Asheboro Rehabilitation and Healthcare Center

Inspectors wroteBased on staff interviews and record review, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of falls for 1 of 7 residents (Resident #97) reviewed for MDS accuracy.

Inspectors wroteBased on record review and interviews with staff, the facility failed to refer residents (Residents #2 and Resident #66) for a level II Preadmission Screening and Resident Review (PASRR) for newly diagnosed serious mental illness for 2 of 2 residents reviewed for PASRR.1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included bipolar type depression, dementia, anxiety disorder, and frontotemporal neurocognitive disorder. She was admitted with a level 1 PASRR as of 10/25/24 and no further screening was required unless a significant change occurred to suggest a diagnosis of mental illness. Record review revealed Resident #2 was diagnosed on [DATE] with schizoaffective disorder. There was no evidence that a referral for level II PASRR screening was completed. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to follow a urology order to change the indwelling urinary catheter monthly for 1 of 2 residents reviewed for urinary catheters (Resident #47).

Inspectors wroteBased on record reviews, observations, Registered Dietitian (RD) and staff interviews, the facility failed to ensure the enteral tube feed (a method of supplying nutrition through a feeding tube that goes directly into the stomach or small intestine) formula was specified in the active physician's order for Resident #3. This failure had been ongoing since June 2025. In addition, the facility failed to store a plastic enteral feeding syringe with the plunger separated from the barrel of the syringe for Resident #11 and Resident #88 which had the potential for bacterial growth and contamination. The deficient practice affected 3 of 4 residents reviewed for enteral feeding management (Resident #3, Resident #11 and Resident #88).

Inspectors wroteBased on record reviews, observations and staff interviews, the facility failed to administer oxygen at the prescribed rate (Resident #88) and failed to secure two oxygen cylinders stored in a resident's room (Resident #12) for 2 of 3 residents reviewed for respiratory care (Resident #88 and #12).

Inspectors wroteBased on observation, record review and Nurse Practitioner (NP) and staff interviews, the facility failed to implement their policies and procedures for hand hygiene when Nurse #1 failed to perform hand hygiene between residents during 2 of 3 medication administration observations and failed to perform hand hygiene before donning gloves and after glove removal during administration of eye drops. This deficient practice was for 1 of 5 staff members observed for infection control practices (Nurse #1). A review of the facility policy titled Medication Administration (not dated): Preparation instructions stated in part: Perform hand hygiene before preparing and administering medications. A review of the facility policy for administering eye drops (not dated) stated in part: perform hand hygiene, apply gloves, administer eye drops, remove gloves, and perform hand hygiene. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure nurse staffing data was posted daily for 1 of 4 days of the survey conducted 8/10/25 through 8/13/25 (8/10/25).

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a clean toilet seat and an environment that was free of urine odor in residents' rooms. This deficient practice affected 1 of 4 residents reviewed for a safe, clean, comfortable, homelike environment (Resident #62).

Inspectors wrote2. Resident # 82 was admitted on [DATE] with cumulative diagnoses of depression anxiety, dementia with behavioral disturbances, unspecified psychosis and affective mood disorder. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #82 had moderate cognitive impairment, exhibited no behaviors and was coded for the use of an antipsychotic and an antidepressant. Review of Resident #82 September 2024 Physician orders included the following order dated 4/23/24: Seroquel (antipsychotic) Extended Release 24 hour 50 milligrams give one tablet by mouth in the afternoon for dementia with mood/psychotic disturbances. Another order dated 8/1/24 read Sertraline (antidepressant) 50 milligrams give one tablet by mouth at bedtime for dementia with behaviors, depression and anxiety. [...]

Inspectors wroteBased on record review, staff, Administrator, resident, Nurse Practitioner (NP) #1 and Consultant Pharmacist interviews, the facility failed to identify the targeted clinical behaviors and side effects to be monitored for the use of psychotropic medications for Resident's #82, #73 and #68. The facility also failed to complete a baseline abnormal involuntary movement scale (AIMS) with the initiation of a newly prescribed antipsychotic for Resident #145. This was for 4 of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on record review and staff interviews the facility failed to revise a smoking care plan to reflect a resident's level of supervision needed for smoking for 1 of 3 residents (Resident #77) reviewed for smoking.

Inspectors wroteBased on record review and staff interviews, the facility failed to transcribe the correct medication administration route for 1 of 1 resident reviewed for gastric feeding tube (Resident #45).

Inspectors wrote2a. Resident #36 was admitted to the facility on [DATE] with diagnosis that included major depressive disorder and schizophrenia. Review of Resident #36's physician orders included an order initiated on 11/6/23 for an antipsychotic medication to be given two times daily. A review of the July 2024 Medication Administration Record revealed Resident #36 was administered antipsychotic medication daily. An annual Minimum Date Set (MDS) assessment dated [DATE] indicated Resident #36's cognition was cognitively impaired. The medications section was coded that she did not receive antipsychotic medication during the 7 -day look back period. On 9/5/24 at 3:28 PM, an interview occurred with the MDS nurse. She explained she had completed the medication section of the MDS and did not code the antipsychotic medication usage section correctly and that it was an oversight. b. [...]

Inspectors wroteBased on observations and staff, Nurse Practitioner (NP), Medical Director (MD) interviews and record review, the facility failed to have systems in place to identify a contracture which resulted in an avoidable wound where 3 fingernails on the resident's left hand punctured 2 areas into the palm of his contracted left hand requiring the need for wound care. The facility also failed to complete and document weekly assessments of the wound (Resident #70). This was for 1 of 2 residents reviewed providing care according to professional standards of practice.

Inspectors wroteBased on observations and staff interviews, the facility failed to clean the Packaged Terminal Air Conditioner (PTAC) vents (Rooms #104, #111, #206, #207, #302, #308, #310, #312, #316, #404, #405, #407 and #408). This was for 13 of 16 resident rooms reviewed for comfortable, clean, and homelike environment.

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to provide scheduled showers for a resident requiring total staff assistance with bathing/showering. This was for 1 (Resident #70) of 3 residents reviewed for activities of daily living.

Inspectors wroteBased on record review, observations, and resident and staff interviews, the facility failed to implement their smoking policy for conducting quarterly smoking assessments, ensuring a resident assessed as an unsafe smoker was supervised, smoking materials were secured, and cigarette butts were disposed of safely for 1 of 3 residents (Resident #69) reviewed for accidents.

Inspectors wroteBased on observations, and staff interviews the facility failed to discard opened food items ready for use by the labeled discard date in 1 of 1 walk-in refrigerators and failed to label, and date opened food left in 1 of 2 nourishment room refrigerators (station 1 reach-in refrigerator). This practice had the potential to affect foods served to residents.

Inspectors wroteBased on record reviews, observations, resident, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification and complaint survey completed on 4/28/2022. This was for 3 deficiencies that were cited in the areas of clean homelike environment, accuracy of assessments, and providing activities of daily living care for dependent residents. The duplicate citations during two federal surveys of record show a pattern of the facility's inability to sustain an effective QAPI program.

Inspectors wroteBased on observations, record review and staff and resident interviews, the facility failed to assess the self-administration of medications for 2 of 2 residents (Resident #5 and Resident #47) reviewed for self-administration.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of feeding tube (Resident #89) and bowel continence (Resident #70). This was for 2 of 23 resident records reviewed.

Inspectors wroteBased on staff interviews and record review, the facility failed to develop a comprehensive care plan in the area of contractures. This was for 1 (Resident #70) of 23 residents reviewed for care planning.

Inspectors wrote2. Resident #55 was admitted to the facility on [DATE] with diagnoses that included a history of a traumatic brain injury and contracture to the right wrist and hand. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #55 was severely cognitively impaired and displayed no rejection of care. She was coded with limited range of motion to one upper extremity. A review of Resident #55's active orders revealed a physician's order for right elbow support and hand therapy carrot as tolerated and to check each shift. The orders was dated 1/4/2023 An OT Discharge summary dated [DATE] indicated Resident #55 received OT therapy from 1/11/2023 through 1/24/2023 for a right elbow and wrist contracture. [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure a bottle of tube feeding formula was dated when opened for use (Resident #200). This 1 of 4 residents reviewed with feeding tubes.

Inspectors wroteBased on observations, record review, staff and Nurse Practitioner interviews, the facility failed to provide a dressing change to a Central venous catheter (CVC) line (a thin, flexible tube (catheter) that is placed into a large vein above the heart) as ordered. This was for 1 of 1 (Resident #14) resident reviewed for infections.

Inspectors wroteBased on observations, staff, Nurse Practitioner (NP) and Medical Director interviews and record review, the facility failed to obtain Physician orders for continuous oxygen (Resident #38) and failed to provide oxygen as ordered (Resident #37). This was for 2 of 6 residents reviewed for respiratory care.