Carver Living Center

F-F880

Based 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. Also, the facility failed to disinfect individually assigned glucometers stored outside of the residents' rooms in accordance with the instructions provided by the manufacturer of the disinfectant wipes for 2 of 3 residents (Residents #66 and #93) observed to have their blood glucose levels checked.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 1. An interview was conducted on 2/4/25 at 6:17 AM with Nurse #1. When Nurse #1 was asked how long he had worked at the facility, he stated this was his first week. Upon further inquiry, the nurse reported he Level of Harm - Immediate received a short orientation from facility for agency nurses. jeopardy to resident health or safety On 2/4/25, the facility provided a copy of the orientation packet given to agency nurses when they first began working at the facility. A review of the Information Packet for Registry Nurses revealed it contained Residents Affected - Few information on the following topics: Welcome to [Name of Facility]; Important Guidelines (including dress code, personal devices, medication protocol, supplies, and identification); Admission Assessment (indicating

the admission documentation required); Nurse Responsibilities in Admission; Daily Responsibilities; and Documentation Expectations. The orientation packet did not include any information about either the disinfection or storage of glucometers.

During an interview conducted with the facility's Director of Nursing (DON) on 2/5/25 at 8:40 AM, the DON stated the only orientation material the facility provided for agency nurses was the Information Packet for Registry Nurses. She acknowledged the facility did not provide education on glucometer disinfection to agency nurses prior to the nurse working at the facility. The DON stated it was assumed that agency nurses had received training to ensure their overall competency to care for residents prior to being hired and assigned to work in their facility.

A follow-up interview was conducted on 2/7/25 at 8:19 AM with the DON to inquire about the training / orientation provided to newly hired staff nurses. When asked, the DON reported that staff nurses went through an orientation program led by the facility's Staffing Coordinator and Human Resources Manager.

She also noted new staff nurses were assigned a mentor to supplement their orientation.

A telephone interview was conducted with the facility's Medical Director on 2/6/25 at 2:27 PM to discuss the concerns related to glucometer disinfection identified during observations conducted at the facility. When asked, the Medical Director reported she had been informed of these concerns. She reported this sounded like a training issue and stated, This is the first time I have heard of this happening. The Medical Director reported she thought glucometer disinfection required better learning or training for all staff throughout.

The facility's Administrator and DON were informed of the immediate jeopardy (IJ) on 2/5/25 at 2:00 PM.

The facility provided the following plan for IJ removal:

Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of

the noncompliance

On 02/04/2025, an agency nurse (Nurse #1) provided care without receiving proper orientation and competency validation regarding glucometer disinfection procedures. The nurse used a glucometer dedicated to Resident #134 for Resident #107 without proper disinfection between residents. When interviewed, the nurse stated they were unaware of facility policies and procedures for glucometer disinfection and did not know which products were approved for disinfection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 All residents requiring blood glucose checks were identified as being at risk. An audit conducted by the Director of Nursing and nursing unit coordinators on 02/04/2025 identified all facility residents requiring blood Level of Harm - Immediate glucose checks and confirmed the presence of residents with blood borne pathogens, creating risk for jeopardy to resident health or cross-contamination. safety

The following immediate actions were taken: Residents Affected - Few - At approximately 7:00 AM on 02/04/2025, upon discovery of the incident, Nurse #1 was immediately removed from resident care duties

- The Director of Nursing contacted Nurse #1 by telephone regarding the requirement to complete comprehensive glucometer competency validation before accepting any future assignments at the facility

Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete

The following systemic changes have been implemented as of 02/05/2025:

1. Comprehensive Glucometer Training and Competency Program:

All licensed nurses (including facility staff and agency staff) must complete the following training and demonstrate competency before performing blood glucose monitoring:

a. Required Equipment and Supplies:

- Gloves

- Glucometer

- Alcohol pads

- Single-use lancet

- Blood glucose testing strips

- Disinfecting wipes

- Paper towels or tissues

b. Complete Glucometer Procedure and Cleaning Steps:

- Obtain needed equipment and supplies

- Perform hand hygiene

- Explain the procedure to the resident

- Provide privacy

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 - [NAME] gloves

Level of Harm - Immediate - Obtain capillary blood glucose sampling jeopardy to resident health or safety - Remove and discard gloves, perform hand hygiene prior to exiting the room

Residents Affected - Few - Retrieve (2) disinfectant wipes from container

- Using the first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of

the glucometer

- After cleaning, disinfect with second wipe, maintaining 3-minute wet contact time. Allow the glucometer to air dry

- Discard disinfectant wipes in waste receptacle

- Perform hand hygiene

- Ensure glucometer is stored in individual plastic bag for each resident to prevent cross contamination

- Place clean dry paper towel or tissue under glucometer before placing on resident table or on top of medication cart to prevent contamination

2. Competency Validation Process:

Direct observation by nurse management of:

- Complete blood glucose monitoring procedure as outlined above

- Proper hand hygiene and glove use at specified steps

- 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

3. Ongoing Monitoring:

- The Director of Nursing maintains documentation of all completed competency validations

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 - The staffing coordinator verifies completion of glucometer competency before scheduling

Level of Harm - Immediate Immediate Jeopardy Removal Date: 2/6/2025 jeopardy to resident health or safety The facility's credible allegation of immediate jeopardy removal was validated on 2/7/25. The validation was evidenced by nurse observations and/or interviews conducted on each hallway with regards to the required Residents Affected - Few infection control practices for the disinfection of glucometers. All nurses who were interviewed reported they had received the required in-service training prior to beginning their shift. The education provided stressed

the importance of using individually assigned glucometers for each resident requiring blood glucose monitoring and storing these glucometers in individual, re-sealable plastic bags. The in-service training also included a review of the manufacturer's instructions for the facility's glucometer and disinfectant wipes related to glucometer disinfection, as well as completing a return demonstration of the proper procedures for effective glucometer disinfection. Nurses observed to conduct blood glucose checks and subsequent glucometer disinfection completed the task without difficulty. The nursing practices observed included the proper handling and storage of glucometers to protect the meters from potential cross-contamination via contact with other meters or surfaces. There were no concerns identified during either the interviews or

observations.

The credible allegation was validated, and the immediate jeopardy was removed on 2/6/25.

2. An interview was conducted on 2/4/25 at 12:14 PM with Nurse #2. During the interview, the nurse estimated that she had worked at the facility four times in the last three months. On 2/4/25 at 12:35 PM, a follow-up interview was conducted with the nurse. At that time, Nurse #2 was asked if she received orientation upon starting to work at the facility. She stated, No, I did not. When asked, Nurse #2 reported she did not know how long a glucometer should remain wet (wet contact time) after using a disinfectant wipe to ensure the meter was adequately disinfected.

On 2/4/25, the facility provided a copy of the orientation packet given to agency nurses when they first began working at the facility. A review of the Information Packet for Registry Nurses revealed it contained the following topics: Welcome to [Name of Facility]; Important Guidelines (including dress code, personal devices, medication protocol, supplies, and identification); Admission Assessment (indicating the admission documentation required); Nurse Responsibilities in Admission; Daily Responsibilities; and Documentation Expectations.

During an interview conducted with the facility's Director of Nursing (DON) on 2/5/25 at 8:40 AM, the DON stated the only orientation material the facility provided for agency nurses was the Information Packet for Registry Nurses. She acknowledged the facility did not provide education on glucometer disinfection to agency nurses prior to the nurse working at the facility. The DON stated it was assumed that agency nurses had received training to ensure their overall competency to care for residents prior to being hired and assigned to work in their facility.

A follow-up interview was conducted on 2/7/25 at 8:19 AM with the DON to inquire about the training / orientation provided to newly hired staff nurses. When asked, the DON reported that staff nurses went through an orientation program led by the facility's Staffing Coordinator and Human Resources Manager.

She also noted new staff nurses were assigned a mentor to supplement their orientation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 A telephone interview was conducted with the facility's Medical Director on 2/6/25 at 2:27 PM to discuss the concerns related to glucometer disinfection identified during observations conducted at the facility. When Level of Harm - Immediate asked, the Medical Director reported she had been informed of these concerns. She reported this sounded jeopardy to resident health or like a training issue and stated, This is the first time I have heard of this happening. The Medical Director safety reported she thought glucometer disinfection required better learning or training for all staff throughout.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32394 potential for actual harm Based on observations, staff interviews, and record reviews, the facility failed to have a medication error rate Residents Affected - Few 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.

The findings included:

1. Resident #85 was admitted to the facility on [DATE REDACTED].

On 2/4/25 at 11:26 AM, Nurse #2 was observed as she prepared nine (9) medications for administration to Resident #85. The medications included two tablets of a combination medication with each tablet containing 8.6 milligrams (mg) sennosides (a stimulant laxative) / 50 mg docusate (a stool softener) taken from a stock medication bottle stored on the medication (med) cart. The medication was administered to Resident #85 on 2/4/25 at 11:40 AM.

A review of Resident #85's current physician's orders revealed his medication orders included 8.6 mg sennosides (a stimulant laxative) to be given as two tablets by mouth two times a day for constipation (Start Date 7/26/24). Resident #85 did not have a physician's order for docusate.

An interview was conducted with Nurse #2 on 2/4/24 at 12:35 PM related to the medication administration observed on 2/4/25 at 11:26 AM. During the interview, Resident #85's Medication Administration Record (MAR) was reviewed. At that time, Nurse #2 confirmed his physician's order was written for 8.6 mg sennosides (not a combination medication including sennosides and docusate). The stock bottle used for the med administration was also pulled from the med cart and the label of this stock bottle reviewed. At that time, Nurse #2 acknowledged each tablet of the medication contained 8.6 mg sennosides with 50 mg docusate. Upon further review of the stock meds available on the medication cart, the nurse identified a bottle containing 8.6 mg sennosides (as the sole active ingredient) was stored on the med cart and available for administration. During the interview, Nurse #2 acknowledged she administered the wrong medication to Resident #85 during the medication observation conducted earlier that morning. The nurse reported she would alert the nurse supervisor to this error.

An interview was conducted on 2/5/25 at 3:43 PM with the facility's Director of Nursing (DON). During the interview, the DON reported she would expect nursing staff to verify the right medication and right dose

during the med administration process as part of the medication rights (right patient, right drug, right dose, right route, and right time).

2. Resident #8 was admitted to the facility on [DATE REDACTED].

On 2/5/25 at 9:08 AM, Nurse #3 was observed as she prepared thirteen (13) medications for administration to Resident #8. The medications included one tablet of a combination medication containing 600 milligrams (mg) calcium carbonate with 10 micrograms (400 units) of Vitamin D taken from a stock medication bottle stored on the medication (med) cart. A continuous observation was conducted as the medications were administered to Resident #8.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 A review of Resident #8's current physician's orders revealed her medication orders included a combination medication containing 500 mg calcium carbonate with 200 units of Vitamin D to be given as one tablet by Level of Harm - Minimal harm or mouth two times a day for hypocalcemia (low levels of calcium in the blood) with a start date of 4/1/22. The potential for actual harm resident's medication orders also included a current (but separate) order for 2,000 units of Vitamin D to be administered as one tablet by mouth one time a day for supplement (Start Date 2/9/21). Residents Affected - Few

An interview was conducted with Nurse #3 on 2/5/25 at 12:14 PM. During the interview, the discrepancy between the dosage of the calcium / Vitamin D combination medication observed to have been administered to Resident #8 on 2/5/25 at 9:08 AM (versus the dosage ordered by the physician) was discussed. At that time, both the resident's Medication Administration Record (MAR) and label of the stock bottle of the calcium / Vitamin D supplement observed to have been pulled for Resident #8's medication administration were reviewed. During the interview, Nurse #3 insisted she knew Resident #8 was ordered 500 mg calcium with Vitamin D and thought she had pulled the correct medication from the stock bottles. The nurse was informed

the label of the stock bottle handed off for review during Resident #8's medication observation indicated the dosage of the tablet administered to the resident was 600 mg calcium / 400 units Vitamin D (not the 500 mg calcium / 200 units of Vitamin D ordered for her).

An interview was conducted on 2/5/25 at 3:43 PM with the facility's Director of Nursing (DON). During the interview, the DON reported she would expect nursing staff to verify the right medication and right dose

during the med administration process as part of the medication rights (right patient, right drug, right dose, right route, and right time).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 32394 Residents Affected - Some Based 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).

The findings included:

1. An observation was conducted on 2/3/25 at 1:24 PM of the Front 200 Hall Medication (Med) Cart in the presence of Nurse #4. The observation revealed the following medications were stored on the med cart:

a. One bubble-pack card containing 29 tablets of 0.125 milligrams (mg) hyoscyamine (a medication that may be used to treat muscle spasms in the bowel or bladder) was stored past its expiration date. The pharmacy labeling on the bubble-pack card indicated this medication was dispensed for Resident #46 on 5/23/23 and had an expiration date of 5/23/24.

b. One stock bottle of 100 mg docusate (a stool softener) was stored past its expiration date. The stock bottle originally contained 200 softgels (with approximately 180 remaining in the bottle) and was observed to have

a manufacturer expiration date of September 2024.

c. According to the manufacturer, containers of latanoprost eye drops (a medication used to treat glaucoma) may be stored at room temperature up to 77 degrees Fahrenheit (o F) for 6 weeks.

One opened bottle of 0.005% latanoprost eye drops dispensed from the pharmacy for Resident #160 on 12/2/24 was stored on the medication cart. The bottle was not dated as to when it had been opened to allow for the determination of its shortened expiration date.

An interview was conducted on 2/3/25 at 1:38 PM with Nurse #4. After examining the labeling on the medications, Nurse #4 agreed the hyoscyamine and docusate medications were expired. She also expressed concern related to not knowing when the latanoprost eye drops dispensed for Resident #160 had been opened. Nurse #4 reported the resident's medications had been recently moved to this med cart, so

she would check the resident's previous medication cart to see if there was another bottle of latanoprost dispensed for her on that cart.

2. An observation was conducted on 2/3/25 at 1:39 PM of the Back 200 Hall Medication (Med) Cart in the presence of Nurse #5. The observation revealed the following medications were stored on the med cart:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 a. One bubble-pack card containing 3 tablets of 40 milligrams (mg) rosuvastatin (a medication used to treat high levels of lipids and cholesterol in the blood) was stored past its expiration date. The pharmacy labeling Level of Harm - Minimal harm or on the bubble-pack card indicated this medication was dispensed for Resident #108. The labeling did not potential for actual harm contain a legible dispensed date. However, the medication had an expiration date of 11/19/24.

Residents Affected - Some b. Twenty (20) syringes containing 0.5 mg lorazepam (an antianxiety medication and a controlled substance medication) was stored in the locked drawer of the medication cart. The medication was labeled by the pharmacy as dispensed for Resident #150 on 12/2/24 with an expiration date of 12/19/24.

An interview was conducted with Nurse #5 at the time of the med storage observation on 2/3/25 at 1:39 PM.

During the interview, the nurse confirmed the rosuvastatin and lorazepam identified on the med cart were expired. Nurse #5 reported she would remove both medications from the med cart and bring them to the Director of Nursing (DON).

3. According to the manufacturer, in-use prefilled pens of Lantus insulin should be stored at room temperature and used within 28 days.

An observation was conducted on 2/4/25 at 6:22 AM of the Front 400 Hall Medication (Med) Cart in the presence of Nurse #1. The observation revealed an in-use Lantus insulin pen dispensed for Resident #175 was not labeled as to when it was opened to allow for the determination of its shortened expiration date. Additionally, the label on the insulin pen did not indicate when it was dispensed from the pharmacy.

At the time of the observation conducted on 2/4/25 at 6:22 AM, Nurse #1 was shown the insulin pen and asked when it had been opened. Nurse #1 stated he did not know and confirmed there was no date written

on the pen to indicate when it was opened.

4. An observation was conducted on 2/4/25 at 6:30 AM of the 400 Hall Medication Storeroom in the presence of Nurse #1 and the facility's Director of Nursing (DON). The observation revealed the following medications were stored in the medication storeroom:

a. The manufacturer's storage instructions for a multi-dose vial of Tuberculin PPD (Purified Protein Derivative) injectable solution (used for skin testing in the diagnosis of tuberculosis) indicated that once opened, the product should be discarded after 30 days.

One (1) opened multi-dose vial of Tuberculin PPD injectable solution was stored in the med room refrigerator. Neither the vial nor the manufacturer box it was stored in were labeled as to when the vial had been opened to allow for the determination of its shortened expiration date.

b. Three (3) unopened stock bottles of 100 micrograms Vitamin B-12 were stored in the medication storeroom. Each bottle contained 100 tablets and was labeled to have a manufacturer expiration date of January 2025.

An interview was conducted with the Director of Nursing (DON) at the time of the med storage observation conducted on 2/4/25 at 6:30 AM. At that time, the DON reported that the Tuberculin PPD injectable solution needed to be discarded, and the stock bottles of Vitamin B-12 also needed to be removed from the medication storeroom due to being past their expiration date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 A follow-up interview was conducted with the DON on 2/7/25 at 8:21 AM. During the interview, the medication storage observations were discussed. The DON reported she had been made aware of the Level of Harm - Minimal harm or concerns related to expired medications and the failure to date medications as to when they were opened. potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38129

Residents Affected - Few Based 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.

Findings included:

1. Resident #185 was admitted to the facility on [DATE REDACTED] with the diagnosis of chronic atrial fibrillation (irregular heartbeat).

A review of Resident #185's hospital record dated 2/5/24 documented the resident had a medication allergy to aspirin and Compazine (nausea).

A review of Resident #185's facility electronic medical record documented the resident had no known allergies in the medication allergy tab. The Medication Administration Record dated February 2024 documented no known allergies. The resident was not prescribed aspirin and/or Compazine. The resident was discharged on [DATE REDACTED].

On 2/6/24 at 1:42 pm an interview was conducted with the Director of Nursing (DON). The DON stated the resident's medication allergy(s) were required to be listed in their medical record by the admitting nurse.

20906

2. Resident #70 was admitted to the facility on [DATE REDACTED] with the diagnosis of type 2 diabetes mellitus, stage 4 prostate cancer and Lupus.

The quarterly Minimum Data Set(MDS) dated [DATE REDACTED] revealed Resident #70's cognition was intact.

Resident #70 had orders dated 11/4/24 for Methadone HCL oral tablet 5mg by mouth one time a day for pain at 8:00 AM and 1.5 tablet by mouth at bedtime(10:00PM).

An interview on was conducted on 02/03/25 at 1:52 PM with Resident#70 who stated back in November 2024 he requested pain medication and was receiving it very late after the scheduled time. Resident #70 stated he did not understand why staff were so late giving him his medication.

A review of Resident #70's Medication Administration Record for November 2024 revealed there was no documentation the medication was given on 11/4/24 at 10:00 PM. The scheduled 10:00 PM dose was documented as administered on 11/5/24 at 9:59 AM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 An interview was conducted on 2/5/25 at 4:00 PM in conjunction with a record review with the Director of Nursing. She reviewed the Medication Administration Audit report and confirmed the scheduled dose Level of Harm - Minimal harm or Methadone of 1.5mg on 11/4/24 at bedtime was not documented until 11/5/24. The Director of Nursing potential for actual harm stated she had received reports from residents that Nurse #18 was not giving medication as scheduled, when she counseled the Nurse#18 about medication administration, she would state she had given the Residents Affected - Few medication and documented late. She stated Nurse #18 no longer worked for the facility due to a history of not documenting when medications were given or not documenting at all.

A telephone interview was conducted on 2/6/25 at 8:40 AM, the assigned Nurse#18 who stated if the medication was scheduled for 10:00 PM she was pretty sure she had given the medication and may have charted late.

A telephone interview was conducted on 2/7/25 at 10:06 AM, with the Nurse Practitioner #2 who stated Resident #40 had reported pain medications were administered late. The Nurse Practitioner#2 further stated

she reviewed the record and there have been times Resident #70 received the pain medication much later than scheduled and there would be late documentation.

38077

3. Resident #187 was admitted to the facility on [DATE REDACTED].

Review of the discharge return not anticipated Minimum Data set assessment dated [DATE REDACTED] revealed the resident was discharged home/ community.

Review of the medical records revealed no nursing notes or AMA form related to Resident's #187 discharge.

During an interview on 2/5/25 at 11:07 AM, Unit Manager #4 stated the resident had brief stay at the facility.

The resident was admitted to the facility on [DATE REDACTED] at around 6:00 PM and left the facility Against Medical Advice (AMA) on 10/15/24. The resident's family were in the facility on 10/15/24 and hurriedly took Resident #187 home. The Unit Manager #4 stated that any resident who wants to be discharged on AMA, the resident/resident representative had to be signed the AMA form. Unit Manager #4 indicated there was no document in the chart that indicated the resident left the facility AMA. The Unit Manager further indicated she was unsure why there was no documentation about the resident leaving the facility AMA.

The nurse assigned to Resident #187 on 10/15/24 was unavailable to be interviewed.

During an interview on 2/7/25 at 1:43 PM, the Administrator indicated if any resident was leaving the facility Against Medical Advice (AMA), then the AMA form should be signed by the resident and/or resident's family. If the family refuses to sign it, then 2 staff members had to sign it as witnesses. The resident's medical records should be uploaded with the AMA form and a note indicating the circumstances of the discharge.

The Administrator indicated Resident #187 was a PACE ( Program of All-Inclusive Care for the Elderly) resident and was closely followed by PACE for all his medical care and other needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Immediate 32394 jeopardy to resident health or safety Based 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 Residents Affected - Few #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. Also, the facility failed to disinfect individually assigned glucometers stored outside of the residents' rooms in accordance with the instructions provided by the manufacturer of the disinfectant wipes for 2 of 3 residents (Residents #66 and #93) observed to have their blood glucose levels checked.

Immediate jeopardy began on 2/4/25 when Nurse #1 was observed to perform blood glucose testing for Resident #107 using a glucometer dedicated to Resident #134 without disinfecting the shared glucometer between residents.

Immediate jeopardy was removed on 2/6/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) for finding #2 and for

the facility to complete agency and employee staff training with monitoring to ensure appropriate interventions are put into place.

The findings included:

The manufacturer instructions for cleaning and disinfecting the (Brand Name) glucometer used at the facility were summarized in a Technical Brief (Revised 9/24). The Technical Brief read in part, To minimize the risk of transmitting bloodborne pathogens, the cleaning and disinfecting procedures should be performed as recommended in the instructions below. The (Brand Name) meter may only be used for testing multiple patients when standard precautions and the manufacturer's disinfecting procedures are followed. The meter should be cleaned and disinfected after use on each patient. The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of bloodborne pathogens .Clean and disinfect

the meter following step-by-step instructions in the Quality Assurance (QA) / Quality Control (QC) Reference Manual.

Cleaning and Disinfecting Procedures specified in the glucometer's QA/QC Reference Manual (Revised 10/24) included, in part:

--Cleaning:

Step 1 (of 7): Wear appropriate protective gear such as disposable gloves.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Step 3 (of 7): Wipe surface of the meter to clean blood and other body fluids .

Level of Harm - Immediate Step 4 (of 7): If blood is visible on the meter, it should be cleaned prior to each disinfection step. jeopardy to resident health or safety --Disinfecting:

Residents Affected - Few Step 5 (of 7): Pull out 1 new towelette and wipe the entire surface of the meter horizontally and vertically to remove bloodborne pathogens. Carefully wipe around the test strip port by inverting the meter so that the test strip port is facing down.

Step 6 (of 7): Treated surface must remain wet for recommended contact time. Please refer to wipe manufacturer's instructions.

The manufacturer's Technical Brief for the glucometer listed the disinfectant wipes used at the facility as one of the EPA-registered wipes recommended to clean and disinfect the (Brand Name) glucometer. The instructions on the label of the disinfectant wipes read in part: To clean and disinfect and deodorize hard, nonporous surfaces: Wipe surface to be disinfected. Use enough wipes to treated surface to remain visibly wet to the contact time listed. Let Dry. Special instructions for cleaning and decontamination against human immunodeficiency virus (HIV), hepatitis B and hepatitis C indicated, Allow surfaces to remain wet for one minute, let air dry. For all other organisms, see directions for contact time. Mycobacterium bovis (an organism that can cause tuberculosis) was killed in 2 minutes. The instructions indicated enough wipes should be used for the treated surface to remain visibly wet for 3 minutes to kill Clostridium difficile spores.

1. A medication administration observation was initiated on 2/4/25 at 5:39 AM with Nurse #1. Nurse #1 identified himself as an agency (temporary staff) nurse. Upon approaching the medication (med) cart, a glucometer was observed to be placed directly on top of the med cart. Nurse #1 reported he needed to do a blood glucose check for Resident #107. Nurse #1 was observed as he collected supplies (a test strip, lancet and alcohol wipe), donned gloves, picked up the glucometer stored on top of the medication cart, and entered Resident #107's room to conduct the blood glucose check. Nurse #1 inserted a strip into the glucometer and used a lancet to puncture the resident's finger. As he held the glucometer (with the strip inserted) at an angle and applied a drop of blood to the strip, the glucometer was observed to have lettering

on the side of the meter. After the blood glucose check was completed, Nurse #1 returned to the med cart and placed the glucometer back on top of the medication cart. The side of the glucometer was observed to be labeled with the name of Resident #134. Nurse #1 removed his gloves, opened a drawer of the med cart, and placed this glucometer in the drawer directly in contact with other glucometers which were each stored inside an individual, resealable bag. As the nurse did so, an individually assigned and labeled glucometer for Resident #107's (in a clear, plastic resealable bag) was observed to be stored in the same drawer. At that time, Resident #107's glucometer was pointed out to the nurse. When asked why Resident #107's assigned glucometer was not used for her blood glucose check, Nurse #1 stated, [I] grabbed the wrong one by mistake.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 The interview with Nurse #1 continued on 2/4/25 at 5:46 AM. During the interview, the nurse was informed that the glucometer (labeled for Resident #134) used to check Resident #107's blood glucose was not Level of Harm - Immediate observed to be disinfected either before or after it was used for her. When asked if this was correct, the jeopardy to resident health or nurse stated, Correct. When asked if it would be correct to say he did not disinfect this glucometer at any safety point in time, he responded, yes. The nurse was then asked when glucometers should be disinfected. Nurse #1 stated, I don't know the routine here. The nurse further explained, I don't know the protocol [at the facility]. Residents Affected - Few Nurse #1 reported he thought that most places where he worked would have the glucometers cleaned only once at the start of the first nursing shift. Upon further inquiry, the nurse confirmed he didn't disinfect any glucometers on his current night shift while working from 7:00 PM - 7:00 AM. He reported Resident #107 was

the only resident whose blood glucose was checked during his shift.

On 2/4/25 at 6:17 AM, a follow-up observation and interview were conducted with Nurse #1. When asked if there were disinfectant wipes stored on the medication cart, Nurse #1 was observed as he pulled each drawer of the med cart open to look. There were no disinfectant wipes stored on the med cart. Nurse #1 stated there should be sanitation wipes in a container on the med cart. However, he added that if these wipes were not available on his med cart, he could always use alcohol wipes kept in individual packets on

the med cart. The nurse held up two packets of alcohol wipes (taken from the medication cart drawer) to show what he could alternatively use for cleaning/disinfection of the glucometers (alcohol is not an EPA-registered disinfectant approved for glucometer disinfection). When asked to confirm whether he had conducted any other blood glucose checks during his shift, he stated, That was the only blood glucose I had to do.

An interview was conducted on 2/4/25 at 6:28 AM with the facility's Director of Nursing (DON) as she was standing nearby in the hallway assigned to Nurse #1. When the DON was informed there were no disinfectant wipes on Nurse #1's medication cart, she provided a container of the facility's EPA-registered disinfectant wipes to enable a review of the manufacturer labeling. The DON reported she would expect

these wipes to be used for glucometer disinfection with a wet contact time of three (3) minutes, as the product labeling indicated.

On 2/4/25 at 1:30 PM, the facility's DON provided a copy of the facility's (Brand Name) glucometer instructions printed on page 47 of its User Instruction Manual. At that time, an interview conducted with the DON revealed the facility did not have a policy/procedure specifically related to glucometer disinfection. The DON reported the facility used the glucometer instructions which read:

Cleaning and Disinfecting Guidelines:

Healthcare professionals should wear gloves when cleaning the [Brand Name] meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting

the meter between patient use.

--Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe.

--To use a wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid in the test strip and key code ports of the meter.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 --Many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used; use one wipe to clean and a second wipe to disinfect. Level of Harm - Immediate jeopardy to resident health or An interview was conducted on 2/7/25 at 8:08 AM with the facility's Infection Preventionist. During the safety interview, the Infection Preventionist was asked what her thoughts were with regards to the concerns identified with the glucometer's disinfection observed on 2/4/25. She stated, It's unfortunate. Residents Affected - Few

A telephone interview was conducted with the facility's Medical Director on 2/6/25 at 2:27 PM to discuss the concerns related to glucometer disinfection identified during observations conducted at the facility. When asked, the Medical Director reported she had been informed of these concerns. She stated, This is the first time I have heard of this happening. The Medical Director reported she thought glucometer disinfection required better learning or training for all staff throughout.

Upon request, the facility provided a Diagnosis Report for its current residents (dated 2/4/25 at 3:39 PM).

The Diagnosis Report indicated 18 residents were identified as having at least one bloodborne pathogen, which included hepatitis B, hepatitis C, and HIV.

The facility's Administrator and DON were informed of the immediate jeopardy (IJ) on 2/4/25 at 3:00 PM.

The facility provided the following plan for IJ removal:

Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of

the noncompliance

On 02/04/2025, an agency nurse used a glucometer (blood glucose meter) dedicated to Resident #134 for Resident #107 without disinfecting the shared glucometer between residents. This occurred for 1 of 3 residents who were observed to have their blood glucose checked (Resident #107). At the time of the incident, Resident #107 had an assigned glucometer that was properly labeled with a label maker and stored

in the medication cart, but the agency nurse incorrectly used another resident's glucometer instead.

All residents requiring blood glucose checks are at risk of being affected by this practice. An audit conducted by the Director of Nursing and nursing unit coordinators on 02/04/2025 identified all facility residents requiring blood glucose checks. All residents were confirmed to have an individual glucometer assigned. Each glucometer is labeled with the resident's name using a label maker and stored in individual re-sealable plastic bags in the medication cart.

The following immediate actions were taken for affected residents:

- At approximately 7:00 AM on 02/04/2025, upon discovery of the incident, the Director of Nursing and the Unit Coordinator cleaned and disinfected the glucometer per manufacturer guidelines and professional standards

- On 02/04/2025, Resident #107 was assigned a new individual glucometer by the Unit Coordinator, labeled with the resident's name using a label maker and stored in an individual re-sealable plastic bag in the medication cart

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 - Resident #107's medical provider was notified of this occurrence by the Director of Nursing with no additional instructions provided Level of Harm - Immediate jeopardy to resident health or Specify the action the entity will take to alter the process or system failure to prevent a serious adverse safety outcome from occurring or recurring, and when the action will be complete

Residents Affected - Few The following systemic changes have been implemented as of 02/04/2025:

1. Staff Education and Competency Validation:

- The agency nurse involved was contacted by telephone by the Director of Nursing to provide education regarding proper glucometer disinfection protocols. The Director left a voicemail, and the nurse will not be allowed to accept a resident care assignment at 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

- 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

- 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

2. Process Changes:

- Visual reminders have been placed on all medication carts outlining the complete glucometer procedure:

1. Obtain needed equipment and supplies:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 - Gloves

Level of Harm - Immediate - Glucometer jeopardy to resident health or safety - Alcohol pads

Residents Affected - Few - Single-use lancet

- Blood glucose testing strips

- Disinfecting wipes

2. Perform hand hygiene

3. Explain procedure to resident

4. Provide privacy

5. [NAME] gloves

6. Obtain blood glucose sampling

7. Remove and discard gloves, perform hand hygiene

8. Retrieve (2) disinfectant wipes

9. Clean with first wipe to remove soil/blood

10. Disinfect with second wipe, maintaining 3-minute wet contact time

11. Allow to air dry

12. Discard wipes

13. Perform hand hygiene

This infection control breach was reported to the local health department on 2/5/2025, and they provided no further recommendations.

Immediate Jeopardy Removal Date: 2/6/2025

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 The facility's credible allegation of immediate jeopardy removal was validated on 2/7/25. The validation was evidenced by nurse observations and/or interviews conducted on each hallway with regards to the required Level of Harm - Immediate infection control practices for the disinfection of glucometers. All nurses who were interviewed reported they jeopardy to resident health or had received the required in-service training prior to beginning their shift. The education provided stressed safety the importance of using individually assigned glucometers for each resident requiring blood glucose monitoring and storing these glucometers in individual, re-sealable plastic bags. The in-service training also Residents Affected - Few included a review of the manufacturer's instructions for the facility's glucometer and disinfectant wipes related to glucometer disinfection, as well as completing a return demonstration of the proper procedures for effective glucometer disinfection. Nurses observed to conduct blood glucose checks and subsequent glucometer disinfection completed the task without difficulty. The nursing practices observed included the proper handling and storage of glucometers to protect the meters from potential cross-contamination via contact with other meters or surfaces. There were no concerns identified during either the interviews or

observations.

The credible allegation was validated, and the immediate jeopardy was removed on 2/6/25.

2. An observation of blood glucose checks and medication administration was initiated on 2/4/25 at 12:04 PM with Nurse #2. Nurse #2 identified herself as an agency (temporary staff) nurse. As the nurse prepared to conduct a blood glucose check for Resident #66, she removed his individually assigned (and labeled) glucometer from the medication (med) cart drawer. The glucometer labeled for Resident #66 was observed to have been stored in the med cart drawer directly in contact with six (6) other glucometers which were stored in individual, resealable bags. The glucometer for Resident #66 was not stored in an individual, resealable bag. Nurse #2 was observed as she placed the glucometer directly on top of the med cart and collected supplies for the blood glucose check (a test strip, lancet and alcohol wipe) and placed these supplies in a clean plastic cup. The nurse removed a container containing (Brand Name) disinfectant wipes from the bottom drawer of the medication cart and placed it on top of the cart. She did not use any of the disinfectant wipes at that time. Nurse #2 was observed as she picked up the cup (containing the supplies) and glucometer and entered Resident #66's room to conduct a blood glucose check. Upon entering the resident's room, Nurse #2 placed the cup and glucometer on Resident #66's dresser while she used hand sanitizer and donned gloves. The nurse checked Resident #66's blood glucose. On 2/4/25 as 12:12 PM, Nurse #2 returned to the med cart. At that time, she disposed of the used supplies, placed the glucometer directly on the pullout tray of the med cart, and removed her gloves. The nurse performed hand hygiene with hand sanitizer and donned clean gloves. Nurse #2 then picked up the glucometer and used one disinfectant wipe to wipe the meter for 15 seconds. Afterwards, she placed the glucometer back on top of the pullout tray of the med cart, then into the drawer of the medication cart with the other glucometers. She did not place Resident #66's meter in an individual, resealable bag.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 The observation of Nurse #2 continued on 2/4/25 at 12:15 PM as the nurse prepared to check Resident #93's blood glucose. The nurse was observed as she pulled Resident #93's individually assigned (and Level of Harm - Immediate labeled) glucometer from the medication (med) cart drawer. His glucometer was observed to be stored in an jeopardy to resident health or individual, resealable bag while in the drawer. Nurse #2 placed the glucometer (in the bag) on top of the med safety cart and began to collect the supplies needed for Resident #93's blood glucose check. The nurse reported

this resident also needed to receive 3 units of Novolin R (regular) insulin. However, she was unable to find Residents Affected - Few an insulin syringe on the med cart. On 2/4/25 at 12:18 PM, the nurse picked up the glucometer (still in the bag) and supplies and left the med cart to retrieve an insulin syringe. She returned to the med cart on 2/4/25 as 12:23 PM. Upon her return, Nurse #2 placed the glucometer (stored in the bag) and supplies on the top of

the med cart. After all of the supplies were collected, Nurse #2 performed hand hygiene and donned a gown and gloves prior to entering the resident's room. Resident #93's room was currently on Enhanced Barrier Precautions (EBP). EBP is an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. On 2/4/25 at 12:27 PM, Nurse #2 entered Resident #93's room, removed his glucometer from its bag and placed the meter on a bedside tray table.

After checking the resident's blood glucose level, the glucometer was again placed on the tray table while the nurse administered the resident's insulin. On 2/4/25 at 12:32 PM, Nurse #2 picked up the glucometer and used supplies and returned to the medication cart. She discarded the used supplies and placed the meter directly on the pullout tray of the med cart. The nurse removed her gloves, performed hand hygiene, and donned clean gloves. She then picked up the glucometer and used one disinfectant wipe to wipe the surface of the glucometer for 20 seconds. The meter was placed directly on top of the med cart as Nurse #2 removed her gloves, put the glucometer back into its individual resealable bag, and returned it to the med cart drawer.

An interview was conducted on 2/4/25 at 12:35 PM with Nurse #2. During the interview, the nurse was asked what the required wet contact time was for the disinfectant wipe to be effective in disinfecting the glucometer. Nurse #2 responded by stating she did not know. When asked, the nurse acknowledged Resident #93's glucometer was not visibly wet when it was put away. Additionally, concern related to the potential for the cross-contamination of both Resident #66's and Resident #93's glucometers was discussed.

During an interview conducted on 2/4/25 at 6:28 AM, the facility's Director of Nursing (DON) reported she would expect the facility's EPA-registered wipes to be used for glucometer disinfection with a wet contact time of three (3) minutes, as the product labeling indicated. On 2/4/25 at 1:30 PM, the facility's DON provided

a copy of the facility's (Brand Name) glucometer instructions printed on page 47 of its User Instruction Manual. At that time, an interview conducted with the DON revealed the facility did not have a policy/procedure specifically related to glucometer disinfection. The DON reported the facility used the glucometer instructions which read:

Cleaning and Disinfecting Guidelines:

Healthcare professionals should wear gloves when cleaning the [Brand Name] meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting

the meter between patient use.

--Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 46 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 --To use a wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid in the test strip and key code ports of the meter. Level of Harm - Immediate jeopardy to resident health or --Many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two safety wipes must be used; use one wipe to clean and a second wipe to disinfect.

Residents Affected - Few Upon request, the facility provided a Diagnosis Report for its current residents (dated 2/4/25 at 3:39 PM).

The Diagnosis Report indicated 18 residents were identified as having at least one bloodborne pathogen, which included hepatitis B, hepatitis C, and human immunodeficiency virus (HIV).

A follow-up interview was conducted on 2/5/25 at 8:40 AM with the facility's DON. During this interview, the DON reported it was assumed that agency nurses had received training to ensure their overall competency to care for residents prior to being hired and assigned to work in their facility.

An interview was conducted on 2/7/25 at 8:08 AM with the facility's Infection Preventionist (IP). During the interview, the IP was asked what her thoughts were with regards to the concerns identified with the glucometers' disinfection observed on 2/4/25. She stated, It's unfortunate. She added that the facility initiated education and training then and there immediately after the concerns were brought to the facility's attention

on 2/4/25.

A telephone interview was conducted with the facility's Medical Director on 2/6/25 at 2:27 PM to discuss the concerns related to glucometer disinfection identified during observations conducted at the facility. When asked, the Medical Director reported she had been informed of these concerns. She stated, This is the first time I have heard of this happening. The Medical Director reported she thought glucometer disinfection required better learning or training for all staff throughout.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 46 345434