Carver Living Center

Resident #104.

On 8/2/2024, the facility nurse interviewed known resident witnesses.

On 8/3/2024, Resident #52 and Resident #104 were re-interviewed by Director of Nursing.

On 8/3/2024, Resident witnesses were reinterviewed by Director of Nursing.

On 8/3/2024, Resident #52's physician was contacted by the Director of Nursing and new orders were received.

On 8/3/2024, Resident #52 completed a telehealth visit with the mental health physician with new orders obtained.

On 10/20/24, Resident #17 and Resident #47 were immediately separated by facility staff.

Resident#47 was placed with 1:1 supervision. Resident #47 was assessed by the facility nurse on 10/20/24 with no negative findings or change of condition. Resident #17 was assessed by the facility nurse with pain and edema noted to left eye orbit and no other change of condition.

On 10/20/24 the provider was notified by the licensed nurse of the assessment of findings for Resident#17. An order for x-ray was obtained. Resident #47's provider was notified and there were no new orders.

On 10/20/24 Resident #17 was assessed for psychosocial harm by the licensed nurse with no ill effects. Resident #17 and Resident #47's responsible parties were notified of the incident by the licensed nurse.

On 10/21/24 Resident #47's care plan was updated to include intervention for 1:1 supervision and Resident #14's x-rays returned with no findings related to this occurrence.

Psych evaluation completed 10/23/24 for Resident #17 and Resident #47.

Root cause analysis was conducted on 10/20/2024: Resident to resident altercation occurred between Resident #14 and Resident #47 in the smoking area. Resident #47 experienced frustration and tension due to overcrowding in the designated smoking space.

The designated smoking area was too small to comfortably accommodate the number of residents who smoke.

The facility's original space plan didn't adequately account for the number of residents who smoke and their need for personal space while smoking.

The facility evaluated the current smoking area was too small which attributed to these behaviors, so the smoking area was moved to a larger area.

Address how the facility will identify other residents at risk and determine if there were any identified problems for those residents: All residents were at risk.

Resident interviews were completed with residents with a brief interview for mental status (BIMS)

345434 02/07/2025

Carver Living Center 303 East Carver Street Durham, NC 27704

Findings included: Resident #382 was admitted on [DATE].

His diagnoses included influenza due to influenza virus with other respiratory manifestations, unsteadiness of feet, and muscle weakness.

Review of Resident #382's baseline care plan initiated on 1/29/25 only included information on medication allergies and code status.

An interview was conducted on 2/06/25 at 5:04 PM with Minimum Data Set (MDS) Coordinator #1.

She stated upon admission that the initial care plans were completed by the admitting nurse.

After reviewing Resident #382's baseline care plan, she noted it had been opened on 1/29/25, the date after admission, but not completed and only included his allergies and code status.

She explained the baseline care plan should have been completed by the admitting nurse.

An interview with the Director of Nursing (DON) was conducted on 2/07/25 at 9:20 AM.

The DON stated the baseline care plans should have been completed with the admission assessment.

345434 02/07/2025

Carver Living Center 303 East Carver Street Durham, NC 27704

During the interview, the Administrator stated, The care plan needs to be reflective of the MDS to meet the needs of the resident.

box (as 2 - 2.5 mg tablets of apixaban).

She provided an Active Inventory list of medications currently

345434 02/07/2025

Carver Living Center 303 East Carver Street Durham, NC 27704

Resident #47's splint was applied, refused or removed.

She further stated nursing and/or nurse aide

the nursing staff to follow the physician orders and therapy instructions for the application of the splint, document appropriately on the Medication Administration Record (MAR) and the Minimum Data Set (MDS) Coordinators to update the resident's care plan.

345434 02/07/2025

Carver Living Center 303 East Carver Street Durham, NC 27704

During an interview on 2/6/25 at 10:42 AM, the Director of Nursing (DON) explained Resident #65 was changed to a supervised smoker as she was observed smoking in a non-smoking area.

The resident was reeducated on the smoking policy and educated on handing over the smoking material to the Smoking Aides after smoking.

The DON indicated that the Smoking Aides had a list of residents who smoked and if they were supervised smoker or not.

The Smoking Aides were supposed to collect all smoking materials when the residents return from the smoking area.

The smoking materials were locked up so that no residents has access to the smoking materials.

During an interview on 2/7/25 at 11:42 AM the Administrator stated the Unit Manager does periodically follow up with Resident #65 regarding having possession of smoking materials, which the resident denies.

The Administrator stated it was his expectation that all smoking materials (cigarettes and lighters) were maintained by facility and be provided to the residents when they go out to smoke.

345434 02/07/2025

Carver Living Center 303 East Carver Street Durham, NC 27704

7:00 am, were unsuccessful.

prefilled bag of enteral formula was observed with no date, time and initials on the label, and there

feeding was started prior to her reporting to work on 2/6/2025 at 7:00 am on the night shift.

She stated nurses were to record the date and time on the label when hanging a new bag of enteral formula.

Attempts to interview Nurse #16, who was assigned to Resident #482 on 2/5/2025 from 7:00 pm to 7:00 am, were unsuccessful.

On 2/7/2025 at 4:25 pm in a follow up interview with Nurse #13, she explained the only way nurses knew when the bag of ready to hand prefilled enteral formula was connected to Resident #482 for administration was by the date and time recorded on the enteral formula label.

She further explained the time documented on Resident #482's MAR indicated the enteral formula was infusing as ordered by the physician, not the time the enteral formula was started.

In an interview with the Director of Nursing on 2/7/2025 at 5:30 pm, she stated enteral formula hung for 24 hours and nurses should always label Resident #482's enteral formula bag with the date, time, and initials to communicate when a new bag of enteral formula was started for administration.

345434 02/07/2025

Carver Living Center 303 East Carver Street Durham, NC 27704

reported this sounded like a training issue and stated, This is the first time I have heard of this

jeopardy to resident health or or training for all staff throughout. safety

345434 02/07/2025

Carver Living Center 303 East Carver Street Durham, NC 27704

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).

345434 02/07/2025

Carver Living Center 303 East Carver Street Durham, NC 27704

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).

• 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.

• 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.

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 concerns related to expired medications and the failure to date medications as to when they were opened.

345434 02/07/2025

Carver Living Center 303 East Carver Street Durham, NC 27704

Review of the discharge return not anticipated Minimum Data set assessment dated [DATE] 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] 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.

345434 02/07/2025

Carver Living Center 303 East Carver Street Durham, NC 27704

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.

345434 02/07/2025

Carver Living Center 303 East Carver Street Durham, NC 27704

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.

345434

Form Approved OMB

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