The Lodge at Rocky Mount Health and Rehabilitation

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to date opened medications and discard expired medications for 3 of 5 medication carts (North Hall 3 medication cart, North Hall 1 medication cart and South Hall medication cart) and in 1 of 2 medication rooms (South Hall Medication Storage Room), reviewed for medication storage.

Inspectors wroteBased on record review and staff interviews, the facility failed to post accurate licensed and unlicensed nursing staffing data for 28 of 31 days reviewed for sufficient staffing (3/08/26, 3/09/26, 3/10/26, 3/11/26, 3/12/26, 3/14/26, 3/15/26, 3/16/26, 3/17/26, 3/18/26, 3/19/26, 3/20/26, 3/21/26, 3/22/26, 3/23/26, 3/24/26, 3/25/26, 3/26/26, 3/27/26, 3/28/26, 3/30/26, 3/31/26, 4/01/26, 4/03/26, 4/04/26, 4/05/26, 4/06/26, and 4/07/26).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of use of a wander/elopement alarm (Resident #11) and the use of anticoagulant medication (Resident #10) for 2 of 25 residents whose MDS assessments were reviewed.

Inspectors wroteBased on record review, observation, and interviews with staff, resident, and the physician, the facility failed to have Resident #1 assessed for injury by a qualified professional prior to moving the resident following a fall in the transportation van. On 6/05/25 when Transportation Driver #1 made an abrupt stop to avoid a collision, Resident #1 slid out of her wheelchair and her left foot wedged under the driver's seat. Transportation Driver #1 stopped the van to check on the resident, she pulled the resident's left foot out from under the driver's seat, repositioned Resident #1 in her wheelchair, and then continued to the hospital for the resident's appointment. Upon arrival at the hospital, the resident had again slid out of the wheelchair, her back was against the legs of the wheelchair, and the rest of her body was on the floor of the van. [...]

Inspectors wroteBased on record review, observation, and interviews with staff, resident, and the Physician, the facility failed to ensure a resident was safely secured in accordance with the manufacturer's instructions in the facility transportation van during a trip to a medical appointment at the hospital. On 6/05/25 when Transportation Driver #1 made an abrupt stop to avoid a collision Resident #1 slid out of her wheelchair and her left foot wedged under the driver's seat. Transportation Driver #1 stopped the van to check on the resident, she pulled the resident's left foot out from under the driver's seat, repositioned Resident #1 in her wheelchair, and then continued to the hospital for the resident's appointment. On arrival at the hospital, Resident #1 had again slid out of the wheelchair, her back was against the legs of the wheelchair, and the rest of her body was on the floor of the van. [...]

Inspectors wroteBased on record review, and staff, Nurse Practitioner and Medical Director interviews, the facility failed to clarify a physician order for phenytoin (a medication used to treat epilepsy and manage seizures) for a resident with a diagnosis of generalized epilepsy (a brain disorder that causes seizures) which resulted in the phenytoin not being administered for 19 days. This deficient practice was identified for 1 of 1 residents reviewed for significant medication error (Resident #287).

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain kitchen equipment clean and in a sanitary condition to prevent cross contamination by failing to clean seven of nine baking sheets. These practices had the potential to affect food served to residents.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to implement their infection prevention program policies and procedures when 1) the Social Worker failed to remove her surgical mask after exiting a resident room that was on droplet precautions (room [ROOM NUMBER]), 2) when the Maintenance Director failed to wear a surgical mask in a resident room that was on droplet precautions (room [ROOM NUMBER]), and 3) Nurse Aide #1 failed to remove her surgical mask after exiting a resident room on droplet precautions (room [ROOM NUMBER]). This deficient practice was observed for 3 of 3 staff members (Social Worker, Maintenance Director, and NA #1) that failed to follow droplet precaution procedures for residents on isolation for influenza.

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to develop a person-centered care plan for 1 of 1 resident reviewed for hearing impairment (Resident #75).

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to secure indwelling urinary catheter tubing to prevent tugging or pulling for 1 of 2 residents reviewed for indwelling urinary catheters (Resident #53).

Inspectors wroteBased on observations, and staff interviews the facility failed to maintain kitchen equipment clean by failing to clean 1 of 1 plate warmer and 1 of 1 knife holder observed. This practice has the potential for cross contamination of food served to residents.

Inspectors wroteBased on record review, observations, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint investigations on 4/15/21 and 11/10/22. The deficiencies included: Care Plan Timing and Revision (F657) and Food Procurement/Store/Prepare/Serve Sanitary (F812). The continued failure during two or more federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program.

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately complete the Minimum Data Set (MDS) for dialysis for 1 of 20 residents reviewed for MDS assessments. (Resident #61) Findings Included: Resident #61 was admitted to the facility on [DATE] with diagnosis that included end stage renal disease. Physician order dated 10/31/23 read dialysis days are Monday Wednesday, and Friday. Review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #61 did not receive dialysis. An interview was conducted on 12/12/23 at 11:32 A.M. with the MDS nurse. The MDS nurse reviewed the admission MDS and confirmed it was inaccurate. The MDS nurse stated when she completed Resident #61 admission MDS, she overlooked Resident #61 received dialysis and she stated Resident #61's admission MDS should have been marked to show Resident #61 received dialysis treatment. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to update a resident's care plan for a resident with impaired swallowing for 1 of 20 residents whose care plans were reviewed (Resident #7).

Inspectors wroteBased on record review and staff interviews the facility failed to transmit the discharge Minimum Data Set (MDS) assessments for 11 of 13 residents reviewed for discharge. (Resident #77, Resident #38, Resident #11, Resident #52, Resident #55, Resident #33, Resident #34, Resident #73, Resident #26, Resident #22, Resident #4).

Inspectors wroteBased on record review and staff interviews the facility failed to develop a baseline care plan within 48 hours after admission for 2 of 20 residents (Resident #7 and Resident #78) for care planning.