Wadesboro Health & Rehab Center

Inspectors wroteBased on observations and staff interviews the facility failed to discard leftover food stored past the use by date in 1 of 1 walk-in cooler. The facility also failed to label and date leftover frozen food removed from its original packaging in 1 of 1 reach-in freezer and 1 of 1 deep freezer. This practice had the potential to affect food served to residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of falls (Resident #32) for 1 of 3 residents reviewed for accidents.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to develop an individualized person-centered care plan in the area of smoking for 1 of 1 resident reviewed for smoking (Resident #58).

Inspectors wroteBased on record review and staff interviews, the facility failed to transcribe the correct route of medication administration for 1 of 1 resident reviewed with gastric feeding tube (Resident #2).

Inspectors wroteBased on staff interviews and record review, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of trach care (Resident #17), prognosis (Resident #47), discharge (Resident #63), and medication (Resident #41 and #55). This was for 5 of 17 residents reviewed for MDS accuracy.

Inspectors wroteBased on observations, and staff interviews the facility failed to discard opened food items ready for use within 7 days of opening in 1 of 1 walk-in refrigerators and in 1 of 2 reach-in refrigerators. The facility also failed to label, and date opened food items in 1 of 1 walk-in refrigerators and in 1 of 2 reach-in refrigerators. This practice had the potential to affect food served to residents.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to complete an annual comprehensive assessment within the required time frame (Resident #29) for 1 of 15 sampled residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to develop a comprehensive care plan for the presence of a nephrostomy tube (a tube that let's urine drain from the kidney through an opening in the skin on the back-Resident #2), and a skin condition (Resident #34). This was for 2 of 15 resident care plans reviewed.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to change a gastrostomy tube dressing site that was ordered to be completed daily for 1 of 2 residents reviewed for gastrostomy tubes (Resident #31).

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to implement the facility's policy for enhanced barrier precautions for 1 of 11 residents reviewed for infection control (Resident #31).

Inspectors wroteBased on record review, staff, Nurse Practitioner, and physician interviews, the facility failed to follow an order for warfarin (a blood thinner used to prevent stroke in a patient with atrial fibrillation [an abnormal heart rhythm]) (Resident #1) and failed to follow a physician order from a physician consultation visit for a blood pressure medication (Resident #2) for 2 of 3 residents reviewed for significant medication errors. Resident #1 did not receive 8 doses of warfarin, and Resident #2 did not receive 23 doses of blood pressure medication.

Inspectors wroteBased on record review, Consultant Pharmacist, and physician interviews, the Consultant Pharmacist failed to provide recommendations when the facility failed to follow admission orders for warfarin (a blood thinning medication used to prevent stroke) for Resident #1, which resulted in Resident #1 missing 8 doses of warfarin (4/10, 4/11, 4/12, 4/13, 4/14, 4/15, 4/16 and 4/17/2024). This was for 1 of 3 residents reviewed for medication errors.

Inspectors wroteBased on record reviews and interviews with staff, Pharmacy Consultant and facility's Nurse Practitioner, the facility failed to act upon recommendations made by the Pharmacy Consultant for 1 of 5 residents whose medications were reviewed (Resident #18).

Inspectors wroteBased on record reviews and interviews with the Nurse Practitioner and the Medical Director, the facility failed to ensure anticoagulation therapy was restarted after surgical procedure for 1 of 1 resident (Resident #40) reviewed for anticoagulant use.

Inspectors wroteBased on record reviews, observations, Nurse Practitioner, Pharmacy Consultant, 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 survey on 11/18/21. This was for four deficiencies that were cited in the areas of Accuracy of Assessments, Reporting and Acting on Reports of Drug Irregularities, Drug Regimen is Free From Unnecessary Psychotropic Meds and Significant Med Errors. The duplicate citations during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAPI program.

Inspectors wroteBased on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessments for 4 of 16 sampled residents whose MDS were reviewed (Residents #9, #31, #55 & # 60).

Inspectors wrote3. Resident #47 was admitted to the facility on [DATE] with diagnoses that included Guillain-Barre syndrome. The resident's annual Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively impaired and required extensive assistance with all activities of daily living including eating. The resident's comprehensive care plan, last revised on 5/11/2023, contained a focus for nutritional risk related to chewing difficulties and altered consistency diet. The care plan indicated the resident had a percutaneous endoscopic gastrostomy (PEG) for medications only. Interventions included administering medications via PEG tube as ordered. Resident # 47's medical record contained the following physician orders: Crush each tablet and empty each capsule into at least 5ml of water or other appropriate liquid. [...]

Inspectors wroteBased on record reviews, observations and staff interviews, the facility failed to ensure the alternating pressure reducing air mattress was set according to the resident's weight for 2 of 2 residents reviewed for pressure ulcers (Residents #24 and #40).

Inspectors wroteBased on record review and staff interview, the facility failed to limit the timeframe for a psychotropic medication (any drug that affects the brain activities associated with mental processes and behavior) ordered to be given on an as needed (PRN) basis for 2 of 2 residents whose medications were reviewed (Residents #31 & #28).