Zebulon Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Zebulon Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF677Mar 31, 2023

  Based on observations, resident and staff interviews, and record review, the facility failed to provide facial shaving for residents who required extensive assistance for 2 of 3 residents reviewed for activities of daily living care. (Resident #4 and Resident #24) The findings included: 1.Resident #4 was originally admitted to the facility on [DATE], with diagnoses that included Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), and Multiple Sclerosis (MS). Resident had history of recurrent hospital admission. Resident #4's care plan revised on 10/24/22 showed a focus for Activities of Daily Living (ADL) self-care performance deficit due to decreased strengthening and activity intolerance. Interventions included 1 person assistance with personal hygiene. […]

• No harm, potential for more than minimal, patternF745Feb 11, 2022

  Based on Physician and staff interviews, and record review the facility failed to obtain a referral for cataract surgery as ordered by the physician for 1 of 1 resident (Resident #19) reviewed for appointments. Findings included: Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included [CONDITION(S)] and type 2 diabetes mellitus. A review of a physician order dated 5/11/2021 revealed refer for cataract surgery to the ophthalmologist of her choice. A Minimum Data Set (MDS) dated [DATE] revealed Resident #19 was cognitively intact and had adequate vision. A plan of care revised on 1/6/2022 addressed Resident #19's potential for impaired vision. […]

• No harm, potential for more than minimal, isolatedF641Jul 24, 2025

  Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of dialysis and medications. This was for 1 of 1 resident (Resident #60) reviewed for dialysis and 1 of 5 residents (Resident #9) reviewed for unnecessary medications.Findings included:1. Resident #60 was admitted to the facility on [DATE].A physician's order for Resident #60 dated 5/30/25 revealed she received dialysis (a treatment for kidney failure) three times weekly on Monday, Wednesday and Friday.A review of Resident #60's July 2025 Medication Administration Record (MAR) revealed documentation indicating she received dialysis on 7/9/25 and 7/14/25.A review of Resident #60's quarterly MDS assessment dated [DATE] revealed she was not coded for receiving… […]

• No harm, potential for more than minimal, isolatedF761Jul 24, 2025

  Based on observation and staff interviews, the facility failed to keep medications in a locked medication cart for 1 of 2 medication carts observed (Medication Cart #1).Findings included:During continuous observation on 7/22/25, which started at 8:30 AM, Medication Cart #1 was observed unlocked and unattended on the 100-hall. A nurse aide was observed near the unlocked medication cart, and she passed it as she moved to and entered another resident's room. One resident was observed on the hall and was 3 rooms away from the unlocked medication cart and then entered the room he was sitting in front of at 8:32 AM. At 8:32 AM a nurse aide walked past the unlocked medication cart. At 8:33 AM a human resources staff member walked past the unlocked medication cart. […]

• No harm, potential for more than minimal, isolatedF554Jun 27, 2024

  Based on observations, record review, and resident and staff interviews the facility failed to complete a self-administration of medication assessment and care plan self-administration of medication before leaving medication at the bedside for 1 of 5 residents (Resident #5) reviewed for unnecessary medication. Findings included: Resident #5 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease. A review of Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. She had impaired functional limitation of range of motion of her upper extremity on one side. […]