Carolina Rehab Center Of Burke
Inspection Findings
F-Tag F0578
Federal health inspectors cited Carolina Rehab Center of Burke in Connelly Spring, NC for a deficiency under regulatory tag F-F0578 during a standard health inspection conducted on 2025-08-25.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 4 deficiencies cited during this inspection of Carolina Rehab Center of Burke.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-15.
F-Tag F0628
F 0628 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Director, Director of Nursing, Discharge Director, Medical Records Director, Dietary Manager, Director of Rehabilitation, Minimum Data Set (MDS) Nurse, Human Resource Manager, Activities Director). The IDT team determined that a Plan of Correction was needed and developed the Plan of Correction for approval to follow for QAPI to ensure monitoring and compliance. The IDT team decided to audit and monitor FULL CODE /DNR /MOST documents in the DNR/MOST book and in the Electronic Medical Record for all new admissions/readmission / significant changes daily for 4 weeks, then 5 times per week for 4 weeks, then 3 times per week for 4 weeks for 4 weeks to ensure ongoing compliance. The audit will be completed by matching the Physician order for all code status to the electronic medical record and the DNR/MOST book located at each nurse's station. The DON or designee will complete the required audits as outlined above.
Results will be reviewed upon completion of audits with QAPI team monthly for the next 3 months minimum to determine success and potential need for continuation or until substantial compliance is achieved.
Alleged Date of Immediate Jeopardy Removal and Compliance: 7/11/25 The facility's corrective action plan was validated on 8/25/25 by the following: Interviews with licensed nursing staff, admissions coordinator, Director of Marketing, Social Worker, and medical records revealed they had received education on resident advanced directives paperwork. They stated when a new admission arrived at the facility with completed advanced directive paperwork, a copy of the paperwork was to be placed inside the medical records box to be scanned into the resident's electronic health record (EHR) and the original was to be placed inside of the advanced directive notebook located at each nurse desk. They revealed if a resident completed their advanced directive paperwork upon their arrival to the facility or anytime during their stay at
the facility the original paperwork was to be placed inside the physician notebook located at each nurse desk and then once signed by the physician the original would then be placed inside the advanced directive notebook and a copy of the paperwork placed inside the medical records box to be scanned into the resident's EHR. They stated the original advanced directive was to be sent as part of the facility packet anytime a resident was leaving the facility for an appointment, transfer to the hospital, or discharged from
the facility. They were able to demonstrate the process, and observations were made of all residents original advanced directive forms located in the advanced directive notebook at each nurse desk and copies of advanced directives were located inside the medical records box waiting to be scanned into the resident's EHR. Review of facility orientation education for new hires and contract staff included education
on advanced directive process. Reviewed the audit and monitoring tools with no issues noted. Interviews with the Administrator and the DON revealed they had received training from their corporate regarding the advanced directive process and making sure all original advanced directives were placed inside the advanced directive notebooks, copies were placed inside the medical records box for scanning, only advanced directives that needed a physician signature were placed inside the physician notebook, and original advanced directive was included with facility paperwork for any resident appointments, transfers, or discharges. The facility's immediate jeopardy removal date and compliance date of 7/11/25 was validated.
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F-Tag F0732
Federal health inspectors cited Carolina Rehab Center of Burke in Connelly Spring, NC for a deficiency under regulatory tag F-F0732 during a standard health inspection conducted on 2025-08-25.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Post nurse staffing information every day.
Scope/Severity Level C: pattern, no actual harm with potential for minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 4 deficiencies cited during this inspection of Carolina Rehab Center of Burke.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-15.
F-Tag F0761
Federal health inspectors cited Carolina Rehab Center of Burke in Connelly Spring, NC for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-08-25.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 4 deficiencies cited during this inspection of Carolina Rehab Center of Burke.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-15.
Carolina Rehab Center of Burke in Connelly Spring, NC inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Connelly Spring, NC, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Carolina Rehab Center of Burke or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.