Fuquay-Varina Health and Rehabilitation Center

Inspectors wroteBased on record review and Resident Representative (RR) and staff interviews, the facility failed to provide written information about advance directive and/or an opportunity to formulate an advance directive and to an obtain advance directive and maintain the advance directives in the medical record for 2 of 4 residents reviewed for advance directives (Residents #52 and #7).

Inspectors wroteNumber of Residents Sampled - 6Number of Residents Cited - 1Based on record reviews, and staff, Guardian and physician interviews, the facility failed to ensure a resident was not prescribed a medication to which the resident had a documented allergy for 1 of 6 residents reviewed (Resident #115).

Inspectors wroteBased on record review, and staff and Medical Director interviews, the facility failed to provide tracheostomy (an opening into the neck through the windpipe) care consistent with professional standards of practice when Nurse #2 cleaned and reused a single use disposable tracheostomy inner cannula when she provided tracheostomy care. This was for 1 of 3 residents reviewed for respiratory care (Resident #109).

Inspectors wroteBased on observations and staff interviews, the facility failed to secure medications and treatment supplies in a locked wound care cart for 1 of 2 wound care carts observed (Station 2 Wound Care Cart).

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to post daily staffing information in an area of the facility visible to residents and visitors on 1 of 4 days of the survey (3/29/26). In addition, the facility failed to have an effective process in place to ensure staffing information data was posted daily, including on the weekend.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure a resident was treated respectfully when a Nurse Aide was using her personal cell phone rather than responding to a resident's verbal yell for help and the activation of his call bell. This was for 1 of 15 sampled residents (Resident # 15).

Inspectors wroteBased on record review and staff interviews, the facility failed to protect a resident's right to be free from misappropriation. This was for 1 of 1 sampled resident who was reported to have possible diversion of her pain medication (Resident #2).

Inspectors wroteBased on record review and interviews with staff and staff members at the North Carolina Board of Nursing, the facility failed to ensure it did not employ a nurse who currently had disciplinary action in effect against her professional license secondary to a history of drug diversion. This was for 1 of 2 staff members whose personnel information was reviewed (Nurse # 13).

Inspectors wroteBased on record review and interviews with resident and staff, the facility failed to implement their abuse policy when they 1) failed to suspend a staff member who was accused of slapping a resident and 2) ensure the incident was reported to the Administrator in order that regulatory reporting timeframes to other agencies were met and an investigation was initiated on the day of the allegation. This was for 1 of 3 sampled residents who alleged abuse had occurred (Resident # 1).

Inspectors wroteBased on observation, record review, and interviews with staff, Registered Dietician (RD), and Nurse Practitioner (NP), the facility failed to discontinue a previous enteral feeding (tube feeding) order when a new order was initiated which resulted in the resident not receiving the enteral feeding as most recently ordered. This was for 1 of 3 sampled residents who received nutrition by an enteral feeding (Resident #12).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of Hospice (Resident #6), Hearing, Speech and Vision (Resident #13), Functional abilities and Goals (Resident #56) and Dialysis (Resident #350) for 4 of 21 residents reviewed for MDS accuracy.

Inspectors wroteBased on record review and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 25 of 61 days reviewed for sufficient staffing.

Inspectors wroteBased on interviews with Resident Council members and staff and review of Resident Council minutes, the facility failed to resolve concerns voiced by the Resident Council members for 1 of 6 months reviewed (July 2024).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide written advance directive information and/or an opportunity to formulate an advance directive for 2 of 21 residents reviewed for advance directive (Residents #14 and Resident #17).

Inspectors wroteBased on record review and staff interview, the facility failed to protect residents' right to be free from misappropriation of resident property for 2 of 21 residents reviewed for misappropriation of resident property (Resident #152 and Resident # 97).

Inspectors wroteBased on staff interviews and record review the facility failed to develop a comprehensive care plan to include application of splints or multi podus boots for 1 of 32 residents (Resident #56) reviewed for comprehensive care planning.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to apply left hand splint, elbow extender splints and multi podus boots as ordered for 1 of 3 sampled residents with limited range of motion/contractures (Resident #56).

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to ensure Resident #64 was scheduled for a neurology appointment for 1 of 1 resident reviewed for medical appointments (Resident # 64).

Inspectors wroteBased on observation and staff interviews, the facility failed to dispose/discard expired medications in 1 of 3 medication carts (Rehab Medication Cart) observed.

Inspectors wroteBased on record review and staff interviews, the facility failed to have a complete and accurate medication and administration record for 2 of 5 residents reviewed for medical record accuracy (Resident #250 and Resident #350).

Inspectors wroteBased on observations and staff interviews, facility staff failed to implement infection control policy and procedures when Physical Therapist Assistant (PTA #1) and Physical Therapist (PT #2) did not don Protective Equipment (PPE) for Enhanced Barrier Precautions (EPB) to include a gown when providing high-contact resident care activities for Resident #251 who had indwelling upper chest dialysis catheter. The deficient practice was identified for 2 of 2 staff members observed for infection control practices (PTA #1 and PT #2).

Inspectors wroteBased on observations, resident and staff interviews the facility, failed to replace stained privacy curtain in resident room (304), failed to remove the black greenish substance from the commode base caulking in resident rooms (304, 309, 708, 713, and 714), failed to repair damaged drywall in resident rooms (306, 309, 503, 605, and 713), failed to repair a broken bedside dresser handle in resident room (403), failed to replace a broken off towel rack in resident bathroom (304), and failed to replace missing resident's overhead bed light covers in rooms (714 and 718). These failures occurred on 2 of 8 hallways (300 Hall and 700 Hall) observed for a safe, clean, homelike environment.

Inspectors wroteBased on record review and staff interviews the facility failed provide to the Resident Representative and Ombudsman a written notification for the reason for transfer to the hospital for 2 of 2 residents reviewed for hospitalization (Resident #56 and #21).

Inspectors wroteBased on record review, and Resident Representative (RR) and staff interviews, the facility failed to conduct care plan meetings or invite residents to their care plan meetings for 1 of 31 residents reviewed for care plans (Resident #47).

Inspectors wroteBased on observations, record review, and staff, police dispatch, physician, and responsible party (RP) interviews the facility failed to prevent a severely cognitively impaired resident (Resident #71) with known wandering behaviors and poor safety awareness from becoming trapped alone in a locked administrative staff's office with the lights off without staff's knowledge. The facility also failed to provide evidence that a thorough investigation of the incident was conducted and to put corrective measures in place after the incident to prevent a potential recurrence. This deficient practice had a high likelihood of causing Resident #71 serious physical and psychosocial harm. Resident #71 did not have the cognitive capacity to express an adverse outcome. A reasonable person would have suffered feelings of fear, anxiety, and/or helplessness from the incident. [...]

Inspectors wroteBased on observations, record review, resident, staff, Physician, and pest control technician interviews the facility failed to control the presence of ants in the facility, maintain an effective pest control program, and to protect a vulnerable resident from having ants crawling on him while in bed. The resident sustained multiple ant bites/stings to his arms, torso, and upper back which resulted in the resident experiencing the discomfort of stinging and itching. Furthermore, the resident stated having ants in his bed, on him, and having been stung/bitten made him feel upset and like No one cared. The facility also failed to implement effective pest reduction measures when the ants were first observed on the resident by staff on 10-6-23. This occurred for 1 of 4 residents (Resident #1) observed for pest control. [...]

Inspectors wroteBased on record review and staff and resident interviews, the facility failed to provide the resident council members with a response to grievances reported during the resident council meetings for 3 of 3 resident council grievances reviewed.

Inspectors wroteBased on record review and staff interviews the facility failed to ensure advanced directive information was accurate throughout residents' electronic and paper medical records for 4 of 5 residents (Resident #42, Resident #52, Resident #57, and Resident #76) reviewed for advanced directives.

Inspectors wroteBased on observation, record review, resident, staff, and Physician interviews, the facility failed to follow physician orders for pressure ulcer dressing changes, compete wound care as ordered, and set an alternating pressure mattress according to the resident's weight. This occurred for 3 of 3 residents (Resident #1, Resident #81, and Resident #32) reviewed for wound care.

Inspectors wroteBased on record review and staff interviews the facility failed to have 8 consecutive hours of Registered Nurse (RN) coverage for 7 of 120 days reviewed.

Inspectors wroteBased on observation, record review, staff, and Physician interviews, the facility failed to have a medication error rate less than 5% as evidenced by 15 medication errors out of 33 opportunities, resulting in a medication error rate of 45.45% for 2 of 4 residents (Resident #14, and Resident #7) observed during the medication administration observation.

Inspectors wroteBased on observations and staff interviews the facility failed to discard expired medications for 1 of 2 medication storage rooms observed (station 1 medication room), failed to keep unattended medications in a locked medication cart for 1 of 5 medication carts observed (700-hall medication cart), and failed to keep unattended medications in a locked treatment cart for 2 of 3 treatment carts observed (station 1 treatment cart and station 2 treatment cart). Findings Included: 1. During observation of the station 1 medication room [ROOM NUMBER]/13/23 at 8:34 AM with the Director of Nursing, the station 1 medication room was observed to contain six bottles of simethicone 125 milligrams which had an expiration date of 9/2023, one bottle of simethicone 80 milligrams which had an expiration date of 8/2023, and one bottle of simethicone 80 milligrams which had an expiration date of 9/2023. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to 1) label/date opened food items stored in 1 of 1 one of one walk-in freezer and 2) label/date food items stored in 1 of 1 dry goods storage area. These practices had the potential to affect food served to all residents.

Inspectors wroteBased on observation and staff interviews, the facility failed to maintain the area surrounding the dumpsters free of debris for 2 of 2 dumpsters observed.

Inspectors wroteBased on record review, observations, and interviews with resident, family, responsible party, physician, police dispatch, and staff, 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 investigation survey of 6/11/2021, the revisit survey of 8/6/21, the complaint investigation survey of 9/20/2021, and the recertification and complaint investigation survey of 6/17/2022. This was for nineteen recited deficiencies on the current recertification and complaint investigation survey of 10/18/2023. The deficiencies included: [...]

Inspectors wroteBased on record review and staff interviews the facility failed to ensure Nurse Aides (NA) received at least 12 hours of in-service training in one year. This was for 5 of 5 NA in-service training records reviewed (NA #12, NA #10, NA #4, NA #5).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide required dementia management training for 7 of 8 nursing staff (Nursing Assistant (NA) #12, NA #10, NA #13, NA #4, NA #5, Nurse #4 and Nurse #5) reviewed for education requirements.

Inspectors wroteBased on record review, resident interview and staff interviews, the facility failed to honor a resident's choice related to showers for 1 of 9 dependent residents reviewed for choices (Resident #29).

Inspectors wroteBased on resident and staff interviews, interview with a Resident Representative and record reviews, the facility failed to develop a baseline care plan within 48 hours of a resident's admission and failed to provide a written summary of the baseline care plan to the Resident or Resident Representative for 4 of 28 sampled residents (Residents #29, #77, #388 and #89).

Inspectors wroteBased on observations, record review and staff interviews the facility failed to develop a comprehensive care plan which addressed wandering behavior and the use of a wander/elopement alarm for 1 of 33 residents (Resident #71) whose comprehensive care plans were reviewed.

Inspectors wroteBased on record review and staff interviews the facility failed to ensure an interdisciplinary team reviewed and revised a resident's comprehensive care plan and failed to ensure the resident's representative was involved in care planning after a quarterly Minimum Data Set (MDS) assessment for 1 of 33 residents (Resident #71) whose care plans were reviewed.

Inspectors wroteBased on record review and staff and family interviews the facility failed to change a resident's soiled brief due to meal trays being passed on the halls for 1 of 8 resident reviewed for activities of daily living care (Resident #53).

Inspectors wroteBased on observation, record review, and staff interview the facility failed to assess the resident's left upper arm shunt site upon returning to the facility after dialysis for 1 of 1 resident reviewed for dialysis. (Resident #390).

Inspectors wroteBased on record review, family and staff interviews the facility failed to ensure a resident attended a medical appointment for 1 of 1 sampled resident reviewed for medically related social services (Resident #88).

Inspectors wroteBased on record review and Medical Director, and staff interviews, the facility failed to ensure an as needed (PRN) psychotropic medication was time limited in duration for 1 of 5 residents reviewed for unnecessary medications (Resident #17).

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to implement their infection control policy when Nurse Aide (NA) #9 did not perform hand hygiene during meal delivery and set up which required NA #9 to reposition the resident's personal belongings for 1 of 2 NAs observed passing meal trays. This had the potential to result in cross-contamination of microorganisms between residents.

Inspectors wroteBased on observations, resident interviews and staff interviews, the facility failed to inform residents (Resident #4, #59, #24 and #36) of the location of the state inspection results, and failed to display state inspection results in a location accessible to residents.

Inspectors wroted. Resident #53 was admitted to the facility on [DATE]. Review of a grievance for Resident #53 completed and submitted on 2/27/23 by Family Member #1 revealed there was documentation of the facility follow-up and no resolution of the grievance or concern. Review of Resident #53's most recent minimum data set assessment dated [DATE] revealed he was assessed as severely cognitively impaired. During an interview on 10/11/23 at 2:15 PM Family Member #1 stated she had not received any response from the facility regarding the grievance she submitted on 2/27/23. During an interview on 10/11/23 at 2:31 PM the Social Worker stated he had been working at the facility for a little over six months. When someone filed a grievance the person who received the grievance gave it to the Administrator and she would then distribute the grievance to the appropriate department. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for 2 of 37 residents reviewed for MDS accuracy (Residents #390 and Resident #30).

Inspectors wroteBased on record reviews and staff interviews, the facility failed to maintain complete and accurate medical records in the areas of wound care (Residents #32, #58, #1 and #81) and splint management (Resident #53). This was for 5 of 32 resident records reviewed.