Carlyle Senior Care Of Florence
Carlyle Senior Care of Florence in Florence, SC — inspection on March 27, 2025.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of R72's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnosis which included strange and inexplicable behavior.
Review of R72's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/03/25 and located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact.
Review of R72's Certification of Inability to Make Healthcare Decisions located in the electronic medical record (EMR) under the Misc tab and dated 07/27/23 revealed two physicians certified the resident was unable to make healthcare decisions for himself.
Review of R72's Informed Consent for psychoactive medication Use located in the electronic medical record (EMR) under the Misc tab and dated 03/20/25 revealed the resident signed the document that indicated the risk and benefits of receiving a psychotropic medication.
Further review revealed the nurse completing the form was the Director of Nursing (DON).
During an interview 03/27/25 at 9:52 AM the Director of Nursing (DON) said she was unaware that R72 had been deemed incapably of making health care decisions.
She agreed the RP should have signed the form and not R72.
She said she only looked at the resident's BIMS score.
She said she spoke with R72 about the medication. He said okay, so she assumed he understood.
But she agreed that if a physician had deemed him incapable it was inappropriate to discuss the risk and benefits of the medications with him and have him sign the document.
425163 03/27/2025
Carlyle Senior Care of Florence 133 West Clarke Road Florence, SC 29501
Review of the facility policy titled HIPAA Security Measures last revised 09/30/24 revealed, it is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and /or records that are in electronic format .
During an observation on 03/25/25 at 10:44 AM, the east unit nursing medication cart was in the hallway and the cart was locked but the computer screen was on and revealed six resident names.
Four residents and three staff walked past the medication cart and computer screen before Licensed Practical Nurse (LPN)7 returned to the cart.
During an interview on 03/25/25 at 10:47AM, LPN7 stated the computer screen was locked.
She said she leaves the screen open with the residents' names but there was no medical information on the screen.
When asked to click on one of the residents' names, she saw that PHI immediately display on the computer screen.
She said she did not know how to lock the screen and would have to close the computer to lock it.
During an interview 03/27/25 at 9:52 AM, the Director of Nursing (DON) stated nursing staff were supposed to keep computer records out of sight and that all computer screens should have been locked when nurses were not at the medication cart.
She said all medical documentation containing PHI should be kept out of view and secured.
425163 03/27/2025
Carlyle Senior Care of Florence 133 West Clarke Road Florence, SC 29501
immediately had a skin assessment after the incident; however, FA confirmed that R12's skin
and had to go down to R52's room because R12 wandered inside.
Once there in the room, R52 and R12 were separated. R52 and R60 said that R12 hit first, who had redness to one side of the neck and there was no redness to R52. LPN4 said that there have been no further incidents between these residents.
425163 03/27/2025
Carlyle Senior Care of Florence 133 West Clarke Road Florence, SC 29501
Review of R52's Quarterly MDS with an ARD of 01/09/25 located in the EMR under the MDS tab with a BIMS score of 10 out of 15, which indicated R52's cognition was moderately impaired.
The MDS indicated that R52 had no behaviors.
Review of R60's Annual MDS with an ARD of 12/05/24, located in the EMR under the MDS tab with a BIMS score of 15 out of 15 which indicated R60's cognition was intact.
Review of R60's Statement from the person alleging abuse or reportable incident dated 02/19/25 indicated, I yelled at [R12] to get out of my room. [R52] got up and tried to make her [R12] get out of the room. [R12] held onto my bed and would not turn it loose. [R12] slapped [R52] and [R52] slapped her [R12] back.
Review of the facility's Initial Report dated 02/19/25 indicated, On 02/19/25 at approximately 7:20 PM, residents [R12 and R52] had a physical altercation.
Residents were immediately separated by staff and law enforcement notified .
Review of R60's statement from the reportable incident dated 02/19/25, indicated, I yelled at [R12] to get out of my room. [R52] got up and tried to make her [R12] get out of the room, [R12] held onto my bed and would not turn it loose. [R12] slapped [R52] and [R52] slapped her [R12] back.
Review of R52's statement from the person alleging abuse or reportable incident dated 02/19/25, indicated, [R12] was in our room. We told her [R12] to get out.
She [R12] would not leave; I pushed her out of the room, and she [R12] slapped me in my face. I slapped her [R12] back in her face.
Review of the facility's investigative documents revealed no evidence of interview with other residents.
During an interview on 03/25/25 at 11:37 AM, R52 said R12 came into her room, went into the bathroom, came out and sat down, so R52 opened the bedroom door and told R12 to get out. R52 said that R12 pushed her, so she pushed R12 back. R52 said that the unknown nurse came into the room and removed her from the room and told her not to come back.
During an interview on 03/26/25 at 2:15 PM, R12 was alert, but confused and unable to recall the incident.
During an interview on 03/26/25 at 5:23 PM, the Administrator confirmed that there were no further residents' interviews.
The Administrator stated that this was an isolated incident and that was the reason why only R52 and R60 was interviewed.
The Administrator confirmed that R12 has a low BIMS score and was unable to be interviewed. He confirmed that a statement was not written regarding this information about R12.
Review of the facility's policy titled QAPI dated 10/24/22, revealed, It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides .The facility conducts at least one distinct performance improvement project (PIP) annually that focuses on high risk or problem prone areas. PIPs shall be designed to achieve and sustain performance improvement over time and to have an expected favorable outcome.
The Quality Assessment and Assurance (QAA) shall select additional members to participate in various subcommittees based upon the PIP topic and participant expertise.
Upon conclusion of the PIP, the sub-committee shall provide the QAA committee with a report, which contains a summary and analysis of activities and recommendations for improvement.
Review of the facility ' s PIP's over the past year and interview on 03/27/25 at 6:52 PM with the Administrator, Director of Nursing (DON), and the Infection Preventionist (IP), the PIP consisted of a one page document that stated the problem to be solved was abuse prevention.
This PIP was completed in two days by the Administrator. A form was filled out using F-F223 for abuse, which is no longer the federal regulation for abuse.
The goal was there would be no abuse in the facility.
There was no documentation to go along with this PIP.
When the Administrator was questioned on the effectiveness of this PIP, he stated Our goal is to have zero abuse.
When asked if he feels that this PIP is achievable, he did not reply.
The survey team entered the facility with three abuse complaints that were all substantiated.
Three weeks prior, the State Agency (SA) investigated several abuse complaints.
The PIP did not contain a summary, how this was identified to QAPI, a sub-committee, or a summary and analysis of the process.
When the Administrator was asked if he understood the purpose of QAPI and an annual PIP, he stated Yes.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
425163 03/27/2025
Carlyle Senior Care of Florence 133 West Clarke Road Florence, SC 29501
During an interview on 03/27/25 at 6:53 PM, the Administrator revealed, My expectation for antibiotic
425163 03/27/2025
Carlyle Senior Care of Florence 133 West Clarke Road Florence, SC 29501
Review of R24's Admission Record located under the Profile tab of the electronic medical record (EMR) revealed R24 was admitted to the facility on [DATE]. R24 was sent to the emergency room (ER) on 02/18/25 for an indwelling urinary catheter. A urine analysis (UA) was completed, and an antibiotic was started. R24 returned to the facility and completed the antibiotic. A culture was not done by the ER and the Infection Preventionist (IP) did not question the antibiotic.
2.
Review of R81's Admission Record located under the Profile tab of the EMR revealed R81 was admitted to the facility on [DATE]. R81 was sent to theER on [DATE] for urinary retention, was catheterized, and came back to the facility on an antibiotic. No UA or culture was completed.
3.
Review of R55's Admission Record located under the Profile tab of the EMR revealed R55 was admitted to the facility on [DATE]. R55 was sent on 03/04/25 to the ER for a change in condition and came back to the facility on an antibiotic. A UA was completed by the ER; however, a culture was not ordered to be completed.
4.
Review of R15's Admission Record located under the Profile tab of the EMR revealed R15 was admitted to the facility on [DATE]. R15 has a Stage IV pressure ulcer to the sacrum.
The Wound Doctor was alerted to an odor coming from the sacrum and ordered an antibiotic (Doxycycline) for 14 days. No culture was order by the provider to determine if antibiotic was needed or appropriate.
During an interview on 03/25/25 at 12:43 PM, Licensed Practical Nurse (LPN9) revealed, I noticed a foul odor coming from the sacrum with drainage. I notified the wound doctor, and he came and evaluated the resident. A culture was not completed on the wound.
Doxycycline was ordered for 14 days. I informed the IP that an antibiotic was started.
425163
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 425163 B.
Wing 03/27/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Carlyle Senior Care of Florence 133 West Clarke Road Florence, SC 29501
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.