Croatan Ridge Nursing and Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF755Feb 2, 2024

  Based on observation, record review and staff interviews, the facility failed to prevent medication diversion, keep an accurate account of control medications and safeguard Residents' controlled substance count records for 3 of 12 residents sampled for misappropriation of property (Resident #3, Resident #260, and Resident #261). The findings included: a. Resident #3 was admitted to the facility on [DATE] with diagnoses including chronic pain. The [DATE] Medication Administration Record (MAR) revealed an order for Norco (used to treat moderate to severe pain) tablet ,d+[DATE] milligrams (MG) every 12 hours as needed for pain. […]

• No harm, potential for more than minimal, patternF812Aug 10, 2022

  Based on observation and staff interviews, the facility failed to ensure perishable items stored for use in the walk-in refrigerator, walk-in freezer and reach-in refrigerator were labeled and dated. The Findings Included: A tour was conducted on 08/07/22 at 11:03 a.m. with Cook #1 of the kitchen's walk-in refrigerator, walk-in freezer and reach-in refrigerator. The following items were found not labeled or dated: * Walk-in Refrigerator: Tortilla shells Stainless steel container of beets 2 packages of salami wrapped in plastic wrap 2 packages of ham wrapped in plastic wrap 2 packages of cheese slices wrapped in plastic wrap Lettuce wrapped in plastic wrap Stainless steel container of sliced onions Stainless steel container of peaches covered in foil which had been torn open… […]

• No harm, potential for more than minimal, isolatedF580Feb 7, 2025

  Based on record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to notify the physician when a resident missed a dose of insulin due to the medication being unavailable for administration. This resulted in the nurse not obtaining authorization to administer insulin from the backup supply. This deficient practice affected 1 of 5 residents sampled for Pharmaceutical Services (Resident #28). The findings included: Resident #28 was admitted to the facility on [DATE] with diagnoses that included diabetes. A review of the physician's orders dated 5/23/24 revealed Resident #28 was prescribed Toujeo Solostar Subcutaneous Solution Pen-injector 300 units/milliliter (ml) (insulin glargine)-inject 25 units subcutaneously (under the skin) at bedtime for diabetes. […]

• No harm, potential for more than minimal, isolatedF602Feb 7, 2025

  Based on record review, resident interview, and staff interviews, the facility failed to protect a resident's right to be free from misappropriation of property when a staff member (Nurse Aide #1) took a cell phone from the Resident. The deficient practice was reviewed for 1 of 3 residents for misappropriation of residents' property (Resident #12). The finding included: Resident #12 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] had Resident #12 coded as moderate cognitively impaired. During an interview with Resident #12 on 2/4/25 at 2:11 p.m. he stated his phone went missing last year but was later found. […]

• No harm, potential for more than minimal, isolatedF756Feb 7, 2025

  Based on record review and Pharmacy Consultant and staff interviews, the Pharmacy Consultant failed to report a irregularity related to a physicians order for an as needed (PRN) psychotropic medication, Ativan, (a medication used to treat anxiety) to ensure it included a rationale for extended use and was time limited in duration for 2 of 5 residents reviewed for unnecessary medications (Resident #22 and Resident #47). The findings included: 1. Resident #22 was admitted to the facility on [DATE] with diagnoses including dementia with anxiety. A review of the physician's order revealed Ativan 0.5 milligrams (mg) every 6 hours as needed for anxiety dated 08/09/2024 to 08/23/2024 and a dated 08/23/2024 to 09/22/2024 for Ativan 0.5 mg every 6 hours as needed for anxiety for 30 days. […]