plan implementation failures.
Charleston Healthcare Center operates on Chesterfield Avenue in Charleston. The complaint-based inspection that uncovered these violations was completed in mid-October, though the specific nature of the original complaint was not detailed in available records.
The case illustrates broader challenges in nursing home care plan implementation, where written requirements don't always translate to consistent daily practice. For Resident #153, the gap between policy and practice lasted months before state oversight intervened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Charleston Healthcare Center from 2025-10-16 including all violations, facility responses, and corrective action plans.