Fuquay-varina Health And Rehabilitation Center

During an interview on 3/31/2026 at 2:05 PM, Nurse #3 stated she sent the physician a text message about the positive test results and did not have the EMR open to see the resident allergies.

The physician texted message back the Doxycycline 100 milligrams order.

Nurse #3 reported she did not recall any allergy alert appearing when she entered the Doxycycline order into the EMR.

The medication had not yet been delivered, so none was administered.

During an interview on 3/31/2026 at 6:15 AM, Nurse #4 stated allergies were listed in the EMR beneath the resident name.

She stated an allergy alert appears when entering a contraindicated medication.During a telephone interview with the physician on 3/31/2026 at 9:30 AM, he stated he was unaware of the allergy to the Doxycycline and that the EMR was unavailable to him. He stated nursing staff normally informs him of allergies.During a telephone interview with the resident's Guardian on 3/31/2026 at 12:10 PM, she stated she went to the facility and requested medical records that included the medication administration record (MAR).

Upon review of the MAR, the Guardian noted the order for Doxycycline and notified the facility of the allergy to Doxycycline.

The Guardian stated Doxycycline should never have been ordered by the physician.

During an interview with the Director of Nursing (DON) on 4/1/2026 at 10:00 AM, she stated nurses should have the resident EMR open when contacting physicians and that the EMR provided allergy alerts.

During an interview with the Administrator on 4/1/2026 at 10:15 AM, she stated she was aware the physician prescribed a medication to which the resident was allergic and that Nurse #3 did not inform the physician when the physician prescribed the medication.

345561 04/01/2026

Fuquay-Varina Health and Rehabilitation Center 410 S Judd Parkway SE Fuquay Varina, NC 27526

#109 had needed tracheostomy care.On 3/31/26 at 2:57 PM an interview with the Administrator

She reported these were for single use only and should not be cleaned and reused.

She stated that

cannula was best practice she felt Nurse #2's goal had been to keep Resident #109 comfortable by providing the care.On 3/31/26 at 2:16 PM a telephone interview with the Medical Director indicated there would have been no risk to Resident #109 when Nurse #2 used sterile technique to clean and reuse a disposable tracheostomy inner cannula. He reported this single incident had not caused Resident #109 any harm.

345561 04/01/2026

Fuquay-Varina Health and Rehabilitation Center 410 S Judd Parkway SE Fuquay Varina, NC 27526

minimal harm information in an area of the facility visible to residents and visitors on 1 of 4 days of the survey (3/29/26). In addition, the facility failed to have an effective process in place to ensure staffing

(Sunday) at 10:00 AM an initial tour was conducted in the facility.

The posted daily staffing information sheet was observed on the counter at the reception desk in lobby and was dated 3/26/26 (Thursday).On 3/30/26 at 3:15 PM an interview with the Scheduler revealed she was responsible for posting daily staffing information sheets.

She reported she had not been in the office on 3/27/26 and she didn't work on the weekends.

She stated although she knew that staffing information sheets were required to be posted daily, the facility did not have a process for ensuring this happened when she was out of the office or on the weekends.

She reported she had not completed and posted the daily staffing information sheets for 3/27/26, 3/28/26 or 3/29/26.

The Scheduler stated she had not had a conversation with the Administrator regarding the implementation of a process to ensure daily staffing information sheets were posted as required.On 4/1/26 at 10:20 AM a review of facility's previous 30 days of daily staffing information sheets from 3/2/26 through 3/30/26 revealed them to be complete.In a follow up interview on 4/1/26 at 11:03 AM the Scheduler stated when she returned to the office, she would create the daily staff postings for the days she had been off, such as on weekends or when she was out of the office, based on the staffing schedules for those days to ensure the record of them was complete and accurate.

She reported this is what she had done when she completed the daily staffing postings for 3/27/26, 3/28/26, and 3/29/26 when she returned to the facility on 3/30/26.On 3/31/26 at 2:57 PM an interview with the Administrator revealed the Scheduler was responsible for posting the daily staffing information sheets.

She reported she was unaware that staffing information sheets were not being posted when the Scheduler was out of the office.

The Administrator reported that anytime she reviewed the daily staffing information sheets, she found them to be complete.

She stated the facility did not have a process in place to ensure staffing information sheets were posted when the Scheduler was out of the office or the weekends.

Based on observations and staff interviews, the facility failed to secure medications and treatment

Cart).

Findings included:During continuous observation on 3/29/26 (Sunday) from 10:29 AM until 10:36 AM the Station 2 Wound Care Cart was observed unlocked and unattended at the nursing station.

There were no staff, residents, or visitors observed in sight of the wound care cart at that time. At 10:30 AM a housekeeping staff member walked past the unlocked wound care cart followed by a nurse aide who also walked past the unlocked wound care cart. At 10:31 AM three visitors walked past the unlocked wound care cart. At 10:32 AM Nurse #1 went to the nursing station, retrieved an item from the nursing station, and left visual range of the Station 2 Wound Care Cart which remained unlocked. At 10:33 AM a nurse aide walked past the unlocked wound care cart. At 10:34 AM three visitors walked by the unlocked wound care cart. At 10:35 AM a visitor walked past the unlocked wound care cart. At 10:35 AM another visitor walked past the unlocked wound care cart and a resident wheeled past the unlocked wound care cart. At 10:36 AM Nurse #1 returned to the nursing station.

During an interview on 3/29/26 at 10:36 AM Nurse #1 stated the nurses on the hall completed wound care on the weekends.

She stated someone must have used the cart and left it unlocked but she did not know who last accessed the Station 2 Wound Care Cart.

She stated all nurses were responsible for the Station 2 Wound Care Cart and it should be locked when left unattended because there were medications in the cart and many confused residents resided in the facility so an unlocked wound care cart could be a safety issue. On 3/29/26 at 10:39 AM an observation was completed of the Station 2 Wound Care Cart with Nurse #1.

The Station 2 Wound Care Cart was observed to contain calcium alginate dressing, iodoform packing strips, collagen wound filler, xeroform medicated petrolatum dressing, zinc oxide paste, Silvasorb gel, diclofenac sodium topical gel 1%, 70% Isopropyl alcohol, lidocaine ointment USP 5%, carbamide Peroxide 6.5%, Ciclopirox olamine cream USP 0.77%, Nystatin cream USP 100,000, Gentamicin Sulfate Cream USP 0.1%, and nystatin topical powder.

During an interview on 3/29/26 at 12:31 PM the Director of Nursing stated wound care carts should be locked at all times when not attended by a nurse due to safety concerns for confused residents.

345561 04/01/2026

Fuquay-Varina Health and Rehabilitation Center 410 S Judd Parkway SE Fuquay Varina, NC 27526