Perry Creek Health And Rehabilitation Center
Perry Creek Health and Rehabilitation Center in Raleigh, NC — inspection on June 6, 2024.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During the complaint survey of 6/6/2024 the facility failed to have a system in place to accurately evaluate the extent nutrition was contributing to the development and non-healing of the wounds and develop a plan to address any nutritional deficit for one of three sampled residents reviewed for pressure sores.
F-F692.
The Administrator also confirmed the ADON was trusted to monitor the resident Medication Administration records (MARs) and Treatment Administration records (TARs) so the information could be accurately presented to the Interdisciplinary team at the QAPI meeting.
The Administrator revealed she really did think the monitoring of the records was being completed despite a lack of any evidence of any monitoring of the records for accuracy or completeness.
The Administrator indicated she really did think the communication in the QAPI meetings indicated the facility plan of correction was working and was being monitored.
An interview was conducted with the ADON on 8/2/2024 at 12:15 PM.
The ADON was unable to explain why sampled residents for the current survey were not a part of the facility QAPI monitoring process for residents with pressure sores and residents requiring nutritional interventions.
The ADON stated she thought the monitoring process for QAPI was complete.
The ADON was also unable to provide any evidence the facility had QAPI monitoring tools of the resident MARs and TARs for accuracy and completeness of the record.
The ADON stated she was aware in the 7/30/2024 QAPI meeting with the interdisciplinary team that the MARs and TARs had a lot of blanks.
The ADON stated the QAPI team decided to implement further measures of education, disciplinary action, intercom announcements, and signs posted throughout the building to try to improve the consistency of documentation by the nursing staff.
345529
F-F842: During the complaint survey of 8/6/2024 the facility failed to ensure the medical records were accurate and complete regarding administration of medication and treatments.
This was for four of six sampled residents whose medical records were reviewed for documentation related to medications and treatments being documented correctly in the medical record.
345529
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 345529 B.
Wing 06/06/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Universal Health Care/North Raleigh 5201 Clarks Fork Drive NW Raleigh, NC 27616