STATE OF SOUTH CAROLINA

ADMINISTRATIVE LAW COURT

South Carolina Department of Health and )

DOCKET NO. 22-ALJ-07-0392-CC
Environmental Control, )

Petitioner, )

VS. )

Carriage House Senior Living of Florence, )

CONSENT ORDER OF DISMISSAL
Inc., d/b/a Carriage House Senior Living of )

Florence, )

Respondent, )

In Re: Administrative Order AO-HQ-02- )

2022 )

IT APPEARING THAT the parties have agreed that the above-captioned contested case should
be dismissed.

1. Carriage House Senior Living of Florence, Inc. is the licensee of Carriage House Senior
Living of Florence (Carriage House Florence), a community residential care facility (CRCF)
licensed by the South Carolina Department of Health and Environmental Control (the Department)
pursuant to the State Certification of Need and Health Facility Licensure Act, S.C. Code Sections

44-7- 110 et seq., and Standards for Licensing Community Residential Care Facilities, Regulation

61-84. Carriage House Florence is located at 739 South Parker Drive, Florence, South Carolina
and has a licensed capacity of 80 beds.

2. On November 22, 2020, the Department and Carriage House executed a consent order
imposing a monetary penalty against Carriage House Florence based upon violations of Regulation
61-84 relating to infection control standards.
3. On February 17, 2022, the Department and Carriage House Florence executed a second
consent order imposing a monetary penalty and other sanctions against Carriage House Florence
based upon violations of various provisions of Regulation 61-84.

4. On February 24, 2022, the Department visited Carriage House Florence to qoQR+Kt b (

„„ti„, f,II,w-„p inspection. F,llowing the visit, the D,p,Hm,nt ,it,d th, F„iII eg\#bY&a '''\h
violations of Regulation 61-84, including: Section 901.C, for failing to render cara: ;§ordance a
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medications; Section 1203.A, for failing to initial medication administration records (MARs) as

medications were administered; Section 1203.F, for failing to have documented reviews of MARs
at shift changes; Section 1205.B, for failing to maintain residents’ medications in their original
packaging; Section 1206.A, for storing discontinued medications with current medications;
Section 1206.C.2, for failing to have documented reviews of controlled sheets at shift changes;
Section 1206.F, for storing medications in a resident’s room who has an order not to self-
administer over the counter medications; Section 1601, for failing to keep all equipment and
building components in good repair and operating condition; Section 1703, for failing to keep its
grounds clean and free of vermin and offensive odors; Section 1703.A.1, for failing to clean each
specific area of the facility; Section 2103, for failing to provide window treatments for privacy in
residents’ bathrooms; Section 2301.B, for failing to maintain plumbing fixtures that require hot
water and which are accessible to residents to supply water at a temperature of at least 100 degrees

Fahrenheit; Section 2602.A.1, for failing to equip a resident room with a comfortable single bed;
Section 2604.C, for failing to provide liquid soap and a sanitary individualized method of drying
hands in a shared bathroom; and Section 2604.K, for failing to provide a suppIy of toilet tissue in
a shared bathroom.

5. On March 8, 2022, the Department visited Carriage House Florence to conduct an

investigation. As a result of the visit, the Department cited the Facility for several violations of
Regulation 61-84, including: Section 1206.F, for leaving medication unsecured and accessible in
a resident’s room; Section 1301, for failing to ensure its kitchen and food preparation were in
compliance with Retail Food Establishment, Regulation 61-25; Section 1601, for failing to keep
all equipment and building components in good repair and operating condition; Section 1703, for
failing to keep its grounds free of vermin and offensive odors; Section 1703.A.1, for failing to
clean each specific area of the facility; Section 1703.B.2, for failing to keep its grounds free of
weeds, rubbish, overgrown landscaping, and other potential breeding sources for vermin; Section

2301.B, for failing to maintain plumbing fixtures that require hot water and which are accessible
to residents to supply water at a temperature of at least 100 degrees Fahrenheit; and Section
2604.C, for failing to provide liquid soap in a shared bathroom.

6. On April 20, 2022, the Department visited Carriage House Florence to conduct a routine
foIIow-up inspection and a food and sanitation follow-up inspection. As a result of the visit, the
Department cited the Facility for several violations of Regulation 61-84, including: Section

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504.A.1, 504.A.3, 504.A.4, 504.A.5, 504.A.6, 504.A.7, 504.A.9, 504.A.11, and 504.A.12, for
failing to have documentation of staff members’ initial and annual training in basic first-aid,
contagious and/or communicable disease, medication management, specific-person care, restraint

techniques, OSHA standards regarding blood-borne pathogens, confidentiality of resident

information and records, fire response, and emergency procedures/disaster preparedness; Section

505.A, for failing to have a health assessment, including a two-step tuberculin skin test (TST) for
a staff member; Section 701.B.6, for failing to have monthly notes of observation for residents;
Section 801.B, for retaining a resident who required the daily care of a licensed nurse and was
inappropriate for a CRCF; Section 1201.A, for failing to have a medication available for
administration; Section 1203.A, for failing to initial MARs as medications were administered;
Section 1205.B, for failing to maintain residents’ medications in their original packaging; Section
1206.F, for storing medications in a resident’s room who has an order not to self-administer

medications; Section 1301.A, for failing to ensure its kitchen and food preparation were in
compliance with Retail Food Establishment, Regulation 61-25; Section 1601, for failing to keep
all equipment and building components in good repair and operating condition; Section 1703, for
failing to keep its grounds clean and free of vermin and offensive odors; Section 1703.A.1, for
failing to clean each specific area of the facility; Section 1703.A.3, for failing to safely store
harmful chemicals in a manner that make them inaccessible to residents; Section 1703.B.2, for
failing to keep its grounds free of weeds, rubbish, overgrown landscaping, and other potential
breeding sources for vermin; Section 1706.B.3, for failing to keep soiled clothing in
enclosed/covered containers; Section 2104, for failing to take safety precautions against fire and
other hazards when oxygen is dispensed, administered, or stored; Section 2301.B, for failing to
maintain plumbing fixtures that require hot water and which are accessible to residents to supply
water at a temperature of at least 100 degrees Fahrenheit; Section 2602. A.1, for failing to equip
resident rooms with comfortable single beds having mattresses with moisture-proof covers, sheets,

blankets, bedspreads, pillows, and piilowcases; Section 2604.K, for failing to provide a supply of
toilet tissue in each bathroom; and Section 2611.D, for failing to keep supplies/equipment off of
the floor.

7. On May 16, 2022, the Department visited Carriage House Florence to conduct a routine
follow-up inspection and a food and sanitation follow-up inspection. As a result of the visit, the
Department cited the Facility for several violations of Regulation 61-84, including: Section 703.A,

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for failing to review and/or revise a resident’s individual care plan (ICP) at least semi-annually
and by failing to have a resident’s ICP signed by the administrator (or his designee); Section 901.C,

for failing to render care in accordance with orders from physicians or other authorized health care
providers regarding administration of medications; Section 1203.F, for failing to have documented
reviews of MARs at shift changes; Section 1206.A, for storing discontinued medications with
current medications; Section 1206.C.1, for failing to maintain records of administration and
disposition of a resident’s controlled substance to enable an accurate reconciliation of the
medication; Section 1206.C.2, for failing to have documented reviews of control sheets at shift
changes; Section 1206.F, for storing medications in a resident’s room who has an order to not self-

administer medications; Section 1301 .A, for failing to ensure its kitchen and food preparation were
in compliance with Retail Food Establishment, Regulation 61 -25; Section 1601, for failing to keep
all equipment and building components in good repair and operating condition; Section 1703, for
failing to keep its grounds clean and free of vermin and offensive odors; Section 1703.A.1, for
failing to clean each specific area of the facility; Section 1703.A.3, for failing to safely store
harmful chemicals in a manner that make them inaccessible to residents; Section 1703.B.2, for

failing to keep its grounds free of weeds, rubbish, overgrown landscaping, and other potential
breeding sources for vermin; Section 1706.B.3, for failing to keep soiled clothing in
enclosed/covered containers; Section 2301 .B, for failing to maintain plumbing fixtures that require

hot water and which are accessible to residents to supply water at a temperature of at least 100
degrees Fahrenheit; Section 2602.A.1, for failing to equip resident rooms with comfortable single
beds having mattresses with moisture-proof covers, sheets, blankets, bedspreads, pillows, and
pillowcases; and Section 2604.C, for failing to provide liquid soap in a shared bathroom.
8. By certified letter dated May 25, 2022, the Department notified Carriage House Florence
that it was considering an enforcement action and requested it attend an enforcement conference
on June 16, 2022, to discuss the above-referenced violations.
9. On June 16, 2022, the Department and Carriage House Florence (collectively, the Parties)
met for the enforcement conference. The Parties discussed the violations. At the conclusion of

the conference, the Department requested Carriage House Florence submit pictures in response to

the violations discussed at the enforcement conference. The Department received copies of
photographs on June 23, and 25, 2022.

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 10. On August 16, 2022, the Department mailed via certified mail, return receipt requested to
Carriage House Florence an administrative order revoking the Facility’s license to operate as a
CRCF based upon the abovementioned violations.
11. On August 30, 2022, the Board of Health and Environmental Control (the Board) received
Carriage House Florence’s request for final review (RFR) of the Department’s administrative
order.

12. On September 29, 2022, the Board mailed notice of its decision not to conduct a final
review conference concerning Carriage House Florence’s RFR.
13. By letter dated October 25, 2022, Carriage House Florence filed a request for a contested

case hearing with the Administrative Law Court.

14. Following issuance of the administrative order, the Department communicated with

Carriage House Florence and its counsel regarding the alleged regulatory violations and the
Facility’s efforts to obtain and maintain compliance with Regulation 61-84.
15. On or around November 23, 2022, the Department received an application for an amended

license for Carriage House Florence as a result of a change of ownership.

16. The Parties have agreed to resolve this matter via a Consent Order. The following terms

were agreed upon by the Department and Carriage House Senior Living of Florence, Inc., d/b/a
Carriage House Senior Living of Florence.
THEREFORE IT IS AGREED

1. Carriage House Florence agrees to the assessment of a $10,000 monetary penalty by the
Department for its violations of Regulation 61-84. The agreed upon monetary penalty shall be
paid in two payments of $5,000. The first payment of $5,000 shall be due and payable within 30
days of execution of this Consent Order of Dismissal. The second payment of $5,000 shall be due

and payable within 60 days of execution of this Consent Order of Dismissal. Carriage House
Florence shall make payments of the assessed monetary penalty by certified check or money order
payable to the S.C. Department of Health and Environmental Control, as explained in this
paragraph. Payments shall be sent to the following address:
Attention: Angie Smith, Director
Bureau of Community Care
SCDHEC/Healthcare Quality
2600 Bull Street
Columbia, SC 29201

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 buS / '7 ' eg ?Z 'Cl
Z&' 2. Upon signing of this Consent Order of Dismissal, contested case number
Is hereby dismissed with prejudice with each party bearing its own fees and

costs. The Department agrees to thereafter rescind its revocation and, upon payment of the
required fees (which does not include payment of the monetary penalty referenced in paragraph 1)
and submission of the required documentation, will issue an amended license in accordance with
the licensure application regarding a change of ownership for the Facility.
3. For a period of five years following execution of this Consent Order of Dismissal, Carriage

House Florence agrees to not seek licensure as a CRCF in South Carolina and to not manage or

operate a CRCF in South Carolina.

4. For a period of five years following execution of this Consent Order of Dismissal, the
shareholders and officers of Carriage House Florence, either individually or through entities or

organizations formed by or on behalf of the shareholders or officers, agree to not seek licensure as
a CRCF in South Carolina and to not manage or operate a CRCF in South Carolina.

5. This Consent Order of Dismissal contains the entire agreement between the Parties with
respect to the resolution and settlement of the matters set forth herein. The Parties are not relying

upon any representations, promises, understanding, or agreements except as expressly set forth
within this Consent Order of Dismissal.
6. The Parties understand that this Consent Order of Dismissal governs only liability to the
Department for sanctions arising from the matters set forth herein.

o ORDEBE

The HJMorabl J Roan L. Reibold

,e-Mlminis' 4 Law Judge

/ /CS ,2023
Columbia, South Carolina
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JAN 23 2023

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WE MOVE AND CONSENT:

FOR THE SOUTH CAROLINA DEPARTMENT OF

HEALTH AND ENVIRONMMENTAL CONTROL

Vito Wicevic, Esquire

Ashley C. Biggers, Esquire
2600 Bull Street
Columbia, SC 29201
(803) 898-3350

Attorneys for South Carolina Department of Health and Environmental Control

.UP

C o 1: 1rIf:J i1 : qJ2 u t h C :r : 1i n a 92023

FOR CARRIAGE HOUSE SENIOR LIVING OF FLORENCE, INC., D/B/A CARRIAGE

HOUSE SENIOR LIVING OF FLORENCE

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John Patrick ''Jack’' Riordan

Willson Jones Carter & Baxley, P.A.
325 Rocky Slope Road, Suite 201
Greenville, S.C. 29607

Attorney for Carriage House Senior Living of Florence, Inc. d/b/a Carriage House Senior Living
of Florence

11 , 2023
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 CERTIFICATE OF SERVICE
I, James Smith Harrison, III, hereby certify that I have this date served this order upon all
parties to this cause by depositing a copy hereof in the United States mail, postage paid, in the
Interagency Mail Service, or by electronic mail, to the address provided by the party(ies) and/or
their attorney(s) .

Jfk--– JL T)c____ TrI

GenEAGi:iii
Judicial Law Clerk

January 25, 2023

Columbia, South Carolina

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JAN 25 2023 ’

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