The Lodge at Rocky Mount Health and Rehabilitation

Based on observations, record review and staff interviews, the facility failed to date opened medications and discard expired medications for 3 of 5 medication carts (North Hall 3 medication cart, North Hall 1 medication cart and South Hall medication cart) and in 1 of 2 medication rooms (South Hall Medication Storage Room), reviewed for medication storage.The findings included:a. An observation conducted of the North Hall 3 medication cart with Nurse #6 on 4/10/26 at 2:09 PM revealed:- one undated, opened and used bottle of Erythromycin Ophthalmic Ointment 0.5%. The manufacturer's instruction stated discard 28 days after opening.- one undated, opened and used Trilogy Elipta inhaler. The manufacturer's instruction on outside of box read to discard 6 weeks after opening.- one undated, opened and used Nystatin Cream tube. The manufacturer's instruction stated to discard 14 days after opening.- one undated, opened and used bottle of Clotrimazole Betamethasone Dipropionate. The manufacturer's instruction stated to discard 6 months after opening. - on undated, opened and used bottle 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, Nurse Practitioner and Medical Director interviews, the facility failed to clarify a physician order for phenytoin (a medication used to treat epilepsy and manage seizures) for a resident with a diagnosis of generalized epilepsy (a brain disorder that causes seizures) which resulted in the phenytoin not being administered for 19 days. This deficient practice was identified for 1 of 1 residents reviewed for significant medication error (Resident #287). The findings included: Resident #287 was admitted to the facility on [DATE] with diagnoses which included generalized epilepsy and stroke. Resident #287 had a physician order dated 4/11/24 for phenytoin sodium extended 100 milligram (mg) capsule. Give 100 mg by mouth twice a day on Monday, Tuesday, Wednesday, Friday, Saturday, and Sunday for generalized epilepsy. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #287 had moderate cognitive impairment. Resident #287 had a care plan in place, last…

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 and staff interviews, the facility failed to maintain kitchen equipment clean and in a sanitary condition to prevent cross contamination by failing to clean seven of nine baking sheets. These practices had the potential to affect food served to residents. The findings included: During an observation of the kitchen dish drying rack on 2/05/25 at 11:37 AM, seven stacked baking sheets with dark dried grease built up under the rim. A second observation on 2/06/25 at 10:35 AM revealed 7 baking sheets stacked ready for use on the rolling food preparation rack were in the same condition. In an interview with the Dietary Manager on 2/06/25 at 10:42 AM he revealed staff should have cleaned and gotten all the grease built up off the baking sheets. In an interview on 2/06/25 at 10:53 AM the Administrator stated that dietary should maintain their cleaning schedule and deep clean the baking sheets.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to implement their infection prevention program policies and procedures when 1) the Social Worker failed to remove her surgical mask after exiting a resident room that was on droplet precautions (room [ROOM NUMBER]), 2) when the Maintenance Director failed to wear a surgical mask in a resident room that was on droplet precautions (room [ROOM NUMBER]), and 3) Nurse Aide #1 failed to remove her surgical mask after exiting a resident room on droplet precautions (room [ROOM NUMBER]). This deficient practice was observed for 3 of 3 staff members (Social Worker, Maintenance Director, and NA #1) that failed to follow droplet precaution procedures for residents on isolation for influenza. The findings included: The facility's policy titled Infection Prevention and Control Program last revised June 2023 noted the program was a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and…

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, record review, and resident and staff interviews, the facility failed to develop a person-centered care plan for 1 of 1 resident reviewed for hearing impairment (Resident #75). The findings included: Resident #75 was admitted to the facility on [DATE]. Resident #75 was hospitalized on [DATE] and returned to the facility on 1/13/25. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #75 had moderate cognitive impairment and was coded for minimal hearing difficulty with the use of hearing aids. Review of the care plan revealed no care plan related to Resident #75's hearing impairment and use of hearing aids. An interview and observation were conducted on 2/03/25 at 2:15 pm with Resident #75. This surveyor had to move close and speak loudly within one to three inches of the right ear for Resident #75 to hear questions. Resident #75 reported she was very hard of hearing, and she did not have her hearing aids today. Resident #75's hearing aids were 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and resident and staff interviews, the facility failed to secure indwelling urinary catheter tubing to prevent tugging or pulling for 1 of 2 residents reviewed for indwelling urinary catheters (Resident #53). The findings included: Resident #53 was admitted to the facility on [DATE] with diagnoses that included neurogenic bladder (a condition that occurs when the nervous system connection to the bladder is disrupted) with urinary retention. Review of a physician's order dated 12/4/24 read in part; Check placement of catheter securement every shift. Resident #53's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she had moderate cognitive impairment. She was coded as having an indwelling urinary catheter. An interview was conducted with Resident #53 on 02/03/25 at 11:35 AM. Resident #53 stated she had experienced pain from her urinary catheter when she was up in the chair. Resident #53 stated a leg strap was placed to secure the catheter tubing which helped…

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, and staff interviews the facility failed to maintain kitchen equipment clean by failing to clean 1 of 1 plate warmer and 1 of 1 knife holder observed. This practice has the potential for cross contamination of food served to residents. The findings included: a. Observations of the kitchen were conducted on 12/1023 at 10:05 AM, and 12/12/23 at 12:18 PM the three cylinder well plate warmer was observed with dark black dried food particles inside each well. b. Observations of the kitchen conducted on 12/12/23 at 12:18 PM and 12/13/23 at 9:07AM revealed a buildup of dried food particles on top of the wall mounted magnetic knife holder. During an interview with the Dietary Manager on 12/13/23 at 9:08 AM he stated he would add the plate warmer to the cleaning schedule and start daily cleaning audits. In an interview on 12/13/23 at 9:15 AM the Administrator stated she would have the kitchen do daily audits and keep the plate warmer clean.

Based on record review, observations, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint investigations on 4/15/21 and 11/10/22. The deficiencies included: Care Plan Timing and Revision (F657) and Food Procurement/Store/Prepare/Serve Sanitary (F812). The continued failure during two or more federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross-referenced to: F657: Based on record review and staff interviews, the facility failed to update a resident's care plan for a resident with impaired swallowing for 1 of 20 residents whose care plans were reviewed (Resident #7). During the recertification and complaint survey of 4/15/21, the facility was cited for failure to update a resident's Care Plan to include transfers with a mechanical lift. An interview was conducted on 12/13/23 at 1:41 P.M.…

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 complete the Minimum Data Set (MDS) for dialysis for 1 of 20 residents reviewed for MDS assessments. (Resident #61) Findings Included: Resident #61 was admitted to the facility on [DATE] with diagnosis that included end stage renal disease. Physician order dated 10/31/23 read dialysis days are Monday Wednesday, and Friday. Review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #61 did not receive dialysis. An interview was conducted on 12/12/23 at 11:32 A.M. with the MDS nurse. The MDS nurse reviewed the admission MDS and confirmed it was inaccurate. The MDS nurse stated when she completed Resident #61 admission MDS, she overlooked Resident #61 received dialysis and she stated Resident #61's admission MDS should have been marked to show Resident #61 received dialysis treatment. An interview was conducted on 12/13/23 at 10:11 A.M. with the Director of Nursing (DON). During the interview, the DON confirmed…

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 update a resident's care plan for a resident with impaired swallowing for 1 of 20 residents whose care plans were reviewed (Resident #7). The findings included: Resident #7 was admitted to the facility on [DATE] with diagnosis that included acute respiratory disease and dysphagia (difficulty swallowing foods or liquids). Resident #7's physician order dated 8/11/23 read NPO (nothing by mouth). Review of the quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #7 was severely cognitively impaired, he had a swallowing disorder of loss of liquids/solids when eating, coughing/choking when eating, and received 51% or more through a feeding tube. Review of Resident #7's care plan last updated 11/16/23 showed a focus area Resident #7 had impaired swallowing related to dysphagia with potential for aspiration. Interventions included to encourage resident to eat/drink slowly, encourage resident to eat meals out of his room, monitor and report…

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.