Carolina Rehab Center of Burke

In the surveyor’s words

From the most serious findings on record at Carolina Rehab Center of Burke, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 31, 2026

  Based on observations, general statues, google maps, record review, staff, resident, and physician assistant interviews, the facility failed to safely transport Resident #1 to his medical appointment. On 08/03/26 while being transported to a medical appointment Resident #1 began to slide out of his wheelchair. The Van Driver, who was a Nursing Assistant (NA) pulled the van over, removed Resident #1's seatbelt and attempted to reposition Resident #1 back in his wheelchair and was unsuccessful. The Van Driver then lowered Resident #1 down onto the floor of the van and called NA #1 with his cell phone and reported what had occurred. NA #1 communicated to the Van Driver that she would alert management and to stay where he was. […]

• Immediate jeopardy, isolatedF628Aug 25, 2025

  Based on record reviews, and Responsible Person and staff interviews, the facility failed to ensure a resident's Do Not Resuscitate (DNR) goldenrod form (a portable physician's order printed on goldenrod colored paper that communicates an individual's wishes regarding resuscitation efforts for emergency responders) and Medical Orders for Scope of Treatment (MOST) form (outlines health care and end-of-life care instructions) stating DNR and Do Not Intubate (DNI) (intubation is a medical procedure where a tube is inserted into the airway to support breathing) were provided to Emergency Medical Services (EMS) upon emergent transfer to the hospital on Sunday 6/22/25. […]

• Actual harm, isolatedF760Jan 22, 2024

  Based on record reviews and family member, staff, and Medical Director interviews, the facility failed to prevent significant medication errors when Medication Aide #1 administered medications prescribed for Resident #2 to Resident #1 which include Clonazepam (a medication to treat anxiety), Buspar (a medication to treat anxiety), Gabapentin (anticonvulsant medication), Seroquel (antipsychotic medication) and Trazodone (antidepressant) for which he had no diagnosis and all had the potential side effects of dizziness and drowsiness. Resident #1 was sent to the emergency department on 12/08/23 for further evaluation where it was determined he had an accidental drug overdose as evidenced by Resident #1 having altered mental status and drowsiness. […]

• No harm, potential for more than minimal, patternF641Aug 1, 2024

  Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of oxygen therapy, functional limitation in range of motion, dialysis, hospice and prognosis, hypoglycemic medication (used to help reduce the amount of sugar in the blood), and Preadmission Screening and Resident Review (PASRR) for 6 of 20 sampled residents (Residents #23, #71, #130, #74, #38, and #6). Findings included: 1. Resident #23 was admitted to the facility on [DATE] with diagnoses that included pneumonia. A physician's order dated 06/04/24 for Resident #23 read, oxygen at 1-2 liters per minute (LPM) via nasal cannula. […]

• No harm, potential for more than minimal, patternF695Aug 1, 2024

  Based on observations, record review, and staff interviews the facility failed to keep emergency tracheostomy (surgically created airway in the front of the neck) supplies needed for an unplanned extubation (removal of airway tube) or emergency supplies for mechanical ventilation (ambu bag) at bedside and easily accessible for immediate use in an emergency (Resident #56). The facility also failed to post cautionary and safety signs that indicated the use of oxygen (Resident #39, Resident #71, and Resident #23). This affected 4 of 4 residents reviewed for respiratory services. Findings included: 1. Resident #56 was admitted to the facility 07/12/24 with diagnoses including respiratory failure with hypoxia (lack of oxygen), tracheostomy status, and pneumonia. […]