THE RETREAT AT BRIGHTWATER

Nursing Home Inspector

171 BRIGHTWATER DRIVE
MYRTLE BEACH, SC 29579
Horry County
Phone: 843-903-8300
Provider Number: 425395
Last Inspection: 01/06/2017

About the Nursing Home

Number of Beds: 67
Number of Residents: 45
Beds Available: 22
Percent Occupancy: 67%
Insurance Accepted: Medicare
Types of Councils: None
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

23

Facility
22

County
22

SC
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

23

2017
29

2016
29

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

1/6/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 2/3/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 2/3/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 2/3/2017
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 2/3/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 2/3/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 2/3/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 2/3/2017
 

1/15/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 2/15/2016
 
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 2/15/2016
 
Failed To: Allow residents to easily view the results of the nursing home's most recent inspection. Widespread : Potential 4 2/15/2016
 
Failed To: Protect each resident from all abuse, physical punishment, and involuntary separation from others. Isolated : Minimal 3 2/15/2016
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 2/15/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 2/15/2016
 
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Minimal 3 2/15/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 2/15/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 2/15/2016
 

9/12/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated : Minimal 3 10/12/2014
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 10/12/2014
 
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Minimal 3 10/12/2014
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 10/12/2014
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Isolated : Immediate 5 10/12/2014
 
Failed To: Operate and provide services according to Federal, State, and local laws and professional standards. Pattern : Minimal 4 10/12/2014
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Isolated : Immediate 5 10/12/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

No Complaint Deficiencies Reported

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg SC State Avg
Number of Residents 45 76.78 89.32
Registered Nurses 1.23 0.87 0.85
Licensed Practical / Vocational Nurses 1.49 1.26 0.95
Certified Nursing Assistants 3.76 2.70 2.40
Total Staff Hours 6.48 4.83 4.20

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% SC State Avg%
of high risk long-stay residents with pressure ulcers 0 6 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 94 93 93
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 69 89 93
of long-stay residents experiencing one or more falls with major injury 8 3 3
of long-stay residents who have depressive symptoms 0 0 1
of long-stay residents who lose too much weight 21 10 8
of long-stay residents who received an antianxiety or hypnotic medication 48 32 25
of long-stay residents who received an antipsychotic medication 28 18 14
of long-stay residents who self-report moderate to severe pain 12 6 5
of long-stay residents who were physically restrained 0 0 1
of long-stay residents whose ability to move independently worsened 26 20 18
of long-stay residents whose need for help with daily activities has increased 22 15 14
of long-stay residents with a catheter inserted and left in their bladder 6 2 1
of long-stay residents with a urinary tract infection 7 5 5
of low risk long-stay residents who lose control of their bowels or bladder 18 35 54
of short-stay residents assessed and appropriately given the pneumococcal vaccine 86 86 82
of short-stay residents who had an outpatient emergency department visit 11 11 13
of short-stay residents who made improvements in function 63 67 66
of short-stay residents who newly received an antipsychotic medication 1 1 1
of short-stay residents who self-report moderate to severe pain 8 16 13
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 74 85 81
of short-stay residents who were rehospitalized after a nursing home admission 25 23 21
of short-stay residents who were successfully discharged to the community 70 62 54
of short-stay residents with pressure ulcers that are new or worsened 1 0 0