Carver Living Center: Immediate Jeopardy Violations - NC
The February 4 incident at Carver Living Center triggered immediate jeopardy findings from federal inspectors. The nurse, identified only as Nurse #1, was working his first week at the facility when he grabbed the wrong glucose meter from a medication cart and used it on Resident #107 without cleaning it before or after the test.
The meter belonged to Resident #134. Resident #107 had her own assigned meter stored in the same drawer, properly labeled and in a plastic bag.
"I grabbed the wrong one by mistake," the nurse told inspectors when confronted about the error.
Eighteen residents at the facility had known bloodborne pathogens including hepatitis B, hepatitis C, and HIV, according to facility records reviewed during the inspection.
The nurse admitted he never disinfected any glucose meters during his entire 12-hour night shift. When asked about disinfection protocols, he said, "I don't know the routine here" and "I don't know the protocol."
The facility's orientation packet for agency nurses contained no information about glucose meter disinfection, inspectors found. The Director of Nursing acknowledged that agency nurses received no education on the topic before working at the facility.
"It was assumed that agency nurses had received training to ensure their overall competency to care for residents prior to being hired," the Director of Nursing told inspectors.
The nurse suggested he could use alcohol wipes from individual packets stored on the medication cart for cleaning. Alcohol is not an EPA-registered disinfectant approved for glucose meter disinfection.
No disinfectant wipes were available on his medication cart, inspectors observed.
The Medical Director called the incident "a training issue" and said it was "the first time I have heard of this happening." She told inspectors that glucose meter disinfection "required better learning or training for all staff throughout."
Inspectors observed additional disinfection failures with two other residents. Nurse #2, another agency worker, wiped glucose meters for Residents #66 and #93 for only 15 and 20 seconds respectively. The facility's EPA-registered disinfectant wipes required a three-minute wet contact time to be effective.
When asked about the required contact time, Nurse #2 said she "did not know."
Resident #93's room was under Enhanced Barrier Precautions to prevent transmission of multidrug-resistant organisms. The nurse placed his glucose meter directly on a bedside tray table during the test, then wiped it for 20 seconds before returning it to storage.
Resident #66's meter was stored loose in the medication cart drawer, in direct contact with six other meters that were properly bagged. After disinfection, the nurse returned it to the drawer without placing it in a protective bag.
The facility had no written policy for glucose meter disinfection. Staff relied on manufacturer instructions that recommended cleaning and disinfecting meters "between patient use" with commercially available EPA-registered disinfectant wipes.
Manufacturer guidelines required two wipes when blood was visible — one to clean, a second to disinfect. The instructions specified taking "extreme care not to get liquid in the test strip and key code ports of the meter."
The facility's disinfectant wipes killed HIV, hepatitis B and hepatitis C in one minute. Other organisms required up to three minutes of contact time.
Inspectors immediately removed Nurse #1 from patient care duties. The facility assigned Resident #107 a new glucose meter and contacted her medical provider about the incident.
The facility implemented emergency training for all licensed nurses, including competency validation through direct observation. Visual reminders outlining proper glucose meter procedures were placed on all medication carts.
The immediate jeopardy designation was removed February 6 after inspectors validated the facility's corrective actions. All interviewed nurses reported receiving required training before beginning their shifts.
But medication errors plagued the facility beyond infection control failures.
Inspectors observed an 8% medication error rate during a 25-dose observation period, exceeding the 5% federal threshold.
Nurse #2 administered a combination laxative containing both sennosides and docusate to Resident #85, who was only prescribed sennosides. The correct medication was available on the cart.
"I acknowledged she administered the wrong medication," the nurse told inspectors after reviewing the stock bottles and physician orders.
Nurse #3 gave Resident #8 a calcium supplement containing 600 milligrams calcium and 400 units of Vitamin D instead of the prescribed 500 milligrams calcium with 200 units of Vitamin D.
The nurse "insisted she knew Resident #8 was ordered 500 mg calcium with Vitamin D and thought she had pulled the correct medication," inspectors noted.
Expired medications littered storage areas. A bubble-pack card of hyoscyamine for Resident #46 had expired in May 2024. A stock bottle of docusate expired in September 2024. Twenty syringes of lorazepam for Resident #150 expired December 19, 2024.
Three stock bottles of Vitamin B-12 had expired in January 2025.
Multiple medications lacked required dating to track shortened expiration periods after opening. An opened bottle of latanoprost eye drops had no opening date, making it impossible to determine if the six-week room temperature storage limit had passed.
A Lantus insulin pen for Resident #175 carried no opening date or pharmacy dispensing date. Insulin pens must be discarded 28 days after opening.
An opened tuberculosis testing solution in the medication room refrigerator had no opening date. The product must be discarded 30 days after opening.
Record-keeping failures compounded the medication problems.
Resident #185's hospital records documented allergies to aspirin and Compazine, but the facility's electronic medical record listed "no known allergies." The Director of Nursing said admitting nurses were "required to list the resident's medication allergy(s) in their medical record."
Resident #70, a cancer patient with intact cognition, told inspectors he received pain medication "very late after the scheduled time" in November 2024. Records showed his scheduled 10 PM methadone dose on November 4 was not documented until 9:59 AM on November 5.
The assigned nurse "no longer worked for the facility due to a history of not documenting when medications were given or not documenting at all," the Director of Nursing told inspectors.
Resident #187 left the facility against medical advice, but no AMA form or nursing notes documented the discharge. The Unit Manager said the resident's family "hurriedly took Resident #187 home" but acknowledged "there was no document in the chart that indicated the resident left the facility AMA."
The Administrator said AMA forms should be signed by residents or families, or witnessed by two staff members if families refuse to sign.
The facility's Infection Preventionist called the glucose meter incidents "unfortunate" but noted that training began immediately after inspectors identified the problems.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carver Living Center from 2025-02-07 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Carver Living Center in Durham, NC was cited for immediate jeopardy violations during a health inspection on February 7, 2025.
The February 4 incident at Carver Living Center triggered immediate jeopardy findings from federal inspectors.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.