Carolina Rivers Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Carolina Rivers Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF578May 15, 2023

  Based on records reviews and staff interviews, the facility failed to have Advance Directives (AD) in the residents' records for 7 of 7 sampled residents. (Resident #49, Resident #95, Resident #21, Resident #47, Resident #58, Resident #84, Resident #6). Findings included: 1- Resident #49 was admitted to the facility on [DATE]. Minimum Data Set (MDS) dated [DATE] indicated Resident#49's cognition was severely impaired. Review of the computerized clinical record for Resident #49 revealed no advanced directive noted in the resident's medical record. […]

• No harm, potential for more than minimal, patternF565Jan 14, 2022

  Based on record reviewed and staff and resident interviews, the facility failed to resolved grievances that were reported in resident council meetings for 4 of 6 months reviewed (July 2021, September 2021, October 2021, and November 2021). Findings included: Record review of Resident Council Meeting minutes for the months of July 2021, September 2021, October 2021, and November 2021 all revealed concerns about call light times. There was no attached resolution of these grievances. During an interview on 1/11/21 at 9:30 AM, Resident #2 revealed he and his roommate attend resident council meeting every month. He further indicated that staff does not address concerns brought up in the meetings. […]

• No harm, potential for more than minimal, isolatedF689Oct 1, 2024

  Based on record review and staff interviews, the facility failed to prevent a resident from rolling off the bed during care which resulted in an abrasion of the posterior scalp and left ankle soft tissue swelling from a fall for 1 of 3 sampled residents reviewed for supervision to prevent accidents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE]. Her diagnoses included hemiplegia following cerebral infarction (stroke) affecting left side. Resident #1 ' s care plan, initiated 1/3/24 had a care focus area of activities of daily living/ personal care with one of the interventions noted as totally dependent on two-person assistance for bed mobility initiated 5/27/24. […]

• No harm, potential for more than minimal, isolatedF644Aug 16, 2024

  Based on observation, staff interview, and medical record review, the facility failed to refer a resident with newly evident diagnoses of serious mental illnesses for Pre-Admission Screening and Annual Resident Review (PASRR) Level II screen for 1 of 4 sampled residents reviewed for PASRR (Resident #33). The findings included: Resident #33 was admitted to the facility on [DATE] with diagnoses including unspecified other psychoactive substance abuse with psychoactive substance-induced psychotic disorder, and depression. The comprehensive admission Minimum Data Set (MDS) assessment dated [DATE] had Resident #33 coded as cognitively intact and was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. […]

• No harm, potential for more than minimal, isolatedF758Aug 16, 2024

  Based on record review, and staff interviews, the facility failed to ensure a Physicians order for an as needed (PRN) psychotropic medication, Ativan, was time limited in time duration for 1 of 5 resident reviewed for unnecessary medications (Resident #34). The findings included: Resident #34 was admitted to the facility on [DATE]. The resident's cumulative diagnoses included chronic obstructive pulmonary disease, and anxiety disorder. The quarterly MDS dated [DATE] revealed Resident #34 was cognitively intact and on an antianxiety medication two out of seven days of the look back period. […]