Carter Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Carter Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF584Jul 17, 2023

  Based on observation, interview, record review, review of the website accuweather.com, and review of the facility's policies, it was determined the facility failed to have an effective system to address an ongoing problem with its cooling system by ensuring the room temperatures were safely maintained between seventy-one (71) degrees Fahrenheit (F) and eighty-one (81) degrees F. The facility also failed to ensure a safe, comfortable and homelike environment was provided to residents for ten (10) of fifty (50) sampled residents (residents that had room temperatures taken), Resident #23, #34, #47, #77, #81, #86, #94, #101, #108, and #118. […]

• Immediate jeopardy, patternF689Jul 17, 2023

  Based on observation, record review, review of the facility's documents, and review of the facility's policy, it was determined the facility failed to ensure the residents' environment remained free of accident hazards related to water temperatures outside the acceptable range for thirty-two (32) of one hundred ten (110) residents (Resident #94, #64, #98, #25, #16, #46, #90, #69, #108, #77, #60, #107, #95, #85, #414, #53, #99, #68, #34, #36, #54, #15, #73, #71, #100, #26, #21, #70, #31, #91, #9, and #164). Observation of water temperature checks on 07/10/2023 beginning at 4:43 PM, revealed water temperatures in Rooms 14, 15, 16, 19, 20, 23, 29, 48, 49, and 50 were not within the acceptable parameters for ensuring resident safety. […]

• Actual harm, isolatedF600Aug 29, 2025

  Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from verbal abuse and neglect which resulted in actual harm for 1 out of 10 sampled residents, Resident (R) 29. On 08/24/2025, Resident 29 had an incontinent episode and required the assistance of staff to help change her. However, instead of changing the resident, State Registered Nurse Aide (SRNA) 1 became verbally abusive to the resident and both, SRNA1 and SRNA11, neglected to provide the resident hygiene care to remove the feces from the resident. Instead, SRNA 1 and SRNA 11 covered the resident with a feces-covered blanket for a period of over three hours. […]

• Actual harm, isolatedF609Aug 29, 2025

  Based on interview, record review, and review of the facility's policy, State Registered Nurse Aide (SRNA) 10 failed to immediately report an allegation of staff abuse/neglect for 1 of 10 sampled residents, Resident (R) 29.SRNA10 did not notify the Administrator when R29 reported to her that SRNA1 and SRNA11 failed to provide timely hygiene care and left R29 soiled for hours after an episode of fecal incontinence on 08/24/2025. Resident 29 stated the SRNAs actions were neglectful of her care which made her scared of SRNA1, and SRNA10 reported the resident was visibly upset, causing the resident psychosocial harm.Refer to F600The findings include:Review of the facility's policy titled, Abuse, Neglect, Misappropriation and Exploitation Policy, dated 07/01/2025, revealed abuse was the willful… […]

• No harm, potential for more than minimal, widespreadF812Aug 29, 2025

  Based on observation, interview, review of the U.S. Food and Drug Administration 2022 Food Code, and facility policy review, the facility failed to follow safe food handling practices, ensure food items located in dry storage were properly labeled and dated, and ensure expired food items were discarded. This had the potential to affect all 112 current residents that received food from the kitchen.The findings include:Review of the document, U.S. Food and Drug Administration 2022 Food Code, 01/18/2023 Version, in Chapter 3 Food, revealed food employees would not contact exposed, ready-to-eat food with bare hands and shall use single-use gloves. It also stated food employees shall minimize bare hand contact with exposed food not in a ready-to-eat form. […]