Carlyle Senior Care Of Blackville

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, document review, and facility policy review, the facility failed to timely report an allegation of sexual abuse to the state survey agency that involved 1 (Resident #5) of 3 sampled residents reviewed for abuse.Findings included:A facility policy titled, Abuse, Neglect and Exploitation, revised 10/24/2022, revealed, VII. Reporting/Response A. The facility will have written procedures that include: 1.

Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.An admission Record revealed the facility admitted Resident #5 to the facility on [DATE REDACTED]. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, muscle weakness, anxiety disorder, depression, and adult failure to thrive.A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/03/2025, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition.The Medical Records (MR) Clerk's Incident Witness Statement dated 12/10/2025, revealed On 12-10-25 @ [at] approximately 3:30 pm I was on back hall near back hall nurses station, [Resident #5] said I have something to tell you. Resident said you know that guy right there he raped me. Per the Incident Witness Statement, the MR Clerk revealed she immediately notified the Administrator of the allegation.Licensed Practical Nurse (LPN) #9's Witness Statement dated 12/10/2025, revealed that at 3:35 PM, she saw the MR Clerk and Certified Nurse Aide (CNA) #6 coming up the middle hall and both stated that Resident #5 accused CNA #6 of rape. Per the Witness Statement, LPN #9 stated

she notified the Abuse Coordinator, the Administrator.Contained within the facility investigation file was a facsimile report which indicated the facility notified the state survey agency of Resident #5's allegation sexual abuse perpetrated by CNA #6 on 12/11/2025 at 4:52 PM.During an interview on 12/20/2025 at 2:56 PM, the Administrator, who served as the Abuse Coordinator, stated she was notified of the allegation of sexual abuse on 12/10/2025 when CNA #6 notified her that Resident #5 alleged he raped them. The Administrator stated she did not submit a facility reportable incident to the state survey agency on 12/10/2025. Per the Administrator, the resident's allegation was reported to the state survey agency on 12/11/2025, but it should have been reported immediately.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Carlyle Senior Care of Blackville

1612 Jones Bridge Road Blackville, SC 29817

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and their arms were on the bed at the time. CNA #7 stated she and CNA #6 assisted the resident back to bed then completed passing out the meal trays to other residents. CNA #7 stated that after the trays were passed, she notified LPN #8 that she needed to check on Resident #3. CNA #7 stated she knew she was to alert a nurse before moving a resident after a fall and that she should have alerted LPN #8 before moving

the resident.During an interview on 12/21/2025 at 3:55 PM. LPN #8 stated CNA #7 approached her and informed her that Resident #3 needed to be checked but did not notify her why the resident needed checked. LPN #8 stated she went to see Resident #3, who was lying in their bed at the time and the resident stated they did not need anything so she returned to her duties. LPN #8 stated on the following day, 09/18/2025, LPN #9 asked her about a fall Resident #3 reported to her. LPN #8 stated both she and LPN #9 went to Resident #3's room to inquire further about the fall, and Resident #3 stated they had not notified the nurse of the fall on 09/17/2025.During an interview on 12/22/2025 at 1:03 PM, the Director of Nursing (DON) stated she recalled Resident #3 reporting a fall to LPN #9. The DON stated there was no documentation of the fall in Resident #3's electronic medical record, she was concerned there was a discrepancy, so she retrieved the schedules from the day before and discovered CNA #7 was assigned to

the resident. The DON stated she contacted CNA #7, who informed her that the resident had almost fallen, and she found Resident #3 leaning on the bed. The DON stated CNA #7 told her that she and CNA #6 assisted Resident #3 back to bed and had not notified LPN #8 before moving Resident #3. The DON stated CNA #6 told her that he did not notify the nurse that Resident #3 had fallen. The DON stated when she spoke with LPN #8, LPN #8 recalled CNA #7 notifying her that Resident #3 needed to be checked but did not notify her that the resident had fallen. The DON stated she expected all staff to notify a nurse before moving a resident after a fall and expected a nurse to perform a physical assessment on the resident to determine if there were any injuries from the fall. The DON stated CNA #6 and CNA #7 should have lowered Resident #3 to the floor then gone to get the nurse immediately before attempting to get the resident back in the bed, even if the resident insisted they be placed back in the bed.During an interview on 12/22/2025 at 3:30 PM, the Administrator stated she expected staff to notify a nurse if a resident fell and not move the resident before a nurse assessed them.

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