Cycle 1
Health 2025-05-15 · Fire 2025-05-15
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Mt Pleasant, SC
Oak Harbor Healthcare
4-star overall rating with 3-star inspections with $7,901 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
921 Bowman Road, Mt Pleasant, SC
(843) 884-8903
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
132
Certified beds
Average residents
122
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1977-11-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
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
0.37
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.22 · national 2.35
Total nurse hours
3.36
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
2.92
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
3.65
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,426
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9930
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.15
Baseline 18.92% · Performance 19.05% · Measure score 5.15 · Achievement 5.15 · Improvement 0
Healthcare-associated infections
4.97
Baseline 7.84% · Performance 6.35% · Measure score 4.97 · Achievement 4.97 · Improvement 4.75
Total nurse turnover
4.15
Baseline 63.11% · Performance 46.73% · Measure score 4.15 · Achievement 4.15 · Improvement 3.78
Adjusted total nurse staffing
1.75
Baseline 3.44 hours · Performance 3.57 hours · Measure score 1.75 · Achievement 1.75 · Improvement 0.07
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.28% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 163 · Observed rate 6.75% · Lower 95% interval 6.55% |
| Discharge to community | 58.06% |
50.57%
7.5 pts better
|
No Different than the National Rate · Eligible stays 123 · Observed rate 54.47% · Lower 95% interval 49.36% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 94.9% |
95.27%
0.4 pts worse
|
Numerator 149 · Denominator 157 |
| Falls with major injury | 2.55% |
0.77%
1.8 pts worse
|
Numerator 4 · Denominator 157 |
| Discharge self-care score | 41.03% |
53.69%
12.7 pts worse
|
Numerator 48 · Denominator 117 |
| Discharge mobility score | 41.88% |
50.94%
9.1 pts worse
|
Numerator 49 · Denominator 117 |
| Pressure ulcers or injuries, new or worsened | 2.55% |
2.29%
0.3 pts worse
|
Numerator 4 · Denominator 157 · Adjusted rate 2.65% |
| Healthcare-associated infections requiring hospitalization | 6.35% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 105 · Observed rate 4.76% · Lower 95% interval 3.51% |
| Staff COVID-19 vaccination coverage | 2.3% |
8.2%
5.9 pts worse
|
Numerator 4 · Denominator 174 |
| Staff flu vaccination coverage | 14.22% |
42%
27.8 pts worse
|
Numerator 32 · Denominator 225 |
| Discharge function score | 53.85% |
56.45%
2.6 pts worse
|
Numerator 63 · Denominator 117 |
| Transfer of health information to provider | 91.94% |
95.95%
4 pts worse
|
Numerator 57 · Denominator 62 |
| Transfer of health information to patient | 96.88% |
96.28%
0.6 pts better
|
Numerator 62 · Denominator 64 |
| Resident COVID-19 vaccinations up to date | 8.75% |
25.2%
16.4 pts worse
|
Numerator 7 · Denominator 80 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.0
0.2 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.9
0.1 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
90.5%
9 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 100.0% · Q3 100.0% · Q4 99.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.0% |
90.6%
0.6 pts worse
|
95.5%
5.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
3.0%
2.3 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
2.9%
1.5 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 4.1% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
6.2%
1.4 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 6.5% · Q3 8.9% · Q4 12.8% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.1% |
20.4%
5.3 pts better
|
19.6%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 14.7% · Q3 18.5% · Q4 13.3% · 4Q avg 15.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.6% |
16.3%
1.7 pts better
|
16.7%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 16.9% · Q3 12.7% · Q4 9.7% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.2% |
14.9%
2.7 pts better
|
16.3%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 26.9% · Q3 5.6% · Q4 2.5% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.2% |
12.4%
0.2 pts better
|
14.9%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 16.7% · Q3 9.8% · Q4 3.7% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.7%
0.5 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.6%
1.4 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.3% |
17.2%
9.1 pts worse
|
19.8%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 33.5% · Q3 26.6% · Q4 23.5% · 4Q avg 26.3% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.8%
About the same
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 7.2% · Q3 3.8% · Q4 4.4% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
79.8%
18.1 pts better
|
81.7%
16.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 96.9% · Q3 97.6% · Q4 98.8% · 4Q avg 97.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
14.1%
2.2 pts better
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 10.9% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.6%
0.5 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 0.9% · Q4 1.6% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.7% |
78.0%
0.3 pts worse
|
79.7%
2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.6% |
24.7%
8.1 pts better
|
23.9%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 15.1% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-29 · Fire 2024-03-29
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-03-16 · Fire 2022-03-16
6 health deficiencies
Top issue: Quality of Life and Care (3 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
2025-05-15
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-05-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-02
D · Potential for more than minimal harm
2024-03-29
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-03-28
D · Potential for more than minimal harm
2024-03-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-28
D · Potential for more than minimal harm
2024-03-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-28
D · Potential for more than minimal harm
2024-03-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-15
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 2025-06-09
D · Potential for more than minimal harm
2025-05-15
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2025-06-09
F · Potential for more than minimal harm
2024-03-29
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 2024-04-19
E · Potential for more than minimal harm
2024-03-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-29
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-29
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-04-19
G · Actual harm
2023-11-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-02
D · Potential for more than minimal harm
2023-05-04
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-31
D · Potential for more than minimal harm
2022-03-16
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2022-04-14
D · Potential for more than minimal harm
2022-03-16
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-04-14
D · Potential for more than minimal harm
2022-03-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-04-14
D · Potential for more than minimal harm
2022-03-16
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-04-14
Penalties and ownership
What sits behind the stars
$7,901
2023-11-09
Fine
Fine · fine $7,901
Fine
Ownership
Hopewell Healthcare, Inc.
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Newlands, Frank
Operational/Managerial Control · Individual
Onshift Inc
Operational/Managerial Control · Organization
Peterson, Forrest
Corporate Director · Individual
Sato, Ami
Corporate Officer · Individual
Thatcher, Brent
Corporate Officer · Individual
Twomagnets LLC
Operational/Managerial Control · Organization
Wiscombe, Braden
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Sandpiper Post Acute
Mount Pleasant, SC
1-star overall rating with 1-star inspections with $84,974 in total fines with 16 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Franke Health Care Center
Mount Pleasant, SC
3-star overall rating with 3-star inspections with 3 recent health deficiencies
#3
Retreat at Wellmore of Daniel Island
Charleston, SC
4-star overall rating with 3-star inspections with $12,740 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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