Inspection Reports for
Carter Nursing and Rehabilitation
250 MCDAVID BLVD, GRAYSON, KY, 41143
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
64% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 29, 2025
Visit Reason
The inspection was conducted following a complaint alleging verbal abuse, neglect, and poor care of Resident 29, including failure to provide timely hygiene care after an incontinent episode and inappropriate staff behavior.
Complaint Details
The complaint investigation was substantiated. Resident 29 was verbally abused and neglected by staff who left her in feces for hours after a fall and incontinent episode. Staff failed to report the abuse timely. The facility suspended involved staff and reported to authorities.
Findings
The facility failed to protect Resident 29 from verbal abuse and neglect resulting in actual harm, failed to timely report suspected abuse, failed to meet professional standards in medication administration for Resident 42, failed to follow safe food handling practices affecting all residents, and failed to ensure proper infection prevention related to catheter care for Resident 12.
Deficiencies (5)
F600: The facility failed to protect Resident 29 from verbal abuse and neglect by staff who left her in feces for over three hours, causing psychosocial harm.
F609: The facility failed to timely report suspected abuse and neglect of Resident 29 to the Administrator and proper authorities.
F658: The facility failed to ensure medication administration met professional standards when Resident 42 was given Zofran without a valid standing or provider's order.
F812: The facility failed to follow safe food handling practices, including improper hand hygiene by dietary staff and failure to label, date, and discard expired food items, potentially affecting all residents.
F880: The facility failed to ensure proper infection prevention by allowing Resident 12's catheter urine collection bag to lie on the floor, increasing risk of infection.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SRNA1 | State Registered Nurse Aide | Named in verbal abuse and neglect of Resident 29 |
| SRNA11 | State Registered Nurse Aide | Named in neglect of Resident 29 |
| SRNA10 | State Registered Nurse Aide | Failed to report abuse and later cleaned Resident 29 |
| LPN11 | Licensed Practical Nurse | Administered Zofran without proper order for Resident 42 |
| KMA14 | Kentucky Medication Aide | Administered Zofran without proper order for Resident 42 |
| DA2 | Dietary Aide | Failed to perform hand hygiene and glove use during food handling |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 29, 2025
Visit Reason
The inspection was conducted following a complaint regarding neglect and verbal abuse of Resident 29 by staff members, as well as failure to report suspected abuse promptly.
Complaint Details
The complaint involved Resident 29 being verbally abused and neglected by staff members SRNA1 and SRNA11, who left her in feces for hours and made inappropriate remarks. SRNA10 failed to report the abuse promptly. The facility suspended the involved staff and reported the incident to the Office of Inspector General and local police. Resident 29 was cognitively intact and dependent on staff for toileting hygiene.
Findings
The facility failed to protect Resident 29 from verbal abuse and neglect, resulting in actual harm. Additionally, staff failed to timely report suspected abuse. Another finding involved improper medication administration for Resident 42 without a valid standing or provider order.
Deficiencies (3)
F600: The facility failed to ensure Resident 29 was free from verbal abuse and neglect, leaving her in a soiled condition for over three hours, causing psychosocial harm.
F609: The facility failed to timely report suspected abuse and neglect of Resident 29 to the Administrator and authorities as required by policy.
F658: The facility failed to ensure medication administration met professional standards when Resident 42 was given Zofran without a valid standing or provider order.
Report Facts
Residents reviewed for medication administration: 6
Residents sampled: 10
BIMS score: 15
BIMS score: 3
Medication administration time: 3.54
Medication order time: 3.52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SRNA1 | State Registered Nurse Aide | Named in verbal abuse and neglect of Resident 29. |
| SRNA11 | State Registered Nurse Aide | Named in neglect of Resident 29. |
| SRNA10 | State Registered Nurse Aide | Failed to report suspected abuse of Resident 29. |
| LPN11 | Licensed Practical Nurse | Entered medication order for Zofran and acknowledged error in standing order assumption. |
| KMA14 | Kentucky Medication Aide | Administered Zofran without a valid standing or provider order. |
| Administrator | Facility Administrator | Suspended involved staff and reported incident to authorities. |
| Medical Director | Medical Director | Interviewed regarding medication administration and standing orders. |
| Director of Nursing | Director of Nursing | Stated expectations for medication administration and standing orders. |
Inspection Report
Routine
Deficiencies: 11
Date: Jul 17, 2023
Visit Reason
Routine inspection of Carter Nursing and Rehabilitation to assess compliance with healthcare regulations including resident safety, care planning, medication administration, infection control, and facility maintenance.
Findings
The facility had multiple deficiencies including failure to prevent misappropriation of resident property, inadequate background checks, incomplete care plans, unsafe water temperatures causing immediate jeopardy, medication errors, improper medication storage, failure to accommodate resident food allergies, improper food storage, and lapses in infection prevention practices.
Deficiencies (11)
F0602: The facility failed to protect a resident from misappropriation of property when a staff member removed and replaced a resident's ring without consent.
F0606: The facility failed to screen a new employee for disqualifying offenses in the background check, hiring a Maintenance Director with prior convictions.
F0656: The facility failed to develop and implement effective care plan interventions to prevent resident-to-resident altercations for four residents.
F0657: The facility failed to update a resident's care plan within 7 days of readmission to include ostomy care interventions.
F0689: The facility failed to maintain safe water temperatures, with readings up to 120°F, posing immediate jeopardy to resident safety.
F0689: The facility failed to ensure mechanical lifts were safe, with one sit-to-stand lift having a crooked footplate.
F0759: The facility failed to ensure medication error rates were below 5%, with 11% error rate due to unavailable medications during administration.
F0761: The facility failed to maintain proper temperature control for medications stored in the North Hall medication refrigerator, with temperatures up to 50°F and missing temperature logs.
F0806: The facility failed to accommodate a resident's food allergy to chocolate, administering medications in a chocolate fudge cookie.
F0812: The facility failed to store food safely in nourishment refrigerators, with elevated temperatures, unlabeled food, and incomplete temperature logs.
F0880: The facility failed to maintain an effective infection prevention program by not requiring staff to wear gowns when providing high-contact care to a resident on Enhanced Barrier Precautions.
Report Facts
Medication error rate: 11
Water temperature: 120
Medication refrigerator temperature: 50
Nourishment refrigerator temperature: 53
Nourishment refrigerator temperature: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Named in medication error for administering medication in chocolate fudge cookie despite resident allergy. |
| SRNA #11 | State Registered Nurse Aide | Failed to wear gown during Enhanced Barrier Precautions care. |
| SRNA #25 | State Registered Nurse Aide | Failed to wear gown during Enhanced Barrier Precautions care. |
| SRNA #26 | State Registered Nurse Aide | Failed to wear gown during Enhanced Barrier Precautions care. |
| Maintenance Director | Failed to replace broken thermostat causing unsafe water temperatures; failed to properly inspect mechanical lifts. | |
| LPN #12 | Licensed Practical Nurse | Observed medication administration with unavailable medications. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 17, 2023
Visit Reason
The inspection was conducted as an annual survey of Carter Nursing and Rehabilitation to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 5, 2023
Visit Reason
The inspection was conducted due to complaints and allegations regarding failure to maintain safe room temperatures, resident-to-resident abuse, and misappropriation of resident property.
Complaint Details
The complaint investigation was substantiated with findings of immediate jeopardy related to unsafe room temperatures and multiple substantiated incidents of resident-to-resident abuse and misappropriation of resident property.
Findings
The facility failed to maintain safe and comfortable room temperatures between 71 and 81 degrees Fahrenheit, resulting in immediate jeopardy to resident health and safety. Multiple incidents of resident-to-resident abuse were documented, affecting eleven residents. Additionally, one incident of misappropriation of resident property was identified and addressed.
Deficiencies (3)
F 0584: The facility failed to maintain room temperatures between 71 and 81 degrees Fahrenheit, exposing ten residents to unsafe heat conditions, causing immediate jeopardy to resident health and safety.
F 0600: The facility failed to protect eleven residents from resident-to-resident abuse, including physical assaults such as hitting, slapping, and throwing coffee.
F 0602: The facility failed to keep one resident free from misappropriation of property when a staff member removed and replaced the resident's ring without consent.
Report Facts
Residents affected by temperature issue: 10
Residents affected by abuse: 11
Number of air conditioning units repaired or replaced: 2
Temperature readings: 91.3
Number of air conditioning units serviced: 10
Number of fans purchased: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SRNA #29 | State Registered Nurse Aide | Witnessed and reported resident-to-resident abuse involving coffee throwing. |
| LPN #5 | Licensed Practical Nurse | Responded to resident-to-resident abuse incident involving coffee throwing and head hitting. |
| LPN #10 | Licensed Practical Nurse | Witnessed and failed to redirect resident leading to resident-to-resident abuse incidents. |
| SRNA #31 | State Registered Nurse Assistant | Involved in misappropriation of resident property by removing and replacing resident's ring. |
| Director of Nursing | Director of Nursing | Provided assessments and investigations related to resident abuse and environmental safety. |
| Executive Director | Executive Director | Oversaw investigations and facility response to abuse and environmental safety issues. |
Inspection Report
Routine
Deficiencies: 1
Date: Nov 7, 2019
Visit Reason
The inspection was conducted to assess compliance with medication storage and administration policies, focusing on ensuring drugs and biologicals are stored securely and only authorized personnel have access.
Findings
The facility failed to ensure medications were stored in locked compartments and left medications unattended in a resident's room, posing a risk to wandering residents. There was no documented evidence that the resident was assessed as able to self-administer medications, and staff left medications unattended contrary to facility policy.
Deficiencies (1)
F 0761: The facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys. Medications were found unattended in Resident #70's room despite the presence of wandering residents.
Report Facts
Residents sampled: 24
Residents who wander: 8
Pills found unattended: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Removed unattended medications from Resident #70's room and involved in medication handling |
| Kentucky Medication Aide #1 | Medication Aide | Left medications unattended in Resident #70's room |
| Unit Manager Registered Nurse #1 | Registered Nurse | Provided expectations on medication administration and storage |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding medication storage policies and risks |
| Director of Nursing | Director of Nursing | Interviewed regarding medication storage policies and handling of refused medications |
| Administrator | Administrator | Interviewed regarding facility expectations on medication storage and resident safety |
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