Carter Nursing and Rehabilitation

Based 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.The findings include:Review of the document, U.S. Food and Drug Administration 2022 Food Code, 01/18/2023 Version, in Chapter 3 Food, revealed food employees would not contact exposed, ready-to-eat food with bare hands and shall use single-use gloves. It also stated food employees shall minimize bare hand contact with exposed food not in a ready-to-eat form. Review of the facility's policy titled, Safe Food Handling, revised 02/05/2025, revealed the facility would follow safe food handling to significantly reduce the risk of foodborne illness thus strengthening the safety of the food provided to the residents. Further review revealed Care Team Members in nutrition/culinary would effectively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings include:Review of the facility policy's titled, Medication Administration, dated 12/12/2023, revealed medications were administered, as ordered by the physician and in accordance with professional standards of practice.Review of R42's Face Sheet revealed the facility admitted the resident on 01/31/2018 with diagnoses of dementia, diabetes, and congestive heart failure (CHF). Review of R42's quarterly Minimum Data Set [MDS], with an Assessment Reference Date of 06/19/2025, revealed the facility assessed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings include:Review of the facility's policy titled, Indwelling Catheter, dated 12/12/2023, revealed the facility would provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures. Review of the CDC's document Summary of Recommendations from the Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009), for Health Care Providers, dated 03/25/2024, revealed to keep the urine collection bag below the level of the bladder at all times. It also stated, Do not rest the bag on the floor. Review of R12's Face Sheet revealed the facility admitted the resident on 11/01/2012 with diagnoses of multiple sclerosis, dementia, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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). The findings include: Review of the facility's policy titled, Medication Administration, dated 2023, revealed medications were administered by licensed nurses, or other staff who were legally authorized to do so in this state; as ordered by the Physician and in accordance with professional standards of practice; and in a manner to prevent infection from contamination. Further review revealed to keep the medication cart clean, organized, and stocked with adequate supplies. 1. Observation of the medication administration on 07/14/2023 at 8:11 AM, with Licensed Practical Nurse (LPN) #12 revealed Resident #69…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). This was higher than the acceptable range of thirty-six (36) to forty-one (41) degrees Fahrenheit on the Refrigerator Temperature Log. Also, the facility's policy temperature range was for the residents' food to store…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Further review of the facility investigation revealed that Law Enforcement had been notified after Resident #415 reported his/her ring missing. The findings include: Review of the facility's policy titled, Resident Rights, revised date December 2016, revealed the residents had a right to be free from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). The findings include: Review of the Kentucky National Background Check Disqualifying Offenses List revealed, Pursuant to 906 [NAME] 1:190, Section 1(4), a disqualifying offense included, a conviction of, or plea of guilty to a misdemeanor offense of unlawfully possessing or trafficking in a legend drug or controlled substance occurring less than seven (7) years from the date of the criminal background check. Review of 21 CFR 1308.11 (d)(23) revealed it listed marihuana as a controlled substance with a Drug Enforcement Agency (DEA) Controlled Substances Code Number of 7360. Review of the Maintenance Director's employee file…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings include: In an interview with the Director of Nursing (DON) on 07/11/2023 at 9:32 AM, she stated the facility did not have a specific care plan policy; however, utilized the Resident Assessment Instrument (RAI) manual. Review of the RAI manual, section 4.7 titled, The RAI and Care Planning, dated 10/2019, revealed the care plan described the services that were to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. 1. Review of the facility's investigative reports revealed Resident #364 was involved in the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include: In an interview with the Director of Nursing on 07/11/2023 at 9:32 AM, she stated the facility did not have a specific care planning policy; they followed the Resident Assessment Instrument (RAI) Manual guidance. Review of the RAI Manual, Section 4.7 The RAI and Care Planning, dated 10/2019, revealed the care plan was revised on an ongoing basis to reflect changes in the resident and the care that the resident required. Review of Resident #5's admission Record revealed the facility admitted the resident, on 05/17/2022, with diagnoses which included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings include: Review of the facility's policy titled, Storage of Medication Requiring Refrigeration, dated 2023, revealed it was the policy of the facility to assure proper and safe storage of medication requiring refrigeration and to prevent the potential alteration of medication by exposure to improper temperature control. Further review of the policy revealed the facility would ensure that all medications and biologicals would be stored at proper temperatures and other appropriate environment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include: Review of the facility's policy titled, Medication Administration, copyright date 2023, revealed medications were administered by licensed nurses, or other staff who were legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice. There were no references to allergies in the policy. Review of Resident #65's medical record revealed the facility admitted the resident, on 11/06/2017, with diagnoses of Cerebral Palsy, Expressive Language Disorder, and Anxiety. Review of Resident #65's Quarterly Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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). The findings include: Review of the facility's policy titled, Enhanced Barrier Precautions, dated January 2023, revealed enhanced barrier precautions (EBP) were used to prevent the transmission of multidrug-resistant organisms (MDRO). Further review revealed the definition of EBP referred to the use of gown and gloves during high contact resident care activities for residents with known MDROs or at an increased risk of being infected with MDROs. Continued review of the policy revealed explanation and compliance guidelines which stated staff members were expected…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings include: Review of the facility Policy titled Storage of Medications, undated, revealed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Per Policy, the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Continued review of the Policy, revealed only licensed nurses, pharmacy personnel, and those lawfully authorized to administer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.