Ahoskie Health and Rehabilitation Center

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to update the resident's code status information when Resident #12's Responsible Party requested a change from do not resuscitate to full code. This was for 1 of 4 residents reviewed for advanced directives (Resident #12).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set Assessments (MDS) for 2 of 32 residents whose MDS assessments were reviewed for accuracy (Resident #22, and Resident #25).

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to secure the indwelling urinary catheter tubing to prevent tugging or pulling for 1 of 1 resident reviewed for indwelling urinary catheter (Resident #11).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a resident receiving dialysis had a physician's order for dialysis for 1 of 2 sampled residents reviewed for dialysis (Resident #6).

Inspectors wroteBased on record review, and staff interviews, the facility failed to monitor the North Carolina (NC) Nurse Aide (NA) Registry to ensure 1 of 6 nurse aides employed at the facility remained listed on the NC Nurse Aide Registry with an active Nurse Aide I certification (NA#1).

Inspectors wroteBased on observations, manufacturers' instructions, and staff and Pharmacy Consultant interviews, the facility failed to remove one (1) multi-dose insulin injector pen that was expired and 2 bottles of expired eye drops in 1 of 4 medication carts (East Annex Medication Cart #1) reviewed for medication storage and labeling.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain 1 of 2 nourishment room refrigerators and freezer clean, and in a sanitary manner to prevent cross contamination by failing to clean up spills (South Unit refrigerator).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure accurate daily staff nursing postings for 13 of 30 days reviewed for accurate nurse staffing information (11/17/25, 11/18/25, 11/21/25, 11/22/25, 11/23/25, 11/24/25, 11/27/25, 11/29/25, 11/30/25, 12/2/25, 12/11/25, 12/12/25 and 12/13/25).

Inspectors wroteBased on record reviews and staff interviews, the facility failed to develop a person-centered care plan in the areas of antipsychotic medication use (Resident #8), and preferred activities (Resident #109) for 2 of 32 residents whose care plans were reviewed.

Inspectors wroteBased on record review and staff interview the facility failed to designate a full-time Director of Nursing (DON) for the Skilled Nursing Facility (SNF) when the current DON went out on family medical leave.

Inspectors wroteBased on record review, staff interviews, and Consultant Pharmacist interview, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for residents receiving an antipsychotic medication, which is used for medication monitoring of side effects of antipsychotic medication for 3 of 5 residents reviewed for unnecessary medications (Resident #7, Resident #62, and Resident #57).

Inspectors wroteBased on record review, staff interviews, and Medical Director interview, the facility failed to hold a blood pressure medication as ordered by the physician when the blood pressure was above the parameter for 1 of 1 resident reviewed for a significant medication error (Resident #101).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately document the administration of 14 doses of blood pressure medication in the medical record for 1 of 1 resident reviewed for a significant medication error (Resident #101).

Inspectors wroteBased on record review, staff interviews, and resident interview, the facility failed to hold a care plan meeting or invite the resident to participate in the care planning process for 1 of 22 residents whose care plans were reviewed (Resident #62).

Inspectors wroteBased on observation, record review, and staff and resident interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of a pressure reducing surface for pressure ulcer (Resident #7) and the use of a continuous positive airway pressure (CPAP) machine (Resident #95) for 2 of 22 residents whose MDS assessments were reviewed.

Inspectors wroteBased on record review, staff interviews, and resident interview, the facility failed to revise the care plan in the area of antipsychotic medication use (Resident #62) and risk for pain (Resident #101) for 2 of 22 residents reviewed for care plan revision.

Inspectors wroteBased on record review, staff interview and Consultant Pharmacist interview, the Pharmacist failed to identify and report a medication irregularity when an Abnormal Involuntary Movement Scale (AIMS) assessment was not initiated for Olanzapine (antipsychotic medication used to regulate behaviors) or 1 of 4 residents reviewed for unnecessary medications (Resident #57).

Inspectors wroteBased on observations, record review, and interviews with resident, Speech Language Pathologist, Registered Dietitian, and staff, the facility failed to honor food preferences for 1 of 4 residents reviewed for preferences (Resident #66).

Inspectors wroteBased on record review and staff interviews, the facility failed to develop a care plan that addressed dementia care for 1 of 3 residents reviewed for comprehensive care plans (Resident #39).

Inspectors wroteBased on record review, staff and pharmacy interviews, the facility failed to complete the shift change inventory sheet consistently and accurately for 4 of 7 medication carts reviewed.

Inspectors wroteBased on observations and staff interviews, the facility failed to secure medication storage cabinets in an unlocked room, remove expired medications from storage cabinets and refrigerator, failed to monitor temperatures of a refrigerator storing medication, and failed to secure a medication cart for 2 of 9 storage areas reviewed (Training Room and [NAME] Hall medication cart).

Inspectors wroteBased on record review, observations, staff interviews, and pharmacy interviews the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place following the 12/17/20 complaint investigation survey and 2/4/22 recertification survey. The facility had deficiencies previously cited in the areas of pharmacy services/procedures/pharmacist/records (F755) and label/store drugs and biologicals (F761). F761 was cited on 12/17/20 during a complaint investigation survey and on 2/4/22 during a recertification survey and F755 was cited on 2/4/2022 during a recertification survey. These deficiencies were cited again during the facility's current recertification and complaint investigation survey of 8/10/23. [...]

Inspectors wroteBased on record reviews and staff interviews, the facility failed to assess residents for eligibility and ensure residents were offered the pneumococcal vaccinations upon admittance into the facility (Resident #66, Resident #80, Resident #94) and offer annual influenza vaccine (Resident #66) for 3 of 5 residents reviewed for immunizations.