Carter Nursing and Rehabilitation

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from verbal abuse and neglect which resulted in actual harm for 1 out of 10 sampled residents, Resident (R) 29. On 08/24/2025, Resident 29 had an incontinent episode and required the assistance of staff to help change her. However, instead of changing the resident, State Registered Nurse Aide (SRNA) 1 became verbally abusive to the resident and both, SRNA1 and SRNA11, neglected to provide the resident hygiene care to remove the feces from the resident. Instead, SRNA 1 and SRNA 11 covered the resident with a feces-covered blanket for a period of over three hours. The resident reported she was scared of SRNA1, and SRNA10 stated this upset the resident, which caused the resident psychosocial harm.

Inspectors wroteBased on interview, record review, and review of the facility's policy, State Registered Nurse Aide (SRNA) 10 failed to immediately report an allegation of staff abuse/neglect for 1 of 10 sampled residents, Resident (R) 29. SRNA10 did not notify the Administrator when R29 reported to her that SRNA1 and SRNA11 failed to provide timely hygiene care and left R29 soiled for hours after an episode of fecal incontinence on 08/24/2025. Resident 29 stated the SRNAs actions were neglectful of her care which made her scared of SRNA1, and SRNA10 reported the resident was visibly upset, causing the resident psychosocial harm.

Inspectors wroteBased on observation, interview, review of the U.S. Food and Drug Administration 2022 Food Code, and facility policy review, the facility failed to follow safe food handling practices, ensure food items located in dry storage were properly labeled and dated, and ensure expired food items were discarded. This had the potential to affect all 112 current residents that received food from the kitchen.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to assure that all services, as outlined by the comprehensive care plan being provided, met professional standards of quality for 1 of 6 residents reviewed for medication administration, Resident (R) 42. Review of R42's Medication Administration Record (MAR) and interviews from staff revealed the resident was administered a Zofran tablet (used to treat nausea) on 08/29/2025 at 3:54 PM by Kentucky Medication Aide (KMA) 14 without a standing order or provider's order for Zofran.

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) document, and facility policy review, the facility failed to ensure a resident who had an indwelling catheter received appropriate treatment and services to prevent urinary tract infections for 1 of 2 sampled residents, Resident (R) 12.

Inspectors wroteBased on observation, record review, review of the facility's documents, and review of the facility's policy, it was determined the facility failed to ensure the residents' environment remained free of accident hazards related to water temperatures outside the acceptable range for thirty-two (32) of one hundred ten (110) residents (Resident #94, #64, #98, #25, #16, #46, #90, #69, #108, #77, #60, #107, #95, #85, #414, #53, #99, #68, #34, #36, #54, #15, #73, #71, #100, #26, #21, #70, #31, #91, #9, and #164). Observation of water temperature checks on 07/10/2023 beginning at 4:43 PM, revealed water temperatures in Rooms 14, 15, 16, 19, 20, 23, 29, 48, 49, and 50 were not within the acceptable parameters for ensuring resident safety. The water temperatures ranged between one hundred twelve (112) degrees Fahrenheit (F) and one hundred twenty (120) degrees F. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents' medications were administered at an error rate below five percent (5%). Observation of the medication administration revealed a medication error rate of eleven percent (11%). Medications were not available for four (4) of thirty-six (36) opportunities for two (2) of ten (10) residents sampled for medication administration (Residents #69 and #94).

Inspectors wroteBased on observation, interview, review of the facility's refrigerator temperature logs, review of the manufacturer's instructions for [NAME] Ready Care Nutrition, and review of the facility's policy, it was determined the facility failed to store food safely for two (2) of two (2) nourishment refrigerators. Observations, on 07/11/2023, of the South Unit nourishment refrigerator revealed residents' food products with no name and no room number. The 06/2023 and 07/2023 temperature logs had elevated temperatures recorded. The temperature logs for 03/2023, 04/2023, and 05/2023 were incomplete. Observation of the North Unit nourishment refrigerator revealed the documentation of the 07/2023 temperature log had a range of recorded temperatures of forty-six (46) to fifty-three (53) degrees Fahrenheit (F). [...]

Inspectors wroteBased on interview, record review, review of the facility's investigation report, and review of the facility's policies, it was determined the facility failed to keep the resident free from misappropriation of resident property, for one (1) of fifty (50) sampled residents (Resident #415). On 12/04/2020, Resident #415 reported to the Infection Preventionist/ Staff Development Coordinator (IPSD) that a female (later identified as State Registered Nurse Assistant (SRNA) #31) removed a diamond ring from his/her finger and replaced it with a cheap ring on 12/03/2020. Additionally, review of the facility's investigation report, dated 12/04/2020, revealed SRNA #31 later came to the facility and returned the ring to the Executive Director (ED). The facility terminated SRNA #31 immediately. [...]

Inspectors wroteBased on interview, record review, review of 906 [NAME] (Kentucky Administrative Regulations) 1:190, Section 1(4), a disqualifying offense, and review of 21 CFR (Code of Federal Regulations) 1308.11, it was determined the facility failed to screen a new employee for disqualifying offenses in the background check for (1) of eleven (11) personnel files reviewed (the Maintenance Director).

Inspectors wroteBased on interview, record review, review of the facility's investigative reports, and review of the Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to develop and implement effective care plan interventions for four (4) of fifty (50) sampled residents (Residents #364, #264, #89, and #99). Residents #364, #264, #89, and #99 were involved in resident-to-resident altercations and did not have their care plans fully developed or implemented to prevent abuse.

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to update the care plan for one (1) of fifty (50) sampled residents (Resident #5). The facility failed to update Resident #5's care plan following the resident's readmission, with an ostomy on 06/01/2022. The facility did not update the care plan to include interventions to care for the ostomy until 05/12/2023.

Inspectors wroteBased on observations, interviews, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure the proper temperature ranges for one (1) of two (2) medication refrigerators. The facility failed to store medications in the North Hall medication refrigerator at a proper temperature. Observation of the refrigerator thermometer on 07/14/2023, revealed a temperature of fifty (50) degrees Fahrenheit (F). Also, review of the temperature logs revealed no temperatures were recorded for 07/03/2023, 07/10/2023, and 07/11/2023.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to accommodate a resident's food allergy for one (1) of fifty (50) sampled residents (Resident #65). Resident #65, whose Medication Administration Record (MAR) documented the resident was allergic to chocolate, received a chocolate fudge cookie with crushed medications during medication administration on 05/12/2023.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an infection prevention program. Observation on 07/13/2023 and 07/15/2023 revealed State Registered Nurse Aides (SRNA) #11, #25, and #26 failed to wear all the required Personal Protective Equipment (PPE) in a room with a posted Enhanced Barrier Precautions (EBP) sign. The SRNAs were providing ostomy care and changing soiled linens for one (1) of nineteen (19) residents who was on EBP (Resident #5).

Inspectors wroteBased on observation and interview, it was determined the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, for one (1) of twenty-four (24) sampled residents, Resident #70. Observation of Resident #70's room on 11/04/19, revealed a cup of medications prescribed for Resident #70, sitting on the bedside table. In addition, there was no documented evidence the resident was assessed as able to self-administer medications.