Carver Living Center

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to provide a dignified dining experience by ensuring all residents seated at the same table were served their meals at the same time for 1 of 2 sampled residents (Resident #141).

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to accommodate food preferences for 1 of 10 residents reviewed for food preferences (Resident #109).

Inspectors wroteBased on observations, record review and interviews with staff and the Medical Director, the facility failed to implement their infection control policies and procedures when Nurse #14 administered medications to Resident #112 through a gastrostomy tube (tube that enters through the abdominal wall into the stomach) and did not wear a gown and gloves and when Nurse #14 failed to wear gloves when handling Resident #75's glucometer after a finger stick with a blood sample on the test strip. The deficient practice occurred for 1 of 4 staff observed for infection control practices (Nurse #14).

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to post an updated daily nurse staffing sheet for residents and visitors on 1 of 4 days during the survey period (5/11/26).

Inspectors wroteBased on record reviews, observations, and interviews with staff and the Medical Director, the facility staff failed to utilize a resident's assigned blood glucose meter (glucometer) and instead used a loose, unassigned, and unlabeled glucometer located in the medication cart to check Resident #8's blood glucose (sugar) level. In addition, the staff member did not disinfect the glucometer before or after obtaining Resident #8's blood glucose level and would have had no way to know if another staff member had previously disinfected the loose, unassigned, and unlabeled glucometer. This occurred while there were 11 residents identified with a known bloodborne pathogen in the facility with 4 of the 11 residents requiring blood glucose levels. Loose, unlabeled glucometers can be contaminated with blood and must be disinfected after each use with an approved product and procedure. [...]

Inspectors wroteBased on record review, and staff and Responsible Party (RP) interviews, the facility failed to notify the Responsible Party (RP) of Resident #1's change in condition after a new diagnosis of peripheral vascular disease (PVD) with the lack of pedal pulses in both feet and failed to notify the Medical Director, who was the resident's attending physician, of a new diagnosis of PVD, and failed to notify the Medical Director of the identification of a new wound and transfer to the hospital for 1 of 8 residents (Resident #1).

Inspectors wroteBased on observation and staff interviews, the facility failed to protect residents' healthcare information by leaving confidential medication information unattended, visible, and accessible to others on the computer screen for 2 of 5 (upper and lower medication carts on the 100-hall) medication carts observed.

Inspectors wroteBased on record review, staff, and resident interviews, the facility failed to implement their grievance policy and procedures when Resident #2 reported his catheters and wheelchair charger were missing for 1 of 3 residents reviewed for grievances (Resident #2).

Inspectors wroteBased on record review, and staff and Medical Director interviews, the facility failed to ensure that during provider visits the provider reviewed the total plan of care for 1 of 8 residents (Resident #1) newly diagnosed peripheral vascular disease (PVD). Resident #1 was examined by the Medical Director and the Medical Director failed to recognize Resident #1 did not have active pedal pulses in both feet. An interview with the Medical Director revealed that there was no examination of the feet during her visit on 3/25/2025. Resident #1 needed an assessment of his feet based on the new diagnosis of PVD to recognize the need for further treatment, review the plan of care, and consultations. This deficient practice occurred for 1 of 3 residents reviewed for Physician visits (Resident #1).

Inspectors wroteBased on observation and staff interviews, the facility failed to secure residents' medications in a locked medication cart for 2 of 5 (upper and lower carts on hall 100) medication carts reviewed.

Inspectors wroteBased on record reviews, and interviews with staff, Physician Assistant, and responsible party (RP), the facility failed to protect 2 cognitively impaired residents' right to be free from sexual abuse. On 4/4/25 at approximately10:00 PM, a Medication Aide observed a female resident (Resident #1) in a male resident's (Resident #2) room sitting upright on Resident #2's bed. Resident #2 was standing in front of Resident #1 with his pants down and his penis inside of her mouth. When the Medication Aide asked what was going on, Resident #2 backed away from Resident #1 removing his penis from her (Resident #1) mouth. The residents did not have the capacity to consent to sexual relations. Resident #1's RP stated due to Resident #1's advanced dementia she was not aware of her behaviors and had no insight into what happened. [...]

Inspectors wroteBased on record reviews, observations, and interviews with staff and Medical Director, the facility failed to provide an agency nurse (Nurse #1) with orientation and training to meet residents' care needs, including education and verification of the nurse's competency on glucometer (blood glucose meter) disinfection. Nurse #1 used a shared glucometer without disinfecting the meter between residents for 1 of 3 residents (Resident #107) who was observed to have her blood glucose checked. This occurred while there were 18 residents identified with a known bloodborne pathogen in the facility. [...]

Inspectors wroteBased on record reviews, observations, and interviews with staff and Medical Director, the facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents for 1 of 3 residents (Resident #107) observed to have her blood glucose (sugar) level checked. This occurred while there were 18 residents identified with a known bloodborne pathogen in the facility. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-registered disinfectant in accordance with the manufacturer of the glucometer potentially exposes residents to the spread of bloodborne infections. Care must also be taken by personnel handling and storing glucometers to protect the glucometers against cross-contamination via contact with other meters or equipment. [...]

Inspectors wroteBased on record review, and resident, staff and Nurse Practitioner interviews, the facility failed to protect the rights of residents from resident to resident abuse for 4 of 5 residents reviewed for abuse. (1) On 8/2/2024, two residents, Resident #52 and Resident #104, who had a previous history of a resident-to-resident altercation on 6/9/2024, were involved in a resident to resident altercation in the smoking area. Nursing staff responded to a loud noise from the smoking area and observed Resident #52, who had a history of aggressive behavior, lying on the concrete floor of the smoking area. Resident #104 was observed sitting in his wheelchair. Resident #52 and Resident #104 were observed swinging their arms and hitting each other. The nursing staff immediately separated Resident #52 and #104. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to: 1) Discard expired medications on 2 of 5 medication (med) carts observed (Front 200 Hall Med Cart and Back 200 Hall Med Cart) and in 1 of 2 medication storerooms (400 Hall Medication Storeroom); and 2) Date medications as to when they were opened to allow for the determination of its shortened expiration date for meds stored on 2 of 5 med carts (Front 200 Hall Med Cart and Front 400 Hall Med Cart) and in 1 of 2 medication storerooms (400 Hall Medication Storeroom).

Inspectors wroteBased on record review, staff interviews and Resident Council Interview, the facility failed to resolve grievances that were reported during Resident Council meetings for 3 of 3 consecutive months (November 2024, December 2024 and January 2025).

Inspectors wroteBased on record review and staff interviews, the facility failed to develop a baseline care plan within 48 hours of admission for 1 of 9 residents reviewed for new admission (Resident #382).

Inspectors wroteBased on observation, staff interviews and record review, the facility staff failed to provide care according to professional standards by borrowing medication from one resident (Resident #14) to give to another (Resident #8) for 1 of 5 residents observed during the medication administration observation.

Inspectors wroteBased on observations, resident interviews, staff interviews and record review, the facility failed to apply a left hand splint for 1 of 1 resident (Resident #47) reviewed for contractures.

Inspectors wroteBased on observation, record review, resident and staff interviews, the facility failed to supervise smoking for a resident who required supervision when smoking and failed to secure smoking materials (cigarettes) for 1 of 4 residents (Resident #65) reviewed for safe smoking.

Inspectors wroteBased on record review, observation and staff interviews, the facility failed to label the bag of ready to hang prefilled enteral formula (a liquid nutritional product that is delivered into the gastrointestinal tract) that was infusing through a gastrotomy tube with the date, time and initials of the nurse that started the new bag of enteral formula for 1 of 3 residents reviewed for gastrostomy enteral feedings (Resident #482).

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 25 opportunities, resulting in a medication error rate of 8% for 2 of 5 residents (Residents #85 and #8) observed during the medication administration observation.

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to maintain accurate medical records in the areas of medication allergies (Resident #185), failed to document the administration of pain medication (Resident #70), and document discharge to community Against Medical Advice (AMA) (Resident #187) for 3 of 8 residents' records reviewed.

Inspectors wroteBased on staff interviews and record review, the facility failed to develop a comprehensive care plan that accurately reflected the services provided to a resident when it incorrectly indicated Resident #10 was receiving Hospice services. This occurred for 1 of 2 residents (Resident #10) reviewed for hydration.

Inspectors wroteBased on staff, Registered Dietitian (RD), and Nurse Practitioner (NP) interviews and facility and hospital record reviews, the facility failed to obtain and monitor a resident's monthly weight in February 2024 to identify when a resident's weight loss began and allow for the early assessment and initiation of nutritional interventions. This occurred for 1 of 2 residents (Resident #6) reviewed with a significant weight loss.

Inspectors wroteBased on staff and Registered Dietitian (RD) interviews and record reviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment to indicate a resident's weight was not obtained during the previous 30-day period for 1 of 2 residents (Resident #6) reviewed who experienced a significant weight loss.

Inspectors wroteBased on record review, staff and Nurse Practitioner (NP) interviews, the facility failed to provide a physician's order for the use of a BIPAP (bilevel positive airway pressure) machine treatment for 1 of 1 resident (Resident #11) reviewed for respiratory services.

Inspectors wroteBased on interviews with residents, staff, and the consultant Registered Dietitian (RD) interview, and record review, the facility failed to provide a nourishing snack for all residents and receive an agreement with the resident group for a greater than 14-hour lapse between the evening meal and breakfast meal the following day for residents residing on 6 of 6 resident hallways and 2 of 2 resident dinning rooms.

Inspectors wroteBased on observations, resident and staff interviews, and record reviews, the facility failed to allow residents assessed to be safe to smoke the ability to smoke independently at times according to their preferences for 2 of 2 sampled residents (Resident #14 and #26). This practice had the potential to affect other safe smokers in the facility.

Inspectors wroteBased on observations, resident, staff interviews and record review, the facility failed to apply right hand splint for 1 of 3 residents review for range of motion (Resident #28).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to secure the urinary catheter tubing per the physician order on 2 of 4 residents observed for urinary catheters (Resident #64 and #144); failed to keep a urinary catheter bag and/or the catheter tubing from touching the floor to reduce the risk of infection or injury for 1 of 4 residents (Resident #168) reviewed with urinary catheters.

Inspectors wroteBased on observations, interviews with staff, and record reviews, the facility failed to: 1) Label medications with the minimum information required, including the name of the resident, on 3 of 4 medication (med) carts (Front 100 Hall Med Cart; 400 Hall Med Cart for Rooms 402 - 420; Middle 100 Hall Med Cart); 2) Accurately label medications to determine their shortened expiration date in accordance with the manufacturer's instructions on 3 of 4 med carts (Front 100 Hall Med Cart; 400 Hall Med Cart for Rooms 404 - 420; Back 100 Hall Med Cart) and 1 of 2 medication store rooms (300 Hall Med Room); and, 3) Discard expired medications on 3 of 4 medication carts observed (Front 100 Hall Med Cart; Middle 100 Hall Med Cart; Back 100 Hall Cart).

Inspectors wroteBased on observations and staff interviews, the facility failed to: 1) ensure dietary staff had all facial hair contained in a face covering and 2) to label, date, and/or remove expired food items stored in 3 of 3 nourishment rooms (200 Hall Nourishment Room/Memory Care, 300 Hall Nourishment Room, and 400 Hall Nourishment Room).

Inspectors wroteBased on observations, resident and staff interviews and record review, the facility's quality assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the recertification dated 9/29/22 and complaint surveys dated 12/14/21, 3/2/23, and 9/28/23 to achieve and sustain compliance. This was for recited deficiencies on a recertification survey on 12/1/23. The deficiencies were in the areas of resident rights, range of motion use of splint, securing resident medication, and use of personal protective equipment (PPE) for infection control. The continued failure during the federal surveys of record showed a pattern of the facility's inability to sustain an effective quality assurance program.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to determine whether the self-administration of medications was clinically appropriate for 2 of 2 sampled residents (Resident #179 and Resident #377) who were observed to have a medication at bedside.

Inspectors wroteBased on observations, staff interviews and record reviews, the facility failed to notify the provider in accordance with the physician's order of elevated blood glucose (sugar) levels for 1 of 1 sampled resident (Resident #115) observed to have her blood glucose level checked.

Inspectors wroteBased on observations, staff interviews and record reviews, the facility failed to administer mealtime insulin as scheduled by a physician's order. The mealtime insulin was administered more than 3 hours after its scheduled time and within less than two hours of a second dose of mealtime insulin scheduled to cover the next meal. This occurred for 1 of 1 sampled resident (Resident #115) observed to have her blood glucose level checked.

Inspectors wroteBased on observations, staff interviews, and record review, the facility staff failed to disinfect a blood glucose meter (glucometer) stored on the med cart and used for an individual resident in a manner that would protect against the cross-contamination from contact with other equipment and surfaces. This was observed for 1 of 1 sample resident (Residents #115) observed to have two consecutive blood glucose (sugar) checks completed.

Inspectors wroteBased on observation, record review and staff interview and Nurse Practitioner (NP) interviews, the facility failed to allow 1 of 4 residents the choice to take a shower (Resident #1). Resident #1 was very sad and stated she felt less than a person not being able to get a shower.

Inspectors wroteBased on record review and resident, staff, and Nurse Practitioner interviews, the facility failed to protect 1 of 3 residents (Resident #3) right to be free from physical abuse when Resident #4 assaulted Resident #3 which resulted in chest pain, left thumb pain, swelling and an x-ray being ordered to the chest and thumb. Resident #3 was administered Acetaminophen as needed (PRN) for pain. This assault made Resident #3 feel scared.

Inspectors wroteBased on record review, resident interview and staff interview the facility failed to follow the abuse policies in the area of protection after an allegation of abuse for 1 of 3 resident (Resident #3), by not implementing Q 15-minute checks on Resident #4 following a resident-to-resident abuse.

Inspectors wroteBased on observations, record review, resident, Nurse practitioner (NP)and staff interview, the facility's quality assurance (QA) program failed to implement, monitor, and revise as needed the action plan developed for the recertification surveys dated 8/12/2021 and 9/29/2022 and complaint surveys dated 3/2/2023 and 5/4/2023 in order to achieve and sustain compliance. These were repeat deficiencies cited during a complaint survey on 9/28/2023. The repeat deficiencies were in the areas of Minimum Data Set (MDS) Accuracy of (F641) and Resident-to-resident abuse (F600). The continued inadequate root cause analysis and lack of sustained compliance during five federal surveys of record shows pattern of the facility's inability to sustain an effective QA program.

Inspectors wroteBased on observations, staff interviews, resident interviews and record review, the facility failed to ensure the resolution of grievances for 1 of 4 residents who preferred to have showers instead of a bed bath (Resident #1).

Inspectors wroteBased on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) in the area of Preadmission Screening and Resident Review (PASRR) for 1 of 3 sampled residents reviewed for accurate assessments (Resident #3).