Signature Healthcare of Roanoke Rapids

Inspectors wroteBased on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of the use of an anticoagulant medication for 1 of 30 residents whose MDS assessments were reviewed (Resident #17).

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to post cautionary and safety signs indicating the use of supplemental oxygen for 2 of 3 residents reviewed for respiratory care (Resident #1 and Resident #17).

Inspectors wroteBased on observations, record reviews, manufacturer recommendations, and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 39 opportunities, resulting in a medication error rate of 7.69% for 2 of 4 residents observed during the medication administration observations (Resident #6 and Resident #26).

Inspectors wroteBased on record review, and interviews with resident, staff, and pharmacist the facility failed to ensure the accurate documentation and administration of controlled medications (Residents # 1 and # 4) and that the facility's system to account for controlled medications was being followed between shift change and upon receipt and removal of controlled medications in sufficient detail to enable an accurate reconciliation. This was for 3 of 3 sampled residents whose controlled drug records were reviewed for accurate documentation of administration and removal from locked storage (Residents # 1, # 2, and # 4) and for 1 of 1 unit's records reviewed for accounting of controlled medications at shift change and upon receipt or return of controlled medications.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the accuracy and completeness of documentation related to bowel movements and/or medication administration. This was for 2 of 4 residents whose medical records were reviewed for documentation of bowel movements and/or medication administration (Residents # 1 and # 4).

Inspectors wroteBased on record review and interviews with family member and staff, the facility failed to ensure transportation was arranged for a resident's follow-up appointments following his discharge from the hospital and subsequent admission to the facility for his medical care. This was for 1 of 3 residents reviewed for professional standards of practice (Resident # 1).

Inspectors wroteBased on record review and interviews with staff, family member, and Wound Nurse Practitioner (NP), the facility failed to ensure a resident diagnosed with cancer was administered pain medication when the resident requested. This was for 1 of 3 sampled residents reviewed for pain (Resident # 1).

Inspectors wroteBased on record review and staff, Resident Representative (RR), Nurse Practitioner (NP), and physician interviews, the facility failed to obtain a STAT (immediate or rapid response) mobile x-ray exam when Resident #1 fell and experienced left leg pain for 1 of 3 residents reviewed for falls.

Inspectors wroteBased on record review, and staff, resident, and Medical Director interviews, the facility failed to administer doses of scheduled rapid-acting insulin due to a staffing issue (Resident #1 and Resident #3) and failed to follow up with a pulmonary consultation recommendation to discontinue a steroid medication (Resident #2) for 3 of 3 residents reviewed for significant medication error.

Inspectors wroteBased on record review and interviews with resident and staff, the facility failed to ensure sufficient nursing staff to provide nursing services to residents when 2 of 3 assigned staff members (Medication Aide #2 and Unit Manager #1) did not report to work as scheduled. This deficient practice resulted in significant medication not being administered as ordered for 2 of 3 residents reviewed for significant medication error (Resident #1 and Resident #3).

Inspectors wroteBased on record review, resident interview, staff interview, and nurse consultant interview, the facility failed to perform a transfer from the wheelchair to the bed according to the care plan for one (Resident #1) of three residents reviewed for accidents. Resident #1 sustained a left leg fracture above the knee with extreme pain requiring a visit to the emergency room at the hospital after being transferred without a mechanical lift.

Inspectors wroteBased on record review and staff interviews, the facility failed to annually review and update the facility assessment, which had the potential to affect 80 of 80 residents in the facility, and to ensure the facility assessment identified and addressed the care required for the population of residents with a tracheostomy (Resident #35 and #56).

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of dialysis (Resident #15 and Resident #70), use of a wander elopement alarm (Resident #57), use of hypoglycemic medication (medication that help lower blood sugar levels in people diagnosed with diabetes) (Resident #44), for 4 of 23 residents whose MDS assessments were reviewed.

Inspectors wroteBased on observations and staff interviews the facility failed to (1) label and date an open insulin injector pen and an open albuterol inhaler (Unit 3) and failed to refrigerate a medication according to the manufacturer's recommendation (Unit 1) for 2 of 2 medications carts reviewed, and (2) failed to ensure 1 of 3 wound treatment carts were secured while unattended (Unit 3).

Inspectors wroteBased on observations, and staff interviews, the facility failed to maintain kitchen equipment clean and in a sanitary condition to prevent the potential cross contamination of food by failing to clean 1 of 1 plate dispenser and failed to clean the shelf under the steam table for 1 of 1 steam tables observed. These practices had the potential to affect food served to residents.

Inspectors wroteBased on observations, and staff interviews, the facility failed to ensure garbage was contained in a closed dumpster and doors were kept closed for 1of 2 dumpsters observed.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment for 1 of 23 residents whose MDS assessments were reviewed (Resident #56).

Inspectors wroteBased on observations, record review, and staff and Responsible Party (RP) interviews, the facility failed to develop a person-centered care plan for 1 of 1resident reviewed for activities (Resident #44).

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to obtain a physician order for tracheostomy (a surgical opening through the front of the neck into the windpipe for an air passage to help breathe) care for 1 of 2 residents reviewed for tracheostomy (Resident #35).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a resident receiving dialysis had a physician's order for dialysis. This was for 1 of 2 sampled residents reviewed for receiving dialysis. (Resident #70).

Inspectors wroteBased on record review, and staff and Ombudsman interviews, the facility failed to notify the Ombudsman in writing of a resident transfer for 2 of 3 residents reviewed for hospitalization (Resident #35 and Resident #11).

Inspectors wroteBased on staff interviews and record review, the facility failed to have a Registered Nurse (RN) for at least eight consecutive hours a day, 7 days week for 17 of 192 days reviewed (5/7/23; 5/13/23, 6/4/23, 6/24/23, 7/1/23, 7/2/23, 7/8/23, 7/9/23, 7/15/23, 7/16/23, 7/29/23, 7/30/23, 8/5/23, 8/12/23, 8/13/23, 8/19/23, and 8/20/23).

Inspectors wroteBased on record review, staff interviews, and Psychiatric Nurse Practitioner interviews, the facility failed to refer a resident with newly evident serious mental health diagnoses for a Preadmission Screening and Annual Resident Review (PASARR) level II screening for 1 of 3 residents reviewed for PASARR (Resident #22).

Inspectors wroteBased on record review, staff interviews and Responsible Party (RP) interview, the facility failed to provide written notification for reason of transfer to hospital to the Resident or Responsible Party (RP) for 3 of 3 residents reviewed for hospitalization (Resident #69, Resident #2, and Resident #72).