River Trace Nursing And Rehabilitation Center
River Trace Nursing and Rehabilitation Center in Washington, NC — inspection on August 22, 2025.
Found 11 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
cognitively impaired and had an indwelling urinary catheter.
An observation conducted on 8/18/25 at 11:45 AM revealed Resident #7 walked around the day room and a urinary catheter bag which contained urine, hung on the right side of his walker.
The urine in the bag was visible.
There were several residents, a visitor and staff in the day room.
An observation was conducted on 8/18/25 at 12:40 PM. Resident #7 was in the day room and a urinary catheter bag hung on the right side of his walker.
The urinary catheter bag was one-quarter full of urine and visible to staff, residents and visitors.
In an interview with Nurse #1 on 8/18/25 at 12:40 PM she revealed she was not aware a urinary catheter bag should be covered for dignity.
Nurse #1 stated she didn’t think the facility had privacy bags available for catheter bags.
On 8/18/25 at 12:52 PM an interview was conducted with Nurse Aide (NA) #1. NA #1 stated she was assigned to Resident #7 that day.
She further stated she had never seen a urinary catheter bag privacy bag on the unit and if he had one it would be in his room, but she didn’t see one that morning.
A follow-up observation was conducted on 8/18/25 at 4:00 PM. Resident #7 was seated in the day room.
His urinary catheter bag hung on the right side of his walker and urine was visible through the bag.
In an interview with the Director of Nursing (DON) on 8/19/25 at 1:09 PM she stated all urinary catheter bags should have a privacy cover and that the facility supplied them.
The DON indicated the covers were to preserve the dignity of residents with indwelling urinary catheters by keeping the urine hidden from the view of visitors, residents and staff.
In an interview with the Administrator on 8/19/25 at 2:11 PM, she stated the facility provided privacy bags to cover urinary catheter bags.
She further stated all urinary catheter bags should be covered with a privacy bag.
The Administrator indicated the cover was for the resident’s privacy and dignity.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
River Trace Nursing and Rehabilitation Center
250 Lovers Lane Washington, NC 27889
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited River Trace Nursing and Rehabilitation Center in Washington, NC for a deficiency under regulatory tag F-F0554 during a standard health inspection conducted on 2025-08-22.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Allow residents to self-administer drugs if determined clinically appropriate.
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 11 deficiencies cited during this inspection of River Trace Nursing and Rehabilitation Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-26.
Federal health inspectors cited River Trace Nursing and Rehabilitation Center in Washington, NC for a deficiency under regulatory tag F-F0578 during a standard health inspection conducted on 2025-08-22.
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 11 deficiencies cited during this inspection of River Trace Nursing and Rehabilitation Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-26.
protocol and to identify any concerns related to control substance.
The DON addressed all concerns identified during the audit to include but not limited to re-training of staff when indicated.
The Administrator or DON presented the findings of the audit tools and quizzes to the Quality Assurance Performance Improvement (QAPI) Committee monthly for 3 months and reviewed to determine trends and/or issues that needed further interventions and the need for additional monitoring.
Alleged date of compliance: 12/19/24 The facility's plan of correction was validated on 8/22/25 through interviews with nurses and medication aides, a review of the facility's initial audits, in-service education records, a review of the facility's audit tools, a review of the facility's revised HCF-257 form, a review of the facility's record of replacement of medications at the facility's expense, an observation of medication administration to include narcotic administration and reconciliation, an observation of the lock box and the assistant DON's process for monthly review and accounting for narcotics, and the facility's QAPI.
The facility's date of completion of 12/19/24 for the corrective action plan was validated.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
River Trace Nursing and Rehabilitation Center
250 Lovers Lane Washington, NC 27889
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited River Trace Nursing and Rehabilitation Center in Washington, NC for a deficiency under regulatory tag F-F0656 during a standard health inspection conducted on 2025-08-22.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 11 deficiencies cited during this inspection of River Trace Nursing and Rehabilitation Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-26.
Federal health inspectors cited River Trace Nursing and Rehabilitation Center in Washington, NC for a deficiency under regulatory tag F-F0657 during a standard health inspection conducted on 2025-08-22.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 11 deficiencies cited during this inspection of River Trace Nursing and Rehabilitation Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-26.
Federal health inspectors cited River Trace Nursing and Rehabilitation Center in Washington, NC for a deficiency under regulatory tag F-F0726 during a standard health inspection conducted on 2025-08-22.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Scope/Severity Level J: isolated, immediate jeopardy to resident health or safety.
This represents an immediate jeopardy situation, the most serious level of deficiency.
This was one of 11 deficiencies cited during this inspection of River Trace Nursing and Rehabilitation Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-26.
Federal health inspectors cited River Trace Nursing and Rehabilitation Center in Washington, NC for a deficiency under regulatory tag F-F0755 during a standard health inspection conducted on 2025-08-22.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity Level E: pattern, 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 11 deficiencies cited during this inspection of River Trace Nursing and Rehabilitation Center.
Correction Status: Past Non-Compliance.
The facility reported correction as of 2024-12-19.
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff and Medical Director interviews, the facility failed to notify the physician or Nurse Practitioner (NP) of abnormal laboratory test results.
This deficient practice affected 1 of 6 sampled residents (Resident #130).Resident #130 was admitted to the facility on [DATE] with diagnoses that included obstructive sleep apnea, chronic kidney disease, chronic atrial fibrillation (a condition where the heart beats irregularly and often too fast), and congestive heart failure. Resident #130 had a telephone order called in from the NP from the Cardiology office on 10/11/24 for a BMP (basic metabolic panel, which was a common blood test that measures glucose, calcium, sodium, potassium, chloride, carbon dioxide, blood urea nitrogen and creatinine), draw to be done at the facility.
The order was signed off by a nurse on 10/14/2024.
Several unsuccessful attempts were made to reach the NP that ordered the lab.
Review of the lab results report showed the blood specimen was collected on 10/16/2024, reported to the facility on [DATE] and reviewed by the Medical Director on 10/21/2024.
The lab results showed out of range for glucose which was 113 with a reference range of 70-99, creatinine which was 1.53 with a reference range of .57-1.00, carbon dioxide which was 19 with a reference range of 20-29, red blood count 3.60 with a reference range of 3.77-5.28, hemoglobin which was 11.0 with a reference range of 11.1-15.9, hematocrit which was 33.6 with a reference range of 34.0-46.6, and iron which was 23 with a reference range of 27-139. An interview was held with the patient access representative at the cardiology office on 8/20/2025 at 12:30 PM.
She stated the office never received the results of Resident #130's BMP.
She went on to say the NP ordered additional blood work on 10/30/2024 to be completed at an offsite provider and the results were reported to the NP the same day. An interview with the Assistant Director of Nursing was held on 8/20/2025 at 11:00 AM at which time she revealed the facility completes the blood drawings and the results should have been reported to the provider that ordered the blood test.A telephone interview with the facility Medical Director was held on 8/20/2025 at 2:00 PM, and he referred this surveyor back to the Assistant Director of Nursing to see who should have reported the lab results to the ordering provider. He went on to say he did not feel the lack of reporting adversely affected this resident.And interview was conducted with the Director of Nursing on 8/20/2025 at 3:15 PM, she revealed she was not sure of the policy as she was new to the facility.
She went on to say typically lab results would be a provider-to-provider conversation.A follow up interview with the Assistant Director of Nursing was conducted on 8/20/2025 at 3:30 PM, she stated the nurse assigned to the hall where the resident lived should have called in the results to the provider that ordered the lab work.An interview with the Administrator was held on 8/20/2025 at 3:40 PM, she revealed she was new to the facility and not sure who should have reported the blood draw results to the provider that ordered the labs.An interview was conducted with the Regional Nurse Consultant on 8/20/2025 at 3:50 PM.
She revealed anyone could communicate the results of blood work but typically the unit manager would notify the prescribing provider of the results.
Facility ID:
Federal health inspectors cited River Trace Nursing and Rehabilitation Center in Washington, NC for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-22.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity Level E: pattern, 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 11 deficiencies cited during this inspection of River Trace Nursing and Rehabilitation Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-26.
Federal health inspectors cited River Trace Nursing and Rehabilitation Center in Washington, NC for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-22.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level J: isolated, immediate jeopardy to resident health or safety.
This represents an immediate jeopardy situation, the most serious level of deficiency.
This was one of 11 deficiencies cited during this inspection of River Trace Nursing and Rehabilitation Center.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-26.