Laurel Baye Healthcare Blackville

F-F880.

On 02/20/25 at 11:40 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 02/19/25. The IJ was related to 42 CFR 483. 80 Infection Control.

On 02/21/25 at 2:43 PM, the facility provided an acceptable IJ Removal Plan. On 02/21/25 at 3:00 PM, the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of a compliance at a lower scope and severity of F.

Findings include:

Review of the undated facility policy titled, Equipment Inspections, revealed, The Maintenance Director is responsible for ensuring that all required inspections for the building and equipment are completed in a timely manner. The maintenance director shall ensure that required inspections performed at regular intervals by licensed vendors in accordance with state and/or local regulations. Contracts shall be maintained with appropriate vendors to ensure that inspections are conducted as needed/required . Outside vendors must keep the Maintenance Director or Administrator with reports of all inspections conducted. Keep these reports in the administrative files (proof of completed inspections may need to be provided to the fire marshal or other licensing authority).

Review of the undated facility policy titled, Preventative Maintenance, revealed, The maintenance director will ensure that all preventative maintenance tasks are performed according to the regular schedule to maintain the building and equipment in a safe manner and to extend the life of the property. The maintenance director shall maintain a record of all preventative maintenance and routine maintenance that is needed and performed at the facility. At the minimum, records shall indicate the frequency of all needed maintenance tasks and whether the task would typically be performed by an outside contractor or by the maintenance director. The Administrator shall periodically review preventative maintenance records.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 425319 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425319 B. Wing 02/21/2025

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 0880 Review of the undated facility policy titled, Maintenance Work Area/Supplies, revealed, The Maintenance Director is responsible for ensuring that the maintenance work area and maintenance supplies are Level of Harm - Immediate maintained in a safe, efficient and cost-effective manner. The Maintenance Director will maintain his/her work jeopardy to resident health or area in a clean and safe manner, following all safety procedures outlined in the Safety policy. The safety Maintenance Director will keep a Material Data Safety Sheet (MDSS) on all chemicals and hazardous materials used in the Maintenance Department (e.g., paint, caulking, cleaning products, lubricants, etc.). Residents Affected - Many Product manufacturers supply these sheets. Ensure that a copy of each MSDS is provided to administration.

Review of the undated facility policy titled, Safety (General), revealed, Staff should report all unsafe conditions and equipment to their supervisors. Inspect all mechanized equipment routinely prior to use. Ensure that all heating appliances are inspected on an annual basis and are properly maintained.

Record review of the facility's contract with Laundry [NAME] revealed the contract was signed on 02/21/25.

The contract stated, All linen and laundry are washed according to CDC guidelines. Hot water provides an effective means of destroying microorganisms. A temperature of at least 160 F (71 C) for a minimum of 25 minutes, using only non-allergic soaps, detergents, bleaches, or other chemicals to render the finished products clean and usable.

Review of an Ecolab Service Call dated 12/13/24 revealed, the machine at this time was at the appropriate chemical sanitization level. The facility was unable to provide any documentation for sanitization levels for 2025.

During an observation on 02/19/25 at 12:17 PM, Washer One was running with linens and resident's gowns, but there was no visible detergent coming from the tubing. Housekeeper (HK) 1 stated, they have no way of conducting temperature checks on the washers, because they have never done it before. There were no visible thermometer gauges to detect the water temperature for the Washer One or Washer Two.

During an observation on 02/19/25 at 3:30 PM, Washer One was inoperable due to the laundry detergent pumps not pumping into the washer machine. No visible signs of detergent or suds during the wash cycle. Additionally, there was no visible liquid coming through the lines to the washer. There wasn't a temperature gauge on Washer One or Washer Two to determine the temperature for proper sanitization for each machine.

During an observation on 02/19/25 at 6:00 PM, Washer Machine one was inoperable due to laundry pumps malfunctioning.

On 02/21/25 at 2:43 PM, the facility provided an acceptable IJ Removal Plan, which included the following:

The laundry staff stopped doing laundry when they realized that the water temperature was not 160 degrees and that the dispenser for detergent was not dispensing appropriately on 2/19/25 at 12:17 pm.

The Ecolab technician repaired the detergent dispenser on 2/19/25 at 3 :45 pm. There were no other chemicals that were not dispensing at that time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 425319 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 425319 B. Wing 02/21/2025

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 0880 The Ecolab technician has been asked for a service visit to check all our chemicals to be sure that they are dispensing appropriately and in correct amounts. He will be at the facility today 2/21/25, late evening, to Level of Harm - Immediate inspect and provide a written report. jeopardy to resident health or safety We have signed a contract with a Laundry Service, [NAME] Laundry Service, who will start service today 2/21/25 and have pick up scheduled for around 5 pm. Residents Affected - Many All residents have the potential to be affected by the deficient practice.

The laundry staff were in-serviced on 2/20/25 by the housekeeping supervisor and the nurse consultant regarding checking the dispensers when washing clothes to be sure that chemicals are dispensed properly, and if not, they are to notify the housekeeping supervisor or the maintenance supervisor immediately. Any newly hired housekeeping staff will be trained during their orientation period regarding checking the dispensers to be sure that chemicals are

The administrator will monitor monthly to assure that Ecolab has made monthly visits and will review the dispenser function logs and the washing machine temperature logs on a weekly basis.

The Administrator will bring all Ecolab reports, temperature logs, and dispenser logs to be reviewed in QA monthly x 3 and then quarterly until it is determined that the deficient practice is not likely to occur.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 425319