Rocky Mount Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Rocky Mount Health & Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF684Mar 27, 2025

  Based on staff interviews, clinical record review, and facility document review, the facility staff failed to provide care and/or services to address resident needs for two (2) of 28 current sampled residents (Resident #26 and Resident #94). The findings include: 1. The facility staff failed to promptly notify Resident #94's medical provider of abnormal laboratory results. Laboratory results reported on 1/17/25 at 11:13 p.m. was not documented as being reported to the medical provider until 1/19/25 at 2:02 p.m. (The medical provider initialed the laboratory results on 1/22/25.) Resident #94's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/14/25, was signed as completed on 3/18/25. […]

• No harm, potential for more than minimal, patternF842Mar 27, 2025

  3. The facility staff failed to ensure Resident #94's clinical record included the correct information related to documents sent with the resident to the local emergency department. Resident #94's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/14/25, was signed as completed on 3/18/25. Resident #94 was assessed as rarely/never able to make self understood and as rarely/never able to understand others. Resident #94 was documented as having problems with long-term memory and as having problems with short-term memory. Resident #94's clinical record included the following information as part of a nursing progress note dated 1/31/25 at 2:01 p.m.: . All paperwork sent including face sheet, copy of DNR/Advanced Directive, order summary, transfer sheet, care plan . […]

• No harm, potential for more than minimal, patternF880Mar 27, 2025

  3. The facility staff failed to ensure that Resident #94's indwelling urinary catheter and/or drainage collection bag was positioned in a manner to decrease the risk for the development of infections. Resident #94's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/14/25, was signed as completed on 3/18/25. Resident #94 was assessed as rarely/never able to make self understood and as rarely/never able to understand others. Resident #94 was documented as having problems with long-term memory and as having problems with short-term memory. On 3/25/25 at 11:55 a.m., the surveyor noted the drainage tube (from the urine collection bag connected to the indwelling urinary catheter) was in contact with the floor beside the resident's bed. […]

• No harm, potential for more than minimal, isolatedF561Mar 27, 2025

  Based on resident and staff interview, record review and facility document review, the facility staff failed to promote resident self-determination through support of resident choice related to bathing for 1 of 28 current residents in the survey sample, resident # 41. The findings included: For resident # 41 (R41) the facility staff failed to provide three showers weekly per resident preference. R41's diagnoses included but were not limited to pneumonia, respiratory failure unspecified with hypoxia, hypertension, diabetes mellitus, chronic obstructive pulmonary disease and muscle weakness. […]

• No harm, potential for more than minimal, isolatedF578Mar 27, 2025

  Based on staff interviews and clinical record review, the facility staff failed to ensure a Durable Do Not Resuscitate (DDNR) form was signed by the ordering medical provider for one (1) of 28 sampled current residents (Resident #73). The findings include: Resident #73's DDNR order form was not signed by the ordering medical provider. Resident #73's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/7/25, was signed as completed on 1/9/25. Resident #73 was assessed as able to make self understood and as able to understand others. Resident #73's Brief Interview for Mental Status (BIMS) summary score was documented as a 14 out of 15; this indicated intact or borderline cognition. […]