East Carolina Health and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF686Apr 13, 2021

  Based on record review, staff interviews, and physician interview, the facility failed to assess and identify for pressure injury areas for 1 of 4 residents reviewed for pressure ulcers (Resident #38). Upon admission to the hospital, the hospital identified the presence of four pressure areas. Three areas were deep tissue wounds and one was unstageable. Following readmission to the nursing home, treatment records were not consistently documented as completed. Immediate jeopardy began on 6/25/20 when the facility failed to assess and identify pressure injury areas for Resident #38. Resident #38 was sent to the hospital and 4 pressure injury areas were identified as present on admission. […]

• Actual harm, isolatedF689Sep 11, 2025

  Based on observation, record review, and interviews with resident, staff, and a representative from the company that manufactures the mechanical lifts used at the facility, the facility failed to ensure a resident was safely transferred by a mechanical lift. A mechanical lift sling broke while Resident # 3 was being transferred resulting in Resident # 3 sustaining a fractured humerus (large bone of the upper arm). This was for 1 of 3 residents reviewed for accidents (Resident # 3).The findings included:Resident # 3 was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF689Apr 5, 2024

  Based on observation, record review, and interviews with staff, Physician, Psychiatric Nurse Practitioner, and the facility's Pharmacy Consultant the facility failed to 1) analyze Resident #2's falls to determine causative factors and implement interventions to reduce the risk for further falls and 2) ensure a paraplegic resident (Resident # 1) did not roll out of bed during care. Resident # 2 was identified to have an impacted arm fracture (a fracture that generally occurs following a fall). This was for two of three sampled residents reviewed for accidents. The findings included: 1. Resident # 2 was admitted to the facility on [DATE]. Resident # 2's diagnoses in part included vascular dementia, bipolar disorder, personality disorder, chronic kidney disease, and hypertension. […]

• No harm, potential for more than minimal, widespreadF727Mar 25, 2026

  Based on record review and staff interviews, the facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours for 2 of 142 days reviewed for staffing (12/28/25 and 1/24/26).The findings included: Review of the facility's daily nurse staffing sheets from 11/1/25 through 3/22/26 revealed the following: a. On 12/28/25 the daily nurse staffing sheet indicated a daily census of 85. Review of the daily nurse staffing sheet revealed there was no RN working on any shift that day. b. On 1/24/26 the daily nurse staffing sheet indicated a daily census of 77. Review of the daily nurse staffing sheet revealed there was no RN working on any shift that day. […]

• No harm, potential for more than minimal, widespreadF812Jun 30, 2022

  Based on observations, record review and staff and Registered Dietitian interviews, the facility failed to maintain food items in the walk in freezer in a frozen state for 2 of 2 freezer observations, failed to maintain the correct concentration of sanitizer in the three compartment sink for 2 of 2 observations and failed to maintain the dish machine wash temperature at the minimum manufacture requirements for 2 of 2 wash cycles. The findings included: 1. On 6/26/22 at 10:15 AM an observation of the walk in freezer with Cook #2 revealed foods in the freezer including hush puppies, three boxes of vegetables, and ice cream felt soft and not frozen. Cook #2 opened a sealed box of ice cream. One 3 ounce container of ice cream was removed. […]