O'berry Neuro-medical Treatment Center
Inspection Findings
F-Tag F0689
F 0689
- 4. Indicate how the facility plans to monitor its performance to make sure that the solutions are sustained.
Level of Harm - Minimal harm or potential for actual harm
A 100% audit was initiated on 4/9/25 that was completed on 4/14/25 concerning supervision levels of residents. This was completed by the unit consultant and the risk manager. The Risk manager reported all areas reviewed were in 100% compliance with supervision levels and have the code status and condition sheet on their person. She found that due to new admissions some code status and condition sheets were
in the process of being updated (Cluster 1). The unit consultant found that 30% of the areas he monitored were out of compliance and immediate steps were taken to correct the issues/concerns noted.
Residents Affected - Few
The Floor Shift Nurse Supervisors will monitor their assigned areas daily for one week to ensure proper supervision is maintained for all residents. The unit nurse managers will monitor daily for one week.
Performance Improvement Specialist will randomly monitor all homes to ensure compliance and to address any concerns noted as needed for two weeks. The results of their monitoring will be submitted to the Quality Data Manager who will compile the information, conduct an additional audit of 15% of the population served to determine compliance. This information will be shared during Clinical Review Team meetings as needed based upon the development of trends or lack of improvement in areas identified and discussed during QAPI meetings quarterly to determine next steps and opportunities for improvement.
Implemented 4/9/25 and completed on 4/17/25.
Performance Improvement Specialist will monitor for 3 months with the Quality Data Manager following up with an additional audit of 15% of the population randomly selected. This will be discontinued once we have 100% compliance with maintaining supervision levels as identified by the Care Plans. First meeting was held on 5/13/25.
The management team met and discussed the incident and outcomes on 6/24/25 and presented it to the clinical review team on 6/25/25. Per report we continued 100% compliance with staff following supervision levels and staff having the code status and condition sheets on their person.
Validation of the plan of correction.
A review was completed of the signature pages for the in-service training for staff campus wide on abuse, neglect, exploitation, exchange of responsibility, code status and condition sheet and plan of protection.
Interview with staff showed they received in-service training regarding abuse, neglect, exploitation, exchange of responsibility, code status and condition sheet and plan of protection.
A review of the audit tool used by the facility to monitor performance was found to be completed according to the plan of correction. The monitoring documentation showed the audits were completed on 7/17/25.
The facility's corrective action plan completion date of 6/26/25 was validated.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
34A002
If continuation sheet
O'Berry Neuro-Medical Treatment Center in Goldsboro, 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 Goldsboro, 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 O'Berry Neuro-Medical Treatment Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.