1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Bishopville, SC
3-star overall rating with 4-star inspections with $8,512 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
207 Chappell Drive, Bishopville, SC
(803) 484-5636
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
116
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Carlyle Senior Care
Operator or chain grouping
Approved since
1989-09-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 2 overall / 3 health / 3 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.40
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.22 · national 2.35
Total nurse hours
3.60
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.99
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
26%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
9,695
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9830
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 20.50% · Performance 22.85% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.75% · Performance 8.19% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.41
Baseline 28.57% · Performance 37.50% · Measure score 6.41 · Achievement 6.41 · Improvement 0
Adjusted total nurse staffing
2.73
Baseline 3.71 hours · Performance 3.85 hours · Measure score 2.73 · Achievement 2.73 · Improvement 0.18
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.11% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 98 · Observed rate 12.24% · Lower 95% interval 7.46% |
| Discharge to community | 47.51% |
50.57%
3.1 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 39.66% · Lower 95% interval 37.41% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 98.95% |
95.27%
3.7 pts better
|
Numerator 94 · Denominator 95 |
| Falls with major injury | 6.32% |
0.77%
5.6 pts worse
|
Numerator 6 · Denominator 95 |
| Discharge self-care score | 37.04% |
53.69%
16.6 pts worse
|
Numerator 20 · Denominator 54 |
| Discharge mobility score | 29.63% |
50.94%
21.3 pts worse
|
Numerator 16 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 10.53% |
2.29%
8.2 pts worse
|
Numerator 10 · Denominator 95 · Adjusted rate 7.37% |
| Healthcare-associated infections requiring hospitalization | 8.19% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 65 · Observed rate 10.77% · Lower 95% interval 4.45% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 142 |
| Staff flu vaccination coverage | 31.82% |
42%
10.2 pts worse
|
Numerator 49 · Denominator 154 |
| Discharge function score | 31.48% |
56.45%
25 pts worse
|
Numerator 17 · Denominator 54 |
| Transfer of health information to provider | 96.88% |
95.95%
0.9 pts better
|
Numerator 31 · Denominator 32 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 20% |
25.2%
5.2 pts worse
|
Numerator 6 · Denominator 30 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.0
About the same
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.7 |
1.9
3.8 pts worse
|
1.8
3.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.7 · Observed 5.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
90.5%
9.3 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.1% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.7% |
90.6%
5.1 pts better
|
95.5%
0.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
3.0%
1.8 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.5% · Q3 2.8% · Q4 7.0% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
2.9%
1.6 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 2.2% · Q4 1.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
6.2%
About the same
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 5.1% · Q3 4.9% · Q4 8.8% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.1% |
20.4%
0.7 pts worse
|
19.6%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 21.6% · Q3 18.3% · Q4 16.3% · 4Q avg 21.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.1% |
16.3%
5.8 pts worse
|
16.7%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 21.7% · Q3 18.5% · Q4 21.2% · 4Q avg 22.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 32.6% |
14.9%
17.7 pts worse
|
16.3%
16.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 43.1% · Q3 31.1% · Q4 28.1% · 4Q avg 32.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.4% |
12.4%
11 pts worse
|
14.9%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 23.6% · Q3 20.2% · Q4 23.4% · 4Q avg 23.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.6% |
0.7%
2.9 pts worse
|
1.0%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.4% · Q3 2.2% · Q4 3.7% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.4% |
1.6%
5.8 pts worse
|
1.7%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 4.7% · Q3 10.3% · Q4 2.7% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.1% |
17.2%
2.1 pts better
|
19.8%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 14.0% · Q3 13.9% · Q4 16.3% · 4Q avg 15.1% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
5.8%
0.5 pts better
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 4.0% · Q3 4.9% · Q4 5.3% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.5% |
79.8%
0.3 pts worse
|
81.7%
2.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 80.0% · Q2 77.8% · Q3 78.4% · Q4 82.8% · 4Q avg 79.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 31.6% |
14.1%
17.5 pts worse
|
12.0%
19.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.6% · Observed 33.3% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.6%
1.6 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.1% |
78.0%
13.1 pts better
|
79.7%
11.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.2% |
24.7%
5.5 pts worse
|
23.9%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.2% · Observed 33.3% · Expected 26.3% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-08-07
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-15
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-06-10
Inspection history
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-08-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-16
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-04-20
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-05-01
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-05-01
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-05-01
Penalties and ownership
Fine · fine $8,512
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
W-2 Managing Employee · Individual
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