Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Currituck Health & Rehab Center during CMS and state inspections, most recent first.
A resident with heart failure was admitted to hospice care, but staff failed to complete the required MDS Significant Change in Status Assessment (SCSA) following this change. The responsible MDS nurse acknowledged missing the assessment and could not explain the omission, and the administrator confirmed that the assessment should have been completed.
A resident with bipolar disorder and schizophrenia had a PASRR Level II determination requiring follow-up psychiatric services, but the MDS assessment was incorrectly coded to indicate the absence of serious mental illness. The MDS nurse acknowledged the error, and the administrator confirmed the assessment should have reflected the correct PASRR status.
A resident who was cognitively intact and independent with bed mobility had bilateral quarter bed rails installed without documented attempts at alternatives or an assessment for entrapment risk. Staff interviews confirmed that no alternatives were tried and no supporting assessments were available, despite the resident's independence and lack of recent falls.
A staff member took checks from a resident without consent, successfully cashed one for $1,000, and attempted to cash additional checks. The incident was discovered after the resident's responsible party was alerted by the bank and notified both the facility and law enforcement. The staff member was subsequently identified, arrested, and terminated. Facility staff were unaware the resident had checks in her possession, and the deficiency was cited for failing to protect the resident from misappropriation of property.
A resident with COPD and on continuous oxygen therapy was repeatedly found smoking in unsafe conditions, both inside and outside the facility, often near oxygen equipment. Despite being aware of the resident's non-compliance with the smoking policy, the facility failed to conduct timely reassessments or enforce effective interventions, allowing the resident to continue smoking unsupervised. The facility's attempts to manage the situation, such as confiscating smoking materials and using lockboxes, were ineffective, contributing to ongoing safety risks.
A resident with renal insufficiency developed a UTI with ESBL-producing E. coli, but the facility failed to notify the physician of the C&S results in a timely manner. This led to the resident being treated with an ineffective antibiotic, resulting in seizure-like symptoms and hospitalization for acute metabolic encephalopathy. The delay in communication and treatment highlighted procedural lapses in the facility's handling of lab results.
A resident with a history of aggressive behavior punched another resident, who was on blood thinners, causing bruising and swelling. Despite interventions in place, the facility failed to prevent the altercation, leading to the assaulted resident feeling unsafe and transferring to another facility.
A resident with renal insufficiency and CHF developed a UTI with ESBL-producing E. coli. The facility failed to act on lab results indicating resistance to the prescribed antibiotic, leading to ineffective treatment. The resident's condition worsened, resulting in hospitalization for acute metabolic encephalopathy. Staff interviews revealed lapses in communication and responsibility for reviewing lab results.
A medication error rate of 12.12% was identified in an LTC facility, involving two residents who did not receive prescribed medications during observed administration. A resident with chronic conditions did not receive Klor-Con, Fluticasone Propionate, and Polyethylene Glycol, while another resident with diverticulitis did not receive Polyethylene Glycol. The errors were attributed to a nurse's failure to offer the medications, with discrepancies noted in the Medication Administration Record.
The facility did not follow the approved menu for pureed diets, affecting 7 residents. Staff used incorrect scoop sizes for pureed chicken and omitted pureed bread, contrary to the menu specifications. The Interim Dietary Manager confirmed the error in portion sizes.
The facility failed to maintain accurate medical records and medication administration for several residents. A resident's seizure was not properly documented, leading to incomplete records. Another resident's MAR inaccurately reflected medication administration, as medications were not offered. Similarly, a third resident's MAR showed incorrect documentation of a laxative administration. These deficiencies highlight issues in documentation and communication among staff.
A facility failed to accurately document a resident's code status in the EMR, resulting in a discrepancy between a physician order for full code status and a signed DNR form. The resident, with severe cognitive impairment, had conflicting documentation due to a recent transition to a new EMR system. Staff interviews revealed inconsistencies in verifying and updating code status, contributing to the oversight.
A facility failed to provide a CMS Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to a resident before discharge from Medicare Part A skilled services. The resident continued to stay in the facility after services ended, and although a Notice of Medicare Non-Coverage (NOMNC) was given by phone to the resident's power of attorney, the SNF ABN was not issued. The Social Worker, responsible for issuing these notices, could not explain the oversight, and the Administrator confirmed the SNF ABN should have been completed.
The facility failed to accurately code the MDS assessments for three residents, leading to deficiencies in documenting smoking status, medication use, and pain management. A resident with COPD was inaccurately coded as a non-smoker, another resident was incorrectly documented as receiving anticoagulants instead of antiplatelets, and a third resident's opioid use was not reflected in the MDS. These errors were acknowledged by the facility's staff and attributed to a lack of diligence by the previous MDS nurse.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in smoking and antipsychotic medication management. A resident with COPD was not initially care planned for smoking despite documented incidents, and another resident receiving Risperidone lacked a care plan focus on antipsychotic use. The MDS nurse's abrupt departure contributed to these oversights.
A resident was discharged from a facility without ensuring a caregiver, medications, or home health services were in place. Despite being bedbound and requiring extensive assistance, the facility assumed family support would suffice. The resident's spouse was incapacitated, and the listed home health agency did not serve the resident's area. The resident was left without necessary support, highlighting a failure in discharge planning.
A resident discharged to the community did not receive a complete discharge summary. The summary lacked contact information for medical equipment providers, details on necessary assistive devices, and follow-up appointments with a PCP. Interviews confirmed these deficiencies, with the interdisciplinary team responsible for the incomplete documentation.
A Pharmacy Consultant failed to identify that a resident was prescribed an ineffective antibiotic for a UTI. The resident, with renal insufficiency and CHF, received levofloxacin despite C&S results showing resistance. The Pharmacy Consultant did not have access to the C&S report during the review, leading to the oversight. Interviews revealed that the C&S results and prescribed antibiotic should have been compared to ensure effectiveness.
A facility failed to follow infection control protocols when staff did not use required PPE for residents on contact isolation and enhanced barrier precautions. A nurse aide entered a resident's room without a gown and gloves, while a nurse and another aide provided care to another resident without gowns. Both incidents occurred despite available PPE and prior staff training.
Failure to Complete MDS SCSA After Hospice Enrollment
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment (SCSA) for a resident who was admitted to hospice care. The resident, who had a diagnosis of heart failure, was enrolled in the hospice program at the facility, as documented on a Long-Term Care Status Form. Despite this significant change in condition, there was no evidence in the medical record that an MDS SCSA was completed. During interviews, the MDS nurse confirmed responsibility for completing the assessment and acknowledged that it was missed, without being able to provide a reason for the oversight. The facility administrator also confirmed that an SCSA should have been completed when the resident began receiving hospice services.
Inaccurate PASRR Coding on MDS Assessment
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Preadmission Screening and Resident Review (PASRR) for one resident with diagnoses of bipolar disorder and schizophrenia. The resident's PASRR Level II determination indicated that nursing home placement was appropriate and required follow-up psychiatric services by a psychiatrist, with no expiration date on the determination. However, the resident's annual MDS assessment was incorrectly coded to indicate that the resident was not considered by the state Level II PASRR process to have a serious mental illness or related condition. The MDS nurse responsible for coding acknowledged that the resident's PASRR status was Level II and admitted to not coding the annual MDS assessment accurately. The administrator also confirmed that the MDS assessment should have been coded accurately.
Failure to Attempt Alternatives and Assess Entrapment Risk Before Bed Rail Use
Penalty
Summary
The facility failed to attempt alternatives prior to the installation and use of bed rails and did not assess for risk of entrapment when completing assessments for one resident. The resident was admitted with a diagnosis of hypertension and was cognitively intact, independent with bed mobility and transfers, and had no recent falls or behavioral issues. Despite these factors, bilateral quarter bed rails were ordered and installed to promote bed mobility, with the stated goal of preventing decline in bed mobility. Documentation revealed that the resident had a physician's order for the bed rails and had given verbal consent after being informed of potential risks and benefits. However, there was no evidence in the assessment or care plan that any alternatives to bed rail use had been attempted or considered prior to installation. Additionally, the assessment did not include an evaluation for risk of entrapment associated with the use of bed rails. Interviews with facility staff, including the DON, Maintenance Director, Therapy Director, and Administrator, confirmed that no alternatives had been tried and that there was no documentation of such attempts. Staff also could not provide records of a therapy or nursing assessment supporting the need for bed rails or documenting failed alternatives. The Maintenance Director reported conducting safety inspections and checking for entrapment risk during installation, but this was not documented in the resident's assessment.
Failure to Prevent Misappropriation of Resident Property by Staff
Penalty
Summary
A staff member, identified as Nurse Aide #1 and employed through an agency, took checks belonging to a resident without the resident's knowledge. One of the checks was cashed for $1,000, and additional checks were presented for cashing. The incident came to light when the resident's Responsible Party, who also held Power of Attorney, was notified by the bank about the suspicious activity. The Responsible Party then informed the facility and law enforcement, leading to an investigation. The resident had approximately five checks with her at the facility, and the bank ultimately refunded the lost funds after the account was closed. Interviews with facility staff revealed that the Business Office Manager was unaware that the resident had checks in her possession, and it was noted that residents are discouraged from keeping cash, checks, or credit cards on their person. Law enforcement confirmed that Nurse Aide #1 was arrested and charged in connection with the fraudulent checks. The facility's internal investigation substantiated the misappropriation, and the nurse aide's employment was terminated. The deficiency was identified as a failure to protect the resident's right to be free from misappropriation of property.
Failure to Supervise Resident Smoking with Oxygen
Penalty
Summary
The facility failed to provide necessary supervision and enforce its smoking policy, leading to multiple incidents involving a resident who was found smoking in unsafe conditions. The resident, who was initially assessed as a non-smoker upon admission, was observed smoking on several occasions both inside and outside the facility, often in the presence of supplemental oxygen devices. Despite being aware of the resident's smoking behavior, the facility did not conduct timely reassessments or implement effective interventions to address the resident's non-compliance with safe smoking practices. The resident, diagnosed with chronic obstructive pulmonary disease (COPD) and prescribed continuous oxygen therapy, was found smoking in non-designated areas and with oxygen equipment nearby, posing a significant fire hazard. The facility's staff, including nurses and nursing assistants, were aware of the resident's repeated violations of the smoking policy but failed to take appropriate actions, such as completing new smoking assessments or updating the resident's care plan to reflect the risks associated with their smoking behavior. Additionally, the facility's smoking policy, which required residents to sign a Safe Smoking Contract and prohibited the storage of smoking materials in resident rooms, was not enforced effectively. Throughout the period of observation, the resident continued to smoke unsupervised, despite multiple incidents and warnings. The facility's attempts to manage the situation, such as confiscating smoking materials and using lockboxes, were ineffective as the resident retained access to their smoking materials. The lack of consistent supervision and enforcement of the smoking policy contributed to the ongoing safety risk posed by the resident's smoking behavior in the presence of oxygen equipment.
Failure to Notify Physician of UTI Results Leads to Resident Hospitalization
Penalty
Summary
The facility failed to notify the physician when a resident experienced a change of condition due to a urinary tract infection (UTI) with extended-spectrum beta-lactamase (ESBL) producing Escherichia coli. The resident's urine culture and sensitivity (C&S) results, which indicated the presence of ESBL, were not communicated to the physician in a timely manner. This oversight led to the resident being treated with an ineffective antibiotic, levofloxacin, which the bacteria was resistant to, delaying appropriate treatment. The resident, who had been admitted with renal insufficiency, began showing signs of agitation and combativeness, prompting the Assistant Director of Nursing (ADON) to order laboratory tests. The preliminary urinalysis results were reviewed by the physician, who advised waiting for the C&S report before initiating treatment. However, the C&S results were not communicated to the physician until a week later, after the ADON returned from being out of town. By this time, the resident's condition had worsened, leading to seizure-like symptoms and hospital admission for acute metabolic encephalopathy caused by the untreated UTI. Interviews with staff revealed a breakdown in communication and procedure adherence, as the charge nurses were expected to report lab results to the physician during their shift, but this was not consistently done. The Director of Nurses acknowledged that the results should have been reported sooner, and the physician expressed expectations for timely notification and appropriate antibiotic selection based on C&S results. The delay in treatment resulted in the resident experiencing further complications, including altered mental status and bradycardia, before being stabilized with the correct antibiotic treatment in the hospital.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when a moderately cognitively impaired resident punched a severely cognitively impaired resident in the face. The assaulted resident, who was on a daily blood thinner, sustained bruising and swelling to the left side of his face. The incident left the resident feeling scared and unwilling to be near the aggressor. The two residents were immediately separated, with the aggressor moved to another room by himself. The assaulted resident requested to be sent to the emergency room for evaluation and did not return to the facility, eventually transferring to a different facility. The assaulted resident had a history of hemiplegia and hemiparesis following a stroke, vascular dementia, psychotic disturbance, and anxiety. His care plan included interventions to avoid activities that could result in injury due to his blood-thinning medication. The aggressor had a history of physical aggressive behavior, with interventions in place such as one-to-one observation and room changes to prevent altercations. Despite these measures, the incident occurred, highlighting a failure in the facility's ability to prevent resident-to-resident abuse. Staff interviews and written statements revealed that the incident was reported to the nurse on duty, who followed protocol by notifying the necessary parties and separating the residents. However, the facility's failure to adequately monitor and manage the aggressor's behavior, despite his known history, contributed to the occurrence of the altercation. The facility's inability to prevent the incident resulted in emotional and physical harm to the assaulted resident, who did not return to the facility after the hospital evaluation.
Failure to Respond to UTI Lab Results Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide necessary care and services for a resident who experienced a urinary tract infection (UTI) with extended-spectrum beta-lactamase (ESBL) producing Escherichia coli. The resident, who had renal insufficiency and congestive heart failure, showed signs of a change in condition, including increased agitation and combativeness. Despite a urinalysis (UA) and culture and sensitivity (C&S) test being ordered, the facility did not effectively follow up on the results. The C&S results, which indicated resistance to the prescribed antibiotic levofloxacin, were not communicated to the physician in a timely manner, leading to the administration of an ineffective antibiotic. The resident's condition worsened, resulting in seizure-like symptoms and hospitalization for acute metabolic encephalopathy due to the untreated UTI. The facility's failure to promptly review and act on the C&S results delayed the effective treatment of the infection. The Assistant Director of Nursing (ADON) and other nursing staff did not ensure that the physician was informed of the resistant bacteria, and the physician's order for levofloxacin was not questioned despite the resistance noted in the C&S report. Interviews with staff revealed a lack of communication and responsibility in checking laboratory results. The Director of Nurses (DON) acknowledged that the expected procedures for reviewing and reporting lab results were not followed, as charge nurses relied on nurse managers to review results the next day. This oversight contributed to the resident receiving an ineffective antibiotic, which allowed the UTI to progress and cause further complications.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 12.12%, exceeding the acceptable threshold of less than 5%. This was identified during medication administration observations involving two residents. Resident #18, who has diagnoses including chronic obstructive pulmonary disease and congestive heart failure, did not receive several prescribed medications during the observed medication pass. Nurse #3 failed to offer or administer Klor-Con Extended Release, Fluticasone Propionate nasal spray, and Polyethylene Glycol 3350 powder to Resident #18, despite these medications being recorded as administered in the Medication Administration Record (MAR). Resident #18 confirmed not receiving these medications and expressed that she had not been offered Klor-Con since December 2023. Nurse #3 admitted to not offering the medications, citing anticipated refusal by Resident #18 as the reason. However, another nurse, Nurse #6, reported being able to administer all medications to Resident #18 without issues. The Pharmacy Consultant and Medical Director acknowledged the omission of Klor-Con as a medication error but not a significant one, given the resident's normal potassium levels and the nature of the diuretic prescribed. The Director of Nursing (DON) and the Administrator both emphasized that medications should be offered and administered as ordered, and any refusals should be documented accurately. Similarly, Resident #71, who is severely cognitively impaired and diagnosed with diverticulitis, did not receive the prescribed Polyethylene Glycol 3350 powder during the observed medication pass. Nurse #3 did not offer this medication, mistakenly believing it had been discontinued, yet it was recorded as administered in the MAR. Resident #71 confirmed not receiving the medication, which is intended to address constipation. The DON and Administrator reiterated that the medication should have been administered as ordered unless refused by the resident.
Failure to Follow Approved Pureed Diet Menu
Penalty
Summary
The facility failed to adhere to the approved menu for residents on a pureed diet, affecting 7 residents. During a dinner meal observation, it was noted that the staff used incorrect scoop sizes for serving pureed chicken and omitted pureed bread entirely. The menu specified that residents should receive one #10 scoop of pureed chicken and two #20 scoops of pureed bread. However, a staff member used a blue scoop, which was later identified as a #16 scoop, for the chicken and did not serve any bread, assuming the breading on the chicken patties sufficed. The Interim Dietary Manager confirmed the discrepancy in portion sizes and acknowledged that the correct portions were not served.
Deficiencies in Medical Record Documentation and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, leading to deficiencies in documentation and medication administration. For Resident #6, the facility did not document the assessment and orders related to a change in condition when the resident experienced a seizure. Despite multiple nurses being involved in the incident, none documented the necessary information, including vital signs or interventions, on the Situation, Background, Appearance, and Review (SBAR) Communication Form or the progress notes. Additionally, there was a discrepancy in the Medication Administration Record (MAR) regarding the administration of IV antibiotics, which was incorrectly documented as refused by the resident. Resident #18's medical records also contained inaccuracies. The MAR indicated that certain medications were administered or refused, but observations and interviews revealed that these medications were not offered to the resident. Nurse #3 admitted to not offering the medications and incorrectly documenting their administration, citing the resident's usual refusal as the reason for her actions. This inconsistency in documentation was acknowledged by both the nurse and the Director of Nursing (DON), who emphasized the importance of accurate record-keeping. Similarly, Resident #71's records showed discrepancies in medication administration. The MAR recorded the administration of a laxative, but observations indicated that the medication was not offered. Nurse #3 mistakenly believed the medication had been discontinued and documented its administration inaccurately. Interviews with the resident and the DON confirmed the error, highlighting the need for accurate documentation and proper communication regarding medication orders.
Discrepancy in Resident's Code Status Documentation
Penalty
Summary
The facility failed to accurately document the code status of a resident in the electronic medical record (EMR), leading to a discrepancy between a physician order and a signed Do Not Resuscitate (DNR) form. The resident, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, had a physician order for full code status dated 3/19/24. However, the EMR contained a DNR form dated 03/20/24, signed by both the resident and the physician. The care plan, revised on 6/26/24, indicated the resident had chosen DNR status, yet the quarterly Minimum Data Set (MDS) assessment revealed the resident was severely cognitively impaired. Interviews with various staff members, including nurses, the Assistant Director of Nursing (ADON), the Social Worker (SW), and the Director of Nursing (DON), highlighted inconsistencies in verifying and documenting code status. The facility had recently transitioned to a new EMR system, which did not automatically update code status to match physician orders, unlike the previous system. This transition contributed to the oversight, as some nurses were unaware of the need to update DNR status in multiple areas of the EMR. The SW mentioned an audit conducted on 5/16/24 to verify residents' code statuses, but Resident #63 was not included in this audit. The Medical Director emphasized the importance of ensuring accurate and reconciled information regarding code status in the system.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to a resident prior to discharge from Medicare Part A skilled services. Resident #30 was readmitted to the facility and received Medicare Part A services, which ended on April 24, 2024, while the resident remained in the facility. Although a Notice of Medicare Non-Coverage (NOMNC) was given by phone to the resident's power of attorney on April 22, 2024, there was no record of an SNF ABN being provided. The facility's Social Worker, responsible for issuing the NOMNC, stated that she typically issued the SNF ABN form alongside the NOMNC when a resident stayed in the facility after Medicare Part A services ended, but could not explain why it was not done in this case. The Administrator confirmed that the SNF ABN should have been completed for residents with remaining days who choose to stay for long-term care.
Inaccurate MDS Coding for Smoking and Medication Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in documenting smoking status, medication use, and pain management. Resident #31, who was admitted with chronic obstructive pulmonary disease (COPD), was inaccurately coded as a non-smoker on the MDS, despite nursing documentation and the resident's own admission of smoking since his arrival at the facility. The Director of Nursing and the Administrator acknowledged that the MDS should have accurately reflected the resident's smoking status. Resident #3, admitted with a stroke diagnosis, was prescribed Aspirin, an antiplatelet, but the MDS inaccurately documented the use of anticoagulants instead. The Regional MDS Consultant confirmed the error, noting the facility was training a new MDS nurse. Similarly, Resident #54, who was receiving oxycodone for pain management, was not coded for opioid use on the MDS, despite receiving the medication as ordered. The Regional MDS Consultant attributed this oversight to the previous MDS nurse's lack of diligence before leaving the position abruptly.
Deficiencies in Care Planning for Smoking and Antipsychotic Use
Penalty
Summary
The facility failed to develop and implement comprehensive individualized person-centered care plans for two residents, leading to deficiencies in the areas of smoking and antipsychotic medication management. Resident #31, who was admitted with chronic obstructive pulmonary disease (COPD), was initially assessed as a non-smoker. However, documentation revealed that the resident had been smoking since admission, including an incident where he removed his oxygen to smoke. Despite this, the resident's care plan did not initially address smoking behaviors, and the facility's transition from Point Click Care to Matrix systems resulted in a lack of documentation for the care plan. The care plan was only revised months later to include smoking-related goals and interventions. Resident #65, diagnosed with Alzheimer's and dementia with behavioral disturbances, was prescribed Risperidone, an antipsychotic medication, upon readmission. However, the resident's care plan did not include a focus on the use of psychotropic medications, despite the resident receiving the medication regularly. Interviews with facility staff revealed that the MDS nurse was responsible for updating care plans, but the care plan for Resident #65 was not updated to reflect the use of antipsychotics. The MDS nurse had vacated the position abruptly, and the facility was unable to provide a reason for the oversight.
Unsafe Discharge Planning for Resident
Penalty
Summary
The facility failed to provide a safe discharge planning process for a resident who was discharged to an independent living apartment. The resident, who was bedbound and required extensive assistance with activities of daily living (ADLs), was discharged without ensuring a caregiver was available, without a means to obtain necessary medications, and without securing a home health provider for continuity of care. The resident's discharge summary did not include essential information such as contact details for the medical equipment company or a scheduled primary care physician (PCP) appointment. The resident's family member had informed the facility that the resident's spouse, who was the primary caregiver, had suffered a stroke and was in another skilled nursing facility, leaving no one to care for the resident at home. Despite this, the facility proceeded with the discharge, assuming that the resident's family would assist at home. However, the resident was left alone during the day without a caregiver, and the home health agency listed on the discharge summary did not have the resident in their system, nor did they provide services in the resident's area. The facility's social worker and director of rehabilitation believed the resident's discharge was safe, citing the resident's ability to propel herself in a wheelchair and perform some ADLs independently. However, the resident was found at home without medications, a wheelchair, or home health services, and was unable to perform necessary tasks such as toileting and meal preparation. The facility's physician was unaware of the discharge issues and stated that concerns raised by the family should have been addressed, including ensuring the resident had medications and a wheelchair at home.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to provide a complete discharge summary for a resident who was discharged to the community. The resident, who was cognitively intact, required extensive assistance with activities of daily living and had a medical history that included a urinary tract infection with antibiotic-resistant bacteria, sepsis, a chronic immune system disease, and a history of deep vein thrombosis. The discharge summary was incomplete, lacking contact information for the medical equipment provider, details about necessary assistive devices, and information on scheduled follow-up appointments with a primary care physician. Additionally, it did not include instructions on how to obtain medications needed at home. Interviews with the resident's family member and the social worker confirmed the deficiencies in the discharge summary. The family member noted the absence of information regarding follow-up doctor's appointments, and the social worker acknowledged the missing details about the wheelchair provider and incorrect contact information for the home health provider. The interdisciplinary team was responsible for completing the discharge summary, but it failed to include essential information for the resident's transition to home care.
Pharmacy Consultant Fails to Identify Ineffective Antibiotic Prescription
Penalty
Summary
The Pharmacy Consultant failed to identify an irregularity in the drug regimen review for a resident who was prescribed and received an ineffective antibiotic for a urinary tract infection (UTI). The resident, who had renal insufficiency and congestive heart failure, was found to have a UTI caused by Escherichia coli (E. coli) that was resistant to the antibiotic levofloxacin. Despite this, the resident was prescribed and administered levofloxacin for several days. The Pharmacy Consultant did not identify any irregularities during the medication review because the culture and sensitivity (C&S) results were not available in the electronic medical record at the time of the review. Interviews with facility staff, including the Pharmacy Consultant and the Director of Nurses (DON), revealed that the C&S results and the prescribed antibiotic should have been compared to ensure effectiveness. The Pharmacy Consultant stated that he did not have access to the C&S report during his review, as it was not uploaded to the electronic medical record until after his review. The resident's physician expected the facility to review the C&S results and inform him if the prescribed antibiotic was ineffective, to prevent complications from an untreated UTI.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to adhere to infection control measures as observed in two separate incidents involving residents on contact isolation and enhanced barrier precautions. In the first incident, a nurse aide entered the room of a resident on contact precautions without wearing the required personal protective equipment (PPE), specifically a gown and gloves, while delivering a meal tray. The nurse aide moved the resident's personal items without wearing gloves, despite the facility's policy requiring PPE for contact precautions to prevent the transmission of infectious agents. The nurse aide later acknowledged the mistake, attributing it to confusion between contact precautions and enhanced barrier precautions. In the second incident, a nurse and a nurse aide provided care to a resident on enhanced barrier precautions without wearing gowns, as required by the facility's policy. The care activities included handling a urinary catheter, providing gastrostomy tube care, and changing a wound dressing. Both staff members admitted to not wearing gowns during these procedures, with one citing a lack of PPE in the room as the reason. The facility's policy mandates the use of gowns and gloves for high-contact activities to prevent the transmission of multi-drug resistant organisms. Interviews with the infection preventionist and the director of nursing confirmed that the staff involved had received training on the appropriate use of PPE for both contact precautions and enhanced barrier precautions. The facility had adequate PPE supplies, and it was the responsibility of the nursing staff to ensure PPE was restocked as needed. Despite this, the staff failed to comply with the infection control protocols, leading to the observed deficiencies.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Barco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Laurel Park Rehabilitation And Healthcare Center | 16.3 mi | ★★★★★ | 0 | 0 |
| Elizabeth City Health And Rehabilitation | 17.3 mi | ★★★★★ | 6 | 0 |
| Jones & Cabacoy Veterans Care Center | 25.9 mi | — | 0 | 0 |
| Autumn Care Of Chesapeake | 27.6 mi | ★★★★★ | 0 | 0 |
| Princess Anne Health & Rehabilitation Center | 27.6 mi | — | 0 | 0 |
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