NC State Veterans Home-Kinston

In the surveyor’s words

From the most serious findings on record at NC State Veterans Home-Kinston, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Jul 28, 2025

  Based on record review, and interviews with staff, Responsible Party, Manager at the facility's contracted x-ray company, and Physician the facility failed to ensure nursing staff reported a fall with injury to a physician/medical provider resulting in the physician/medical provider not having all relevant information as a treatment plan was developed and implemented. On [DATE] Resident # 1 sustained a fall while Nurse Aide # 1 and Nurse Aide # 2 were caring for him. The resident was crying in pain while on the floor and had obvious injury to his left knee. The on-call provider was erroneously informed that the resident had pain, warmth, and swelling to the left knee for no known reason. […]

• Immediate jeopardy, isolatedF600Jul 28, 2025

  Based on record review, observations, and interviews with staff, Responsible Party, a Manager at the facility's contracted x-ray company, and Physician the facility failed to protect a severely cognitively impaired resident's right to be free of neglect after he sustained a fall with obvious injury on [DATE] between 6:00 AM and 7:00 AM. Nurse Aide # 1 and Nurse Aide # 2 were preparing to use a sit-to stand lift to transfer Resident # 1, who was totally dependent on staff for sitting balance and required a total mechanical lift for transfers, from the bed to the chair when the resident slid off the side of the bed and landed on his knees. The resident was crying while on the floor and Nurse Aide # 1 reported she could tell something was wrong. […]

• Immediate jeopardy, isolatedF684Jul 28, 2025

  Based on record review, and interviews with staff, the facility's contracted x-ray company, Responsible Party, and Physician the facility failed to ensure nursing staff effectively communicated amongst themselves to ensure staff who cared for Resident #1 were aware of a fall with obvious injury that occurred and that Resident # 1 received comprehensive assessment and treatment. Resident # 1, who was severely cognitively impaired, sustained a fall on [DATE] between 6:00 AM and 7:00 AM. Night shift nursing staff members, who were assisting with Resident # 1 during the accident, were aware the resident was crying in pain as a result of the fall but did not disclose the fall. A comprehensive assessment was not completed prior to moving the resident after the fall. […]

• Immediate jeopardy, isolatedF689Jul 28, 2025

  Based on observation, record review and interviews with staff, and physician the facility failed to provide the necessary supervision to prevent accidents and provide care in a safe manner for a severely cognitively impaired resident totally dependent on staff for care and required a total mechanical lift for transfers. On [DATE] between 6:00 AM and 7:00 AM Nurse Aide #1 and Nurse Aide #2 were preparing to use a sit-to stand mechanical lift to transfer Resident # 1 from the bed to the chair. On [DATE] while seated on the side of the bed, the resident slid to the floor on his knees and was crying on the floor. The resident was manually lifted from the floor to the bed following the fall. […]

• Immediate jeopardy, isolatedF580Jan 13, 2025

  Based on record reviews and interviews with facility staff, physician's office staff, Nurse Practitioner (NP), and Medical Director, the facility failed to notify the physician or nurse practitioner (NP) immediately of an unwitnessed fall with head injury for a resident prescribed an anticoagulant (blood thinner) in order for the physician to determine the necessary treatment plan. The resident fell on Saturday [DATE] and the physician was not notified until Monday [DATE]. Resident #1 continued to receive his anticoagulant medication. On [DATE], Resident #1 had an acute change in condition and was sent to the hospital. […]