Ahoskie Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Ahoskie Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Feb 4, 2022

  Based on record review and physician and staff interviews, the facility neglected to protect the residents' right to be free from abuse when Resident #29 physically abused Residents #39 and #53. Resident #53 sustained injuries that required emergency room evaluation. This was for 1 of 1 resident (Resident #29) reviewed for resident-to-resident abuse. Immediate Jeopardy began on 11/08/21 when the facility failed to implement effective interventions to protect residents from the physical abuse of Resident #29 resulting in the resident placing Resident #53 in a headlock and pulling her to the floor. Immediate Jeopardy was removed on 1/30/22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. […]

• Immediate jeopardy, patternF689Feb 4, 2022

  Based on record review, staff interview and observation, the facility failed to provide supervision to prevent residents with severe cognitive impairment who displayed exit seeking behaviors from exiting the facility unsupervised for 2 of 2 residents (Resident #21, Resident #29) reviewed for wandering behavior. The facility also failed to implement 1 to 1 supervision for Resident #29. Immediate jeopardy began for Resident #21 on 1/11/22 when he exited the facility unsupervised and was observed by police near a local gas station approximately 0.75 miles from the facility at night. Immediate Jeopardy began for Resident #29 on 1/29/22 when he exited the facility unsupervised while he was supposed to be on 1 to 1 staff supervision. […]

• Immediate jeopardy, patternF725Feb 4, 2022

  Based on record review, observation, and physician and staff interviews, the facility failed to have sufficient staffing to prevent and protect Residents #53 and #39 from being physically abused by Resident #29 for 1 of 1 resident reviewed for resident-to-resident physical abuse (Resident #29) and to provide supervision to prevent residents with severe cognitive impairment (Resident #21 and Resident #29) from exiting the facility unsupervised for 2 of 2 residents reviewed for wandering. Immediate Jeopardy began on 11/08/21 when the facility failed to have sufficient staff to protect residents from physical abuse resulting in Resident #29 placing Resident #53 in a headlock and throwing the resident to the floor. […]

• Immediate jeopardy, patternF835Feb 4, 2022

  Based on record review, observation, and interviews with physician and staff, the facility Administration failed to provide oversight and leadership to 1) ensure the facility was free from abuse and to prevent and protect Resident #53 and #39 from being physically abused by Resident #29, 2) provide supervision to prevent residents with severe cognitive impairment from exiting the facility unsupervised (Residents #21 and #29); and 3) provide sufficient staffing to meet the needs of the residents. Immediate Jeopardy began on 11/08/21 when the facility leadership failed to implement interventions to maintain a safe and abuse free environment for the residents resulting in Resident #29 placing Resident #53 in a headlock and pulling her to the floor. […]

• Actual harm, patternF686Feb 4, 2022

  Based on observation, record review, resident, staff, physician, and wound clinic nurse interviews, the facility failed to assess and identify skin changes for 1 of 4 residents who was at risk for pressure ulcer development. (Resident #40). Findings included: Record review of hospital discharge record dated 11/17/21 revealed Resident #40 had a surgical debridement (removal of dead tissue) of necrotic sacral pressure ulcer. Resident #40 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]