Carolina Rehab Center of Burke

Inspectors wroteBased on record reviews, and Responsible Person and staff interviews, the facility failed to ensure a resident's Do Not Resuscitate (DNR) goldenrod form (a portable physician's order printed on goldenrod colored paper that communicates an individual's wishes regarding resuscitation efforts for emergency responders) and Medical Orders for Scope of Treatment (MOST) form (outlines health care and end-of-life care instructions) stating DNR and Do Not Intubate (DNI) (intubation is a medical procedure where a tube is inserted into the airway to support breathing) were provided to Emergency Medical Services (EMS) upon emergent transfer to the hospital on Sunday 6/22/25. [...]

Inspectors wroteBased on record review, and physician assistant (PA) and staff interviews, the facility failed to maintain accurate advance directives throughout the medical record for 1 of 5 residents reviewed for advance directives (Resident #46). Resident #46 was admitted to the facility on [DATE]. Review of an admission progress note dated 8/7/2025 indicated Resident #46 was alert and oriented to person, place, time and situation. Review of Resident #46's Physician's orders, revealed an order dated 8/7/2025 that read code status (DNR). Review of a provider progress note dated 8/8/2025 indicated Resident #46 was seen by the Physician Assistant (PA) and the PA discussed advance directives with Resident #46 and verified Resident #46 wanted to be a Do Not Resuscitate (DNR) and that a MOST form and goldenrod (DNR form) was signed. [...]

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to discard expired vials of influenza vaccine in 1 of 3 medication rooms (Jasmine medication room), failed to date an opened insulin pen and discard loose pills in 1 of 4 medication carts (Dogwood medication cart).

Inspectors wroteBased on record review and staff interviews and observation, the facility failed to post census information for 322 of 323 days reviewed for daily nurse staffing (October 2024, November 2024, December 2024, January 2025, February 2025, March 2025, April 2025, May 2025, June 2025, July 2025 and 8/1/2025-8/19/2025). Review of the daily nurse staffing sheets from 10/1/2024 through 8/18/2025 revealed there was no census information entered. Observation of the daily nurse staffing sheet dated 8/19/2025 revealed the census was entered. During an interview on 8/19/2025 at 11:30 AM the Scheduler stated she was responsible for completing and posting the daily nurse staffing sheet. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of oxygen therapy, functional limitation in range of motion, dialysis, hospice and prognosis, hypoglycemic medication (used to help reduce the amount of sugar in the blood), and Preadmission Screening and Resident Review (PASRR) for 6 of 20 sampled residents (Residents #23, #71, #130, #74, #38, and #6).

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to keep emergency tracheostomy (surgically created airway in the front of the neck) supplies needed for an unplanned extubation (removal of airway tube) or emergency supplies for mechanical ventilation (ambu bag) at bedside and easily accessible for immediate use in an emergency (Resident #56). The facility also failed to post cautionary and safety signs that indicated the use of oxygen (Resident #39, Resident #71, and Resident #23). This affected 4 of 4 residents reviewed for respiratory services.

Inspectors wroteBased on observations, record review, and interviews the facility failed to educate nursing staff to ensure emergency tracheostomy supplies were immediately available to provide respiratory care needs for 1 of 1 resident reviewed for tracheostomy (surgically created airway in the front of the neck) care. This was for 5 of 5 nurses (Staff Development Coordinator Nurse, Infection Preventionist Nurse, Nurse #1, Nurse #2, and Nurse #3) reviewed for competency.

Inspectors wroteBased on observations and staff interviews the facility failed to date and cover an open food item and discard food with signs of spoilage in 1 of 1 walk-in cooler; date an open beverage item and date milkshakes to identify their use-by date in 1 of 1 reach-in cooler; label and date open food items and discard expired beverages in 1 of 1 dry storage room; date an open food item in the food preparation area of 1 of 1 kitchen; and maintain clean refrigerators in 3 of 3 nourishment rooms (100/400 hall, 300 hall, and 200 hall). This failure had the potential to affect food served to residents.

Inspectors wroteBased on record review, family and staff interviews, the facility failed to immediately notify a resident's Responsible Party of a medication change for 1 of 1 sampled resident (Resident #23).

Inspectors wroteBased on record review and staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASRR) re-evaluation after a significant change in the physical or mental status for a resident with a serious mental health diagnosis for 1 of 1 resident reviewed for PASRR (Resident #6).

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to develop an individualized, person-centered Activities of Daily Living (ADL) care plan that included how much staff assistance was needed to care for a resident who required assistance with ADL for 1 of 2 sampled residents reviewed for ADL (Resident #71).

Inspectors wroteBased on record review and staff interviews the facility failed to revise an advance directive care plan for 1 of 20 residents whose care plans were reviewed for accuracy (Resident #38).

Inspectors wroteBased on observations, record review and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation surveys conducted on 4/15/21 and 2/9/23. This was for a repeat deficiency in the area of infection control that was cited on 4/15/21 and 2/9/23 during the recertification and complaint investigation surveys, and subsequently recited during the complaint investigation survey completed on 2/17/24. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to implement their infection control policy when Nurse #1 did not perform hand hygiene after incontinence care and before donning new gloves to cleanse a wound, and failed to change gloves and perform hand hygiene between different wounds for 3 of 3 wound care observations on 1 of 3 residents reviewed (Resident #6).

Inspectors wroteBased on record reviews and family member, staff, and Medical Director interviews, the facility failed to prevent significant medication errors when Medication Aide #1 administered medications prescribed for Resident #2 to Resident #1 which include Clonazepam (a medication to treat anxiety), Buspar (a medication to treat anxiety), Gabapentin (anticonvulsant medication), Seroquel (antipsychotic medication) and Trazodone (antidepressant) for which he had no diagnosis and all had the potential side effects of dizziness and drowsiness. Resident #1 was sent to the emergency department on 12/08/23 for further evaluation where it was determined he had an accidental drug overdose as evidenced by Resident #1 having altered mental status and drowsiness. [...]

Inspectors wroteBased on record review and staff and resident interviews, the facility failed to have physician orders for tracheostomy (an opening surgically created through the neck into the trachea) care and provide nursing supervision of tracheostomy care as specified in the resident's plan of care for 1 of 1 resident reviewed for tracheostomy care (Resident #3).

Inspectors wroteBased on observations, record reviews, resident, staff and Nurse Practitioner interviews, the facility failed to administer pain medication as ordered and requested for 2 of 4 residents (Resident #329 and Resident #330) reviewed for management of pain.

Inspectors wroteBased on record review, observations, staff, and Speech Language Pathologist interviews the facility failed to assist a dependent resident with mealtime assistance for 1 of 5 residents reviewed for activities of daily living (Resident #46).

Inspectors wroteBased on observations, record reviews and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey of 04/15/21. This was for one deficiency that was originally cited in April 2021 in the area of infection control and was subsequently recited on the current recertification survey of 02/09/23. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance Program.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to implement their infection control policies when 1 of 1 staff member Nurse Aide (NA) #1 failed to perform hand hygiene after doffing used gloves and donning clean gloves while providing incontinence care to a 1 of 3 residents (Resident #32).