Cycle 1
Health 2025-04-02 · Fire 2025-04-02
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Charleston, SC
Retreat at Wellmore of Daniel Island
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
580 Robert Daniel Drive, Charleston, SC
(843) 566-1000
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2019-04-12
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
0.86
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.31
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.67
Nurse aide staffing · state 2.22 · national 2.35
Total nurse hours
4.85
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.18
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.62
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.20
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.86
CMS adjusted RN staffing hours
Adjusted total hours
4.84
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
534
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
68.12
Composite VBP score used to determine payment impact.
Payment multiplier
1.0214
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.50
Baseline 17.92% · Performance 17.49% · Measure score 8.50 · Achievement 8.50 · Improvement 4.30
Healthcare-associated infections
8.87
Baseline 6.18% · Performance 5.18% · Measure score 8.87 · Achievement 8.87 · Improvement 7.92
Total nurse turnover
4.28
Baseline 69.62% · Performance 48.21% · Measure score 4.28 · Achievement 3.78 · Improvement 4.28
Adjusted total nurse staffing
5.59
Baseline 5.22 hours · Performance 4.67 hours · Measure score 5.59 · Achievement 5.59 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.95% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 276 · Observed rate 6.52% · Lower 95% interval 6.02% |
| Discharge to community | 57.72% |
50.57%
7.1 pts better
|
Better than the National Rate · Eligible stays 247 · Observed rate 55.47% · Lower 95% interval 51.15% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 92.56% |
95.27%
2.7 pts worse
|
Numerator 199 · Denominator 215 |
| Falls with major injury | 0.47% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 215 |
| Discharge self-care score | 54.39% |
53.69%
0.7 pts better
|
Numerator 93 · Denominator 171 |
| Discharge mobility score | 50.29% |
50.94%
0.6 pts worse
|
Numerator 86 · Denominator 171 |
| Pressure ulcers or injuries, new or worsened | 0.47% |
2.29%
1.8 pts better
|
Numerator 1 · Denominator 215 · Adjusted rate 0.5% |
| Healthcare-associated infections requiring hospitalization | 5.18% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 156 · Observed rate 2.56% · Lower 95% interval 3.39% |
| Staff COVID-19 vaccination coverage | 7.81% |
8.2%
0.4 pts worse
|
Numerator 5 · Denominator 64 |
| Staff flu vaccination coverage | 5.08% |
42%
36.9 pts worse
|
Numerator 6 · Denominator 118 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 114 · Denominator 171 |
| Transfer of health information to provider | 98.98% |
95.95%
3 pts better
|
Numerator 195 · Denominator 197 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 20.75% |
25.2%
4.4 pts worse
|
Numerator 22 · Denominator 106 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.0
0.1 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.0 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.9
1.5 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 70.8% |
90.5%
19.7 pts worse
|
93.4%
22.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 79.2% · Q2 72.0% · Q3 65.4% · Q4 67.7% · 4Q avg 70.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 64.0% |
90.6%
26.6 pts worse
|
95.5%
31.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 64.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.0%
0.2 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 3.8% · Q4 3.2% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.7% |
2.9%
7.8 pts worse
|
11.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 16.0% · Q3 12.5% · Q4 3.2% · 4Q avg 10.7% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
6.2%
0.3 pts better
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 5.0% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.4% |
20.4%
1 pts better
|
19.6%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 20.0% · 4Q avg 19.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
16.3%
16.3 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 need for help with daily activities has increased | 3.1% |
12.4%
9.3 pts better
|
14.9%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
0.7%
0.8 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.5% · Q4 2.4% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.6%
1.6 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.5% |
17.2%
10.7 pts better
|
19.8%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 9.3% · Q3 4.4% · Q4 3.8% · 4Q avg 6.5% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
5.8%
0.6 pts better
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 7.1% · Q3 4.7% · Q4 1.7% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 52.5% |
79.8%
27.3 pts worse
|
81.7%
29.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 64.0% · Q2 54.2% · Q3 45.5% · Q4 45.7% · 4Q avg 52.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.1% |
14.1%
About the same
|
12.0%
2.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.1% · Observed 14.5% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.6%
1.4 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 66.7% |
78.0%
11.3 pts worse
|
79.7%
13 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.6% |
24.7%
3.1 pts better
|
23.9%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.6% · Observed 20.7% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-17 · Fire 2024-04-17
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-05-13 · Fire 2022-05-13
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-02
K227 · Egress Deficiencies
Fire Safety
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
Corrected 2025-05-08
D · Potential for more than minimal harm
2024-04-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-03
D · Potential for more than minimal harm
2022-05-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-06-10
Inspection history
Recent health citations
J · Immediate jeopardy
2025-09-11
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.
Not marked corrected
F · Potential for more than minimal harm
2025-04-02
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 2025-05-02
F · Potential for more than minimal harm
2024-04-17
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 2024-05-02
E · Potential for more than minimal harm
2024-04-17
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-04-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-08
D · Potential for more than minimal harm
2024-04-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-08
D · Potential for more than minimal harm
2024-04-17
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 2024-05-17
D · Potential for more than minimal harm
2024-04-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-17
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-05-14
D · Potential for more than minimal harm
2023-09-05
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-09-15
F · Potential for more than minimal harm
2022-05-13
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 2022-07-18
E · Potential for more than minimal harm
2022-05-13
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 2022-06-10
D · Potential for more than minimal harm
2022-05-13
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2022-06-27
D · Potential for more than minimal harm
2022-05-13
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 2022-06-27
D · Potential for more than minimal harm
2022-05-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-06-27
D · Potential for more than minimal harm
2022-05-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-06-27
D · Potential for more than minimal harm
2022-05-13
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 2022-06-27
D · Potential for more than minimal harm
2022-05-13
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-07-18
Penalties and ownership
What sits behind the stars
$12,740
2025-09-11
Fine
Fine · fine $12,740
Fine
Ownership
Wdi Parent LLC
5% Or Greater Direct Ownership Interest · Organization
Thompson, Brenda
5% Or Greater Indirect Ownership Interest · Individual
Thompson, Donald
5% Or Greater Indirect Ownership Interest · Individual
Seeds, Ashley
W-2 Managing Employee · Individual
Suntrust Bank
5% Or Greater Security Interest · Organization
Thompson, Donald
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Riverside Health and Rehab
Charleston, SC
1-star overall rating with 1-star inspections with $33,883 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Oak Harbor Healthcare
Mt Pleasant, SC
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
#3
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
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