Louisburg Healthcare & Rehabilitation Center

Inspectors wroteBased on observation, record review, resident and staff interviews, the facility failed to assess a resident's ability to keep a rescue albuterol inhaler (a medication used to rapidly open airways and relief breathing difficulties) at bedside for self-administration for 1 of 2 residents reviewed for self-administration of medications (Resident #25).

Inspectors wroteBased on record review, and staff interviews, the nurse failed to provide care according to professional standards when she borrowed and administered Resident #35's Potassium Chloride Extended Release (ER) tablets to Resident #8 and left the room without ensuring the resident had taken the medication for 1 of 5 residents reviewed for medications (Resident #8).

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to store an unknown white cream in a locked cart. A white cream was observed on top of an empty barrier dressing package on the resident's bedside table. This occurred for 1 of 1 resident reviewed for medication storage. (Resident #52)

Inspectors wroteBased on record review and interviews with staff, the facility failed to ensure the medical record was complete regarding documentation of wound care for 1 of 3 residents reviewed for pressure ulcers (Resident # 17).

Inspectors wroteBased on record review, and staff and resident interviews, the facility failed to provide resolution of Resident Council Meeting grievances for 4 of 11 monthly Resident Council Meetings. The Resident Council had repeated concerns regarding a wider variety of drink options and clothes/items not coming back from laundry (7/24/24, 8/28/24, 9/23/24, and 10/29/24).

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to maintain Resident #14's dignity by failing to remove a urinal from the overbed table while the resident's meal was in front of him (Resident #14). The facility also failed to promote resident independence and dignity when staff stood over Resident #35 while assisting him to eat. These deficient practices occurred for 2 of the 2 residents reviewed for dignity and respect.

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to assess a resident for self-administration of medication for 1 of 5 residents reviewed for medication administration (Resident #57).

Inspectors wroteBased on observation, record review, and Responsible Party (RP), staff and Nurse Practitioner interviews, the facility failed to provide foot care as ordered for 1of 1 resident reviewed for foot care (Resident #17).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours for 2 of 181 days reviewed for staffing (9/15/24 (Sunday) and 12/07/24 (Saturday).

Inspectors wroteBased on observations and staff interviews, the facility failed to keep food service equipment clean, free from debris, grease buildup, and/or dried spills by failing to clean the convection oven during two kitchen observations. This practice had the potential to affect food served to the residents who resided in the facility.

Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to provide a written grievance summary for 2 of 6 grievances (9/23/24, 1/29/25) on behalf of Resident Council and 1 of 1 resident (Resident #57) reviewed for grievances.

Inspectors wroteBased on record review, resident, staff, Pharmacist and Medical Director Interview, the facility failed to ensure medication was available as ordered for 1 of 3 residents reviewed for administration of medication to meet needs of the resident. (Resident #2)

Inspectors wroteBased on record review, resident, staff, and Medical Director Interview, the facility failed to prevent a significant medication error by not following physicians order and failing to administer Aripiprazole (an antipsychotic medication used to treat schizophrenia and Letrozole (an antineoplastic medication used to treat breast cancer) for 1 of 3 residents (Resident #2) reviewed for significant medication error.

Inspectors wroteBased on observations, record review, staff and resident interviews, pest control technician interviews, and Nurse Practitioner interviews, the facility failed to maintain an effective pest control program to protect vulnerable residents from ants. On 6/23/24 Resident #1 was observed in bed with small black ants all over the floor, bedside table, bed linens, her gown, inside her incontinence brief, and on her body. Resident #1 complained of itching everywhere and had numerous small, reddened areas spread across the back and sides of her body. On 6/26/24 Resident #2 was observed in bed with small black ants all over the floor, furniture, bed linens, and clothing of Resident #2. Fire ants inject venom when they bite that causes a burning sensation and can cause localized sterile blisters, whole body allergic reactions such as anaphylactic shock, and, occasionally, death. [...]

Inspectors wroteBased on record review, staff interviews, Nurse Practitioner, Consultant Pharmacist, and Medical Director interviews the facility failed to attempt a gradual dose reduction (GDR) per Consultant Pharmacist recommendations of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (Resident #38).

Inspectors wroteBased on record review and staff interviews, the facility failed to refer residents with serious mental health diagnoses for a Preadmission Screening and Resident Review (PASRR) level II screening for 1 of 3 residents reviewed for PASRR (Resident #38).

Inspectors wroteBased on interviews with staff and record review the facility failed to ensure a baseline care was completed within 48 hours after admission and failed to complete all sections of the baseline care plan for a new admission for 1 of 3 residents (Resident #63) reviewed.

Inspectors wroteBased on observations, record review, resident and staff interviews, and Medical Director interview, the facility failed to obtain and implement physician orders for the care and monitoring of a resident on hemodialysis for 1 of 2 residents for dialysis (Resident #15).

Inspectors wroteBased on observation and staff interviews the facility failed to label and date an open bottle of eye drops for one of two medication carts observed for medication storage (Hall 400).

Inspectors wroteBased on record review, staff interviews, Consultant Pharmacist, Nurse Practitioner, and Medical Director interviews, the facility failed to obtain outpatient psychiatrist visit notes for a resident prescribed psychotropic medication for 1 of 5 residents reviewed for unnecessary medications (Resident #38)

Inspectors wroteBased on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the 7/28/21 recertification and complaint investigation, the 10/1/21 revisit survey, and the 10/5/23 complaint investigation. This was for two deficiencies cited in the area of Label/Store Drugs and Biologicals and Influenza/Pneumococcal Vaccines. The continued failure of the facility during two or more federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. Findings Included: This tag was cross-referenced to: F761: Based on observation and staff interviews the facility failed to label and date an open bottle of eye drops for one of two medication carts observed for medication storage (Hall 400). [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to offer the pneumococcal vaccine for 1 of 5 residents (Resident #19) and administer the pneumococcal vaccine to eligible residents for 1 of 5 residents reviewed for immunizations (Resident #43).

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to maintain a medication rate not greater than 5% when a medication was administered after a meal instead of the physician order to give at 7:30 AM on an empty stomach, and when one medication was omitted. The result of the medication errors could have resulted in a negative effect for 2 of 3 residents (Resident #8 and Resident #9) observed for medication administration. There were 2 errors in 25 opportunities observed resulting in a medication error rate of 8%.

Inspectors wroteBased on observation and staff interview the facility failed to: 1) Discard 2 vials of an expired controlled substance (Ativan) stored in a locked box in the medication room refrigerator on the 100 hall for 1 of 2 medication storage rooms inspected; and 2) failed to date an opened vial of insulin stored in the 100 hall medication cart for 1 of 3 medication carts inspected.

Inspectors wroteBased on observation and staff interviews the facility failed to sanitize scissors before and after use during wound care for one of one treatment nurse observed during wound care.

Inspectors wroteBased on record review and staff interviews the facility failed to complete a Minimum Data Set (MDS) admission assessment within the required timeframe for 1 of 1 resident (Resident #7) reviewed for Resident Assessments.

Inspectors wroteBased on record review, and staff, Emergency Medical Services (EMS) personnel, and Medical Director interviews, the facility failed to identify the urgent need for medical attention for a resident with new onset seizure activity on 8/12/23 at approximately 10:30 am which is a medical emergency. They did not immediately initiate EMS (Emergency Medical Services) to transfer the resident to an acute care hospital for medical evaluation and interventions for 1 of 2 residents reviewed with a medical emergency. EMS was contacted at 10:58 am and upon their arrival Resident #1 continued with seizure activity and required 3 doses of Versed (a medication used to stop a seizure) for seizure activity to cease. Upon arrival at the hospital Resident #1 was unresponsive and in status epilepticus (a seizure lasting for more than 5 minutes), a medical emergency that may lead to brain damage or death. [...]