Carlyle Senior Care Of Aiken

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect a cognitively impaired female resident, R3, who lacked capacity to consent, from sexual contact initiated by another resident, R2. R3’s records showed a diagnosis of unspecified dementia with behavioral disturbance and a need for substantial to maximal assistance with ADLs. R3 wandered throughout the facility and required a helmet when out of bed due to multiple falls. R2’s records showed diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and other sexual dysfunction not due to a substance or unknown physiological condition. His MDS indicated he was unable to complete the BIMS interview and required partial to moderate assistance with ADLs. R2’s medical record documented a history of periods of inappropriate behavior and inappropriate gestures toward staff during personal care. His care plan identified a history of pulling at his penis, inappropriate behavior, and inappropriate gestures, with an approach to monitor and record occurrences of hypersexuality toward staff, inappropriate responses to verbal communication, and violence or aggression toward staff or others. Despite this documented pattern, the facility did not prevent an incident in which R2 engaged in sexual contact with R3. On the night of the incident, a CNA walking down the hall observed R2 lying naked on his bed and R3 kneeling beside the bed, with R2’s hand over R3’s hand, placing it on his genital area. The CNAs’ and Unit Manager’s interviews consistently described R2 as unclothed from the waist down and R3 as fully clothed, with R2 using his hand to guide R3’s hand onto his penis and attempting to pull her into the bed. CNA2 initially saw the interaction, left to seek help, and returned with CNA3, who positioned herself between the residents to separate them. When the Unit Manager arrived, she observed R3 on the floor beside the bed and R2 on the bed, and while assessing R3 for injury, noted R3’s hand under R2’s cover with the cover moving. The Administrator confirmed that both residents were nonverbal and unable to have appropriate communication, that R3 wandered throughout the facility, and that R2 usually remained in his room. The State Agency determined that the facility’s noncompliance with 42 CFR §483.12, Freedom from Abuse, Neglect, and Exploitation, resulted in Immediate Jeopardy related to the failure to ensure R3 remained free from sexual abuse.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with severe cognitive impairment and a known risk for elopement was able to exit the facility unsupervised. The resident, who had diagnoses including vascular dementia with behavioral disturbance, psychotic disorder, and delusional disorder, was assessed as being at risk for elopement and wore a WanderGuard device daily. On the day of the incident, the resident was last seen by staff in the early morning, after which he was able to leave the building through a service hall door without staff noticing his absence immediately. The facility's policy required that residents at risk for elopement receive adequate supervision and that exit doors be equipped with alarms to prevent unauthorized exits. Despite these measures, the resident exited through a service door that was supposed to be alarmed. Staff initiated a search after realizing the resident was missing, conducting multiple checks inside the building before expanding the search outside. The resident was eventually found across the street on school grounds, having left the facility without injury. Interviews with staff confirmed that the resident's WanderGuard was functioning, but the door alarm did not sound due to damaged wiring. Further investigation revealed that the service hall door's alarm system had frayed wiring, which rendered the alarm ineffective and allowed the resident to exit undetected. The door in question was primarily used by dietary, maintenance, and laundry staff and was not a typical route for the resident. Facility leadership acknowledged that the damaged alarm wiring was likely caused by the high volume of equipment and personnel using the door. The failure to maintain the alarm system in working order and to provide adequate supervision for a high-risk resident led to the resident's successful elopement.

Removal Plan

• The wander guard for Resident DC was checked and found to be fully operational.
• A subsequent check of the wander guard revealed it was still functional.
• A comprehensive assessment of Resident DC was conducted, and it was documented that there were no injuries or any signs of distress.
• Resident DC was placed under 1-on-1 supervision for close observation and monitoring.
• A detailed inspection of the wander guard system at the facility's service hall exit uncovered that a wire had come loose, which directly impacted the alarm functionality of the door. This issue was promptly addressed, with the maintenance supervisor completing the necessary repairs.
• A backup alarm was installed on the interior door leading to the service area.
• A comprehensive check was performed on all other residents utilizing wander guards to verify their integrity and functionality, ensuring that no other residents were at risk of elopement.
• An accurate headcount of all residents was conducted to confirm that everyone was present and accounted for within the facility, ensuring the safety of all our residents.
• All exits were thoroughly inspected to verify that backup alarms were present and operational. This meticulous check confirmed the effective functioning of all backup alarms.
• An audit was carried out to identify residents who had undergone risk assessments related to potential elopement. This included a review of care plans to ascertain that interventions, such as the use of wander guards, were adequately addressed and implemented.
• Resident DC's care plan was updated to reflect the new risks associated with elopement incorporating specific interventions tailored to ensure his safety.
• The maintenance supervisor will perform inspections of the entire wander guard system and all backup alarms for every door to ensure they are functioning correctly.
• The wander guard alarm on 60 hall does not function, but the backup alarm functions and a stop sign has been placed over this door.
• All nursing staff across all shifts received training on resident safety protocols, specifically focused on checking alarms and monitoring wander guards. Any staff members on leave will receive this educational briefing upon their return to work.
• Agency staff will undergo training on these protocols before commencing their shifts.
• New hires will receive targeted training during their orientation regarding wander guard monitoring, alarm response procedures, and general resident safety.
• The Minimum Data Set (MDS) nurse will conduct audits of new admissions for elopement risk and ensure that appropriate safety interventions are put in place without delay.
• The maintenance supervisor will monitor alarm functionality daily for two consecutive months, moving to a weekly schedule thereafter. The results of this ongoing observation will be reviewed weekly by the facility administrator to ensure consistent compliance.
• Newly hired staff will receive dedicated training on topics related to wandering, elopement, and overall resident safety from the in-service coordinator during orientation.
• A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) has been implemented to systematically review and analyze all audit findings.
• The results of the alarm monitoring will be reviewed in the QA meetings monthly for three months, then quarterly, until it is determined that the deficient practice is not likely to recur.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure timely completion and submission of MDS assessments for one resident, R81, after record review, interview, document review, and review of the RAI manual. The October 2024 RAI Manual stated that entry MDS completion must be no later than 7 days from the event date, significant change MDSs must be completed no later than 14 days from the ARD and no later than 14 days from the determination date of the significant change, and comprehensive assessments must be transmitted electronically within 14 days of completion. R81’s admission record showed an admission date of 12/05/23 and diagnoses of respiratory insufficiency, muscle weakness, and difficulty in walking. Review of R81’s MDSs showed multiple late completions and submissions. The entry MDS with an ARD of 11/25/24 was completed on 12/04/24 and accepted on 12/05/24, the discharge return anticipated MDS with an ARD of 02/08/25 was completed and accepted on 03/05/25, the entry MDS with an ARD of 02/11/25 was completed and accepted on 03/05/25, and the significant change MDS with an ARD of 04/24/25 was completed and accepted on 05/08/25. During interview, the MDS Coordinator confirmed the MDSs were completed and submitted late and stated the facility did not have a specific policy for following the MDS, with nurses following the MDS manual for coding. The MDS validation report showed warning messages for the 11/25/24 and 04/24/25 MDSs stating submitted values did not match the IQIES database, and the MDS Coordinator confirmed the February 2025 MDSs were submitted more than 14 days after the ARD.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that urinary catheter care was performed for one resident who was reviewed for catheters and UTI. The resident was admitted with diagnoses including UTI and neuromuscular dysfunction of the bladder, and had a physician order for catheter care every shift. The facility policy titled, Catheter Care, stated that for a male, with a new moistened cloth, starting at the urinary meatus and moving down, the shaft of the penis should be cleansed. During observation of catheter care, a CNA removed the resident’s incontinence brief, retracted the foreskin, and wiped around the head of the penis three times with three different wipes, changing gloves between each wipe. The CNA then wiped the tubing, removed her gloves, and replaced the same incontinence brief. There was no evidence that the shaft of the penis was cleaned during the care. The CNA later confirmed she was trained to clean the shaft of the penis and stated that she did not clean it. The DON stated that the shaft of the penis does not need to be cleaned during catheter care and could not confirm the procedure stated in the facility’s policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a resident's nasal cannula was stored properly when not in use for one of two residents reviewed for oxygen therapy, Resident 65. The facility's Oxygen Safety policy dated 04/2025 stated it was the policy of the facility to provide a safe environment for residents, staff, and the public and addressed the use and storage of oxygen and oxygen equipment. Resident 65 was readmitted to the facility with diagnoses including quadriplegia, had a BIMS score of 15 out of 15 on the quarterly MDS dated 08/06/25, and was coded as receiving oxygen therapy. The physician order dated 02/27/25 ordered oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. During observation on 09/11/25 at 2:35 PM, Resident 65's oxygen nasal cannula was wrapped around the top of the resident's oxygen concentrator, and on 09/12/25 at 12:00 PM it was observed lying at the foot of the resident's bed uncovered. During interview, LPN3 verified the cannula was left out uncovered and stated it should be stored in a bag. Later, LPN4 observed the cannula lying on the floor uncovered and stated it should not be on the floor and should be stored in a bag. The DON also stated that a resident's nasal cannula should be stored in a bag when not in use.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that daily nurse staffing information was posted in a manner that residents and visitors could access and read it. Review of the facility policy titled Nurse Staffing Posting Information dated May 2025 showed that nurse staffing information was to be made readily available in a readable format to residents, staff, and visitors at any given time. On entrance to the facility, surveyors observed the current daily nurse staffing information posted on a glass bulletin board with multiple notices behind it inside the case, approximately six feet high. The posting included all three shifts for the day, but it was not readable or accessible for residents in a wheelchair or for those with vision problems. Similar observations were made on subsequent survey days, and during an interview the DON stated she was responsible for posting the daily nurse staffing information and was not aware it had to be posted in an accessible area for residents and visitors.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to honor a resident’s right to be free from unnecessary physical restraint when a CNA used a bear hug hold on a resident after an altercation with another resident. The resident had diagnoses including dementia and anxiety disorder, and the care plan identified him as at risk for potentially physically and verbally aggressive behavior related to dementia and agitation, with interventions to approach him in a non-threatening manner and from the front in a calm manner. According to staff interviews, the resident struck another resident in the head with a plate cover, and the CNA then came from behind, wrapped both arms around him, and held him to prevent movement before guiding him to a wing chair, where he remained until police and EMS arrived. The CNA stated she had not received training on that type of technique and that it was not an approved restraint. The DON stated the bear hug was not appropriate, could be considered a restraint, and that staff had not been trained to use such holds.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an allegation of abuse involving a resident within the required 2-hour timeframe. The facility's policy mandates immediate investigation and reporting of abuse allegations to the Administrator, state agency, adult protective services, and other required agencies within 2 hours if the events involve abuse or result in serious bodily injury. However, Nurse 1 did not report the allegation made by the resident, who stated that a man came into her room and touched her breast. Nurse 1 admitted to not taking the allegation seriously at the time and failed to notify the abuse coordinator. The incident was only discovered when the resident spoke with Social Services during an interview about abuse, who then reported it immediately. The resident involved had a history of major depressive disorder, hyperlipidemia, hypertension, and cerebral infarction, and was moderately cognitively impaired with a BIMS score of 9 out of 15. The Director of Nursing confirmed that the allegation was not reported by Nurse 1 and reiterated the policy that any type of abuse must be reported within 2 hours. The failure to report the abuse allegation promptly led to a deficiency in the facility's compliance with its abuse reporting policy.