East Carolina Health and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews with staff and Physicians the facility failed to notify the physician when residents developed pressure sores for 2 of 3 sampled residents with pressure sores (Residents # 1 and Resident #8).The findings included:1. Resident # 1 resided at the facility from 3/11/25 until her discharge to the hospital on 8/29/25. Resident # 1's diagnoses included cellulitis of the lower extremities, lymphedema, venous insufficiency, chronic kidney disease, anxiety, and gout.Resident # 1's electronic record included pictures as part of the documentation regarding Resident # 1's sacral pressure sore development and assessment. The first picture was recorded on 4/4/25. In the documented picture, the sacral pressure sore appeared to have both black and yellow slough tissue in the wound bed.The electronic record did not include orders on 4/4/25 for the treatment of the pressure sore or that the physician was contacted.The Wound Care Nurse was interviewed on 9/9/25 at 4:15 PM and on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews with staff and physicians the facility failed to 1) ensure Nurse Aides reported skin breakdown to a nurse prior to the wound bed being unstageable (Resident # 1); 2) ensure effective communication amongst nursing staff and the Wound Physician to ensure orders were obtained, initiated, and carried out for pressure sore treatments per the Wound Care Physician's plan of care (Resident # 1 and Resident #8); 3) ensure further diagnostic studies were completed per the Wound Care Physician's directions when a wound continued not to heal (Resident # 1), and 4) ensure the settings of a pressure relieving air mattress were set correctly for pressure relief (Resident # 8). This was for 2 of 3 of three sampled residents with pressure sores (Residents # 1 and # 8). The findings included:1. Resident # 1 resided at the facility from [DATE] until her discharge to the hospital on [DATE]. Resident # 1's diagnoses included cellulitis of the lower extremities, lymphedema, venous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, Resident Representative (RR), and staff interviews, the facility failed to invite a resident to participate in the development of his plan of care for 1 of 3 residents were reviewed for care planning (Resident #271). The findings included: Resident #271 was admitted to the facility on [DATE], and his diagnosis included non-traumatic brain dysfunction, renal insufficiency, diabetes, and hypertension. Resident #271's care plan dated 11/22/24 revealed a goal to discharge to the community by the next review period with a target date of 12/11/24. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed resident #271 was cognitively intact. An interview with Resident #271 was held on 12/16/24 at 2:18 PM during which he stated he had never been invited to participate in the development of his plan of care. An interview with Resident #271's Resident Rrepresentative was held on 12/18/24 at 2:02 PM, she stated she had not ever been invited to participate in the development of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days following the Assessment Reference Date (ARD, last day of the assessment period) for 1 of 2 residents reviewed for assessments (Resident #48). Findings included: Resident #48 was admitted to the facility on [DATE]. Review of Resident #48's MDS assessments revealed a quarterly MDS assessment with an ARD of 11/15/24 in the electronic health record with the status of in progress. During an interview on 12/17/24 at 12:45 PM MDS Nurse #1 and MDS Nurse #2 stated quarterly MDS assessments were to be completed no later than the ARD plus 14 calendar days. Due to staffing challenges, they were behind with Resident #48's quarterly MDS assessment and it was not completed timely according to the Resident Assessment Instrument (RAI) manual requirements as the assessment was still in progress. During an interview on 12/18/24 at 8:23 AM the Administrator stated MDS assessments should be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code a Minimum Data Set (MDS) assessment for antipsychotic use, hospice status, and wound status for 3 of 18 resident assessments reviewed (Resident #50, Resident #58, and Resident #173). Findings included: 1. Resident #50 was admitted to the facility on [DATE]. Review of Resident #50's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was assessed to have received an antipsychotic medication during the 7-day look back period. Review of Resident #50's Medication Administration Record (MAR) for November 2024 revealed Resident #50 did not receive an antipsychotic medication in November 2024. During an interview on 12/17/24 at 12:54 PM MDS Nurse #1 and MDS Nurse #2 stated due to staffing difficulties they were pulling answers forward from the previous assessment and then validating the information to save time when completing MDS assessments. Risperdal was discontinued on 10/2/24 for Resident #50 but the question was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop and implement a comprehensive care plan for a resident that exhibited aggressive verbal behaviors, a resident prescribed an antipsychotic medication, and a resident that had a surgical wound, for 3 of 18 residents reviewed for development and implementation of a comprehensive care plan (Resident #55, Resident #62 and Resident #58). The findings included: 1. Resident #55 was admitted to the facility on [DATE] with diagnosis that included cerebral infarction, encephalopathy, and cognitive communication deficit. A review of the comprehensive care plan dated 10/3/23 and last revised on 7/30/24 did not reveal a comprehensive care plan about behaviors. A review of Resident #55's Minimum Data Set (MDS) dated [DATE] revealed he was mildly cognitively impaired and did exhibit verbal behavioral symptoms directed toward others. An interview with the Social Worker on 12/17/24 at 1:37 PM, revealed Resident # 55 was referred to Psychiatric Therapy for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, and staff interviews, the facility failed to store the wet syringe separately from the barrel when Nurse #3 did not separate a bolus enteral feeding syringe (a large 2 part syringe used to administer oral medications or liquid feedings) used for medication administration through a gastrostomy tube (a hollow tube inserted directly through the skin of the abdomen into the stomach to deliver nutrition, hydration, and medication) for one of one resident (Resident #21). The deficient practice occurred for one of one staff member observed for medication administration via a gastrostomy tube. Findings included: During an observation of medication administration on 12/18/24 at 1:52 PM Nurse #3 entered Resident #21's room to administer medications via a gastrostomy tube. Nurse #3 administered the medication using a 2-part piston and barrel bolus enteral feeding syringe through a gastrostomy tube, rinsed the piston and barrel syringe with water and replaced the piston into the barrel and then placed the wet syringe back into a plastic storage bag. An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, and staff interviews, the facility failed to implement their policy for Enhanced Barrier Precautions (EBP) when Nurse #3, the Wound Nurse, and the Wound Physician failed to apply a gown before entering residents' rooms to provide high contact care activities for two of two residents (Resident #21 and Resident #58). The deficient practice occurred for three of three caregivers observed for infection control practices. These deficient practices placed residents at risk for infection. Findings included: Review of the facility policy on EBP, dated 4/1/2024, revealed in part EBP was an infection control intervention designed to reduce the transmission of multidrug-resistant organisms that employed the use gloves and gowns during high contact resident care activities. The policy further stated EBP use included care for residents with indwelling medical devices during high contact resident care. High contact care was further defined to include feeding tubes. 1. During an observation of medication administration on 12/18/24 at 1:52 PM Nurse #3 entered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interviews, the facility failed to follow their infection control policy and procedure to ensure facility staff received infection control training on Enhanced Barrier Precautions (EBP) to know what required EBP and when to implement EBP for 1 of 1 staff reviewed for infection control training (Wound Care Nurse). The findings included: The facility Enhanced Barrier Precautions Policy stated in part: East Carolina Rehab and Wellness will educate all employees on the reason for EBP. In an interview with the Wound Care Nurse on 12/18/24 at 2:19 PM, she stated she had worked at the facility since May of 2024, she had not been trained on EBP and was unaware that the facility used EBP. An interview with the Director of Nursing (DON) on 12/18/24 at 2:29 PM revealed she did not know if the Wound Care Nurse had been educated on EBP. She further stated the Staff Development Coordinator (SDC) provided the education and the DON did not know where those education documents were located. The SDC was no longer employed at the facility. The DON was not able to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to develop and implement a comprehensive care plan for 1 of 1 resident reviewed for physical environment (Resident #6). The findings included: Resident #6 was admitted to the facility on [DATE] with diagnoses that included essential hypertension (high blood pressure) and dysphagia (trouble swallowing). A review of Resident #6's medical record on 9/17/24 at 3:32 PM did not reveal comprehensive care plans had been developed and implemented. In an interview with the Minimum Data Set (MDS) nurse on 9/18/24 at 8:38 AM she looked for Resident #6's care plan in the EMR and stated he did not have one. She further stated he had been here for about 6 weeks and should have had a comprehensive care plan done within the first 21 days after admission. She felt that it was not completed as the previous MDS nurse left the facility around the time of his admission. An interview with the Director of Nursing (DON) on 9/18/24 at 8:40 AM revealed the MDS nurse was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and an emergency room physician interview the facility failed to provide care to a feeding tube site for one (Resident #1) of three sampled residents reviewed for feeding tube care. Findings included: Resident #1 was readmitted to the facility after a hospital admission from 2/8/2024 to 2/13/2024. Resident #1 had cumulative diagnoses, one of which included oropharyngeal dysphagia status post percutaneous gastrostomy tube placement. Documentation on a skin assessment dated [DATE] by Nurse #10 did not reveal a description or any representation of what the gastrostomy tube site looked like upon the return of Resident #1 from the hospital. Nurse #10 no longer worked for the facility at the time of the investigation and contact information was not available for an interview. Resident #1 had an active February 2024 enteral feed order initiated on 9/9/2022 for, every night shift clean tube site daily with normal saline, pat dry, and apply drain sponge if drainage noted.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, Medical Director/Physician interview, and Pharmacist interview the facility failed to remove narcotic pain medications from the medication cart within the parameters set by the physician's orders for narcotic medication; failed to follow procedures for disposal of wasted narcotic medication; and failed obtain an order for narcotic pain medication prior to removing narcotic pain medication from the medication cart. Additionally, the facility failed to have effective safeguards and systems in place to control for, account for, and periodically reconcile controlled medications to protect the residents right to be free from potential drug diversion. This was for three residents, (Resident #6, Resident #7, Resident #8) of three residents reviewed for pharmacy services for narcotic medication. Findings included: 1. Resident #6 was admitted to the facility on [DATE] with multiple diagnoses some of which included benign neoplasm of the pituitary gland, history of cerebral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interview, and Pharmacist interview the facility failed to document the administration of narcotic medication in the medication administration record for 3 (Resident #6, Resident #7, and Resident #8) of 3 residents reviewed for accuracy of documentation of narcotic medication. Findings included: 1. Resident #6 had a current March 2024 physician's order for Oxycodone with Acetaminophen 5-325 milligram (mg) tablets to be administered by mouth every 4 hours as needed for severe pain at the 8 to 10 level. Documentation on the Controlled Drug Receipt/Record/Disposition form dated as initiated on 2/26/2024 recorded the removal of a dose of Oxycodone with Acetaminophen 5-325 mg tablet for Resident #6 on the following dates and times by Nurse #5: 3/1/2024 at 6:00 PM, 3/1/2024 at 10:10 PM, 3/4/2024 at 4:10 PM, and 3/4/2024 at 10:05 PM. There was no corresponding documentation on the Medication Administration Record (MAR) of Resident #6 for the administration of the doses of Oxycodone with Acetaminophen on 3/1/2024 and 3/4/2024 removed from the cart by Nurse #5.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, staff interviews, hospice staff interview, physician interview, pharmacy consultant interview, and psychiatric nurse practitioner interview the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation of 4/13/2021, the recertification and complaint survey of 6/30/2022, the recertification and complaint investigation of 11/2/2023, and the complaint investigation of 2/27/2024. This was for 3 repeat deficiencies in the areas of supervision to prevent accidents, hospice services, and pharmacy services. The continued failure of the facility during four federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This citation is cross referenced to: F689: Based on observation, record review, and interviews with staff, Physician, Psychiatric Nurse Practitioner, and the facility's Pharmacy Consultant the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, resident interviews, Medical Director interview, and Pharmacist interview the facility failed to protect residents right to be free from potential diversion of a total of seventeen narcotic tablets for two (Resident #7 and Resident #6) of three residents reviewed for diversion of narcotics. Findings included: Documentation on the facility abuse prevention program policies and procedures, dated as last reviewed on 3/6/2023, revealed the facility residents have the right to be free from verbal, sexual, physical, and mental abuse. The documentation further stated the following definition for misappropriation of property, is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a patient's belongings or money without a patient's permission. 1. Resident #7 was admitted to the facility on [DATE] with multiple diagnoses some of which included an ankle fracture, osteoarthritis, polyneuropathy, and fibromyalgia. Documentation on admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, hospice staff interview, and physician interview the facility failed to communicate and coordinate with hospice to identify a resident had sustained a dislocated finger. This was for one (Resident # 3) of two sampled hospice residents. The findings included: Resident # 3 was admitted to the facility on [DATE]. The resident's diagnoses in part included a history of stroke, hemiplegia and hemiparesis, dysphagia, and advanced dementia. According to a hospital Discharge summary, dated [DATE], Resident # 3 had been hospitalized from [DATE] until 1/19/24. The hospital discharge summary also included the following information. The resident had pulled out his gastrostomy tube and nasogastric tube multiple times. A discussion was held with the family and he was to be made hospice with comfort care provided. According to the facility record, on 1/19/24 Resident # 3 was transferred to the facility as a hospice resident. On 1/25/24 a significant change Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, pharmacy consultant interview, and pharmacy operations manager interview the facility failed to provide pharmacy services within the time frame for a scheduled dose of a medication for one (Resident #6) of four residents observed during a medication pass observation. Findings included: 1.Resident #6 was admitted on [DATE] and had cumulative diagnoses including seizures. On Saturday 2/24/2024 at 7:57 AM, Nurse #1 was observed and interviewed as she prepared and administered medications to Resident #6. Nurse #1 indicated Resident #6 had an order for Levetiracetam oral solution and that the bottle was almost empty. Nurse #1 explained that in the electronic medication administration record she could see the Levetiracetam solution had already been ordered from the pharmacy and did not come in. Nurse #1 further explained she would administer what was left of the Levetiracetam in the bottle to Resident #6 and call the pharmacy to obtain more. Nurse #1 was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, resident, and staff interview the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey and complaint investigation completed on 11/2/2023, the recertification survey and complaint investigation completed on 6/30/2022, and the recertification survey and complaint investigation completed on 4/13/2021. This was for one repeat deficiency in the area of catheter care originally cited on 11/2/2023 during a recertification survey and complaint investigation, for one repeat deficiency in the area of infection control that was cited on 6/30/2022 during a recertification survey and complaint investigation, and for one repeat deficiency in the area of infection control cited during a recertification survey and a complaint investigation completed on 4/13/2021. The continued failure of the facility during three federal surveys showed a pattern of the facility's inability to sustain an effective Quality…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and resident interview the facility failed to protect a resident's right to be free from mistreatment when an employee (Housekeeper #2) hit Resident #5 with a cell phone charging cord causing pain. This was for one (Resident #5) of three residents reviewed for abuse. Findings included: Resident #5 had multiple diagnoses including diabetes mellitus, heart failure, and hypertension. Documentation on a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #5 was coded as having moderately impaired cognition with no moods or behaviors. He was also assessed as using a wheelchair. An interview was conducted with Resident #5 on 2/23/2024 at 1:04 PM. Resident #5 stated that in January he was sitting in his wheelchair talking with other residents in the hallway when Housekeeper #2 came up to him, swung a cell phone charging cord, and hit him in the leg. Resident #5 stated he hollered and cussed because of the pain. Resident #5 stated Housekeeper #2 tried to say she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview the facility failed to complete a thorough investigation of an allegation of staff to resident abuse by not obtaining a written statement from the perpetrator for 1 (Resident #5) of 3 residents reviewed for abuse investigations. The findings included: Documentation in the facility Abuse Prevention Program Policies and Procedures, dated as last reviewed on 3/6/2023 revealed a policy on investigation of incidents and allegations. The policy stated, All reports of resident abuse, neglect, and misappropriation of resident property shall be promptly and thoroughly investigated by facility management. Documentation under the procedures stated, 5. The following actions may be taken to investigate an allegation of abuse or neglect . Interview staff members (on any shift) who have had contact with the resident during the period of the alleged incident. Documentation in a facility reported incident dated 1/19/2024 revealed in the results of the 5-day investigation in part, On 1/16/2024 it was reported that [Resident #5] was stating that someone had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview the facility failed to use the urinary tract prevention method of keeping the drainage bag and tubing off the floor for 1 of 3 (Resident #4) residents reviewed for indwelling catheter care. Findings included: Resident #4 had multiple diagnoses some of which included hemiplegia and hemiparesis following cerebral infraction affecting right dominant side and urinary retention. Resident #4 had a physician's order initiated on 12/7/2023 for an indwelling catheter for the diagnosis of urinary retention. Documentation on a significant change Minimum Data Set assessment dated [DATE] revealed Resident #4 was coded as severely cognitively impaired, dependent for activities of daily living care, had an indwelling catheter, and a urinary tract infection in the last 30 days. Resident #4 was observed on an initial tour on 2/23/2024 at 9:55 AM. Resident #4 was lying in a low bed that was positioned almost to the floor. The catheter drainage bag and tubing were hooked to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews with staff and the consultant pharmacist and record reviews the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 25 opportunities resulting in a medication error rate of 8% for 2 (Resident #6 and Resident #8) of 4 residents observed during the medication administration observation. The findings included: 1.Resident #6 was admitted on [DATE] and had cumulative diagnoses including seizures. On 2/24/2024 at 7:57 AM, Nurse #1 was observed and interviewed as she prepared and administered medications to Resident #6. Nurse #1 indicated Resident #6 had an order for Levetiracetam oral solution and that the bottle was almost empty. Nurse #1 explained that in the electronic medication administration record she could see the Levetiracetam solution had already been ordered from the pharmacy and did not come in. Nurse #1 further explained she would administer what was left of the Levetiracetam in the bottle to Resident #6 and call the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview the facility failed to follow infection control procedures for the cleaning and disinfecting of a glucometer during a medication pass observation for one (Nurse #1) of two nurses observed for infection control procedures during medication pass. Finding included: A review of the facility's policy entitled Obtaining a Fingerstick Glucose Level dated October 2011 included in part: 18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. A review of an additional facility policy entitled Glucometer Cleaning Instructions (not dated) included the following instructions: -Perform hand hygiene before handing the meter, then don gloves. -Use [Name Brand] Germicidal Disposable Wipes to wipe down Glucometer. -Then, allow 2 minutes wet time. -Do not allow cleaning solution to run into the meter through areas such as around the buttons or the meter's test strip or data ports. -This will be performed after each use of a glucometer. -Disinfection will also be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, resident interview and staff interviews, the facility failed to provide supervision to a resident (Resident # 47), who was assessed as a supervised smoker, while Resident #47 was smoking in the designated smoking area, secure Resident #47's smoking materials and complete quarterly smoking assessments for a resident (Resident #7 ), who was assessed as not requiring supervision when smoking, for 2 of 2 residents reviewed for accidents. Findings included: 1. The facility's undated Smoking Policy stated a safe to smoke with supervision-assisted smoker: a. Must request smoking items, which are to be stored at the nursing station, form staff daily and return them to the station at end of day. b. All tobacco products must be lit by either a staff member of a responsible adult. c. May not possess or use matches, lighters, or any other flame producing device. d. Must smoke in designated areas. Resident #47 was admitted to the facility on [DATE]. The 5-day admission Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately assess cognitive patterns, anticoagulant medication use, and mood for 3 of 20 Minimum Data Set (MDS) assessments reviewed (Resident #55, Resident #47, and Resident #62). Findings included: 1. Resident #55 was admitted to the facility on [DATE] with diagnoses including non-Alzheimer's dementia. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #55 spoke clearly, made herself understood and had the ability to understand others. The assessment for the Brief Interview for Mental Status (BIMS) indicated an interview was not conducted because the resident is rarely/never understood. A staff assessment for Resident #55's cognitive pattern was completed and noted short- and long-term memory problems and moderately impaired cognitive skills for daily decision making. During an interview with Resident #55 on 10/30/2023 at 12:10 p.m., she was observed understanding questions asked and clearly speaking, making herself…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) screening for 1 of 1 resident reviewed for PASRR (Resident #51). Findings included: Review of Resident #51's PASRR dated [DATE] revealed her PASRR number ended in an 'E' (which was a level II PASRR) and expired on [DATE]. Resident #51 was admitted to the facility on [DATE]. Her active diagnoses included schizophrenia. Review of Resident #51's significant change Minimum Data Set assessment dated [DATE] revealed she was assessed as not being considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Review of North Carolina Medicaid Uniform Screening Tool (NC MUST) documentation on [DATE] at 10:34 AM with Social Worker #1 revealed Resident #51's most recent PASRR screen was on [DATE] and her PASRR number ended in an 'E' and was expired on [DATE]. Resident #51 did not have a current PASRR. During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure an individualized person-centered care plan was accurate for smoking for 1 of 19 residents reviewed for comprehensive care plan (Resident #47). Findings included: Resident #47 was admitted to the facility on [DATE]. The 5-day admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 was moderately cognitive impaired and did not use tobacco products. The smoking assessment dated [DATE] indicated Resident #47 was safe to smoke with supervision based on Resident #47 cognitive loss, visual deficits, and dexterity problems. The smoke assessment further indicated Resident #47 needed adaptive equipment (smoking apron) when smoking, and the facility was to store Resident #47's cigarette and lighter. The care plan dated 10/4/2023 indicated Resident #47 wished to smoke cigarettes and had been assessed as safe to smoke independently. Interventions included Resident#47 was informed on the facility's smoking policy and encouraged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, resident interview and staff interviews, the facility failed to attach an indwelling urinary catheter tubing to a secure device to prevent tension and possible injury, to position the urinary collection bag at a lower level than the urinary bladder to allow gravity drainage of urine into the collection bag, to ensure the urinary tubing was not touching the floor for 1 of 2 residents reviewed for urinary catheter (Resident #47). Findings included: Resident #47 was admitted to the facility on [DATE], and diagnoses included obstructive uropathy. The 5-day admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 was moderately cognitively impaired and used an indwelling catheter for urination. Physician orders dated 9/13/2023 included using an indwelling catheter to bedside drainage for urinary retention. In reviewing the electronic medical record from 9/13/2023 to 11/2/2023, there was no nursing documentation indicating the use of a catheter secure device…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, resident and staff interviews, the facility failed to administer supplemental oxygen as prescribed by the physician and failed to place signage indicating the use of oxygen for 1 of 1 resident reviewed for oxygen use (Resident #269). Findings included: Resident #269 was admitted to the facility on [DATE], and diagnoses included chronic obstructive pulmonary disease (COPD). The baseline care plan dated 10/20/2023 indicated Resident #269 was cognitively intact, received oxygen therapy while a resident in the facility and had COPD. Interventions included setting oxygen at 3 liters per minute by nasal prongs continuously and humified (increased moisture level). Physician orders dated 10/20/2023 included oxygen via nasal cannula at 3 liters per minute every shift for shortness of breath. Nursing documentation dated 10/20/2023 at 5:40 p.m. by Nurse #2 reported Resident #269 was receiving oxygen at 4 liters via nasal cannula on admission. There was no further documentation in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and resident and staff interview, the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint surveys of 6/30/22 and 4/13/21. This was for 5 recited deficiencies in the areas of Accuracy of Assessments (F641), Preadmission Screening and Resident Review (PASRR) (F644), Baseline Care Plans (F655), Care Plan Timing and Revision (F657), and Free of Accident Hazards/ Supervision/Devices (F689). The continued failure during 2 or more federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. The findings included: The tag is cross-referenced to: F641-Based on record review and staff interviews, the facility failed to accurately assess cognitive patterns, anticoagulant medication use, and mood for 3 of 20 Minimum Data Set (MDS) assessments reviewed (Resident #55, Resident #47, and Resident #62). During the recertification and complaint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.