Tarboro Health and Rehabilitation LLC

In the surveyor’s words

From the most serious findings on record at Tarboro Health and Rehabilitation LLC, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 13, 2022

  Based on observations, record review and interviews with the resident, facility staff, and physician the facility failed to provide a safe transfer of a resident using a mechanical lift which caused a resident (Resident #72) to fall and fracture her right upper leg. This was for 1 of 3 residents reviewed for accidents. The findings included: Resident #72 was admitted to the facility on [DATE]. Her diagnoses included diabetes, [CONDITION(S)], bilateral lower extremity amputations and a fracture of the right femur. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #72 was cognitively intact. She required extensive assistance with bed mobility, dressing, toilet use ad personal hygiene. She was totally dependent with the assistance of 2 staff for transfers. […]

• No harm, potential for more than minimal, widespreadF838Nov 16, 2023

  Based on record review and staff interviews the facility failed to review and annually update the Facility Assessment and to ensure the Facility Assessment identified and addressed the care required for the population of residents with a tracheostomy and to address the staff training necessary to competently provide tracheostomy care. Findings included: Review of the Facility Assessment revealed the assessment was last updated in November 2022. The document indicated the facility had completed education/training/competencies with staff specific to resident care needs, however, the facility lacked training/competencies to care for residents who required a trach. […]

• No harm, potential for more than minimal, widespreadF867Nov 16, 2023

  Based on record review, observations, staff, and resident interviews, the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint investigation surveys of 10-13-22. This was for 4 recited deficiencies in the areas of Emergency Preparedness (E001), Safe/Clean/Comfortable/Homelike Environment (F584), Respiratory/Tracheostomy care and Suctioning (F695), and Facility Assessment (F838). The continued failure during 2 federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. […]

• No harm, potential for more than minimal, widespreadF838Oct 13, 2022

  Based on record review and staff interviews the facility failed to review and annually update the Facility Assessment. Findings included: Review of the Facility Assessment revealed the assessment was last updated in September 2022. The document indicated the facility had a facility based and community-based risk assessment utilizing an all-hazards approach however there was not a risk assessment completed in the document. The Facility Assessment also indicated the facility had an Emergency Preparedness Plan that was up to date however the Emergency Preparedness Plan that was present was not complete. The Administrator was interviewed on 10-13-22 at 5:07pm. The Administrator stated he was not able to produce a facility based and community-based risk assessment. […]

• No harm, potential for more than minimal, patternF561Oct 13, 2022

  Based on observation, record review, resident and staff interviews, the facility failed to (1) honor resident choice to receive a shower for 2 of 2 residents (Resident #82 and Resident #77), (2) honor resident choice when to receive [CONDITION(S)] care and enteral feedings for 1 of 1 resident (Resident #16) and the facility failed to (3) honor resident choice to receive double portions as ordered by the Physician for 1 of 1 resident (Resident #25) reviewed for choices. Findings included: 1 Resident #82 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #82 was mildly cognitively impaired with no documentation of refusal of care. […]