Accordius Health At Midwood, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Charlotte, North Carolina.
- Location
- 2727 Shamrock Drive, Charlotte, North Carolina 28205
- CMS Provider Number
- 345304
- Inspections on file
- 25
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Accordius Health At Midwood, Llc during CMS and state inspections, most recent first.
A resident who remained in the facility after Medicare Part A skilled services ended was not provided with the required CMS-10055 Advanced Beneficiary Notice (ABN), although they did receive the CMS-10123 Notice of Medicare Non-Coverage (NOMNC). Staff interviews revealed confusion over responsibility for issuing these forms during a transition in the Business Office Manager position, resulting in the ABN not being given as required.
A resident with multiple medical conditions had her code status changed from CPR/Full Code to DNR, as documented by the social worker and on a signed MOST form. However, the care plan was not updated to reflect this change because the MDS Nurse was not informed, and the update was not discussed in the facility's daily meetings as expected.
A resident did not receive food prepared in a form that met their individual needs, as the facility did not consistently modify meals to accommodate specific dietary requirements or physical abilities.
Staff failed to follow infection control policies during care of a resident with a chronic wound and feeding tube. One nurse did not change gloves or perform hand hygiene between wound care steps, while another did not wear a gown during high-contact care despite EBP signage and PPE availability. The DON and administrator confirmed that both hand hygiene and use of gown and gloves were required by facility policy.
A medication error rate of 5 percent or greater was found during the survey, showing that the facility did not maintain medication administration errors below the required limit.
The facility did not notify the Medical Director when significant morning medications were missed for a resident due to dialysis treatments, including seizure medication, insulin, and medications for chronic conditions. Additionally, the facility failed to inform the Responsible Person and Medical Director when a cognitively impaired resident attempted to cut off her cast with a knife. These incidents highlight lapses in communication regarding medication administration and significant resident events.
An incident involving a resident with dementia and a history of wandering highlighted deficiencies in maintaining a hazard-free environment and providing adequate supervision. The resident was found attempting to cut off her cast with a knife accessed from an unlocked maintenance room. The room contained potentially harmful tools and materials. Staff members, including the Nursing Assistant and Maintenance Directors, were unaware of the importance of keeping the maintenance room locked. The incident was not promptly reported to the Administrator and DON, emphasizing the immediate jeopardy faced by the resident due to the accessible hazards.
A resident with complex medical conditions, including dependence on renal dialysis, missed multiple doses of morning medications due to being out of the facility for scheduled dialysis treatments. The missed medications included those for depression, epilepsy, type 2 diabetes, hypertensive heart disease, and chronic kidney disease with heart failure. Nursing staff did not administer the medications upon the resident's return, citing the resident's leave of absence. Documentation showed missed doses, but the resident's vital signs remained within normal limits. Interviews revealed gaps in knowledge and communication among nursing staff and the medical doctor regarding medication administration protocols for dialysis residents.
A new cook at the facility prepared fried chicken by cooking it for 15 minutes in a fryer and then transferring it to the oven. The chicken pieces were piled in a 4-inch pan instead of a 2-inch pan, resulting in undercooked chicken. The cook did not check the temperature before serving, leading to undercooked chicken being served to 15 residents, with 5 consuming it. The issue was identified by a nursing assistant who observed the undercooked chicken during lunchtime.
A facility failed to adhere to infection control protocols by using a single resident's insulin pen for another resident, risking bloodborne pathogen transmission. Despite clear guidelines, a nurse administered insulin to one resident using another's pen. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with medical devices and non-chronic wounds, such as indwelling catheters and tracheostomies. Observations revealed a lack of appropriate personal protective equipment outside the rooms of high-risk residents, indicating systemic issues in infection control measures.
The facility failed to refer three residents with serious mental health diagnoses for PASRR level II evaluations. Despite having diagnoses such as PTSD, psychotic disorder with hallucinations, and bipolar disorder, no PASRR level II referrals were documented for these residents. Both the Social Worker and Administrator confirmed that referrals should have been made based on the residents' conditions.
The facility failed to plan group activities outside of the facility, leading to frustration and feelings of being forgotten among residents. Despite requests during Resident Council Meetings, no outings were offered due to the lack of a transportation van. The Activity Director and Administrator acknowledged the issue but had not provided a solution.
The facility failed to consistently provide bagged meals for two residents with diabetes and end-stage renal disease who required dialysis. The residents reported not receiving their meals, which were supposed to include a sandwich, snacks, and a drink, leading to concerns about low blood sugar and hunger during their treatments. Staff interviews confirmed ongoing issues with meal preparation and accessibility.
The facility failed to verify a cook's competencies and certifications before his first day of employment. The cook began working without necessary training due to miscommunication and staff shortages. The Dietary Manager did not verify the cook's ServSafe certification and culinary school training before hiring him.
The facility failed to provide evening snacks to residents when requested, as confirmed through resident and staff interviews. Four residents with serious conditions reported inconsistencies in receiving evening snacks, and observations confirmed that the nourishment room was inadequately stocked. The Unit Manager and Dietary Manager were unaware of the issue until the survey, and nursing staff had informed dietary staff about the problem multiple times. The Administrator expected snacks to always be available, but the facility failed to ensure consistent provision.
The facility's QAA committee failed to maintain procedures and monitor interventions, resulting in repeat deficiencies in accident hazards and food safety. A cognitively impaired resident accessed a knife from an unlocked maintenance room, and undercooked chicken was served to residents. The facility also failed to properly label and store food items. The Administrator cited staff turnover and lack of accountability as contributing factors.
The facility failed to protect a resident's private health information when an insulin pen labeled with another resident's details was left at the bedside of a cognitively intact resident with diabetes. The incident was reported to the DON, who acknowledged the staff's responsibility to protect health information.
A facility failed to protect a resident from inappropriate physical contact when a Nurse Aide was observed lying in bed with the resident. The resident, who is legally blind and has depression, recalled being awakened but was unsure if the person was in his bed or sitting on it. Another NA confirmed seeing the incident and reported it, but the claim was not immediately investigated, and the incident was not reported to higher management until days later.
A facility failed to follow its abuse policy when a staff member was observed lying in bed with a resident. The incident was not reported immediately, and the staff member continued to work shifts. The delay in reporting and addressing the situation led to a deficiency in the facility's handling of the incident.
A resident with a pressure ulcer and chronic pain syndrome complained of severe pain during wound care, but the nursing staff did not stop the procedure to address the pain. Despite the resident's pain rating of 7 out of 10, the wound care was completed without interruption, leading to a deficiency in pain management.
Failure to Provide Required Medicare Advanced Beneficiary Notice
Penalty
Summary
The facility failed to provide a CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (ABN) to a resident prior to the end of their Medicare Part A skilled services. The resident was admitted and began receiving Medicare Part A services, and a CMS-10123 Notice of Medicare Non-Coverage (NOMNC) was issued to inform the resident that Medicare coverage for skilled services would end. However, the required ABN, which notifies the resident of potential financial liability for services not covered by Medicare, was not provided, even though the resident remained in the facility after skilled coverage ended. Interviews with facility staff revealed confusion regarding responsibility for issuing the required forms during a transition period when a new Business Office Manager (BOM) was being hired. The BOM stated she was responsible for issuing both the NOMNC and ABN but had not started employment at the time the resident's Medicare Part A benefit ended. The former Social Worker and the Administrator provided conflicting accounts of who was responsible for issuing the forms, but both acknowledged that both forms should have been provided when a resident remained in the facility after Medicare Part A coverage ended.
Failure to Update Care Plan with Resident's DNR Code Status
Penalty
Summary
A deficiency occurred when the facility failed to update a resident's care plan to reflect a change in cardiopulmonary resuscitation (CPR) code status. The resident, who had diagnoses including myasthenia gravis, diabetes mellitus, and hypertension, was cognitively intact at the time of the incident. Her care plan continued to indicate CPR/Full Code status, even after she communicated her wish to change to Do Not Resuscitate (DNR) status. The change was documented in the social work progress note and a Medical Orders for Scope of Treatment (MOST) form was signed to reflect the new DNR status. Despite the code status change being discussed with the social worker and documented in the resident's records, the information was not communicated to the MDS Nurse responsible for updating the care plan. The MDS Nurse was unaware of the change and stated that such updates were typically discussed in clinical or standup meetings, but this particular change was missed. The Director of Nursing and the Administrator both confirmed that code status changes were expected to be discussed in daily meetings, but could not explain why this update was overlooked, resulting in the care plan not being revised in a timely manner.
Failure to Provide Food in Appropriate Form for Individual Needs
Penalty
Summary
The facility failed to ensure that each resident received food prepared in a form designed to meet their individual needs. This deficiency indicates that meals were not consistently modified or adapted to accommodate the specific dietary requirements or physical abilities of residents, such as those needing pureed, chopped, or otherwise altered food textures.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to adhere to its Handwashing/Hand Hygiene policy during wound care for a resident with a sacral wound. During an observed wound care procedure, a nurse entered the resident's room, donned a gown, sanitized her hands, and put on gloves. She removed the soiled dressing from the resident's sacrum and, without changing gloves or performing hand hygiene, proceeded to clean the wound and apply a new dressing. The nurse only removed her gloves and gown and performed hand hygiene after completing the entire procedure. In an interview, the nurse acknowledged forgetting to sanitize or wash her hands between steps and suggested she could have double-gloved, but this was not in accordance with policy. Additionally, the facility did not implement its Enhanced Barrier Precautions (EBP) policy during high-contact care activities for a resident with a chronic wound and a feeding tube. During an observation, a nurse aide and a nurse entered the resident's room to reposition and dress the resident. While the nurse aide donned both a gown and gloves, the nurse only wore gloves, despite EBP signage and a PPE caddy indicating that both gown and gloves were required for high-contact care activities such as dressing. The nurse later stated she was unaware of the EBP signage and believed a gown was only necessary when directly caring for the wound or feeding tube, not for dressing the resident. Interviews with the Director of Nursing, who also served as the Infection Preventionist, confirmed that staff were educated to follow hand hygiene protocols and EBP requirements, including wearing gowns and gloves during high-contact care for residents with wounds or indwelling devices. The administrator also confirmed that staff should wear both gown and gloves during such activities. The observed failures involved two staff members and were not in accordance with the facility's established infection control policies.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that medication administration errors remained below the acceptable threshold, as required by regulations. The deficiency was based on direct findings from the survey process.
Communication Gaps in Medication Administration and Incident Reporting
Penalty
Summary
The facility failed to notify the Medical Director when significant morning medications were not administered to Resident #20 due to her being out of the facility for dialysis treatments. These medications included seizure medication, insulin, depression medication, and medications for chronic kidney and heart failure. The missed doses of these medications posed serious risks to Resident #20, including potential seizure activity, diabetic coma, and cardiac complications. Despite the facility's policy requiring notification of the physician when medications are not administered, there was no documentation of the MD being informed of the missed medications for Resident #20. In another instance involving Resident #66, the facility also failed to notify the Responsible Person (RP) when the resident, who was severely cognitively impaired with a history of wandering, was observed attempting to cut her cast off with a knife. The Nursing Assistant (NA) who witnessed the incident did not report it to the nursing staff immediately, and there was no documentation of the incident in Resident #66's progress notes. The RP expressed a desire to have been informed of the incident so they could assess Resident #66's well-being and ensure appropriate actions were taken. The Medical Director was also not made aware of this incident, highlighting a lack of communication regarding significant resident events within the facility.
Deficiency in Preventing Access to Hazardous Items and Ensuring Resident Supervision
Penalty
Summary
The report details a deficiency in maintaining a nursing home area free from accident hazards and providing adequate supervision to prevent accidents, specifically focusing on an incident involving Resident #66. Resident #66, admitted with a history of dementia and a left arm fracture, was observed attempting to cut off her cast with a long ridged knife on 2/21/24. The resident, who was severely cognitively impaired and had a history of wandering, was unattended in the hallway outside the maintenance room, which was unlocked and partially open, allowing her access to the knife. Nursing Assistant (NA) #6 discovered Resident #66 with the knife and safely removed it, but failed to lock the maintenance room door after the incident. The report highlights that the maintenance room contained tools and materials that could pose serious harm or injury to residents if accessed. Interviews with staff members, including NA #6, the Regional Maintenance Director, and the previous Maintenance Director, revealed a lack of awareness regarding the incident and the importance of keeping the maintenance room door locked at all times to prevent resident access to hazardous items. The deficiency was further emphasized by the facility's failure to document the incident promptly to the Administrator and the Director of Nursing (DON). The report underscores the immediate jeopardy faced by Resident #66 due to the accessibility of the knife and the unlocked maintenance room. The root cause analysis identified the Maintenance Director's failure to lock the maintenance room door as a key factor contributing to the deficiency.
Medication Administration Gaps for Dialysis Resident
Penalty
Summary
The facility failed to prevent a significant medication error involving Resident #20, a dialysis resident with a complex medical history including dependence on renal dialysis, seizures, type 2 diabetes, depression, chronic kidney, and heart failure. The error occurred when Resident #20 did not receive her morning medications on multiple occasions due to being out of the facility for scheduled dialysis treatments. The missed medications included those prescribed for depression, epilepsy, type 2 diabetes, hypertensive heart disease, and chronic kidney disease with heart failure. Nursing staff, including Nurse #13 and Nurse #15, did not administer the morning medications upon Resident #20's return from dialysis, citing the reason as resident leave of absence. The facility's Medication Administration Record for April 2024 documented the missed doses of significant morning medications for Resident #20, including Escitalopram, Keppra, Ozempic, Carvedilol, and Humalog. Despite the missed doses, Resident #20's progress notes for April 2024 indicated that her blood pressure and blood sugar levels were within normal limits. Resident #20 expressed awareness of the missed medications, stating that they usually occurred on the days she received dialysis treatments. However, she had not reported the issue to the Administrator or Director of Nursing. Interviews with Nurse #13, Nurse #15, and the Medical Doctor revealed gaps in knowledge and communication regarding the administration of medications for dialysis residents. Nurse #13 and Nurse #15 were not aware of the protocol to hold and administer medications upon the resident's return from dialysis. The Medical Doctor emphasized the importance of being informed about any conflicts between dialysis treatments and medication schedules to make necessary adjustments.
Undercooked Fried Chicken Served Due to Inadequate Cooking Procedures
Penalty
Summary
The deficiency identified in the report pertains to the failure of the facility to ensure that fried chicken was completely cooked before serving to residents. Cook #1, who was new to the facility, prepared the fried chicken by cooking it for 15 minutes in a fryer and then transferring it to the oven. However, due to the chicken pieces being piled on top of each other in a 4-inch pan instead of a 2-inch pan, the chicken was undercooked in the middle and close to the bone. Despite being advised by other staff members, Cook #1 failed to check the temperature of the chicken before serving it to residents. This led to undercooked fried chicken being served to 15 residents, with 5 of them consuming the undercooked chicken. The deficiency was first noticed by Nursing Assistant #6 during lunchtime when she observed undercooked chicken served to Resident #54. Upon further inspection, she found the chicken to be pink, bloody, and undercooked. This prompted the staff to remove all trays from the dining room and halls and provide residents with new trays. The observation continued in the kitchen, where it was confirmed that the fried chicken was undercooked and had to be discarded. Cook #1 admitted to not checking the temperature of the chicken adequately and acknowledged his mistake in the cooking process.
Insulin Pen Misuse and Lack of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that single resident insulin pens were not shared between residents, leading to a serious breach in infection control protocols. Nurse #10 administered insulin to Resident #171 using Resident #172's insulin pen, which posed a significant risk of bloodborne pathogen transmission. Despite clear guidelines from the manufacturer and facility policy stating that insulin pens are for single resident use only, the incident occurred due to a lack of adherence to these protocols. The failure to implement proper procedures for insulin administration and storage resulted in immediate jeopardy being identified on 07/10/23. Additionally, the facility also failed to initiate Enhanced Barrier Precautions (EBP) for residents with medical devices and non-chronic wounds, such as indwelling catheters and tracheostomies, for multiple residents. This lapse in implementing EBP for high-risk residents with medical devices and wounds further compounded the infection control deficiencies within the facility. The observations made during the survey highlighted instances where residents with medical devices did not have appropriate personal protective equipment available outside their rooms, indicating a systemic failure in ensuring proper infection control measures were in place.
Failure to Complete PASRR Level II Referrals for Residents with Serious Mental Health Diagnoses
Penalty
Summary
The facility failed to refer three residents with serious mental health diagnoses for Preadmission Screening and Resident Review (PASRR) level II evaluations. Resident #4 was admitted with diagnoses of PTSD and a mental disorder, but no PASRR level II referral was documented. The Social Worker (SW) and Administrator both confirmed that a PASRR level II referral should have been completed based on the resident's diagnoses. Similarly, Resident #19 was admitted with a diagnosis of psychotic disorder with hallucinations, but no PASRR level II referral was documented. The SW and Administrator again confirmed that a referral should have been made based on the resident's mental health condition. Resident #54 was admitted with adjustment disorder with mixed anxiety and depressed mood, and later received diagnoses of depression disorder and bipolar disorder. Despite these serious mental health conditions, no PASRR level II referral was documented. The SW and Administrator both acknowledged that a PASRR level II referral should have been completed upon admission and when the new diagnoses were made. The failure to complete these referrals indicates a lapse in the facility's adherence to PASRR requirements for residents with serious mental health diagnoses.
Lack of Group Outings for Residents
Penalty
Summary
The facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility. This deficiency affected five residents who reported feeling frustrated, awful, forgotten about, hemmed in, angry, and mad due to the lack of outings. The residents had voiced their desire to go on outings during Resident Council Meetings, but no action was taken to address their requests. The facility's activity calendars from January to April 2024 showed no scheduled activities outside of the facility, and the residents had not been offered any outings since their admission. Resident #203, the Resident Council President, expressed frustration over not being able to go on group outings and reported that other residents felt the same. Despite reporting this to the Administrator, no outings were offered. Resident #102 felt hemmed in and desired to go shopping or out to eat, but had not been out of the facility since admission. Resident #114 also wanted to go out but had not been offered any outings since admission. Resident #216 felt angry and mad about being stuck in the facility and suggested that local sports teams might donate tickets or food for outings. Resident #46, who is legally blind, felt awful and forgotten due to the lack of outings and desired to participate in activities outside the facility. The Activity Director, who had been in her position for five months, stated that the Administrator had told her to wait for outings until they got a van. The facility did not have a transportation van and used a contracted transportation company only for medical appointments. The Director of Nursing confirmed the lack of a van and stated that the facility used a contracted transportation company for medical appointments only. The Administrator acknowledged the residents' desire for outings but could not provide a timeline for obtaining a van and had not come up with an alternative solution to meet this need.
Failure to Provide Bagged Meals for Dialysis Residents
Penalty
Summary
The facility failed to provide breakfast, a bagged meal, or snack for two residents who required dialysis services. Both residents, who were cognitively intact and diagnosed with type 2 diabetes and end-stage renal disease, reported not receiving their bagged meals consistently when leaving for dialysis treatments early in the morning. These meals were supposed to include a sandwich, snacks, and a drink to ensure they had some nutrition during their treatments, which lasted from 5:30 AM to 10:30 AM. The residents expressed concerns about having to wait until lunch to eat and the potential risk of low blood sugar during their treatments. Interviews with the Dietary Manager, Nutritional Manager, Nursing Assistant, and Unit Manager revealed that there were ongoing issues with the preparation and availability of the bagged meals. The Dietary Manager, who had been employed for about a month, acknowledged the problem and stated that dietary staff were responsible for preparing and labeling the bagged meals the night before. However, there were instances where the meals were not prepared or were missing items, and nursing staff could not access the kitchen to prepare the meals themselves. The Nutritional Manager and Nursing Assistant confirmed these issues and noted that there had been some recent improvements after staff education. The Administrator confirmed awareness of the problem and had personally delivered the bagged meals to the dialysis facility on several occasions. The Administrator expected the bagged meals to be prepared and labeled the night before to ensure they were accessible to residents leaving early for dialysis. Despite recent staff education, the deficiency persisted, affecting the residents' ability to have adequate nutrition during their dialysis treatments.
Failure to Verify Cook's Competencies and Certifications
Penalty
Summary
The facility failed to verify Cook #1's competencies and certifications for food production and meal service prior to his first day of employment. Dietary Manager (DM) #1 admitted that new employees should be signed off on competencies before working independently, but Cook #1 was assigned to another staff member for training without proper communication. DM #1 did not ensure that DM #2, who was supposed to train Cook #1, was informed of her responsibilities. Consequently, Cook #1 began working without receiving necessary training, including food temperature training, which was scheduled for the second day. DM #1 also failed to verify Cook #1's ServSafe certification and culinary school training before hiring him, relying solely on his word during the interview process. It was only after Cook #1 started working that DM #1 requested copies of his certifications. Cook #1 confirmed that he had not received any training from the facility and had to start preparing food on his own due to staff shortages. A review of Cook #1's competency checklist revealed discrepancies, with competencies marked as completed on dates before he actually started working. The Regional Director of Operations (RDO) for Dietary later provided Cook #1's ServSafe certification and a screenshot of his culinary school acceptance but could not verify his completion of the program. The RDO confirmed that DM #1 was responsible for the hiring process and verifying competencies and certifications for new kitchen staff.
Failure to Provide Consistent Evening Snacks
Penalty
Summary
The facility failed to provide evening snacks to residents when requested, as observed and confirmed through resident and staff interviews. Four residents, all with diagnoses including type 2 diabetes and other serious conditions, reported inconsistencies in receiving evening snacks. They mentioned that staff often informed them that no snacks were available in the nourishment room and that they did not have access to the kitchen to obtain more. Observations confirmed that the nourishment room was inadequately stocked, with only a few items available. The Unit Manager and Dietary Manager were unaware of the issue until it was brought to their attention during the survey. The Dietary Manager acknowledged the problem and took immediate steps to restock the nourishment room and educate dietary staff on their responsibilities. Interviews with nursing staff revealed that they were aware of the residents' complaints about the lack of evening snacks. One Nursing Assistant mentioned that she had informed dietary staff about the issue multiple times. The Administrator stated that she expected snacks to always be available and that dietary staff should stock enough snacks, sandwiches, and drinks for residents. She also indicated that nursing staff should have notified supervisors or herself if there were issues with snack availability. Despite ordering an overabundance of snacks each month, the facility failed to ensure that residents consistently received their evening snacks as requested.
Repeat Deficiencies in Accident Hazards and Food Safety
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions following multiple surveys, resulting in repeat deficiencies. Specifically, the facility failed to maintain an environment free of accident hazards for a resident who was severely cognitively impaired with a history of wandering. The resident was found attempting to cut her cast off with a knife obtained from an unlocked maintenance room. Additionally, the facility failed to ensure the securement of a resident and her chair during van transport, failed to investigate an injury and complete a root cause analysis, and failed to secure bleach used by a resident, all of which were identified in previous surveys but not adequately addressed or prevented from recurring. The facility also failed to ensure food was prepared and served under sanitary conditions. Undercooked fried chicken was served to residents, with some consuming it, posing a high likelihood of foodborne illness. The facility also failed to label, date, and properly store food items in the walk-in refrigerator, reach-in cooler, and dry storage room. These issues were identified in multiple surveys, indicating a pattern of non-compliance with food safety standards. The Administrator attributed these repeat deficiencies to turnover in department heads and staff, and a lack of systems and accountability in place for staff.
Failure to Protect Resident's Private Health Information
Penalty
Summary
The facility failed to protect Resident #172's private health information when an insulin pen labeled with Resident #172's name, room number, type of insulin, prescription number, and fill date was left at the bedside of Resident #171. Resident #171, who was cognitively intact and had a diagnosis of diabetes mellitus, noticed the label after receiving an insulin shot from Nurse #10. The incident was reported by Resident #171 and her family member to the Director of Nursing (DON). The DON acknowledged that all staff were responsible for ensuring the protection of protected health information and that the prudent action would have been to ensure no protected health information was left visible to another resident.
Failure to Protect Resident from Inappropriate Physical Contact
Penalty
Summary
The facility failed to protect a resident's right to be free from inappropriate physical contact by a staff member. On 4/1/24, a Nurse Aide (NA) was observed lying in bed with a resident, which was reported by another NA. The resident, who is legally blind and has a diagnosis of depression, was cognitively intact and recalled being awakened by a voice but was unsure if the person was in his bed or sitting on it. The resident later identified the person as NA #1 and mentioned that he might have inadvertently touched her thigh. NA #1 denied ever lying in the bed or touching the resident, stating she sat in a chair at the foot of the bed throughout her shift. However, NA #3 confirmed seeing NA #1 lying in bed with the resident and reported it to the nurse on duty, who did not immediately investigate the claim. The incident was not reported to the Director of Nursing (DON) until 4/10/24, despite multiple staff members being aware of the situation. The DON and the Administrator were both surprised by the delay in reporting, as staff usually communicated other incidents promptly. The facility's policy on abuse, neglect, and exploitation was not followed, leading to a failure in protecting the resident from inappropriate physical contact. Interviews with the involved staff and the resident provided conflicting accounts of the event. While the resident was not bothered by the presence of NA #1 in his bed, the facility's policy clearly prohibits such actions. The lack of immediate and thorough investigation by the nursing staff and the delay in reporting the incident to higher management contributed to the deficiency in ensuring the resident's safety and well-being.
Failure to Report and Address Inappropriate Staff-Resident Interaction
Penalty
Summary
The facility failed to follow its policy on reporting and protection, resulting in a deficiency. Nurse Aide (NA) #1 was observed by another staff member, NA #3, lying in bed with Resident #46. Despite this observation, NA #1 continued to work shifts on multiple days following the incident. The facility's policy mandates immediate reporting of such incidents to the Administrator and other required agencies, but this was not done in a timely manner. NA #3 reported the incident to Nurse #13, who did not escalate the report to higher authorities, assuming it was a joke or that supervisors were already aware. Other staff members also overheard discussions about the incident but did not take appropriate action to report it immediately to the Director of Nursing (DON) or the Administrator. The incident was only formally reported on 4/10/24, several days after it occurred, leading to a delay in the suspension of NA #1 and the initiation of an investigation. Resident #46, who is legally blind and dependent on renal dialysis, was cognitively intact and did not express distress over the incident. However, the failure to report and address the situation promptly represents a significant lapse in the facility's duty to protect its residents from potential abuse and exploitation. The DON and Administrator were unaware of the incident until 4/10/24, highlighting a breakdown in communication and adherence to the facility's abuse policy. The facility's policy requires immediate reporting of such incidents, but this protocol was not followed, resulting in a deficiency in the facility's handling of the situation.
Failure to Address Resident Pain During Wound Care
Penalty
Summary
The facility failed to provide appropriate pain management for a resident during wound care. Resident #1, who had a diagnosis of a pressure ulcer on the right hip and chronic pain syndrome, complained of pain rated at a 7 on a scale of 1-10 during wound care. Despite the resident's complaints, Nurse #9 continued with the wound care procedure without stopping to address the pain. The resident had received Acetaminophen-Codeine earlier in the day and was not due for another dose until later. Nurse #9 acknowledged the resident's pain but did not take immediate action to alleviate it, stating that she would get pain medication after completing the wound care. The resident continued to express pain throughout the procedure, but the wound care was completed without interruption. Interviews with the nursing staff and the Director of Nursing confirmed that the resident's pain should have been addressed immediately by stopping the wound care and conducting a full pain assessment. The Administrator also stated that wound care should have been halted to manage the resident's pain. The facility's failure to stop the wound care and address the resident's pain resulted in a deficiency in providing safe and appropriate pain management for the resident.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
