Carlyle Senior Care of Blackville

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure correct installation, use, and maintenance of bed rails for 3 of 3 residents (Residents (R)4, R56, and R72) reviewed for bed rails out of a total of 20 sampled residents. This failure had the potential for risk of resident entrapment and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure 5 of 5 Certified Nursing Assistants ((CNA)5, CNA7, CNA8, CNA9, and CNA10), were provided the required 12-hours of annual in-service training. 1. Review of the facility's employment file for CNA 5 revealed a date of hire of 03/17/23. The employment file for CNA5 contained evidence that CNA5 participated in the annual skills fair provided by the facility but lacked evidence of the 12 hours of in-service training annually.2. Review of the facility's employment filed for CNA7 revealed a date of hire of 03/29/23. The employment file for CNA7 contained evidence that CNA7 participated in the annual skills fair provided by the facility but lacked evidence of the 12 hours of required in-service training annually. 3. Review of the facility's employment filed for CNA8 revealed a date of hire of 09/13/10. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to ensure certified nurse aides (CNAs) notified a nurse of a resident's fall before the staff assisted the resident off the floor. Specifically, on 09/17/2025, CNA #6 and CNA #7 placed Resident #3 back in bed after the resident was found on the floor and did not inform Licensed Practical Nurse (LPN) #8 that the resident had fallen. This failure contributed to a lack of assessment for any injuries the resident might have sustained as the result of the fall. The resident was assessed on 09/18/2025 and had no injuries at the time of the incident on 09/17/2025 or post incident on 09/18/2025. This deficient practice affected 1 (Resident (R)#3) of 3 sampled residents reviewed for accidents.

Inspectors wroteBased on interview, record review, and facility policy the facility failed to ensure that Resident (R)1 had adequate supervision to prevent an elopement on 07/15/25 at approximately 7:30 PM. R1 was observed by a Laundry Aid staff member lying on the ground by a porch at the bottom of three steps, near an exit door at the rear of building. It was determined that R1 self-propelled herself in her wheelchair off the porch. R1 was observed with visible lacerations to the back of her head and her bilateral upper extremities. On July 24, 2025 at 12:16 PM the the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. [...]

Inspectors wroteBased on review of facility policy, observation, interview, and record review, the facility failed to ensure that soiled laundry was washed and appropriately sanitized to prevent the potential spread of infection. Specifically, the washing machine failed to maintain adequate hot water temperature. Furthermore, the facility failed to maintain a process to ensure that washing machines and chemical products were assessed appropriately in 2 of 2 washing machines. On 02/20/25 at 11:40 AM, the Administrator and the Director of Nursing were notified that the failure to ensure soiled laundry was washed and appropriately sanitized to prevent the potential spread of infection constituted Immediate Jeopardy (IJ) at 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. [...]

Inspectors wroteBased on review of facility policy, record review, observation and interviews, the facility failed to provide Residents and/or their Resident Representatives financial quarterly statements for 3 of 4 Residents (R)45, R51, and R52 reviewed for personal funds.

Inspectors wroteBased on review of facility policy, record review and interviews, the facility failed to notify Residents and Resident Representatives of account balances exceeding the Medicaid eligibility limit, which had the potential to disqualify the residents of Medicaid services for 3 of 4 Residents (R)44, R51, and R52 reviewed for personal funds.

Inspectors wroteBased on review of facility policy, record review, and interview, the facility failed to ensure adequate supervision of Resident (R)4 to prevent elopement from the facility on 02/24/24 at approximately 6:30 AM. On 04/05/24 at 4:11 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 04/05/24 at 4:11 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 02/24/24. The IJ was related to 42 CFR 483.25 - Quality of Care. On 04/05/24 the facility provided an acceptable IJ Removal Plan. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a Registered Nurse (RN) was scheduled for at least eight consecutive hours a day on five days during Quarters 3 and 4 of Fiscal Year (FY) 2022. This had the potential to affect all the residents residing in the facility.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure one (Resident (R)224) of twenty sampled residents was clinically appropriate to self-administer medication and did not self-administer his inhalant (nebulizer) medication. The facility's deficient practice increased R224's risk of adverse medication consequences.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure one (Resident (R)24) of three sampled residents reviewed for activities of daily living (ADLs) received assistance with nail care and oral care. The facility's deficient practice increased R24's risk of poor personal hygiene and plaque associated oral diseases.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the attending physician provided a clinical rationale for declining the pharmacist recommendation for one (Resident (R)48) of five sampled residents reviewed for unnecessary medications. This failure increased the risk that residents would continue to receive unnecessary medications that potentially could cause serious adverse effects.

Inspectors wroteBased on record review and interview, the facility failed to ensure that binding arbitration agreements contained explicit language informing residents that signing the binding arbitration was not a condition of admission to the facility and failed to ensure residents indicated by signature that they understood the binding arbitration agreement for 2 (Resident (R) 29 and R58) of 3 sampled residents reviewed for binding arbitration agreements.

Inspectors wroteBased on interview, record review, facility policy review, and Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure the pneumococcal vaccination was offered to four (Resident (R) 38, 50, 51, and 52) of five sampled residents reviewed for influenza/pneumococcal vaccinations.