Carolina Care Health and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, patternF684Aug 25, 2022

  Based on observations, record reviews, Nurse Practitioner (NP), facility staff, and resident interviews, the facility failed to ensure resident's well-being by not providing care and services to prevent oral abscesses, unresolved dental pain and chewing difficulty for 1 of 1 resident (Resident #68). On 10/19/21 was seen by the in-house dentist who noted Resident #68 was in pain due to a tooth infection and referral was made for outside dental treatment and antibiotics were recommended. The antibiotics were ordered the next day by the Nurse Practitioner. Resident #68 was seen by a dentist on 11/21/21 who wrote a referral for an oral surgeon for extraction of all remaining teeth. […]

• Immediate jeopardy, patternF791Aug 25, 2022

  Based on observations, record reviews, and Nurse Practitioner (NP), Dental Clinic Manager, facility staff, and resident interviews, the facility failed to obtain dental services from an oral surgeon for teeth extractions. Resident #68 was seen by a dentist on 11/21/21 who wrote a referral for an oral surgeon for extraction of all remaining teeth. Resident #68 was seen by an oral surgeon on 12/07/21 and the plan was to remove all upper and lower teeth during two appointments using [MEDICATION(S)] which she asked to defer until January 2022 when her Medicaid would take effect. When the oral surgeon's office was contacted in January 2022 it was communicated that the current oral surgeon did not accept Medicaid. […]

• Immediate jeopardy, patternF835Aug 25, 2022

  Based on observations, record reviews and Nurse Practitioner (NP), Dental Clinic Manager, staff, and resident interviews Administration failed to provide leadership and oversight to facility staff to ensure dental referrals for extractions were scheduled for Resident #68 as recommended by the dentist and ordered by the Physician. The Administration failed to have an effective process that involved the interdisciplinary team and explore all options to ensure needed care and services were provided for 1 of 1 sampled resident (Resident #68). Immediate Jeopardy began on 05/10/22 when the facility failed to have systems in place to obtain dental services for Resident #68 for the extraction of all remaining teeth. […]

• Immediate jeopardy, isolatedF689Aug 25, 2022

  Based on record review, staff and Nurse Practitioner interviews, the facility failed to provide care in a safe manner for 1 of 2 residents reviewed for supervision to prevent accidents (Resident #132). The resident fell out of a raised bed onto the floor during incontinence care which resulted in the resident being transported to the local hospital and diagnosed with distal femoral (upper leg bone) fracture, proximal tibial (lower leg bone) fracture and fractured humerus (upper arm bone). The findings included: Resident # 132 was admitted to the facility on [DATE] and readmitted on [DATE]. […]

• No harm, potential for more than minimal, patternF812Jan 5, 2024

  Based on observations, record review and staff interviews, the facility failed to ensure items stored ready for use were labeled and dated and/or failed to remove expired food items in 1 of 2 nourishment rooms (300 Hall). These practices had the potential to affect food served to residents. Findings included: An observation of the 300 Hall nourishment room and interview with the restorative Nurse on [DATE] at 10:30 AM revealed in the nourishment room three thick and clear lemon-flavored liquid cups with use by date [DATE] and nine thick and liquid lemon-flavored cups with the use by date [DATE]. The restorative Nurse further revealed dietary was responsible for checking nourishment refrigerators daily, but staff had been educated to throw away according to the use by date. […]