Raleigh Center

Inspectors wroteBased upon observation and staff interviews. the facility failed to maintain a safe, clean homelike environment for residents. This was found to be true for three (3) of 26 residents reviewed during the long-term care survey process. Resident identifiers: #3, #13, #25. Facility census: 65.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to meet the nutritional needs of the residents in accordance with established national guidelines, due to not following the menu, recipes, and prepping in advance. This had the potential to affect more than a limited number of residents who received their meals from the kitchen. Resident #11, #30, #63, and a sample tray sent to the survey team. Facility census: 65.

Inspectors wroteBased on food tray temperatures, resident interviews and staff interview, the facility failed to serve food to residents that was attractive, palatable and at a safe and appetizing temperature to prevent foodborne illness. The facility failed to ensure cold foods were served cold. This failed practice was true for one (1) of one (1) meal tray tested for food temperatures throughout the survey process but had the potential to effect more than an isolated number of residents. Residents identified: #11, 15, 53, 48, 49, 1 and 69. Facility census: 65.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. Additionally, the facility failed to follow the proper sanitation practices for the kitchen and the food preparation equipment. This practice had the potential to affect more than an isolated number of residents. Facility census: 65.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to store and dispose of garbage and refuse properly. This was a random opportunity for discovery that has the potential to affect more than a limited number of the residents currently residing at the facility. Facility census: 65.

Inspectors wroteBased on record review, observation and staff interviews, the facility failed to ensure a safe and sanitary environment was provided to prevent the development and transmission of communicable diseases and infections. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #33, #50, #58 and #40. Facility Census: 65.

Inspectors wroteBased upon record review and staff interview, the facility failed to accurately record a diagnosis of bipolar on a resident's Minimum Data Set (MDS). This was found to be true for one (1) of 26 residents reviewed during the long term care survey process. Resident identifier: #12. Facility census: 65.

Inspectors wroteBased on observation, record review and staff interview the facility failed to implement a personalized care plan to provide adaptative equipment (plate guard) for Resident #26. This was a random opportunity for discovery and was only true for Resident #26. Resident Identifiers: Resident #26. Facility Census: 65 Findings Include: a) Resident #26 On 3/16/26 at 12:20 PM an observation found Resident 26 did not have a plate guard provided with her noon time meal. Resident #26 has a medical diagnosis which includes hemiplegia, affecting the left non dominant side as well as legal blindness. Resident #26 has an order for a regular/liberalized diet, regular texture, standard thin liquids consistent. [...]

Inspectors wroteBased on record review and staff interview, the facility failed ensure a care plan was revised and updated when a nutritional supplement was discontinued. This was true for one (1) of 26 sampled residents reviewed during the long term care survey process. Resident Identifier: #2. Facility Census: 65.

Inspectors wroteBased on observation, record review and staff interview the facility failed to provide adaptative equipment (plate guard) for Resident #26 as ordered. This was a random opportunity of discovery and was true for only Resident #26. Facility Census: 65Findings Include: a) Resident #26 On 3/16/26 at 12:20 PM an observation found Resident #26 did not have a plate guard provided with her noon meal. Resident #26 has medical diagnoses which includes hemiplegia, affecting the left non dominant side as well as legal blindness. Resident #26 has an order for a regular/liberalized diet, regular texture, standard thin liquids consistent. Plate guard and built up utensils with meals, no salt packet, sugar sub (substitute). [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident's Physician Orders for Scope of Treatment (POST) form was signed by the resident's Power of Attorney (POA). This was true for one (1) of three (3) residents reviewed for the care area of advance directives during the long term care survey process. Resident Identifier: #39. Facility Census: 65.

Inspectors wroteBased on observation and staff interview the facility failed to maintain an accident and hazard free environment by leaving a medicine cart unlocked and unattended. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing in the Long-Term Care Facility. Facility census: 65.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure food was stored/prepared and served in a sanitary manner, due to items sitting on the floor, an oven not being cleaned, and stacking serving pans and bowls while still wet. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents residing in the facility. Facility census: 65.

Inspectors wroteBased on observation, staff interview and the facility policy, the facility failed to ensure the residents had a comfortable, homelike environment. Meal tray service without removal of tray, and staff storing trash bags in residents room on residents hand towel rack. This was a random opportunity for discovery and had the ability to affect a limited number of residents. Resident identifier: Meal tray service without removal of tray and staff storing trash bags in residents room on residents hand towel rack. Facility census: 63.

Inspectors wroteBased on observation and resident and staff interview, the facility failed to ensure residents of the facility were free from abuse and neglect due to a Nurse Aide (NA) neglecting their duties, not serving Resident #2 lunch in a timely manner, and ensuring other residents were free from abuse by Resident #16. These were random opportunities for discovery. Resident identifiers: #2, #6, #24, #16. Facility census: 63.

Inspectors wroteBased on observation, resident interview and staff interview the facility failed to ensure the environment was free of accident hazards. Residents fall mats were preventing a resident to safely make it to his bed in his wheelchair, oxygen was stored in resident sitting area with no signage, and medications were not stored in a safe manner. These were random opportunities for discovery during the long term care survey process and had the ability to affect a more than a limited number of residents currently resding in the facility. Identifier: Resident #26. Facility Census.: 63.

Inspectors wroteBased on observation and resident and staff interviews, the facility failed to offer snacks to residents who wished to revieve a snack at night time, and failed to ensure all ordered snacks were delivered to residents at night time. This was a random opportunity for discovery. Resident identifiers: #24, #28, #33, #51, #52, #22, #58. Facility census: 63.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure food was stored, prepared, and served in a sanitary manner. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents residing in the facility. Facility census: 63.

Inspectors wroteBased on resident interview, record review and staff interview, the facility failed to ensure each resident was treated with dignity. This was a random opportunity for discovery. Resident identifier: #12. Facility Census: 63.

Inspectors wroteBased on observation, staff interview and resident interview, the facility to ensure call light was placed in a position which would allow the resident to use it if she needed to call for help. This is true for one (1) of 22 sampled residents reviewed during the long term care survey process. Resident Identifier: Resident #35. Facility Census: 63.

Inspectors wroteBased on record review and staff interview the facility failed to implement the policy and procedure entitled, Abuse Prohibition. This was a random opportunity for discovery. Resident identifiers: Resident #16, #6 and #24. Facility census 63.

Inspectors wroteBased on record review and staff interview the facility failed to report an allegation of abuse. This was a random opportunity for discovery. Resident identifiers: #16, #6, #24. Facility census: 63.

Inspectors wroteBased on record review, staff interview and the facility policy and procedure review, the facility failed to provide evidence that all alleged violations were thoroughly investigated, and that corrective action was taken. Residents level of care was not reviewed for possible discrepancies and statements were not obtain from all relevant staff members. This was true for one (1) of five (5) residents reviewed for abuse during the long terms survey process. Resident identifier: #4. Facility census: 63. Findings Include: a) Resident #4 On 08/29/24 at approximately 2:40 PM during the review of the facility investigation completed for the incident which occurred on 06/01/24 it was identified that statements from all staff who had cared for the resident during this time had not been obtained. [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to accurately complete a Minimum Data Set (MDS) when Resident #61 was discharged home. This was true for one (1) of 22 residents reviewed during the long term care survey process. Resident Identifier: Resident #61. Facility census: 63.

Inspectors wroteBased on medical record review and staff interview the facility failed to develop and implement the individualized comprehensive care plan for depression. This was true for one (1) of 22 residents reviewed during the long term care survey process. Resident identifier: #26. Facility census: 63.

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice by failing to provide care according to physicians orders. This was a random opportunity for discovery during the Long Term Care Survey Process. Resident identifiers: Resident #15 and Resident #25. Facility census: 63.

Inspectors wroteBased on record review and staff interview the facility failed to timely act upon a Medication Regimen Review (MRR) of a high-risk medication. This was true for 1 (one) of 5 (five) residents reviewed for the care area of unnecessary medications during the Long-Term Care Survey Process. Resident identifier: Resident #16. Facility census 63.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure Resident #24 and #28 were served the correct diet to meet their needs. This was a random opportunity for discovery. Resident identifiers: #24, #28. Facility census: 63.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure garbage and refuse was disposed of properly. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents residing in the facility. Facility census: 63.

Inspectors wroteAccording to record review and resident and staff interviews, the facility failed to accurately complete medical records pertaining to blood pressures for Resident #45 and a diagnosis of depression for Resident #26. This was a random opportunity for discovery. Resident identifiers: #45, #26. Facility 63.

Inspectors wroteBased on observation and staff interview the facility failed to store respiratory equipment at bedside in a sanitary manner according to professional standards of care. This was a random opportunities for discovery. Resident Identifier: #219, #3, #27 Facility Census:

Inspectors wroteBased on record reviews and staff interview the facility failed to ensure a complete and accurate medical record. The facility failed to ensure the Physician Orders for Scope of Treatment (POST) forms were completed per directions specified by the [NAME] Virginia Center for End-of-Life Care. This was true for three (3) of 17 residents reviewed for the Long-Term Care Survey Process. Resident Identifiers: #44, #66, and #8. Facility Census: 63.

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to develop and/or implement the comprehensive care plan. Resident #40's comprehensive care plan was not developed in the area of shoulder pain. Resident #8's care plan was not implemented in the area of nutrition. This deficient practice had the potential to affect two (2) of 17 residents reviewed in the long-term care survey sample. Resident identifiers: #40, #8. Facility census: 63. a) Resident #40 During an interview on 03/06/23 at 12:41 PM, Resident #40 reported bilateral shoulder pain. She stated she was receiving pain medication but still had shoulder pain, particularly in the morning when her clothing was changed. Review of Resident #40's medical records revealed she had a diagnosis of osteoarthritis and a history of right humerus fracture. [...]

Inspectors wroteBased on record review and staff interview and policy procedures the facility failed to provide treatment and care in accordance with professional standards of practice. This was true for two (2) of three (3) records reviewed for accidents. Findings Included: Resident #28 a) On 3/6/23 at 1:04 PM record review shows that Resident #28 had a fall on 2/25/23. The fall was unwitnessed and he presented with a swollen right hand that required an x-ray (negative). According to the facility Falls Management Policy dated 9/15/01, Revision date 6/15/22 Any patient who sustains an injury to the head from a fall and/or has an unwitnessed fall will be observed for neurological abnormalities by performing neuro check, per policy According to the Director of Nursing (DON) on 3/6/23 at 3:25 PM, the neurological checks are to be done in the following sequence. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #48 did not have fall mats to her floor as ordered by the physician. This was a random opportunity for discovery. Resident identifier: #48. Facility census: 63.

Inspectors wroteBased on record review and staff interview, the pharmacist failed to report a medication irregularity for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #8. Facility census: 63.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the controlled substance count was completed and documented by two (2) licensed nurses during shift change. This was a random opportunity for discovery. Facility Census: 63. Findings Included: a) Medication Administration On 03/07/23 at 8:15 AM, a review of the controlled substances count was completed. The following dates were not signed by two (2) nurses during shift change and the narcotic count was not completed: [...]

Inspectors wroteBased on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered the freezer floor needed to be cleaned and the beverage dispenser was not draining properly. This had the potential to affect a limited number of residents receiving nourishment from the kitchen. Facility census: 63.