Roxboro Healthcare & Rehab Center

In the surveyor’s words

From the most serious findings on record at Roxboro Healthcare & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Nov 21, 2022

  Based on record review and staff interview the facility failed to protect a cognitively impaired resident from physical abuse from an employee when a nurse aide (NA #1) slapped a resident on the face for 1 of 3 cognitively impaired residents reviewed for abuse. NA #1 slapped Resident #1 across the face as Resident #1 reached for NA #1 with a hand soiled with feces. Resident #1 did not have the cognition to express an adverse outcome, a reasonable person would have been traumatized by being slapped during care. Findings included: Resident #1 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation on the most recent quarterly Minimum Data Set assessment dated [DATE] coded Resident #1 as being severely cognitively impaired. […]

• Immediate jeopardy, isolatedF607Nov 21, 2022

  Based on staff interview and record review the facility failed to implement their abuse policies and procedures with immediate notification of a supervisor of staff-to-resident abuse, immediate protection of the resident and other residents, and immediate examination of the resident and other residents potentially affected by physical abuse for 1 of 3 cognitively impaired residents reviewed for abuse. NA #1 slapped Resident #1 across the face as Resident #1 reached for NA #1 with a hand soiled with feces. PCA #1 and PCA #2, witnesses to the abuse, did not notify a supervisor immediately resulting in a lack of immediate protection of Resident #1, a lack of a physical assessment of Resident #1, and the other residents in the care of NA #1 at the time of the abuse. […]

• Immediate jeopardy, isolatedF684Aug 3, 2022

  Based on observation, record review and staff and Physician interviews, the facility failed to have a nurse assess Resident #141 after the resident's knees buckled during a standing mechanical lift transfer and was assisted to the floor. Nurse Aide (NA) #6 and Housekeeper #1 transferred the resident back to bed without reporting the fall to the nurse. When Resident #141 complained of pain, later in the shift, she was assessed by the nurse, and x-rays were ordered. Sometime after the nurse assessed Resident #141 for pain, NA #6 reported the fall to the nurse. The resident was evaluated at the hospital on 1/22/22 and had a right femur fracture resulting in Resident #141 undergoing orthopedic surgery. This was for 1 of 2 residents reviewed for accidents (Resident #141). […]

• Immediate jeopardy, isolatedF689Aug 3, 2022

  Based on observation, record review, staff and Physician interviews, the facility failed to safely transfer a resident with a mechanical lift. Resident #141 began to slide to the floor with her foot slipping off the platform. Nurse Aide (NA) #6 left the resident to get staff assistance and then Housekeeper #1 and NA #6 placed the resident back in bed without notifying the nurse. When Resident #141 complained of pain later in the shift, she was assessed by the nurse, and x-rays were ordered. The resident was evaluated at the hospital on [DATE] and had a right femur fracture resulting in Resident #141 undergoing orthopedic surgery. This was for 1 of 2 residents reviewed for accidents (Resident #141). […]

• Actual harm, isolatedF697Jul 12, 2024

  Based on record review and interviews with residents, staff, a Nurse Practitioner, Physician, and pharmacists for three (Residents # 5, # 10, and # 15) of three sampled residents reviewed for pain management the facility failed to provide pain medications for hospice and surgical residents per their orders and/or request and plan of care. For one of these three residents (Resident # 10), a nurse was aware the resident was in pain due to a recent hip replacement surgery but reported she could not access pain medication to administer to the resident resulting in the resident not receiving pain medication when she was in pain. […]