Goldsboro Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Goldsboro Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 17, 2025

  Based on observation, record review, and interviews with staff, Nurse Practitioner and Physician, the facility failed to provide the necessary supervision to prevent an avoidable accident for a resident who had severe cognitive impairment, was on a pureed diet, had a diagnosis of dysphagia (difficulty swallowing), and required staff assistance with eating due to his inability to control the speed and/or quantity of food that entered his mouth (Resident #132). On Saturday, 10/11/25 around 8:30 AM, Nurse Aide #8 left a meal tray in front of Resident #132 so she could pass the remaining meal trays. Shortly after meal trays were passed, Nurse Aide #1 found Resident #132 unresponsive and not breathing. Nurse Aide #1 called for help and code blue (life threatening medical emergency) was called. […]

• No harm, potential for more than minimal, patternF842Feb 15, 2024

  Based on record review and staff interviews, the facility failed to accurately document on the electronic Medication Administration Record (eMAR) when cardiac medications were withheld according to parameters defined by the physician's orders for 3 of 3 residents reviewed for medication administration (Resident's #1, #2, and #3). 1. Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] with diagnosis that included atrial fibrillation, nonrheumatic mitral valve insufficiency, atherosclerotic heart disease of the coronary artery, the presence of an automatic implantable cardiac defibrillator, and stroke. […]

• No harm, potential for more than minimal, patternF880Mar 8, 2021

  Based on observations, record review, Medical Director interview and staff interviews, the facility failed to follow posted Enhanced Droplet Contact Precautions signage on the quarantine/observation hall by not wearing the required Personal Protective Equipment (PPE) when entering resident rooms for 2 of 2 residents, (Resident #1 and Resident #2). Additionally, the facility failed to follow recommendations of the Centers for Disease Control and Prevention (CDC) guidelines for the use of Personal Protective Equipment (PPE) or follow the facility's visitation policy by conducting indoor visitation, beyond [MEDICATION NAME] care, after two new confirmed cases of COVID-19 were identified in the facility for Resident #3 and Resident #4. These failures occurred during the COVID-19 pandemic. 1. […]

• No harm, potential for more than minimal, isolatedF756Dec 17, 2025

  Based on record review, and staff and Pharmacist interviews, the facility failed to have a copy of a monthly medication regimen review (MRR) available for review for 1 of 5 residents reviewed for unnecessary medications (Resident #4). Findings included: Resident #4 was readmitted to the facility on [DATE] with diagnoses that included hypertension, hyperlipidemia, stroke, peripheral vascular disease, chronic kidney disease, depression and insomnia. Review of Resident #4's medical record revealed that a monthly pharmacist medication regimen review was missing for the month of October 2025. An interview was conducted with the Pharmacist #1 on 12/11/25 at 2:03 PM. She revealed that Pharmacist #2 was traveling out of state and unavailable for interview. […]

• No harm, potential for more than minimal, isolatedF880Dec 17, 2025

  Based on observation, record review, and staff interviews, the facility failed to implement their infection prevention program policies and procedures when Nurse Aide (NA) #4 and NA #5 failed to apply personal protective equipment (PPE) during urinary catheter care for a resident on Enhanced Barrier Precautions (EBP). This deficient practice was for 2 of 2 staff members observed for infection control practices (NA #4 and NA #5). The findings included:The facility's Infection Prevention and Control Program (IPCP) policy last revised 10/2018 indicated that the facility was responsible for establishing and maintaining an effective program that provides a safe, sanitary, and comfortable environment and attempts to prevent the development and the transmission of diseases and infections. […]