Heritage Care of Rocky Mount

The facility failed to ensure the implementation of a physician's order for a 2-liter fluid restriction for one resident. The order was not entered into the electronic treatment administration record (eTAR) because the Resident Care Coordinator failed to fax the order to the pharmacy. Consequently, the fluid restriction was not monitored or followed from July 28, 2023, through September 6, 2023.

The facility failed to maintain the rights of a resident by not offering an alternative breakfast meal. This violation occurred on July 10, 2023, and August 11, 2023.

The facility failed to ensure the implementation of physician orders for one resident regarding a 2-liter fluid restriction. The required fluid restriction was not documented in the resident's electronic treatment administration record (eTAR) for the period of July 28, 2023, through September 6, 2023.

The facility failed to ensure aide hours met the minimum requirements for 1 of 15 shifts sampled between 06/10/22 and 08/31/22. Specifically, on 06/15/22, the third shift provided only 17 hours and 41 minutes of aide duty, resulting in a shortage of 6 hours and 19 minutes based on the resident census.

The facility failed to maintain required staffing levels on the third shift on 06/16/22. There were only two staff members working instead of the required minimum of three, leaving the building understaffed.

The facility failed to ensure adequate daily total hours of care were provided on each shift. Specifically, the third shift was not staffed according to the required minimums to ensure resident safety.

The facility failed to ensure an immediate response to an incident involving a resident. Following the discovery of Resident #4 unresponsive on the floor, staff failed to initiate CPR and there was a significant delay in notifying EMS.

Staff failed to respond immediately to an accident involving a resident to provide necessary care and intervention. Evidence showed that despite staff being CPR certified, no life-saving measures were started when the resident was found unresponsive.

The facility failed to assure health care referral and follow-up for 4 of 5 sampled residents. Specifically, Resident #1 did not receive a required cardiology referral despite a physician order, and other residents experienced issues with managing blood sugar levels and medication refusals.

The facility failed to ensure proper health care referral and follow-up for residents. Specifically, the facility did not document or facilitate a required cardiology referral for one resident and failed to manage follow-up care for residents with elevated blood sugar or those refusing medications for chronic conditions.

The facility failed to ensure proper referral and follow-up to meet the healthcare needs of residents. Specifically, staff failed to notify the primary care provider or hospice nurse regarding decreased oxygen saturation levels for one resident and failed to notify the primary care provider regarding meal refusals for another resident.

The facility failed to ensure proper referral and follow-up to meet the healthcare needs of residents. Specifically, staff failed to notify the primary care provider or hospice nurse regarding decreased oxygen saturation levels for one resident and failed to notify the primary care provider regarding another resident refusing meals.