Roxboro Healthcare & Rehab Center

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to keep 9 of 9 ceiling vents free from a buildup of dust and maintain an intact painted surface on the vents in the dining room which resulted in particles of dust and paint chips being blown into the air in the direct vicinity of where residents were observed to be eating food in 1 of 1 dining room.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that seven ceiling vents, two ceiling fans, and two industrial fans in the kitchen and dishwashing area remained free of dust particles blowing onto clean surfaces. This practice potentially compromised the safety of food served to residents.

Inspectors wroteBased on record reviews and interviews with resident and staff, the facility failed to involve residents and/or their representatives in the care planning process for 1 of 20 sampled residents reviewed for care plan participation (Resident #3).

Inspectors wroteBased on observations and staff interviews, the facility failed to prevent a buildup of dust on, and condensation on and around the kitchen Heating Ventilation and Air Conditioning (HVAC) vent, which resulted in moisture damage to the ceiling in the kitchen. These practices had the potential to affect food served to all residents.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to determine whether the self-administration of medications was clinically appropriate for 1 of 1 sampled resident (Resident #82) who was observed to have a medication at bedside.

Inspectors wroteBased on staff and Rehabilitation Director interviews, and record reviews, the facility failed to develop a comprehensive care plan which addressed a resident's contractures and the application / removal of two splints for 1 of 1 resident reviewed for limited range of motion (Resident #80).

Inspectors wroteBased on observations, family and staff interviews, and record review, the facility failed to ensure a resident's nails were clean for 1 of 4 residents (Resident #89) who were reviewed for Activities of Daily Living (ADLs).

Inspectors wroteBased on observations, interviews with the resident, staff, and Occupational Therapist, and record reviews, the facility failed to follow a physician's order to apply two splints (one to the resident's right hand and one to his right elbow) to prevent further contracture for 1 of 1 resident reviewed for limited range of motion (Resident #80).

Inspectors wroteBased on observations, staff interviews, and hospital and facility record reviews, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection for 1 of 2 residents (Resident #89) reviewed with urinary catheters.

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 28 opportunities, resulting in a medication error rate of 7.1% for 2 of 5 residents (Residents #15 and #69) observed during the Medication Administration Observation. 1. On 8/11/24 at 10:37 AM, Nurse #7 was observed as she prepared and administered 5 medications to Resident #15. The medications administered included one 81 milligram (mg) aspirin chewable tablet. A review of Resident #15's medication orders revealed the resident had a current order for an 81 mg EC [enteric-coated] tablet delayed release aspirin to be given as one tablet by mouth one time a day (initiated on 1/3/24). An interview was conducted on 8/11/24 at 1:02 PM with Nurse #7. [...]

Inspectors wroteBased on observations, interviews with staff, and record reviews, the facility failed to: 1) Discard a stock medication without a legible expiration date stored on 1 of 2 medication (med) carts observed (200 Hall Med Cart); and 2) Dispose of loose, unidentified tablets observed in the drawer of 1 of 2 med carts observed (100 Hall Med Cart).

Inspectors wroteBased on record review, staff and consultant pharmacist interviews the facility failed to: 1) Maintain documentation of the pharmacist's Monthly Medication Reviews (MMRs) within the facility and readily available for review; and 2) Retain documentation of the physician's review and response to the pharmacist's findings / recommendations in the resident's medical record. This occurred for 2 of 5 residents reviewed for Unnecessary Medications (Resident #26, and Resident #30).

Inspectors wroteBased on record review and interviews with residents, staff, a Nurse Practitioner, Physician, and pharmacists for three (Residents # 5, # 10, and # 15) of three sampled residents reviewed for pain management the facility failed to provide pain medications for hospice and surgical residents per their orders and/or request and plan of care. For one of these three residents (Resident # 10), a nurse was aware the resident was in pain due to a recent hip replacement surgery but reported she could not access pain medication to administer to the resident resulting in the resident not receiving pain medication when she was in pain. [...]

Inspectors wroteBased on observation, record review, and interviews with residents, staff, and pharmacist for three of three residents (Residents # 5, # 10, #15) whose medications were reviewed the facility failed to ensure 1)nurses had access to back up pain medications in the facility's supply and the pain medications were replenished and available for administration (Residents # 10 and # 15) 2) narcotic pain prescriptions were faxed to the pharmacy correctly in order they be filled (Resident # 15) 3) allergies to pain medications were clarified in a time frame which did not interfere with the delivery of the pain medication from the pharmacy (Resident # 15) 4) prescription request for narcotic pain medication refills were submitted to the physician prior to a resident's supply running out (Resident # 5) and 5) the facility's accounting system of a controlled substance (Oxycodone) accurately [...]

Inspectors wroteBased on observation, record review, and interviews with staff and physicians the facility failed to ensure a staff member did not apply a dressing to a reopened pressure sore without obtaining orders and entering the information into the resident's record so future nurses would know to change the dressing and monitor the pressure sore. This was for one (Resident # 16) of four sampled residents reviewed for care of pressure sores.

Inspectors wroteBased on observations and staff interview the facility failed to label food, discard leftover food that had past the use by date and cover dishes that stored food stored in the walk-in refrigerator, reach-in refrigerator, and reach-in freezer. The facility failed to maintain the walk-in freezer floor free from ice. The dietary staff failed to wash hands after handling dirty and before handling clean dishes during the dishwasher observation. These practices had the potential to affect food being served to residents.

Inspectors wroteBased on observations, resident and staff interviews and record review, the facility's quality assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the recertification and complaint surveys dated 8/3/22 and 6/10/21 to achieve and sustain compliance. The deficiencies were in the areas of accuracy of assessment and food procurement, store/prepare/serve- Sanitary. The continued failure during three federal surveys of record showed a pattern of the facility's inability to sustain an effective quality assurance program.

Inspectors wroteBased on record review, staff and resident interviews, the facility failed to invite the resident to participate in the care planning process for 2 of 19 residents whose care plans were reviewed (Resident #45 and 42).

Inspectors wroteBased on record review, observations, manufacturer's recommendations, and staff interviews, the facility failed to remove an expired multi-dose vial of insulin and failed to date opened medications in 2 of 5 medication administration carts (200 hall cart and 600 hall cart) reviewed for medication storage. Findings Included: 1. A review of the manufacturer's recommendations indicated to discard Lantus multi-dose vial, Lantus Pen, Aspart Flex Pen 28 days after opening and Tresiba (insulin) Flex Touch Pens 8 weeks after opening. On 9/25/23 at 6:10 AM, an observation of the medication administration for the 200 hall cart with Nurse #1 revealed one opened and undated multi-dose vial of Lantus insulin, one opened and undated Aspart Flex Pen (insulin), and two opened and undated Tresiba (insulin) Flex Touch Pens. [...]

Inspectors wroteBased on record reviews and staff interviews, the facility failed to post accurate Registered Nurse (RN) staffing for 13 days of 91 days reviewed for April 2023, May 2023, and June 2023.