Ramseur Rehabilitation and Healthcare Center

Inspectors wroteBased on record review, and staff and Physician interviews, the facility failed to notify the Physician when a STAT (immediately or urgently) x-ray was not completed as ordered for a resident that had right hip pain after a fall on 2/22/25. The order for the x-ray was called to the mobile x-ray provider the evening of 2/22/25. The nurse assigned to the resident on 2/23/25 contacted the mobile x-ray provider to follow up about the STAT x-ray order around 5:00 PM but did not notify the Physician the STAT x-ray had not been completed. Another nurse contacted the mobile x-ray provider on 2/24/25 and the x-ray was completed that afternoon and noted Resident #90 had a displaced right femoral neck fracture (a break in the upper part of the femur [thigh bone],near the hip joint, where broken bone fragments have moved out of their normal alignment). [...]

Inspectors wroteBased on observation, record review, and staff and Physician interviews, the facility failed to provide immediate medical evaluation and treatment when Resident #90 fell and complained of right hip pain on 2/22/25. Nurse #1 notified the Nurse Practitioner and received an order for a STAT (immediately or urgently) of the right hip on 2/22/25. The x-ray was not completed until 2/24/25 and the results revealed a displaced right femoral neck fracture (a break in the upper part of the femur [thigh bone], near the hip joint, where the broken bone fragments have moved out of their normal alignment). In addition, nurses failed to document thorough ongoing assessments of the resident's condition and staff continued to turn and reposition the resident in the bed which was painful for the resident. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments for 2 of 23 residents reviewed for MDS accuracy (Resident #8 and Resident #14).

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to protect the residents right to be free from misappropriation of a narcotic medication (Oxycodone) prescribed to treat pain for Resident #16, Resident #75, and Resident #239. This was for 3 of 3 residents reviewed for misappropriation.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to develop an individualized and comprehensive care plan for a resident with urinary incontinence, a resident at risk for aspiration and failed to care plan antibiotic use. This was for 4 of 25 residents whose care plans were reviewed (Resident #2, #85, #66, and #78).

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to ensure a fall mat was in place according to the care planned fall safety interventions (Resident #31). This was for 1 of 4 residents reviewed for accidents.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to clarify a consultation note and discontinue an order for PICC (peripherally inserted central catheter) line care (Resident #78). This was for 1 of 3 residents reviewed for antibiotic use.

Inspectors wroteBased on record reviews, observations, resident, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following an annual recertification and complaint survey on 06/11/21. This was for two deficiencies that were cited in the areas of Accuracy of Assessments and Free of Accident Hazards/Supervision/Devices. During a complaint survey on 05/16/23, one deficiency was cited in the area of Free of Accident Hazards/Supervision/Devices. In addition, four deficiencies were cited during the annual recertification and complaint survey on 02/23/23 in the areas of Encoding/Transmitting Resident Assessments, Accuracy of Assessments, Care Plan Timing and Revision, and Free of Accident Hazards/Supervision/Devices. [...]

Inspectors wrote2. Resident #86 was admitted to the facility on [DATE]. Resident #86's admission Minimum Data Set (MDS) dated [DATE] indicated his cognition was intact. Review of Resident #86's electronic medical record read he was transferred to the hospital on [DATE]. There was no documentation in the resident's medical record that written notice of transfer or discharge was provided to the resident and/or Resident Representative (RR). Resident #86 returned to the facility on [DATE]. An interview was conducted on 4/30/24 at 3:32 PM with the facility Social Worker (SW). She stated she had been at the facility since [DATE] and was not mailing a notice of discharge or transfer to the RR when the resident was admitted to the hospital. She was unaware she needed to send notification to the resident or RR in writing. An interview was conducted on 4/30/24 at 3:34 PM with the Director of Nursing (DON). [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a Minimum Data Set (MDS) discharge assessment within the required time frame for 1 of 6 residents reviewed for discharge (Resident #58).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) in the area of medication for 1 of 26 residents whose MDS assessments were reviewed (Resident #24).

Inspectors wroteBased on record review and staff interviews, the facility failed to review and revise the care plans in the areas of antibiotic use and JP drain (A Jackson Pratt (JP) drain is a surgical suction drain that gently draws fluid from a wound to help recover after surgery) for Resident #81. This was for 1 of 3 residents reviewed for care plans.

Inspectors wroteBased on record review, observations, and staff and Medical Director interviews the facility failed to protect a resident's right to be free of sexual abuse for 1 of 3 residents investigated for abuse (Resident #7). A moderately cognitively impaired male resident (Resident #39) was found beside Resident #7's bed, a severely cognitively impaired female resident, with his hand moving under the covers around her groin area when a staff member entered Resident #7's room. Resident #7's brief was open and there was stool on the outside of her brief and on her sheets, and Resident #39 had stool on his hands. Resident #39 was interviewed and stated he was playing around with Resident #7 down there and waved his hand in a circular motion around his groin area. Resident #39 stated he had done something stupid, and he should not have done it. [...]

Inspectors wroteBased on record review, observations, and staff and Medical Director interviews the facility failed to implement the following components of the abuse policy: (a) immediately report an allegation of sexual abuse of a severely cognitively impaired female resident (Resident #7) by a moderately cognitively impaired male resident (Resident #39) to the Administrator; (b) the facility failed to provide a physical examination of a severely cognitively impaired female resident (Resident #7) by a trained/licensed professional for signs of sexual abuse; (c) the facility failed to protect a severely cognitively impaired female resident (Resident #7) and all other residents from the possibility of sexual abuse when they failed to put Resident #39 on one-to-one observations when there was an allegation of sexual abuse against Resident #7; [...]

Inspectors wroteBased on record reviews and staff interviews, the facility failed to provide Registered Nurse (RN) coverage at least 8 consecutive hours a day for 7 out of 38 days reviewed for staffing. The failure to have RN coverage for the facility had the high likelihood to impact every resident in the facility.

Inspectors wroteBased on record review and staff and resident interviews, the facility failed to resolve grievances which were reported in the Resident Council meetings for 4 out of 6 months reviewed (August 2022, September 2022, October 2022, November 2022, December 2022, January 2023).

Inspectors wroteBased on record review and staff interviews, the facility failed to review and revise the care plan in the areas of falls (Residents #2, #38 and #58), pressure ulcers (Resident #14), and medications (Residents #43 and #77). This was for 6 of 18 resident records reviewed.

Inspectors wroteBased on observations, record review, resident, and staff interview ' s the facility failed to provide nail care and incontinence care for 3 of 5 residents reviewed for activities of daily living (ADL ' s) (Resident #29, #1, and #2).

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to ensure group activities were planned on weekends to meet the needs of residents who expressed that it was important to them to attend group activities (Residents #35, #13, #3) for 3 of 3 residents reviewed for activities.

Inspectors wroteBased on record reviews, observations, resident, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification and complaint survey completed on 06/11/21. This was for 6 deficiencies that were cited in the areas of Accuracy of Assessments, Services Provided Meet Professional Standards, Activities of Daily Living Care Provided for Dependent Residents, Free of Accident Hazards/Supervision/Devices, Increase/Prevent Decrease in Range of Motion/Mobility, Registered Nurse 8 hours/7 Days/Week, Full Time Director of Nursing, and Posted Nurse Staffing Information. [...]

Inspectors wroteBased on record review and staff and resident interviews, the facility failed to assess and obtain physician orders for the self-administration of medications for 1 of 6 residents (Resident #185) reviewed for self-administration.

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to complete a significant change in status Minimum Data Set (MDS) assessment for a resident with two or more areas of decline in Activities of Daily Living (ADLs) for 1 of 1 resident reviewed for significant change (Resident # 38).

Inspectors wroteBased on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the area of medications for 2 of 21 residents whose MDS were reviewed (Residents # 77 & # 43).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a physician ' s order for a palm splint was accurate on the Medication Administration Record (MAR) for 1 of 3 residents (Resident #29) reviewed for Range of Motion (ROM).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to ensure a fall mat was in place according to the care planned fall safety interventions (Resident #2). This was for 1 of 8 residents reviewed for accidents.

Inspectors wroteBased on record review and staff interviews, the facility failed to display accurate Posted Nurse Staffing Information as compared to the Staff Schedule/Assignment Sheets for 22 out of 38 days reviewed.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete and transmit a discharge Minimum Data Set (MDS) assessment (Resident #56) and failed to transmit a discharge MDS assessment (Resident #67). This was for 2 of 2 residents selected to be reviewed for submission of Resident Assessments within the required timeframe.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure 4 of 5 Certified Nurse Aides (CNAs) had a documented performance review every twelve months to ensure in-service education was designed to address the outcome of the performance reviews (CNA #3, #9, #10 and #11).