Currituck Health & Rehab Center

Inspectors wroteBased on record review, and Responsible Party, Law Enforcement and staff interviews, the facility failed to protect a resident's right to be free from misappropriation of property when a staff member (Nurse Aide #1) took checks from Resident #92 without her knowledge, cashed one of the checks for $1000.00, and attempted to cash additional checks. The deficient practice was for 1 of 1 resident reviewed for misappropriation of resident property (Resident #92).

Inspectors wroteBased on record review and staff interview, the facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment (SCSA) after enrollment in a hospice program for 1 of 3 residents reviewed for death in the facility (Resident #6).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Preadmission Screening and Resident Review (PASRR) for 1 of 1 resident (Resident #40) reviewed for PASRR.

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to attempt alternatives prior to the installation and use of bed rails and did not assess for risk of entrapment when completing assessments for 1 of 2 residents reviewed for bed rails (Resident #67).

Inspectors wroteBased on observation, record review, and interviews with Division of Health Service Regulation (DHSR) Life Safety Surveyor, resident, physician and staff, the facility failed to provide the necessary supervision to ensure residents were safe while smoking when Resident #31 was found smoking in the presence of a supplemental oxygen device, to implement their smoking policy and effective interventions to address the resident's repeated non-compliance with safe smoking practices both inside and outside of the facility, and to monitor the resident to prevent further incidents of unsafe smoking. Resident #31 was assessed on admission as a non-smoker at the facility. On 1/31/24 Resident #31 was observed smoking outside in the designated smoking area and he had smoking materials in his possession in violation of the smoking policy. [...]

Inspectors wroteBased on record review, and interviews with staff, physician and laboratory customer service staff, the facility failed to notify the physician when Resident #6 experienced a change of condition. Resident #6 received a positive result from a urinalysis (UA) and culture and sensitivity (C&S), which indicated the resident had a urinary tract infection (UTI) with extended-spectrum beta-lactamase (ESBL, an enzyme produced by some bacteria that makes them resistant to many antibiotics) in her urine and failed to notify the physician of the C&S results after the report was received from the facility. These deficient practices affected 1 of 4 residents reviewed for a experiencing a change of condition related to a UTI (Resident #6). [...]

Inspectors wroteBased on record review and staff interviews, the facility failed protect a resident's right to be free from abuse when a moderately cognitively impaired resident (Resident #29) punched severely cognitively impaired resident (Resident #231) in the face. Resident #231 was prescribed and received a blood thinner daily. Resident #231 sustained bruising and swelling to the left side of his face. Resident #231 stated he was scared and did not want to be near Resident #29. Resident #29 and Resident #231 were immediately separated. Resident #29 was moved to another room by himself. Resident #231 requested to be sent to emergency room for evaluation and did not return to the facility. Resident #231 transferred from the hospital to a different facility. [...]

Inspectors wroteBased on record review, and interviews with staff and the physician, the facility failed to ensure Resident #6 received necessary care and services for a urinary tract infection (UTI) when she experienced signs and symptoms of a change in condition. The facility failed to follow up on results of urinalysis, failed to effectively respond to a positive urinalysis (UA) report, failed to follow up on results of urine culture and sensitivity, effectively respond to urine culture and sensitivity results (C&S), and administer an antibiotic that was sensitive to the microorganism listed on the C&S report. These deficient practices affected 1 of 4 residents reviewed for UTI (Resident #6). [...]

Inspectors wroteBased on record review, observation, and resident, staff, Pharmacy Consultant and Medical Director interviews, the facility failed to have a medication error rate less than five percent as evidenced by 4 medication errors out of 33 opportunities, resulting in a medication error rate of 12.12% for 2 of 4 residents observed during the medication administration observations (Resident #18 and Resident #71).

Inspectors wroteBased on a dinner meal tray line observation, staff interviews and record review, the facility failed to follow the approved menu for pureed diets for 7 of 7 residents on a pureed diet.

Inspectors wroteBased on record review, observations, resident interviews and staff interviews, the facility failed to maintain a complete and accurate medical record by failing to document the assessment and orders related to a resident's change in condition (Resident #6) and failed to maintain an accurate medical record for documentation of the administration of medications (Resident #6, Resident #18, Resident #71) for 3 of 33 residents whose medical records were reviewed.

Inspectors wroteBased on record review, and staff interviews, the facility failed to accurately document code status in the electronic medical record for 1 of 8 residents (Resident #63) reviewed for advance directives.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (form 10055) prior to discharge from Medicare Part A skilled services for 1 of 3 (Resident #30) residents reviewed for beneficiary protection review.

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code smoking, the use of antiplatelets (medications that prevents blood cells from clumping together to form a clot), and the use of opioids (medications used for relieving pain) for 3 of 33 residents whose Minimum Data Set (MDS) assessments were reviewed (Resident # 3, Resident #54 and Resident #31).

Inspectors wroteBased on record review and staff interviews, the facility failed to develop and implement an comprehensive individualized person centered care plan in the areas of smoking and antipsychotic medications for 2 of 32 residents reviewed for comprehensive care plans (Resident #65, Resident #31).

Inspectors wroteBased on record review and Family Member, Adult Protective Services, Home Health Agency, staff, and physician interview, the facility failed to provide a safe discharge planning process for 1 of 1 resident (Resident #277) reviewed for discharge from the facility. Resident #277 was discharged home on 8/1/24 to an independent living apartment. The facility failed to ensure the resident had a caregiver who could provide care, ensure that resident had a means to obtain medications needed at home, and secure a home health provider for continuity of care.

Inspectors wroteBased on record review and a Family Member and staff interview, the facility failed to provide a complete discharge summary for 1 of 1 resident (Resident #277) reviewed for discharge to the community.

Inspectors wroteBased on record review and staff, Physician, and Pharmacy Consultant interviews, the Pharmacy Consultant failed to identify on a drug regimen review a resident was prescribed and received an antibiotic that was not effective to treat a urinary tract infection (UTI) for 1 of 6 residents reviewed for pharmacy reviews (Resident #6) received an antibiotic ).

Inspectors wroteBased on observations and staff interviews, the facility failed to practice infection control measures when Nurse Aide (NA) #3 did not apply a gown and gloves before entering a resident's room on contact isolation to deliver a meal tray (Resident #177) and when Nurse #3 and NA #5 did not wear gowns when providing gastrostomy tube, urinary catheter and wound care to a resident on enhanced barrier precautions (Resident #68) for 2 of 3 residents reviewed for infection control.

Inspectors wroteBased on observation, record review, staff interviews, Responsible Party (RP) interview, and Physician interview the facility failed to provide supervision of a resident with severe cognitive impairment and known exit seeking behaviors to prevent an unsupervised exit for 1 of 7 residents reviewed for accidents (Resident #56). On 1/01/23 Resident #56 exited the facility out the dining room exit doors unsupervised and without staff knowledge. An alarm sounded, however the alarm announcement was muffled and had static which made the announcement unclear, so the staff were not aware the announcement was in reference to an elopement. Staff did not respond to the alarm due to the poor quality of sound and did not initiate a search for Resident #56. Resident #56 was found by a visitor outside the facility near the dining room door. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to provide written notification for reason of discharge to hospital to the Resident and Responsible Party (RP) for 8 of 8 residents reviewed for hospitalization (Resident #28, Resident #31, Resident #60, Resident #69, Resident #50, Resident #80, Resident #2, and Resident #85).

Inspectors wroteBased on record review and staff interviews, the facility failed to prevent the Director of Nursing (DON) from having a resident care assignment including working on the medication cart with a facility census of greater than 60 residents for 15 of 92 days reviewed (5/20/2022, 6/4/2022, 6/24/2022, 6/25/2022, 6/27/2022, 6/28/2022, 6/29/2022, 6/30/2022, 7/4/2022, 7/5/2022, 7/6/2022, 7/7/2022, 7/8/2022, 7/18/2022, and 7/19/2022).

Inspectors wroteBased on record review, and staff interviews, and resident interview, the facility failed to notify the Resident or Resident Representative of the facility bed hold policy for 4 of 8 residents reviewed for hospitalization (Resident #2, Resident #85, Resident #50, and Resident #80).