Louisburg Healthcare and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 18, 2021

  The facility reported a census of 41 residents with 17 identified as elopement risks and three included in the sample. Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent one cognitively impaired Resident (R) 1, who had a history of exit seeking and falls in the facility, from leaving the facility through an exit door without staff knowledge at approximately 07:18 PM at night. The resident walked through the facility parking lot and up one block on a residential street. At approximately 07:25 PM (7 minutes later), Consultant Staff GG, who left the facility to go home, found R1 walking up the street towards a stop sign and stopped to redirect and assist the resident back into the facility. […]

• Actual harm, isolatedF689Jan 5, 2022

  The facility reported a census of 39 residents, with 15 residents sampled, including four residents reviewed for accidents. Based on interview, record review, and observation, the facility failed to ensure appropriate interventions were initiated for three Residents (R)135, R 7 and R 15, following falls. R135 with a history of falls without interventions experienced a fall with a [CONDITION(S)] (wound to the skin) requiring approximately 20 staples to close. In addition, the facility failed to ensure resident living areas remained free from environmental hazards in one resident room and failed to ensure one resident room door panel did not have exposed sharp edges. […]

• Actual harm, isolatedF689Mar 1, 2021

  The facility reported a census of 36 residents with three sampled and reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide adequate supervision and assistive devices to prevent an accident for one of the three sampled residents, Resident (R)1. The facility staff failed to serve R1's coffee with a lid as care planned. R1 spilled the hot coffee and experienced large second degree [CONDITION(S)] to the bilateral inner thighs and private areas, which covered three percent of his body surface area (BSA). R1 required an ER (emergency room ) evaluation and follow-up treatment care at a burn unit. Findings included: - The Admission Record evidenced the facility admitted R1 on 08/20/2019. […]

• No harm, potential for more than minimal, widespreadF812Aug 26, 2025

  The facility reported a census of 54 residents, one kitchen and one kitchenette. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to prevent the potential for food borne bacteria. This placed the residents at risk of food borne illnesses. Findings included:- During an initial tour of the kitchen on 08/24/25 at 09:23 AM, observation revealed the following areas of concern: 1. One black two-tiered cart utilized to hold milk, juice, clean cups, and other supplies at mealtimes had food debris on both tiers. 2. One three-tiered blue, plastic cart utilized to deliver food to residents at mealtimes had food debris on all tiers. 3. […]

• No harm, potential for more than minimal, widespreadF921Aug 26, 2025

  The facility reported a census of 54 residents; the sample included 16 residents. Based on interviews, record reviews and observation, the facility failed to ensure a safe and sanitary environment in all areas of the facility including the laundry area. This deficient practice placed the residents at risk for contaminated laundry.Findings included:- During an observation on 08/25/2025 at 08:15 AM, the ceiling in clean linen processing room had paint flaking and missing in multiple areas above the resident's clean laundry. […]