Carver Living Center

In the surveyor’s words

From the most serious findings on record at Carver Living Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF880May 22, 2025

  Based on record reviews, observations, and interviews with staff and the Medical Director, the facility staff failed to utilize a resident's assigned blood glucose meter (glucometer) and instead used a loose, unassigned, and unlabeled glucometer located in the medication cart to check Resident #8's blood glucose (sugar) level. In addition, the staff member did not disinfect the glucometer before or after obtaining Resident #8's blood glucose level and would have had no way to know if another staff member had previously disinfected the loose, unassigned, and unlabeled glucometer. This occurred while there were 11 residents identified with a known bloodborne pathogen in the facility with 4 of the 11 residents requiring blood glucose levels. […]

• Immediate jeopardy, isolatedF600Apr 11, 2025

  Based on record reviews, and interviews with staff, Physician Assistant, and responsible party (RP), the facility failed to protect 2 cognitively impaired residents' right to be free from sexual abuse. On 4/4/25 at approximately10:00 PM, a Medication Aide observed a female resident (Resident #1) in a male resident's (Resident #2) room sitting upright on Resident #2's bed. Resident #2 was standing in front of Resident #1 with his pants down and his penis inside of her mouth. When the Medication Aide asked what was going on, Resident #2 backed away from Resident #1 removing his penis from her (Resident #1) mouth. The residents did not have the capacity to consent to sexual relations. […]

• Immediate jeopardy, isolatedF726Feb 7, 2025

  Based on record reviews, observations, and interviews with staff and Medical Director, the facility failed to provide an agency nurse (Nurse #1) with orientation and training to meet residents' care needs, including education and verification of the nurse's competency on glucometer (blood glucose meter) disinfection. Nurse #1 used a shared glucometer without disinfecting the meter between residents for 1 of 3 residents (Resident #107) who was observed to have her blood glucose checked. This occurred while there were 18 residents identified with a known bloodborne pathogen in the facility. […]

• Immediate jeopardy, isolatedF880Feb 7, 2025

  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. […]

• Immediate jeopardy, isolatedF600May 4, 2023

  Based on observations, record review and interviews with resident, family, staff, and Emergency Medical Services paramedic, Police Detective, Nurse Practitioner, psychiatry provider, and Medical Director, the facility failed to protect a resident's right to be free from physical abuse when a resident (Resident #1) assaulted another resident (Resident #2) for 1 of 3 residents reviewed for resident-to-resident abuse. On [DATE], Resident #1 approached his roommate (Resident #2) with a knife (described as a butter knife on a meal tray) to cut Resident #2's head. Resident #2 initially pushed Resident #1 away; however, Resident #1 returned to Resident #2's bedside multiple times and continued to cut his head with the knife. […]