Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carver Living Center during CMS and state inspections, most recent first.
Dignified Dining Service: A resident who was cognitively intact and needed only set-up/clean-up assistance was seated with another resident when the dining attendant served the tablemate first and then served other residents before returning with the resident's tray. The resident watched others eat while waiting and said he was upset that he was the last one served; the attendant said an alternate meal had to be obtained from another dining room, and the DR supervisor, DON, and Administrator stated residents at the same table should be served at the same time.
A nurse used a loose, unlabeled glucometer from the medication cart to check a resident's blood glucose, failing to use the resident's assigned device and neglecting to disinfect the glucometer before or after use. This occurred while several residents with bloodborne pathogens required glucose monitoring, and despite facility policy requiring device disinfection and individual assignment. The incident was observed, and staff interviews confirmed lapses in following infection control protocols and maintaining visual reminders.
A resident with severe cognitive impairment and multiple comorbidities was diagnosed with PVD and absent pedal pulses by a podiatrist, but neither the RP nor the Medical Director was notified of this significant change in condition. The resident later developed a wound and was hospitalized for severe sepsis, with the RP only informed of the hospital transfer and not the underlying diagnosis. Facility staff interviews confirmed a lack of awareness and communication regarding the new diagnosis and change in condition.
Confidential resident health information was left visible and unattended on computer screens attached to two medication carts in a hallway. The screens displayed sensitive details such as names, diagnoses, medications, dates of birth, and room numbers, and were left exposed for several minutes while multiple staff members walked by. Both nurses responsible admitted they failed to use privacy screens as required, and facility leadership could not confirm what education or oversight was in place to prevent such incidents.
A resident with heart failure and paraplegia reported missing self-Cath catheters and an electric wheelchair charger, but staff failed to follow the facility's grievance policy. Despite the resident notifying the DON and Administrator, no grievance form was completed and the issue remained unresolved for about two weeks, with staff not ensuring timely investigation or communication as required by policy.
A resident with multiple chronic conditions was diagnosed with peripheral vascular disease (PVD) by a podiatrist, but the active diagnosis was not coded on the quarterly MDS assessment. Staff interviews revealed that although consultation notes were uploaded to the electronic health record, MDS nurses were unaware of the new diagnosis and did not include it in the assessment.
A resident with multiple comorbidities and a new diagnosis of PVD did not receive a comprehensive assessment from the Medical Director, who was unaware of a podiatrist's findings of absent pedal pulses and did not review or address the updated care plan. Nursing staff could not confirm that the Medical Director was notified of the new diagnosis or podiatry consult, resulting in a lack of follow-up and care plan review.
Two medication carts on separate hallways were found unlocked and unattended, with one cart having a resident's insulin pen left on top and the other also left open. The nurses responsible admitted to not securing the carts, and multiple staff members walked past without addressing the issue. Facility leadership interviews revealed uncertainty about staff education and oversight regarding medication security.
Two cognitively impaired residents, one with advanced dementia and another with a history of inappropriate sexual behaviors, were found unsupervised in a room where sexual activity occurred. Both lacked the capacity to consent, and the male resident had prior behavioral interventions in place. Staff discovered the incident, separated the residents, and found no injuries, but the event revealed a failure to provide adequate supervision and protection.
The facility failed to provide adequate training to agency nurses, resulting in improper disinfection of glucometers between residents. An agency nurse used a shared glucometer without disinfecting it, posing a risk of cross-contamination among residents, including those with known bloodborne pathogens. Another agency nurse demonstrated a lack of competency in disinfection procedures, highlighting the facility's oversight in assuming agency nurses were already trained in these competencies.
A facility failed to disinfect shared glucometers between residents, leading to a deficiency. An agency nurse used a glucometer dedicated to one resident for another without disinfection, and another nurse did not ensure the required wet contact time for disinfection. The facility lacked a specific policy for glucometer disinfection, relying on manufacturer's instructions. The DON confirmed the need for a three-minute wet contact time, which was not followed. The Infection Preventionist and Medical Director acknowledged the issue, noting inadequate training for agency nurses.
The facility failed to prevent resident-to-resident abuse, with multiple altercations occurring in the smoking area. Residents with known aggressive behaviors were involved in physical confrontations, resulting in minor injuries. The facility's inadequate supervision and environmental factors, such as overcrowding, contributed to these incidents.
The facility failed to manage medications properly, resulting in expired medications and unlabeled opened medications on several medication carts and in a storeroom. Observations revealed expired hyoscyamine, docusate, rosuvastatin, lorazepam, and Vitamin B-12, as well as unlabeled latanoprost eye drops and a Lantus insulin pen. Nurses confirmed these deficiencies, and the DON acknowledged the need for corrective actions.
A nurse in an LTC facility borrowed a 5 mg apixaban tablet from one resident to administer to another, violating professional standards. The nurse, an agency staff member, felt responsible for ensuring all medications were given, despite the facility having an emergency medication box with the required medication. The DON confirmed this practice was inconsistent with professional standards.
A resident with multiple health conditions, including chronic respiratory failure, was left unsupervised while smoking, despite being assessed as needing supervision. The resident was found with smoking materials in her possession, contrary to facility policy. Staff miscommunication and misunderstanding of the resident's supervision needs contributed to the deficiency.
The facility exceeded the acceptable medication error rate, reaching 8% due to two errors. One resident received a combination medication not ordered by the physician, while another received a higher dosage of calcium and Vitamin D than prescribed. Nursing staff acknowledged the errors, and the DON emphasized the importance of verifying correct medication and dosage.
The facility failed to maintain accurate medical records for three residents, including missing allergy information, late documentation of pain medication administration, and lack of documentation for a discharge against medical advice. These deficiencies were confirmed through interviews and record reviews, highlighting lapses in maintaining complete and accurate resident information.
The facility did not resolve grievances reported during Resident Council meetings over three months, including issues with late medication administration, unresponsive night shift staff, and inadequate nurse and nurse aide care. Residents confirmed ongoing concerns, and the Activities Director was unsure if grievances were documented. The Administrator was unaware of unresolved grievances as none were found.
A facility failed to develop a comprehensive baseline care plan within 48 hours for a newly admitted resident with influenza, unsteadiness, and muscle weakness. The initial care plan only included medication allergies and code status. Interviews with the MDS Coordinator and DON confirmed that the admitting nurse should have completed the care plan with the admission assessment, but this was not done.
A resident with a left-hand contracture was not wearing a prescribed splint, as observed over several days. The facility staff failed to apply the splint as per physician orders and did not document its application, refusal, or removal. Interviews revealed a lack of awareness and responsibility among staff regarding the splint's application, with the Rehabilitation Director and DON confirming the nursing staff's responsibility for this task.
A facility failed to label enteral formula bags with the date, time, and nurse's initials for a resident receiving gastrostomy feedings. The resident, with a history of stroke and aphasia, required continuous enteral feeding. Observations showed unlabeled bags, and staff interviews confirmed the oversight, with the DON acknowledging the need for proper labeling.
A facility failed to accurately develop a care plan for a resident, incorrectly indicating hospice services were being provided. Despite the resident's medical history of respiratory failure, congestive heart failure, and diabetes, the care plan inaccurately noted hospice care, which was not supported by the MDS assessment or electronic medical records. MDS Coordinators and the Administrator acknowledged the discrepancy, highlighting a failure in the care planning process.
The facility failed to obtain and monitor a resident's monthly weight in February 2024, resulting in a significant weight loss of 14.9% over 80 days. Despite the resident's poor oral intake and increased nutritional needs, there were no documented nutritional assessments or interventions by the RD or CDM since September 2023. The facility's flawed process for obtaining and documenting weights contributed to the lack of timely nutritional interventions.
The facility failed to accurately complete an MDS assessment for a resident who experienced significant weight loss. The resident's weight was not obtained for over 70 days, leading to the use of outdated weight data in the MDS assessment. Interviews with staff confirmed the error and the requirement to use the most recent weight within the last 30 days.
A facility failed to provide a physician's order for BiPAP treatment for a resident with COPD, sleep apnea, and congestive heart failure. Despite the presence of a BiPAP machine in the resident's room and the recommendation from the hospital discharge summary, the necessary order was not transcribed into the medical records or MAR.
Dignified Dining Service
Penalty
Summary
The facility failed to provide a dignified dining experience by not ensuring that all residents seated at the same table were served their meals at the same time for Resident #141. Resident #141 was admitted with diagnoses including Alzheimer's disease, peripheral vascular disease, chronic kidney disease, and blindness in the right eye. The quarterly MDS indicated he was cognitively intact, required set-up or clean-up assistance with eating, and ambulated independently with a walker. His care plan showed he needed set-up or clean-up assistance with meals and received a no added salt therapeutic diet for hypertension, and the meal consumption report showed he consumed 75-100% of meals. During continuous observation of the dining room, Resident #141 was seated at a table with one other resident. The Dining Room Attendant served the tablemate first and then served other residents in the dining room before returning with Resident #141's tray. Resident #141 watched others receive and eat their meals while waiting, and his tray was delivered after the tablemate had finished eating. In interview, Resident #141 stated he was mad that he was the last one served and had to watch everyone else eat and his tablemate finish lunch before he received his meal. The Dining Room Attendant stated they normally served each table at the same time but had run out of the alternate meal and had to obtain one from another dining room for Resident #141. The Dining Room Supervisor, DON, and Administrator all stated that residents at the same table should have been served at the same time.
Failure to Use and Disinfect Resident-Assigned Glucometer
Penalty
Summary
Facility staff failed to utilize a resident's assigned, labeled blood glucose meter (glucometer) and instead used a loose, unassigned, and unlabeled glucometer from the medication cart to check a resident's blood glucose level. The staff member did not disinfect the glucometer before or after use and had no way to verify if it had previously been disinfected. This occurred despite the facility having a policy that required cleaning and disinfecting glucometers between resident use, following manufacturer instructions and infection control standards. At the time of the incident, there were 11 residents in the facility with known bloodborne pathogens, and 4 of these residents required blood glucose monitoring. The observation revealed that the nurse used the loose, unlabeled glucometer on a resident, even though the resident had a designated, labeled glucometer stored in the medication cart. The nurse admitted to not knowing why she did not use the assigned glucometer and confirmed she did not disinfect the device before or after use. The nurse also stated she was unsure if the glucometer had been disinfected previously and placed it back in the cart without cleaning it. Further interviews and observations indicated that the presence of a loose, unlabeled glucometer in the medication cart was not an isolated incident, as another nurse confirmed the existence of such a device, which was reportedly for emergencies but had no clear disinfection protocol. The facility's infection preventionist and DON acknowledged previous issues with glucometer disinfection and had implemented measures such as audits, education, and visual cues, but these were not consistently maintained. The incident was observed and confirmed by multiple staff, and the facility's leadership was unaware that visual cue cards were missing and that a loose glucometer was still present on the cart.
Removal Plan
- Reviewed and updated the facility's Glucometer Procedure: Use, Cleaning, and Infection Control policy to reflect corrective actions and emphasize use of individually assigned, labeled glucometers.
- All licensed nursing personnel acknowledged receipt and understanding of the updated glucometer policy.
- Conducted a comprehensive, system-wide audit to ensure every resident requiring blood glucose monitoring had an individually assigned, correctly labeled glucometer stored in a designated container.
- Removed and discarded all unauthorized/unlabeled glucometers from circulation.
- Implemented a strict protocol for the introduction of new or replacement glucometers, requiring all new glucometers to be delivered to and distributed from the DON's office, labeled for a specific resident before use.
- Prohibited storage of unassigned or unlabeled stock glucometers on medication carts or in general nursing units outside of DON office control.
- Established a process for after-hours or weekend glucometer assignment, requiring nursing leadership to obtain and assign glucometers from the DON's office.
- Updated protocol for removal and discarding of unused glucometers for discharged residents during routine audits.
- In-serviced the Central Supply Clerk and nursing leadership on the new glucometer control protocol.
- Reviewed and confirmed placement of laminated visual reminders outlining glucometer use and disinfection steps on all medication carts and in medication rooms.
- Updated equipment management protocol to require DON or nursing leadership to verify and reinstall all necessary signage and visual aids after any medication cart modification, replacement, or repair.
- Conducted immediate in-service training for all licensed nursing staff (including agency nurses) on the updated Glucometer Procedure: Use, Cleaning, and Infection Control policy.
- Emphasized in training the use of individually assigned glucometers, proper storage, and strict prohibition of using unlabeled or shared glucometers.
- Reinforced hand hygiene procedures and correct use of supplies during blood glucose monitoring.
- Detailed and trained staff on the two-wipe method for cleaning and disinfecting glucometers, including required contact time and air drying.
- Educated staff on the updated procedure for obtaining a new, properly labeled glucometer if a resident does not have one.
- Required all staff to sign an acknowledgement form confirming receipt and understanding of the training.
- Completed direct observational competency validation for all licensed nursing staff (including agency nurses) on blood glucose monitoring procedures.
- Incorporated comprehensive education and competency validation into orientation for all new nursing hires and agency staff, with annual competency refreshers.
- Assigned DON, ADON, and scheduler responsibility for maintaining records of all completed training, signed acknowledgement forms, and competency validations.
- Implemented ongoing direct supervisory support and surveillance of licensed nurses, including agency nurses, to ensure continued adherence to correct blood glucose monitoring procedures.
- Terminated the employment of the agency nurse involved in the incident.
- Notified the medical provider and responsible party for Resident #8 of the incident.
- Removed and discarded the unlabeled glucometer used in the incident.
- Completed an immediate inventory check to confirm sufficient individually assigned, labeled glucometers and appropriate EPA-registered disinfectant wipes were available.
- Reported the infection control breach to the local health department and followed their recommendations, including baseline testing for HIV, Hepatitis B, and Hepatitis C for Resident #8.
- Conducted a root cause analysis to identify contributing factors and inform corrective actions.
Failure to Notify Responsible Party and Medical Director of Change in Condition
Penalty
Summary
The facility failed to notify the Responsible Party (RP) and the Medical Director of a resident's significant change in condition, specifically a new diagnosis of peripheral vascular disease (PVD) with absent pedal pulses in both feet. The resident, who was severely cognitively impaired and had multiple comorbidities including diabetes, dementia, contractures, malnutrition, and hemiplegia, was seen by a podiatrist who documented the new diagnosis and associated symptoms. However, there was no documentation that the RP or the Medical Director was informed of this new diagnosis or the lack of pedal pulses, and the care plan was not updated to reflect these changes. Further review revealed that the resident developed a wound on the right smallest toe and was transferred to the hospital, where a diagnosis of high fever, severe sepsis, and possible osteomyelitis was made. The RP reported only being informed of the hospital transfer due to a fever and wound, but not of the underlying PVD diagnosis or the absence of pedal pulses. The RP also stated that during a care conference prior to the hospital transfer, there was no mention of wounds or PVD. Interviews with facility staff, including the Social Service Coordinator and DON, confirmed that they were unaware of the new diagnosis and had not reviewed the relevant podiatry consultation note. The Medical Director was not notified of the resident's new diagnosis, lack of pedal pulses, or the hospital transfer until well after the events occurred. The DON was unable to specify who was responsible for reviewing consultations and informing the Medical Director of changes in a resident's condition. The facility's process for reviewing and communicating new diagnoses and significant changes in condition was not followed, resulting in a lack of timely notification to both the RP and the Medical Director.
Failure to Protect Resident Health Information on Unattended Medication Carts
Penalty
Summary
Staff failed to protect residents' healthcare information by leaving confidential medication information visible and unattended on computer screens attached to two medication carts in the 100-hall. During early morning observations, both the upper and lower 100-hall medication carts were left in the hallway with their computer screens displaying sensitive resident information, including names, diagnoses, medications, dates of birth, and room numbers. The carts were left unattended for several minutes, during which time multiple nursing assistants walked past and could have viewed the information. Interviews with the responsible nurses revealed that both were aware of the requirement to use privacy screens or otherwise secure resident information but admitted to not doing so, citing forgetfulness. The DON and Quality Assurance Nurse indicated uncertainty about the specific education provided to staff regarding this requirement and noted that shift supervisors and unit managers were responsible for ensuring compliance. The Administrator acknowledged the need for staff accountability but could not explain why the nurses failed to secure the information.
Failure to Implement Grievance Policy for Missing Resident Items
Penalty
Summary
The facility failed to implement its grievance policy and procedures when a resident reported missing personal items, specifically self-Cath catheters and an electric wheelchair charger. The resident, who was cognitively intact and had diagnoses including heart failure and paraplegia, reported the missing items to the DON and Administrator immediately after the incident. Despite this, the resident did not receive any resolution or communication regarding the missing items for approximately two weeks. Interviews with staff revealed that the Unit Manager was informed of the missing items and relayed the information to the Social Worker and Administrator but did not complete a grievance form. The Social Worker was aware of the missing catheters but did not file a grievance or follow up, believing that new catheters were being ordered. The Administrator acknowledged being informed of the missing items but did not ensure a grievance was filed or that the issue was resolved within the facility's required five-day timeframe. This resulted in a failure to follow the facility's grievance policy and to promptly address the resident's concerns.
Failure to Accurately Code MDS for Active PVD Diagnosis
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident who had an active diagnosis of peripheral vascular disease (PVD). The resident, who was admitted with multiple diagnoses including diabetes mellitus, dementia, contractures, protein malnutrition, and hemiplegia, was given a new diagnosis of PVD by a podiatrist following a clinical assessment that identified classic signs and symptoms of the disease. Despite this, the quarterly MDS assessment did not reflect the new diagnosis of PVD. Interviews with facility staff revealed that the process for updating diagnoses involved the Social Service Coordinator receiving and distributing consultation notes, which were then uploaded into the electronic health record. However, the MDS nurses were unaware of the new PVD diagnosis and did not code it on the resident's MDS, stating that they review medical records and consultations for new information. The MDS nurses believed that not coding the diagnosis was accurate, despite the documented evidence and clinical findings supporting the presence of PVD.
Failure to Review and Assess Plan of Care for Resident with New PVD Diagnosis
Penalty
Summary
The facility failed to ensure that the Medical Director reviewed the total plan of care and conducted an appropriate assessment for a resident newly diagnosed with peripheral vascular disease (PVD). The resident, who had a history of diabetes mellitus, dementia, multiple contractures, malnutrition, hemiplegia, and PVD, was severely cognitively impaired and unable to make decisions independently. A podiatrist had previously documented absent pedal pulses, delayed capillary refill, and pigmentary changes in both feet, and diagnosed the resident with PVD, recommending routine or at-risk foot care but not vascular surgery referral. Despite these findings, the Medical Director did not examine the resident's feet or assess pedal pulses during a subsequent visit and was unaware of the podiatrist's consultation and the new PVD diagnosis. Nursing staff could not confirm whether the Medical Director had been notified of the podiatrist's findings or the new diagnosis. The Medical Director's progress notes did not address the recent PVD diagnosis or include a follow-up plan, indicating a lack of communication and review of the resident's updated care needs.
Unsecured Medication Carts Observed on Two Hallways
Penalty
Summary
Surveyors observed that two medication carts, located on the upper and lower 100-hall, were left unlocked and unattended in the hallway. On the upper 100-hall, a resident's insulin pen was found sitting on top of the unlocked cart, with the bottom drawer open, while two Nursing Assistants walked past without intervening. The nurse responsible for this cart acknowledged that she failed to secure the medications before leaving to administer medication to a resident. On the lower 100-hall, the medication cart was also found unlocked and unattended, with two Nursing Assistants passing by. The nurse responsible, an agency nurse, admitted she was aware of the requirement to lock the cart but did not do so. Interviews with facility leadership revealed a lack of clarity regarding staff education and oversight responsibilities. The DON stated that the Quality Assurance Nurse was responsible for education but was unsure what training had been provided. The Quality Assurance Nurse indicated that Unit Managers were tasked with educating staff but did not know what specific education had occurred. The Administrator emphasized the need for staff accountability but could not explain why the nurses left the carts unlocked.
Failure to Protect Cognitively Impaired Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect two cognitively impaired residents from sexual abuse. On the evening of 4/4/25, a Medication Aide observed a female resident with advanced dementia and severe cognitive impairment in the room of a male resident, also with severe cognitive impairment and a history of inappropriate sexual behaviors. The female resident was found sitting upright on the male resident's bed, with the male resident standing in front of her with his pants down and his penis inside her mouth. Neither resident had the cognitive capacity to consent to sexual activity, as confirmed by their diagnoses and statements from responsible parties and staff. The male resident had a documented history of inappropriate sexual behaviors, including disrobing, wandering into other residents' rooms, and making sexual advances or comments. His care plan included interventions such as 1:1 monitoring, redirection, and medication management to address these behaviors. Despite these interventions, he was able to engage in sexual activity with another resident who had no prior history of sexual behaviors and was severely cognitively impaired. The female resident's care plan did not identify any sexually inappropriate behaviors, and she required assistance with activities of daily living and supervision for ambulation. Staff interviews and record reviews confirmed that both residents were unsupervised at the time of the incident. The Medication Aide immediately separated the residents and notified the nurse, who conducted assessments and found no injuries. Both residents were unable to explain what had happened due to their cognitive impairments. The incident was reported to the appropriate authorities, and both residents were placed on 1:1 supervision following the event. The facility's failure to provide adequate supervision and protection resulted in both residents being subjected to sexual abuse, despite known risk factors and care plan interventions for the male resident.
Removal Plan
- Separated Residents #1 and #2 and placed both on 1:1 supervision following the incident.
- Conducted physical and behavioral assessments of both residents by nursing staff and Director of Nursing, with no injuries noted.
- Notified primary care physician, responsible parties, local police department, and Adult Protective Services of the incident.
- Updated care plans for both residents to include documentation of the incident, 1:1 supervision, specific behavioral interventions, and trauma-informed care approaches.
- Conducted medication review and psychiatric evaluation for both residents, resulting in an increased dosage of mood stabilizer for Resident #2.
- Implemented a plan for continued 1:1 supervision for both residents, with interdisciplinary team reassessment to determine ongoing monitoring needs.
- Interviewed all residents with a BIMS score of 10 or greater to assess for any inappropriate/unwanted sexual contact and feelings of safety.
- Assessed all residents on the secured memory care unit for behaviors using a Behavior Assessment tool.
- Completed comprehensive skin assessments on all residents with a BIMS score of 9 or less to check for signs of abuse.
- Updated sexual history/behavior assessments for all residents to ensure current documentation of risk factors.
- Created a comprehensive list of all residents with behavioral concerns to ensure appropriate monitoring.
- Educated all facility staff (including agency personnel) on abuse prohibition, reporting policy, behavioral monitoring, and dementia-specific training, with mandatory in-service meetings and attestation of understanding.
- Established a behavioral monitoring program for residents with behaviors, including 15-minute, 30-minute, or 1:1 supervision as needed.
- Clarified staff responsibilities for immediate intervention, assessment, documentation, and reporting of behavioral incidents.
- Implemented reviews of progress notes, medication administration records, and care plans for behavior documentation by the Director of Nursing or designee.
- Instituted ongoing monitoring by interviewing staff to ensure continued compliance and awareness.
- Required all findings and monitoring results to be reported to the Quality Assurance Performance Improvement committee for review and further action as needed.
Inadequate Training Leads to Improper Glucometer Disinfection
Penalty
Summary
The facility failed to provide adequate orientation and training to agency nurses, leading to improper disinfection of glucometers between residents. Nurse #1, an agency nurse, used a shared glucometer without disinfecting it between residents, specifically for Resident #107, despite the presence of 18 residents with known bloodborne pathogens in the facility. This lack of disinfection posed a high risk of cross-contamination and potential exposure to bloodborne pathogens for residents without existing infections. The deficiency was further highlighted when Nurse #2, another agency nurse, demonstrated a lack of competency in the disinfection of individually assigned glucometers. Nurse #2 was unaware of the required wet contact time for disinfectant wipes, which is crucial for effective disinfection. Both nurses were not provided with specific training or orientation on glucometer disinfection procedures, as the facility assumed agency nurses were already trained in these competencies. Interviews with the Director of Nursing (DON) revealed that the facility's orientation packet for agency nurses did not include information on glucometer disinfection or storage. The DON acknowledged this oversight and the assumption that agency nurses were competent in these areas. The Medical Director also identified this as a training issue, indicating a need for better education on glucometer disinfection for all staff.
Removal Plan
- Comprehensive Glucometer Training and Competency Program: All licensed nurses must complete training and demonstrate competency before performing blood glucose monitoring.
- Competency Validation Process: Direct observation by nurse management of complete blood glucose monitoring procedure, proper hand hygiene and glove use, correct glucometer cleaning and disinfection technique, appropriate wet contact time monitoring, proper barrier use and storage procedures, return demonstration required for all steps, documentation of competency verification in employee file, no blood glucose monitoring permitted until competency validated.
- Ongoing Monitoring: The Director of Nursing maintains documentation of all completed competency validations, the staffing coordinator verifies completion of glucometer competency before scheduling.
Failure to Disinfect Glucometers Between Residents
Penalty
Summary
The facility staff failed to properly disinfect a shared blood glucose meter (glucometer) between residents, leading to a deficiency. This was observed when a nurse, identified as an agency nurse, used a glucometer dedicated to one resident for another resident without disinfecting it between uses. The nurse admitted to not knowing the facility's protocol for glucometer disinfection and did not disinfect the glucometer at any point during his shift. This incident occurred while there were 18 residents identified with a known bloodborne pathogen in the facility, increasing the risk of cross-contamination and infection. Additionally, the facility did not have a specific policy or procedure related to glucometer disinfection, relying instead on the manufacturer's instructions. The Director of Nursing (DON) confirmed that the facility's EPA-registered disinfectant wipes required a wet contact time of three minutes, but this protocol was not followed. Another nurse, also identified as an agency nurse, was observed using a glucometer without ensuring the required wet contact time for disinfection, further contributing to the deficiency. The facility's Infection Preventionist and Medical Director acknowledged the concerns related to glucometer disinfection, with the Medical Director noting that this was the first time such an issue had been reported. The lack of proper training and adherence to disinfection protocols by agency nurses was highlighted as a contributing factor to the deficiency. The facility's assumption that agency nurses had received adequate training prior to their assignment was proven incorrect, as evidenced by the observed lapses in infection control practices.
Removal Plan
- Staff Education and Competency Validation: The agency nurse involved was contacted by the Director of Nursing to provide education regarding proper glucometer disinfection protocols. The nurse will not be allowed to accept a resident care assignment at the facility prior to education and blood glucose competency being validated in person.
- All licensed nurses were educated by the Director of Nursing and nursing unit coordinators regarding: The importance of using appropriate EPA-registered disinfectant wipes, following manufacturer's instructions for cleaning and disinfection, requirements for stocking medication carts with EPA-registered disinfectant wipes, and blood glucose monitoring is performed only by licensed nurses at the facility.
- All licensed nurses' competency to check blood glucose, including proper disinfection, was validated through direct observation by nurse management. This validation included observation of: Proper glucometer disinfection technique, correct storage of glucometers in labeled individual re-sealable plastic bags, and complete blood glucose monitoring procedure.
- Newly hired, contract, agency, as-needed staff, and staff returning from leave will be educated and have their competency validated through direct observation prior to accepting any resident assignment.
- The Director of Nursing is responsible for tracking education completion and competency validation.
- Process Changes: Visual reminders have been placed on all medication carts outlining the complete glucometer procedure: Obtain needed equipment and supplies, perform hand hygiene, explain procedure to resident, provide privacy, don gloves, obtain blood glucose sampling, remove and discard gloves, perform hand hygiene, retrieve disinfectant wipes, clean with first wipe to remove soil/blood, disinfect with second wipe, maintaining wet contact time, allow to air dry, discard wipes, perform hand hygiene.
Failure to Prevent Resident-to-Resident Abuse in Smoking Area
Penalty
Summary
The facility failed to protect residents from resident-to-resident abuse, as evidenced by multiple altercations involving residents with known aggressive behaviors. On one occasion, two residents with a history of altercations were involved in a physical confrontation in the smoking area. Despite previous incidents, both residents were unsupervised smokers, and the altercation resulted in one resident sustaining minor injuries. The facility's response included separating the residents and conducting assessments, but the repeated nature of the incidents suggests inadequate preventive measures. Another incident involved a resident with a history of aggressive behavior striking another resident in the face. The altercation occurred when the aggressor became frustrated with the victim's slow movement in a crowded smoking area. The facility's initial response included separating the residents and conducting assessments, but the overcrowding in the smoking area was identified as a contributing factor to the incident. The facility's failure to adequately supervise residents with known aggressive behaviors and to address environmental factors such as overcrowding in the smoking area contributed to these incidents. The repeated nature of the altercations and the facility's reliance on post-incident interventions rather than preventive measures highlight deficiencies in protecting residents from abuse.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to properly manage medications on several medication carts and in a medication storeroom, leading to the storage of expired medications and the lack of proper labeling for opened medications. During an observation of the Front 200 Hall Medication Cart, it was found that a bubble-pack card of hyoscyamine and a stock bottle of docusate were stored past their expiration dates. Additionally, a bottle of latanoprost eye drops was not labeled with the date it was opened, making it impossible to determine its shortened expiration date. Nurse #4 confirmed these findings and expressed concern about the lack of information regarding the latanoprost eye drops. Further observations on the Back 200 Hall Medication Cart revealed that a bubble-pack card of rosuvastatin and syringes of lorazepam were also stored past their expiration dates. Nurse #5 confirmed these medications were expired and indicated that they would be removed from the cart. Additionally, an in-use Lantus insulin pen on the Front 400 Hall Medication Cart was not labeled with the date it was opened, and Nurse #1 was unable to provide this information. In the 400 Hall Medication Storeroom, an opened multi-dose vial of Tuberculin PPD injectable solution was found without a label indicating when it was opened, preventing the determination of its shortened expiration date. The Director of Nursing (DON) acknowledged that the Tuberculin PPD needed to be discarded. Additionally, three unopened stock bottles of Vitamin B-12 were found to be past their expiration date. The DON was made aware of these issues during a follow-up interview.
Medication Borrowing Between Residents
Penalty
Summary
The facility staff failed to adhere to professional standards of care by borrowing medication from one resident to administer to another. During a medication administration observation, Nurse #3 was seen taking a 5 mg tablet of apixaban, an oral anticoagulant, from Resident #14's supply to give to Resident #8. Resident #8 had been prescribed apixaban for conditions including hemiplegia and atrial fibrillation, while Resident #14 was prescribed the same medication for anticoagulation. Nurse #3, an agency nurse, admitted to borrowing the medication because she felt responsible for ensuring all medications were administered, even if it meant using another resident's supply. The Director of Nursing (DON) confirmed that borrowing medications between residents is not consistent with professional standards and stated that the facility had an emergency medication box that could have been used to obtain the necessary medication for Resident #8. The DON indicated that the emergency box contained 2.5 mg tablets of apixaban, which could have been used to fulfill Resident #8's prescription. The incident highlights a lapse in medication management and communication within the facility, particularly involving agency staff who may not be fully aware of the facility's protocols.
Failure to Supervise Resident During Smoking
Penalty
Summary
The facility failed to adequately supervise a resident who required supervision while smoking, leading to a deficiency in ensuring a safe environment free from accident hazards. The resident, who was admitted with multiple diagnoses including type 2 diabetes mellitus, peripheral vascular disease, chronic obstructive pulmonary disease, and chronic respiratory failure with hypoxia, was initially assessed as an unsupervised smoker. However, a subsequent evaluation determined that the resident should be supervised due to noncompliance with smoking policies and the risk associated with oxygen use. On the day of the incident, the resident was observed smoking alone in the designated smoking area without supervision, despite being assessed as needing supervision. The Smoking Aide responsible for the resident left the area for a restroom break and did not ensure another staff member was present to supervise. Additionally, the resident was found to have smoking materials in her possession, contrary to facility policy that required all smoking materials to be stored in a locked box and distributed by staff. Interviews with staff revealed a lack of communication and understanding regarding the resident's need for supervision. The Smoking Aide and a Nurse Aide both assumed the resident was an unsupervised smoker, and the resident herself indicated she was not usually supervised. This miscommunication and failure to adhere to the facility's smoking policy resulted in the resident being left unsupervised with access to smoking materials, posing a potential safety risk.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an 8% error rate during the observation period. This deficiency was identified through observations, staff interviews, and record reviews. Two medication errors were noted among five residents observed. The first error involved a resident who was administered a combination medication containing sennosides and docusate, despite the physician's order specifying only sennosides. The nurse involved acknowledged the error after reviewing the medication administration record and the stock medication bottle, which confirmed the incorrect medication was administered. The second error involved another resident who was given a combination medication with a higher dosage of calcium and Vitamin D than what was ordered by the physician. The nurse responsible for the administration believed she had selected the correct medication, but upon review, it was confirmed that the dosage administered did not match the physician's order. Both errors were acknowledged by the nursing staff involved, and the Director of Nursing expressed the expectation that staff verify the correct medication and dosage as part of the medication administration process.
Deficiencies in Medical Record Accuracy and Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for three residents, leading to deficiencies in documentation and care. Resident #185's medical records did not reflect known allergies to aspirin and Compazine, as documented in their hospital records. This oversight occurred despite the Director of Nursing's acknowledgment that such allergies should be recorded by the admitting nurse. Although the resident was not prescribed these medications, the absence of this critical information in the medical records represents a significant lapse in maintaining accurate and complete resident information. Resident #70 experienced issues with the administration and documentation of pain medication. The resident reported receiving pain medication late, and a review of the Medication Administration Record confirmed that a scheduled dose of Methadone was not documented as given at the correct time. The Director of Nursing confirmed the discrepancy and noted a history of late documentation by Nurse #18, who no longer works at the facility. Additionally, Resident #187 was discharged against medical advice without proper documentation, including the absence of an AMA form and nursing notes. The Unit Manager and Administrator both acknowledged the lack of documentation, which is required when a resident leaves the facility AMA.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to address grievances reported during Resident Council meetings over a three-month period. The Resident Council minutes from November 2024, December 2024, and January 2025 documented concerns about late medication administration, unresponsive night shift staff to call lights, and issues with nurse and nurse aide care during the night shift. During a Resident Council interview in February 2025, residents confirmed ongoing concerns with the night shift staff, indicating that their issues had not been resolved. The Activities Director mentioned that she would write up grievances for follow-up but was unsure if she had done so for these concerns. The Administrator, who attended the January meeting, stated that he was unaware of any unresolved grievances from the Resident Council for the specified months, as none were documented.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident reviewed for new admission. The resident was admitted with diagnoses including influenza with respiratory manifestations, unsteadiness of feet, and muscle weakness. Upon review, the baseline care plan initiated the day after admission only included information on medication allergies and code status, lacking comprehensive details necessary for immediate care. Interviews with the MDS Coordinator and the Director of Nursing revealed that the baseline care plan should have been completed by the admitting nurse alongside the admission assessment, but this was not done.
Failure to Apply and Document Hand Splint for Resident
Penalty
Summary
The facility failed to apply a left hand splint for a resident with a left-hand contracture and hemiparesis, as per the physician's orders. The resident was admitted with diagnoses including hypertension, diabetes, cerebral vascular accident, and left-hand contracture. The physician's order specified that the resident should wear a left palmar guard all day, except during care and meals, and that staff should assist in its application. However, observations over several days revealed that the resident was not wearing the splint, and it was found in the top drawer of the dresser instead. Interviews with various staff members, including nurses and aides, indicated a lack of awareness and responsibility regarding the application and documentation of the splint. Nurse #20, who was responsible for documenting the application of the splint, was unavailable for interview, and the Medication Administration Records (MAR) showed repetitive statements of the physician's order without documentation of actual application, refusal, or removal of the splint. The Unit Manager confirmed the lack of documentation and was unaware of the splint's location, while other staff members, including Nurse Aide #7 and Smoke Aide #2, were either unaware of the splint's application or believed it was the responsibility of the rehabilitation therapy staff. The Rehabilitation Director and the Director of Nursing confirmed that the nursing staff and/or nurse aides were responsible for applying the splint daily and documenting its application, refusal, or removal. However, the records did not reflect this, and the care plan was not updated to include the splint application. The Administrator expected the nursing staff to follow the physician's orders and therapy instructions, but the lack of documentation and application of the splint indicated a failure to meet these expectations.
Failure to Label Enteral Formula Bags
Penalty
Summary
The facility failed to adhere to its Enteral Feeding policy by not labeling the ready-to-hang prefilled enteral formula bags with the date, time, and initials of the nurse who started the new bag for a resident receiving gastrostomy enteral feedings. This deficiency was observed in the case of a resident who was admitted with diagnoses including cerebral vascular accident and aphasia, requiring total assistance with daily activities. The resident was receiving continuous enteral feeding via a gastrostomy tube as per physician orders. Observations revealed that the enteral formula bags lacked the necessary labeling information, making it impossible to determine when the formula was started. Interviews with nursing staff confirmed that the labeling was not done, and the Director of Nursing stated that the formula should be labeled to communicate when a new bag was started. Attempts to interview the nurses responsible for the resident's care during specific shifts were unsuccessful, further complicating the ability to track the administration of the enteral formula accurately.
Inaccurate Care Plan Reflecting Hospice Services
Penalty
Summary
The facility failed to develop a comprehensive care plan that accurately reflected the services provided to a resident, as it incorrectly indicated that the resident was receiving Hospice services. This discrepancy was identified during a review of the care plan for a resident who was admitted to the facility and had a history of respiratory failure, congestive heart failure, and diabetes. The care plan inaccurately stated that the resident was under hospice care, despite the most recent MDS assessment indicating otherwise. The care plan included several areas of focus, such as ADL self-care performance deficit, risk for nutritional problems, pain management, and risk for pressure ulcer development, all of which incorrectly noted hospice care involvement. Upon review of the resident's electronic medical record, no evidence of hospice services was found from the date of the facility's last recertification through the date of the review. Interviews with the MDS Coordinators revealed that they could not find any documentation of hospice services being provided to the resident, and they acknowledged that the care plan should not have reflected hospice care. The facility's Administrator also confirmed that the care plan should align with the MDS to meet the resident's needs, indicating a failure in the care planning process to accurately reflect the resident's current care status.
Failure to Monitor Resident's Weight Leads to Significant Weight Loss
Penalty
Summary
The facility failed to obtain and monitor a resident's monthly weight in February 2024, which led to a significant weight loss for Resident #6. The resident, who had a history of lymphedema, chronic non-pressure ulcers, depression, and hypotension, was at nutritional risk due to marginal intake and increased nutritional needs for wound healing. Despite the care plan's directive to monitor and report significant weight loss, the facility did not record any weight for Resident #6 in February 2024. This oversight prevented early assessment and intervention for the resident's nutritional needs. Resident #6's weight was last recorded on January 5, 2024, at 179.7 pounds. By March 25, 2024, his weight had dropped to 152.9 pounds, indicating a significant weight loss of 14.9% over 80 days. Throughout January, February, and March, the resident's meal intake records showed varying levels of meal consumption, with a notable increase in meal refusals and low intake in March. Despite these indicators, there were no documented nutritional assessments or interventions by the facility's Registered Dietitian (RD) or Certified Dietary Manager (CDM) since September 2023. Interviews with staff, including the Nurse Practitioner (NP), Nurse Aides (NAs), and the RD, revealed that the resident's poor oral intake and weight loss were attributed to depression. However, the facility's failure to document the resident's weight in February and to communicate his nutritional status to the RD and other relevant staff contributed to the lack of timely nutritional interventions. The facility's process for obtaining and documenting resident weights was identified as flawed, leading to missed opportunities for early detection and management of the resident's significant weight loss.
Inaccurate MDS Assessment Due to Missing Weight Data
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for a resident who experienced significant weight loss. Resident #6, who had a history of lymphedema, chronic non-pressure ulcers, depression, and hypotension, was admitted to the facility and weighed 179.7 pounds on 1/5/24. However, there was no documented evidence that the facility obtained the resident's weight between 1/5/24 and 3/18/24. The quarterly MDS assessment dated 3/18/24 inaccurately reported the resident's weight as 180 pounds, based on the last recorded weight from 1/5/24, which was 73 days prior to the MDS's Assessment Reference Date (ARD). This discrepancy was confirmed through interviews with the Certified Dietary Manager (CDM), the consultant Registered Dietitian (RD), and the facility's MDS Coordinators and Regional Director of Clinical Reimbursement, all of whom acknowledged that the weight used should have been the most recent measure obtained within the last 30 days or a dash should have been placed if no recent weight was available. During interviews, the CDM admitted to using the last available weight for the MDS assessment, while the RD clarified that the Resident Assessment Instrument (RAI) guidelines require the weight reported on an MDS to be the most recent measure obtained in the last 30 days. The Regional Director of Clinical Reimbursement and the Regional Director of Operations both confirmed that the facility typically uses the most recent weight closest to 30 days of the MDS's ARD and acknowledged the error in using the 1/5/24 weight for the 3/18/24 MDS. The failure to obtain and document a more recent weight for Resident #6 led to the inaccurate completion of the MDS assessment, highlighting a deficiency in the facility's assessment process.
Failure to Provide Physician's Order for BiPAP Treatment
Penalty
Summary
The facility failed to provide a physician's order for the use of a BiPAP machine treatment for a resident with chronic obstructive pulmonary disease (COPD), sleep apnea, and congestive heart failure. The resident was readmitted to the facility with a hospital discharge summary recommending the continuation of BiPAP treatment at night with specific settings. However, the resident's admission Minimum Data Set assessment and plan of care did not include the BiPAP treatment, and there were no physician orders or entries in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the BiPAP treatment. Interviews with the Nurse Practitioner, nurses, and the Director of Nursing revealed that the BiPAP machine was present in the resident's room, and the resident had used it in the past. However, the necessary physician's order for the BiPAP treatment was not transcribed into the resident's medical records or the MAR. The admission nurse acknowledged the responsibility for transcribing the BiPAP order but failed to do so. The Director of Nursing and Assistant Administrator confirmed that the physician's order should have been in place at admission.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 79 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Durham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accordius Health At Rose Manor Llc | 0.7 mi | ★★★★★ | 1 | 0 |
| Croasdaile Village | 2.7 mi | ★★★★★ | 8 | 0 |
| Hillcrest Convalescent Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Pettigrew Rehabilitation Center | 2.8 mi | ★★★★★ | 0 | 0 |
| University Health And Rehabilitation Center | 3.5 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.