Raleigh Court Health and Rehabilitation Center

Inspectors wroteBased on observation, staff interview, and facility document review, facility staff failed to prepare, distribute, and serve food in accordance with professional standards for food service safety.

Inspectors wroteBased on staff interviews, clinical record review, and facility document review, facility staff failed to notify the resident representative of a change in condition requiring transfer for 1 of 4 closed records reviewed for the survey (Resident #113)

Inspectors wroteBased on staff interviews, facility document review, and clinical record review, the facility staff failed to develop a comprehensive care plan which addressed hypotension for one (1) of 23 sampled current residents (Resident #74).

Inspectors wroteBased on observation, staff interview, and clinical record review, facility staff failed to provide adequate supervision to ensure the resident environment remained free of accident hazards for 2 of 23 current residents in the survey sample (Resident #107 and #62).

Inspectors wroteBased on staff interviews, facility document review, and clinical record review, the facility staff failed to ensure one (1) of 23 sampled current residents was free from unnecessary medications (Resident #74).

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure that residents are free of any significant medication errors for 1 of 23 sampled residents, Resident #105.

Inspectors wroteBased on observations, staff interviews, and facility document review, the facility staff failed to ensure the posting of the required daily nurse staffing information.

Inspectors wroteBased on staff interview, family report, and ombudsman interview, facility staff failed to treat the resident with dignity and respect as evidenced by failure to answer calls for assistance within an hour for 1 of 6 residents in the survey sample (Resident #1). Resident #1 was admitted with diagnoses including diabetes mellitus, essential hypertension, hypotension, vascular dementia, peripheral vascular disease, osteomyelitis, cognitive communication deficit, and primary and secondary malignant neoplasms. On the most recent Minimum Data Set assessment, the resident scored 15/15 on the Brief Interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. During an interview on 5/21/2024, the ombudsman reported investigating a family concern about call bells dating from 2/9 through 2/11/2024. [...]

Inspectors wroteBased on staff interview and clinical record review, facility staff failed to administer a medication for managing blood pressure (BP) as ordered by the physician/surrogate for 1 of 6 residents in the survey sample (Resident #1). Resident #1 was admitted with diagnoses including diabetes mellitus, essential hypertension, hypotension, vascular dementia, peripheral vascular disease, osteomyelitis, cognitive communication deficit, and primary and secondary malignant neoplasms. On the most recent Minimum Data Set assessment, the resident scored 15/15 on the Brief Interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The surveyor obtained the Medication Administration Audit report for 2/10/2024. [...]

Inspectors wroteBased on staff interview and clinical record review, facility staff failed to obtain a radiological test ordered by the physician/surrogate for 1 of 6 residents in the survey sample (Resident #1). Resident #1 was admitted with diagnoses including diabetes mellitus, essential hypertension, hypotension, vascular dementia, peripheral vascular disease, osteomyelitis, cognitive communication deficit, and primary and secondary malignant neoplasms. On the most recent Minimum Data Set assessment, the resident scored 15/15 on the Brief Interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The surveyor interviewed the nurse practitioner (NP) on 5/21/2024. The NP reported having entered the order for the Computed tomography (CT) scan and stated the scheduler confirmed the order had been entered. [...]

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to ensure a complete and accurate clinical record for 1 of 6 residents, Resident #2.

Inspectors wroteBased on staff interview, clinical record review, and during the course of a complaint investigation, the facility staff failed to provide activities of daily living care for 4 of 24 residents, Residents #109, #79, #100, and #209.

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to follow physician orders for 1 of 24 residents, Resident's #209 and failed to initiate physician orders following an office visit for 1 of 24, Resident #100.

Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to consistently have pharmacy recommendations available for review, and failed to ensure pharmacy recommendation were followed up on by the provider for 1 of 5 resident's sampled for unnecessary medications. Resident #54.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to dispose of expired medications on 1 of 2 units (unit 2) ,and failed to secure medications on 2 of 2 units (unit 1 and 2).

Inspectors wroteBased on family interview, clinical record and staff interview the facility staff failed to honor the legal Power of attorney (POA) for one of 24 residents sampled (Resident #85). On the Minimum Data Set assessment with assessment reference date 9/14/22, the Resident #85 scored 11/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The resident's diagnoses included chronic venous insufficiency, cerebral infarct, diabetes mellitus with peripheral angiopathy, atrial fibrillation, heart failure, chronic kidney disease, essential hypertension, morbid obesity, bacterial pneumonia, and chronic pain. On 12/19 at 9:30 AM, the surveyor interviewed the resident's Power of Attorney (POA) at his request. The POA stated that the administrator has said that the POA was not empowered to make decisions for the resident. [...]

Inspectors wroteBased on family interview, staff interview, and clinical record review, facility staff failed to notify the RP and/or physician with significant changes to resident status for one of 24 current residents in the survey sample (Resident #85). On the Minimum Data Set assessment with assessment reference date 9/14/22, Resident #85 scored 11/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The residents' diagnoses included chronic venous insufficiency, cerebral infarct, diabetes mellitus with peripheral angiopathy, atrial fibrillation, heart failure, chronic kidney disease, essential hypertension, morbid obesity, bacterial pneumonia, and chronic pain. On 12/19 at 9:30 AM, the surveyor interviewed the residents' Power of Attorney (POA) at his request. [...]

Inspectors wroteBased on observations, staff interviews, and resident interview the facility staff failed to maintain a clean and homelike environment in one of two shower rooms (Unit 1 Shower Room).

Inspectors wroteBased on personnel record review, facility staff failed to obtain a criminal background check prior to employment for one of 25 staff members reviewed. Facility Policy Number 702 titled Abuse/Neglect/Misappropriation/Crime Prevention/Screening/Training states under PROCEDURE: 1. Criminal background and reference checks are performed on all employees. The surveyor reviewed the employment records of 25 employees hired since the last standard survey. One non-clinical employee's record did not contain a criminal background check. The surveyor informed the regional nurse consultant (acting as director of nursing and administrator) of the issue on 12/16/22. A background check dated 12/19/22 revealed several convictions. The surveyor reviewed the convictions with the nurse consultant and concluded none were barrier offences. [...]

Inspectors wroteBased on staff interview, clinical record review and facility document review; the facility staff failed to implement written policies and procedures regarding the investigation and reporting of an allegation of resident abuse for one of 24 residents in the survey sample, Resident # 17.

Inspectors wroteBased on staff interview, clinical record review and facility document review, facility staff failed to report an allegation of resident abuse for one of 24 residents within the survey sample, Resident #17.

Inspectors wroteBased on clinical record review, facility document review and staff interview, the facility staff failed to ensure that 1 of 24 residents in the survey sample had a Level II PASARR, Resident #1.

Inspectors wroteBased on clinical record review, facility documentation review, and staff and resident interview, the facility staff failed to develop and implement a person-centered baseline care plan and failed to provide the resident with a summary of the baseline care plan for one of 24 residents in the survey sample, Resident #357.

Inspectors wroteBased on resident interview, staff interview, and clinical record review, facility staff failed to provide wound care as ordered for one of 24 residents sampled (Resident #79). Resident #79 was admitted to the facility with diagnoses which included multiple sclerosis, local infection of skin, right hip pressure ulcer, hypertension, and major depression. On the quarterly Minimum Data Set assessment with assessment reference date 11/17/22, the resident scored 12/15 on the brief interview for mental status, indicating the resident's cognitive status was essentially intact, and was assessed as being without signs of delirium, psychosis, or behaviors affecting care. The resident required the extensive assistance of 1 person for personal hygiene and was totally dependent on 1 person for bathing. [...]

Inspectors wroteBased on clinical record review and staff interview, the facility failed to act on a medication regimen recommendation by the pharmacist for one of five residents sampled for unnecessary medications (Resident #54).

Inspectors wroteBased on staff interview and clinical record review, facility staff failed to administer the intravenous antibiotic vancomycin per physician orders for 1 of 24 sampled residents (Resident #209). Resident #209 was admitted to the facility with diagnoses including acute osteomyelitis, orthopedic surgical aftercare, rheumatoid arthritis, type 2 diabetes mellitus, chronic ulcer of foot, hypertensive heart disease with heart failure, and Charcot's joint, ankle, and foot. Facility staff had not completed a Minimum Data Set assessment at the time of the survey. Surveyors determined the resident was capable of answering questions concerning care. Review of the residents' clinical record revealed an order for Vancomycin HCl 1.25 gm intravenously at bedtime for wound infection related to osteomyelitis right ankle and foot. [...]

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for 1 of 24 residents, Resident #15.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to ensure the residents and/or resident representative(s) were informed of a change in the physician/provider responsible for his or her care.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure 1 of 28 residents (Resident #99) was free of accident hazards as evidenced by failure to ensure the resident was transferred with the correct size sling when using the mechanical lift, which resulted in resident injury.