Cycle 1
Health 2025-04-25 · Fire 2025-04-25
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Charleston, SC
Bishop Gadsden Episcopal Health Care Center
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1 Bishop Gadsden Way, Charleston, SC
(843) 762-3300
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
41
Certified beds
Average residents
23
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2018-02-19
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.48
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.21
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
3.09
Nurse aide staffing · state 2.22 · national 2.35
Total nurse hours
5.79
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.69
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
5.20
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
1.13
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.24
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.45
CMS adjusted RN staffing hours
Adjusted total hours
5.64
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
235
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
76.52
Composite VBP score used to determine payment impact.
Payment multiplier
1.0249
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.95
Performance 18.21% · Measure score 6.95 · Achievement 6.95 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
8.31
Baseline 6.06% · Performance 5.35% · Measure score 8.31 · Achievement 8.31 · Improvement 6.14
Total nurse turnover
6.26
Performance 38.09% · Measure score 6.26 · Achievement 6.26 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
9.09
Baseline 5.13 hours · Performance 5.66 hours · Measure score 9.09 · Achievement 9.09 · Improvement 7.71
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.11% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 461 · Observed rate 6.07% · Lower 95% interval 6.77% |
| Discharge to community | 65.14% |
50.57%
14.6 pts better
|
Better than the National Rate · Eligible stays 450 · Observed rate 65.56% · Lower 95% interval 60.76% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.96% |
95.27%
3.7 pts better
|
Numerator 285 · Denominator 288 |
| Falls with major injury | 0.69% |
0.77%
0.1 pts better
|
Numerator 2 · Denominator 288 |
| Discharge self-care score | 72.69% |
53.69%
19 pts better
|
Numerator 173 · Denominator 238 |
| Discharge mobility score | 55.04% |
50.94%
4.1 pts better
|
Numerator 131 · Denominator 238 |
| Pressure ulcers or injuries, new or worsened | 1.39% |
2.29%
0.9 pts better
|
Numerator 4 · Denominator 288 · Adjusted rate 1.82% |
| Healthcare-associated infections requiring hospitalization | 5.35% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 314 · Observed rate 3.18% · Lower 95% interval 3.3% |
| Staff COVID-19 vaccination coverage | 6.76% |
8.2%
1.4 pts worse
|
Numerator 25 · Denominator 370 |
| Staff flu vaccination coverage | 84.72% |
42%
42.7 pts better
|
Numerator 305 · Denominator 360 |
| Discharge function score | 71.01% |
56.45%
14.6 pts better
|
Numerator 169 · Denominator 238 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 47 · Denominator 47 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 229 · Denominator 229 |
| Resident COVID-19 vaccinations up to date | 33.11% |
25.2%
7.9 pts better
|
Numerator 50 · Denominator 151 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
79.8%
20 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 100.0% · Q3 100.0% · Q4 99.5% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.9% |
14.1%
0.8 pts worse
|
12.0%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.9% · Observed 13.3% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.6%
0.9 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 0.6% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.0% |
78.0%
14 pts better
|
79.7%
12.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.1% |
24.7%
4.6 pts better
|
23.9%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 15.3% · Expected 18.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-20 · Fire 2024-03-20
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-02-17 · Fire 2022-02-17
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-23
F · Potential for more than minimal harm
2024-03-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-22
D · Potential for more than minimal harm
2024-03-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-03-20
F841 · Nursing and Physician Services Deficiencies
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2024-05-01
K · Immediate jeopardy
2022-02-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-21
F · Potential for more than minimal harm
2022-02-17
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-03-21
F · Potential for more than minimal harm
2022-02-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-03-21
D · Potential for more than minimal harm
2022-02-17
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-03-21
Penalties and ownership
What sits behind the stars
Ownership
Adams, David
Corporate Director · Individual
Baldwin, Robert
Corporate Director · Individual
Carter, Heyward
Corporate Director · Individual
Cook, Jonna
Corporate Director · Individual
Hill, Joanne
Corporate Director · Individual
Hussain, Brian
Corporate Officer · Individual
Jones, Greg
Corporate Director · Individual
Kelley, Melinda
Corporate Director · Individual
Kelly, Patrick
Corporate Director · Individual
Kerrison, Lynne L
Operational/Managerial Control · Individual
Mack, Angela
Corporate Director · Individual
Maybank, David
Corporate Director · Individual
Roberts, Evan
Operational/Managerial Control · Individual
Roop, Aaron
Operational/Managerial Control · Individual
Smith, Gregory
Corporate Director · Individual
Tipton, Sarah
Operational/Managerial Control · Individual
Woodliff-Stanley, Ruth
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Kempton Of Charleston
Charleston, SC
5-star overall rating with 4-star inspections with $6,032 in total fines with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Ashley River Healthcare
Charleston, SC
2-star overall rating with 1-star inspections with $46,164 in total fines with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
NHC Healthcare - Charleston
Charleston, SC
5-star overall rating with 5-star inspections with 1 recent health deficiencies
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