Raleigh Court Health and Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812Aug 15, 2024

  Based on observation, staff interview, and facility document review, facility staff failed to prepare, distribute, and serve food in accordance with professional standards for food service safety. The findings were: Facility staff stacked food storage containers one on top of each other after being washed and remained wet. Facility staff left the ice scoop inside the ice machine. On 08/11/24 at 1:15 p.m. during the initial tour of the kitchen, three (3) stacks of food storage containers were observed wet. A dietary aide who accompanied the surveyor during the tour acknowledged the containers had been washed and stacked, one on top of the other, to dry. The dietary aide unstacked the containers to dry separately. The ice scoop was observed inside the ice machine. […]

• No harm, potential for more than minimal, patternF677Dec 19, 2022

  Based on staff interview, clinical record review, and during the course of a complaint investigation, the facility staff failed to provide activities of daily living care for 4 of 24 residents, Residents #109, #79, #100, and #209. The findings included: 1. For Resident #109, the facility staff failed to complete activity of daily living (ADL) care for a dependent care resident. This was a closed record review. Resident #109's diagnoses included, but were not limited to, plantar fascial, fibromatosis, obstructive sleep apnea, diabetes, chronic pain, pain in right foot, non-displaced fracture of proximal phalanx of right great toe, and morbid obesity. […]

• No harm, potential for more than minimal, patternF684Dec 19, 2022

  Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to follow physician orders for 1 of 24 residents, Resident's #209 and failed to initiate physician orders following an office visit for 1 of 24, Resident #100. The findings included: 1. The facility nursing staff failed to administer Resident #209's Miramax powder per the providers order. Resident #209's diagnoses included, but were not limited to, diabetes and muscle weakness. There was no completed minimum data set assessment on this resident. The clinical record included an admission/readmission nursing collection tool completed on 12/09/22 that indicated Resident #209 was orientated to person, place, time, and situation. […]

• No harm, potential for more than minimal, patternF756Dec 19, 2022

  Based on staff interview, clinical record review and facility document review, the facility staff failed to consistently have pharmacy recommendations available for review, and failed to ensure pharmacy recommendation were followed up on by the provider for 1 of 5 resident's sampled for unnecessary medications. Resident #54. The findings included: 1. The facility staff failed to ensure pharmacy recommendations were consistently available for review. During the clinical record review, the surveyors were unable to consistently locate pharmacy recommendations in the clinical record. […]

• No harm, potential for more than minimal, patternF761Dec 19, 2022

  Based on observation, staff interview, and facility document review, the facility staff failed to dispose of expired medications on 1 of 2 units (unit 2) ,and failed to secure medications on 2 of 2 units (unit 1 and 2). The findings included: The facility staff failed to dispose of expired medication in the medication room on unit 2 and failed to secure medications in the medication room and on a medication cart on unit 1. 12/13/22 3:05 p.m., the surveyor and Licensed Practical Nurse (LPN) #3 checked the medication room on unit 2. This medication room contained a medication refrigerator that was unlocked. Inside the refrigerator the surveyor observed a clear narcotic box that was unlocked and opened. This narcotic box contained a 30 ml bottle of Lorazepam (ativan). […]