Signature Healthcare of Roanoke Rapids

In the surveyor’s words

From the most serious findings on record at Signature Healthcare of Roanoke Rapids, in the surveyor’s own words.

• Immediate jeopardy, patternF686Mar 4, 2021

  Based on record reviews, staff interviews, and physician interviews, the facility failed to provide a comprehensive approach to pressure ulcers as evidenced by lack of assessments, lack of documentation, and lack of treatments for 1 or 3 residents reviewed for care and services for pressure ulcers. Resident # 1 was admitted on [DATE] with no skin breakdown and was identified on 1/19/21 with an unstageable pressure ulcer to the coccyx, and on 1/20/21 a deep tissue injury to the left heel, left posterior ankle, and left plantar foot. Immediate Jeopardy began on 1/8/2021 a nurse aide identified an open area on the sacral area and a nurse did not perform a complete assessment until 1/19/21, and at that time it was unstageable. […]

• Immediate jeopardy, isolatedF925Aug 25, 2022

  Based on record review, facility staff, Emergency Department Physician's Assistant, Outpatient Clinic Nurse, [CONDITION(S)] Nurse Manager, and Medical Director interviews, the facility failed to control the presence of flies in the facility resulting in a maggot infestation of a resident's wound for 1 of 6 residents (Resident #263) reviewed for wound care. On 7/30/22 Resident #263's left lower leg wound was infested with maggots. She presented to the emergency department with approximately 60-65 maggots in her left lower extremity wound. […]

• Actual harm, patternF725Mar 4, 2021

  Based on record review and staff interviews the facility failed to provide sufficient nursing staff to ensure wound care treatments were performed as ordered by a physician for 1 (Resident #1) of 3 residents reviewed for pressure sores. The facility also failed to provide sufficient staff to ensure an assessment was completed, blood sugars were monitored as ordered, and medical attention was sought for a change in condition for 1 (Resident #9) of 3 residents reviewed for the provision of care according to professional standards. Findings included: 1. A physician's orders [REDACTED].#1. […]

• Actual harm, isolatedF689May 1, 2025

  Based on record review, resident interview, staff interview, and nurse consultant interview, the facility failed to perform a transfer from the wheelchair to the bed according to the care plan for one (Resident #1) of three residents reviewed for accidents. Resident #1 sustained a left leg fracture above the knee with extreme pain requiring a visit to the emergency room at the hospital after being transferred without a mechanical lift. Findings included: Resident #1 had resided in the facility since 7/17/2019 and had multiple diagnoses some of which included cerebral vascular accident, hemiplegia, hemiparesis, heart failure, and diabetes mellitus. […]

• Actual harm, isolatedF697Jun 18, 2021

  Based on observation, record review, physician and staff interviews, the facility failed to follow physician's orders to administer scheduled pain medication every 4 hours to control a resident's pain for 1 of 1 resident reviewed for pain management (Resident #41). The findings included: Resident #41 was admitted to the facility on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set Assessment (Quarterly) dated 4/16/21 revealed the resident was cognitively intact, had no behaviors and required extensive assistance with bed mobility, transfers, ambulation, dressing and personal hygiene and total assistance with toileting. […]