Ahoskie Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ahoskie, North Carolina.
- Location
- 604 Stokes Street East, Ahoskie, North Carolina 27910
- CMS Provider Number
- 345359
- Inspections on file
- 27
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Ahoskie Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with an indwelling urinary catheter was observed without a securement device on the catheter tubing, and staff interviews revealed inconsistent application and unclear responsibility for ensuring the device was in place. The resident reported that staff did not consistently secure the catheter, despite facility expectations that the device should be applied and checked each shift.
A nurse aide worked multiple shifts with an expired Nurse Aide I certification due to a lapse in monitoring by facility staff. The aide was unaware of the expiration and continued working until the issue was discovered, with the HR Director attributing the oversight to human error.
A resident with severe cognitive impairment remained listed as DNR in the EMR after the responsible party requested a change to full code during a care plan meeting. The MDS Nurse documented the request and reported having informed the SW and former DON, but the SW, who was responsible for updating code status in the EMR and on the communication bar, did not recall receiving this information and did not make the change. The Administrator later acknowledged that the code status should have been updated and described the failure as an oversight.
Surveyors found that the facility failed to accurately code MDS assessments for two residents who had documented Level II PASRR determinations in their records. Both residents had serious mental illness and dementia-related diagnoses, and one had a care plan specifically addressing Level II PASRR recommendations with goals and interventions such as ADL support and therapy services. Despite this documentation, their admission and annual MDS assessments did not reflect the Level II PASRR status. The MDS nurse acknowledged in interviews that both residents should have been coded for Level II PASRR and described the omissions as oversights.
A resident with ESRD and chronic renal failure requiring hemodialysis returned from a hospital stay after a procedure for long-term dialysis access, but the physician’s order for dialysis was not reinstated upon readmission. The resident’s care plan and MDS documented ongoing dialysis needs and related interventions, including coordination with the dialysis center and monitoring of the shunt site, yet no dialysis order appeared in the post-readmission orders. The unit manager confirmed the absence of the order and that it was not re-entered, the DON reported she was unaware the order was missing and that staff likely failed to re-enter it, and the Administrator acknowledged the dialysis order should have been immediately reinstated.
Surveyors found expired medications stored on a medication cart, including an open insulin lispro pen and two bottles of glaucoma eye drops (latanoprost and dorzol/timolol) that remained on East Annex Medication Cart #1 beyond manufacturer-recommended discard dates. A nurse acknowledged these items should have been removed as of their written discard dates, and the Pharmacy Consultant confirmed the correct post-opening time frames. The DON and Administrator reported that unit managers and floor nurses were expected to check medication carts daily and remove expired medications, yet these expired drugs were still present during the survey.
Surveyors found the South Unit nourishment room refrigerator and freezer with dried food particles in the drawers and a brown sticky spill on the freezer shelf that remained uncleaned over consecutive observations. During the first observation, a nurse on the South Unit stated she did not know who was responsible for cleaning the refrigerator. Later interviews revealed that a housekeeper believed she was assigned to clean the refrigerator weekly but had not checked or cleaned the freezer, while the Administrator stated that the dietary department was responsible for cleaning nourishment room refrigerators, showing conflicting staff understanding of cleaning responsibilities.
The facility did not consistently complete required daily nurse staffing postings, omitting the resident census on multiple days. The DON reported she typically prepared the postings the prior evening and updated them with the current census after the morning clinical meeting, while a unit manager was responsible for weekend census updates. On several days, the census information was overlooked and not entered on the postings. The Administrator stated an expectation that daily staff postings be fully completed, including the resident census.
Surveyors found that the facility failed to develop person-centered care plan focuses for two residents: one receiving an antipsychotic medication for a psychotic disorder and another with dementia who valued music, group participation, favorite activities, and religious services. The first resident’s MDS documented severe cognitive impairment and antipsychotic use, and the MAR showed ongoing olanzapine administration, yet no antipsychotic-related focus or interventions appeared on the comprehensive care plan. The second resident’s MDS and progress notes showed strong activity and religious service preferences and regular participation in activities, but the comprehensive care plan lacked an activities focus. Staff interviews, including with the MDS nurse, Activities Director, DON, and Administrator, confirmed that required care plan focuses were omitted due to staff oversight.
The facility did not appoint an interim Director of Nursing (DON) when the current DON went on medical leave. The Staff Development Coordinator, an RN, was the contact for nursing-related questions but was not informed she was the DON designee. The Administrator confirmed the lack of an interim appointment until later.
The facility failed to conduct required AIMS assessments for three residents on antipsychotic medications, missing initial and follow-up evaluations necessary for monitoring side effects. This oversight was attributed to a breakdown in process and communication, as confirmed by the Consultant Pharmacist, Interim DON, and Senior VP of Clinical Operations.
A resident with hypertension, heart failure, and atrial fibrillation received midodrine despite having a systolic blood pressure (SBP) above the prescribed threshold. The MAR showed multiple instances of administration errors over three months. Nurses involved cited possible documentation mistakes, while the Interim DON confirmed ongoing staff education on medication administration.
A resident with hypertension, heart failure, and atrial fibrillation was repeatedly administered midodrine despite having a systolic blood pressure (SBP) above the physician-ordered parameter of 120 mmHg. Interviews with nurses revealed a lack of adherence to the order, with no clear explanation for the discrepancy. The Medical Director confirmed the importance of the parameter to prevent high blood pressure, and the Interim DON noted that nurses were educated on following such parameters.
A resident with moderate cognitive impairment was not involved in their care plan meeting due to a lack of scheduling and documentation by facility staff. The resident expressed a desire to participate, but no meeting was held or invitation extended between two specified dates. Interviews with staff revealed a breakdown in the process, with responsibilities for scheduling and documentation not being fulfilled.
The facility failed to accurately code MDS assessments for two residents, one with a pressure ulcer and another using a CPAP machine. A resident with a pressure ulcer was not coded for a pressure-reducing mattress, despite having a physician order. Another resident using a CPAP machine for sleep apnea was not coded for its use due to a misunderstanding of the assessment tool. These errors were confirmed by interviews with MDS Nurses and the Administrator.
The facility failed to update care plans for two residents regarding antipsychotic medication and pain management. A resident with Alzheimer's was prescribed olanzapine, but the care plan was not revised. Another resident with Parkinsonism and a stage 3 pressure ulcer was on meloxicam for pain, yet the care plan lacked pain management. MDS Nurses were responsible for updates, but the changes were not discussed in clinical meetings, leading to the oversight.
A resident prescribed Olanzapine for mood instability and hallucinations did not receive an AIMS assessment, as required for those on antipsychotic medications. Despite monthly medication reviews by the Consultant Pharmacist, no recommendation for the assessment was made. The facility's process and communication breakdown led to this oversight, as confirmed by the facility's Administrator and Senior VP of Clinical Operations.
A resident with severe malnutrition and other health issues did not receive double portions as per their diet order. Observations confirmed the absence of double portions on meal trays, and interviews revealed communication breakdowns regarding the diet change. The Speech Language Pathologist initiated the change, but the Dietary Manager was not informed, and the Registered Dietitian found the order vague.
A facility failed to develop a comprehensive care plan for a resident with Dementia and Insomnia, who exhibited behaviors like refusing wound care and medications. The care plan lacked a focus on dementia, and staff interviews revealed an oversight by the MDS Nurse, with the Administrator noting the DON's responsibility to ensure accurate care plans.
Failure to Secure Indwelling Urinary Catheter Tubing
Penalty
Summary
A deficiency was identified when a resident with a history of bladder rupture and urinary retention, who was admitted with an indwelling urinary catheter, was observed without a securement device on the catheter tubing. During catheter care performed by a nurse aide, it was noted that the tubing was not secured to prevent pulling, although there was no tension observed at the time. The resident confirmed that staff did not consistently apply a securement device to her catheter. Interviews with staff revealed inconsistent understanding of responsibility for ensuring the catheter securement device was in place. The nurse aide believed it was the nurse's responsibility, while the nurse stated that nurse aides should notify nurses if the device was missing or soiled. The DON indicated that either the nurse or nurse aide could apply the securement device, and the Administrator expected staff to place and check the device each shift. Despite these expectations, the securement device was not consistently used for the resident.
Failure to Monitor and Maintain Active Nurse Aide Certification
Penalty
Summary
The facility failed to ensure that a nurse aide maintained an active Nurse Aide I certification as required by the North Carolina Nurse Aide Registry. Record review and staff interviews revealed that the nurse aide's certification had expired, yet she continued to work multiple shifts as a nurse aide after the expiration date. The nurse aide was unaware of her certification lapse until about a month after it had expired, as she did not receive any notification via mail or email. She subsequently completed the necessary online forms and obtained the required RN signature for renewal, but this occurred after she had already worked several shifts with an expired certification. The Human Resources Director, who was responsible for reviewing Nurse Aide Registry verifications, stated that she reviewed all verifications every six months and attributed the oversight to human error. The Administrator confirmed that the HR Director was responsible for notifying staff of upcoming certification expirations, and acknowledged that the lapse in monitoring led to the nurse aide working without an active certification. The deficiency was identified through record review and interviews with the involved staff and registry representatives.
Failure to Update Resident Code Status After Responsible Party Request
Penalty
Summary
The facility failed to honor a resident’s right to change code status when the responsible party requested a change from do not resuscitate (DNR) to full code. The resident, who had been admitted earlier in the year, had a care plan revised on 3/19/25 that reflected a DNR status and a quarterly MDS assessment documenting severe cognitive impairment. During a care plan meeting on 11/25/25, the resident’s responsible party informed the MDS Nurse that she wanted the resident’s code status changed from DNR to full code, and the MDS Nurse documented this request in a care plan meeting note. Despite this documented request, the resident’s electronic medical record continued to display a DNR code status on the communication bar at the time of surveyor review. The MDS Nurse reported that she informed the Social Worker and the former DON about the responsible party’s request to change the code status, but she could not recall the specific date she did so. The Social Worker stated she was responsible for updating code status information in the electronic medical record and on the communication bar when a resident’s code status changed after admission. She also stated she was not present when the responsible party made the request, did not recall being told about the requested change, and confirmed that the code status had not been updated. During an interview, the Administrator acknowledged that the resident’s code status should have been changed when the responsible party requested it and described the failure to update the code status as an oversight.
Inaccurate MDS Coding for Residents With Level II PASRR Determinations
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents who had Level II Preadmission Screening and Resident Review (PASRR) determinations documented in their records. One resident was admitted with diagnoses including intellectual disabilities, schizophreniform disorder, depression, anxiety, and dementia. The resident’s electronic health record showed a Level II PASRR determination with no end date completed prior to admission. However, the admission MDS did not code the resident as having a Level II PASRR determination, even though the MDS listed multiple psychiatric and cognitive diagnoses. In an interview, the MDS nurse acknowledged that the resident should have been coded for a Level II PASRR and stated the omission was an oversight. The second resident was admitted with diagnoses including depression, schizoaffective disorder, dementia, and psychosis. This resident’s electronic health record also contained a Level II PASRR determination with no end date. The resident’s care plan included a plan for Level II PASRR recommendations related to serious mental illness, with a goal that the resident would receive recommended care and services and interventions such as ADL support and therapy services as needed. Despite this, the resident’s annual MDS did not code the resident as having a Level II PASRR determination, although it documented several psychiatric diagnoses. In an interview, the MDS nurse confirmed that this resident also should have been coded for a Level II PASRR determination and again described the error as an oversight.
Failure to Reinstate Dialysis Order After Resident Readmission
Penalty
Summary
The facility failed to ensure a resident receiving hemodialysis had an active physician’s order for dialysis following readmission from the hospital. The resident, who had end-stage renal disease and chronic renal failure requiring dialysis, was admitted with a care plan that identified the need for hemodialysis and included interventions such as coordinating care with the dialysis center, communicating about medications, diet, and labs, and monitoring the shunt site for infection, pain, bleeding, and absence of thrill or bruit. After the resident was hospitalized for a critical procedure related to long-term dialysis access and then returned to the facility, the physician’s orders on readmission did not include dialysis services, despite the resident’s MDS coding indicating end-stage renal disease and ongoing dialysis. The Annex Unit Manager confirmed there was no dialysis order in the chart after the resident’s return and stated the order was not reinstated, and the DON acknowledged she was unaware the dialysis order was missing and that staff likely failed to re-enter it, while the Administrator stated the dialysis order should have been immediately reinstated after the resident’s return. These findings show that although the resident’s condition and need for dialysis were documented in the care plan and MDS, the facility did not obtain or re-enter a physician’s order for dialysis services upon readmission from the hospital, resulting in the resident receiving dialysis without a corresponding physician’s order in the medical record.
Expired Insulin Pen and Eye Drops Found on Medication Cart
Penalty
Summary
Surveyors identified a deficiency in medication storage and labeling related to expired multi-dose medications on East Annex Medication Cart #1. During an observation, they found one open insulin lispro injector pen with an opened date of 11/3/25 that remained in use beyond the manufacturer’s recommended 28-day discard period. They also found one bottle of latanoprost 0.05% eye drops with an opened date of 10/29/25 and a handwritten discard date of 12/10/25, and one bottle of dorzol/timolol eye drops with an opened date of 11/13/25 and a handwritten discard date of 12/11/25, both still present on the cart after those dates. Manufacturer instructions specified that insulin lispro pens and dorzol/timolol eye drops should be discarded 28 days after opening, and latanoprost eye drops should be discarded 6 weeks after opening. During the medication cart observation, the nurse present acknowledged that the insulin pen should have been removed after 28 days and that the eye drops should have been discarded on the expiration dates written on the bottles. In a phone interview, the Pharmacy Consultant confirmed the discard time frames for each medication based on manufacturer instructions. The DON stated that Unit Managers and floor nurses were responsible for checking medication carts daily for expired medications and discarding them, and the Administrator stated that her expectation was that nursing staff would check the carts daily and ensure there were no expired medications in the carts. Despite these stated responsibilities and expectations, expired medications remained on East Annex Medication Cart #1 at the time of the survey.
Unsanitary Nourishment Room Refrigerator and Freezer Due to Unclear Cleaning Responsibilities
Penalty
Summary
The facility failed to maintain the South Unit nourishment room refrigerator and freezer in a clean and sanitary condition to prevent cross contamination. On 12/17/25 at 11:17 AM, surveyors observed with the South Unit nurse that the clear refrigerator drawers contained small, dried food particles and the bottom shelf of the freezer section had a brown sticky substance spilled on it. During this observation, the South Unit nurse stated she was not aware who was responsible for cleaning the refrigerator. A second observation of the South Unit nourishment room on 12/18/25 at 10:36 AM showed the refrigerator and freezer remained in the same condition, with no cleaning performed between observations. In an interview on 12/18/25 at 10:25 AM, Housekeeper #1 reported she was assigned to clean the South Unit refrigerator once a week but had not looked at or cleaned the freezer that week. In a separate interview on 12/18/25 at 11:29 AM, the Administrator stated that the dietary department was responsible for cleaning the nourishment room refrigerators and that she expected them to be clean, indicating conflicting understandings among staff regarding responsibility for cleaning the nourishment equipment.
Failure to Accurately Complete Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure accurate daily nurse staffing postings for 13 of 30 reviewed days when required resident census information was missing from the posted staffing sheets. Record review of daily nurse staffing postings from mid-November through mid-December showed that on multiple specific dates the postings did not include the resident census, which is required information on the daily staffing notice. During interview, the DON reported she was responsible for completing the daily nurse staffing postings, typically filling them out the previous evening and updating them with the current census after the morning clinical meeting, and stated that a unit manager was responsible for updating the census on weekends. The DON acknowledged that on the days in question the census portion of the daily nurse staffing postings had been overlooked and not updated. In a separate interview, the Administrator stated she expected the daily staff posting to be completed to include the resident census. No specific residents, medical histories, or clinical conditions were identified in the report in relation to this deficiency.
Failure to Develop Person-Centered Care Plans for Antipsychotic Use and Activities
Penalty
Summary
The deficiency involves the facility’s failure to develop person-centered comprehensive care plans addressing all identified needs for two residents. For one resident with vascular dementia with psychotic disturbance, physician orders dated 07/22/25 showed an ongoing prescription for olanzapine 5 mg every 12 hours for a psychotic disorder, and the December 2025 medication administration record confirmed the medication was being administered as ordered. The resident’s quarterly MDS assessment documented severe cognitive impairment and antipsychotic medication use. However, review of the comprehensive care plan last reviewed on 10/24/25 revealed no care plan focus area related to antipsychotic medication use. In interviews, the MDS Nurse, DON, and Administrator each acknowledged that the MDS Nurse was responsible for developing and reviewing care plans and that an antipsychotic medication care plan with appropriate interventions should have been initiated when the medication was prescribed, but it was missed due to an oversight. The second resident, admitted with vascular dementia and assessed as severely cognitively impaired on the admission MDS, had documented preferences indicating it was very important to listen to music, participate in groups, engage in favorite activities, and attend religious services. A progress note dated 10/26/25 showed the resident was taken from the dementia care unit to the main unit to attend a religious service, and a nurse aide reported the resident frequently attended activities on the dementia care unit. Despite this, the comprehensive care plan last reviewed on 10/28/25 did not contain a focus area related to activities. The Activities Director stated she was responsible for developing activity-related care plan components and that residents should have an activities focus, and the MDS Nurse reported she sometimes assisted with adding such focuses. Both the Activities Director and the Administrator stated that the absence of an activities focus on this resident’s care plan was an oversight.
Failure to Designate Interim DON During Medical Leave
Penalty
Summary
The facility failed to designate a full-time Director of Nursing (DON) for the Skilled Nursing Facility (SNF) when the current DON went on family medical leave. The deficiency was identified during a survey where the Administrator explained that the DON was out due to surgery and had been available by phone but not physically present in the building. The DON took medical leave on 9/16/24. During this period, the Staff Development Coordinator (SDC), who was a registered nurse, was the contact person for nursing-related questions, although she was not informed that she was the DON designee. The SDC shared on-call duties with the Wound nurse and reported that staff would contact her with nursing-related questions after hours. The Administrator confirmed that no interim DON was appointed when the DON went out for surgery, and it was only on 9/25/24 that the SDC was officially appointed as the interim DON.
Failure to Conduct AIMS Assessments for Antipsychotic Medications
Penalty
Summary
The facility failed to complete the Abnormal Involuntary Movement Scale (AIMS) assessments for residents receiving antipsychotic medications, which are crucial for monitoring side effects such as Tardive Dyskinesia. This deficiency was identified for three residents who were prescribed antipsychotic medications. Resident #7, diagnosed with dementia and behaviors, was prescribed quetiapine fumarate but did not have an AIMS assessment documented from the start of the medication. The Consultant Pharmacist and Interim Director of Nursing (DON) confirmed that the AIMS assessment should have been completed upon initiation and every six months thereafter, but it was missed due to a breakdown in process and communication. Resident #62, with Alzheimer's Disease and major depressive disorder, was prescribed olanzapine for mood instability. An initial AIMS assessment was completed, but subsequent assessments were not documented within the required six-month period. The care plan for Resident #62 did not include the use of antipsychotic medication, and the Interim DON acknowledged the oversight, attributing it to a failure in identifying the need for follow-up assessments during clinical meetings. Resident #57, diagnosed with anxiety disorder and dementia with behavioral disturbance, was prescribed olanzapine but lacked any documented AIMS assessment. The Senior VP of Clinical Operations and the Consultant Pharmacist both indicated that AIMS assessments should be conducted every six months, but Resident #57 was overlooked. The Administrator admitted that the failure to complete the assessments was due to a breakdown in process and communication within the facility.
Medication Administration Documentation Error
Penalty
Summary
The facility failed to accurately document the administration of blood pressure medication for a resident diagnosed with hypertension, heart failure, and atrial fibrillation. The resident had a physician's order for midodrine, a medication used to treat low blood pressure, with specific instructions to hold the medication if the systolic blood pressure (SBP) was greater than 120 mmHg. However, the Medication Administration Record (MAR) showed that the medication was administered multiple times when the resident's SBP exceeded this threshold. Specifically, the medication was documented as administered 2 times in July, 8 times in August, and 4 times in September, despite the SBP being above 120 mmHg on those occasions. Interviews with the nursing staff involved revealed inconsistencies in their accounts. Nurse #2 stated she did not believe she administered the medication outside the prescribed parameters, as she was familiar with the resident's condition. Similarly, Nurse #3 suggested that any discrepancies might have been due to documentation errors, asserting that she checked the resident's blood pressure before administering the medication. The Interim Director of Nursing confirmed that nursing staff received education on medication administration and documentation, but the errors persisted, indicating a significant deficiency in maintaining accurate medical records and adhering to physician orders.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to adhere to a physician's order regarding the administration of midodrine, a medication used to treat low blood pressure, for a resident diagnosed with hypertension, heart failure, and atrial fibrillation. The physician's order specified that the medication should be held if the resident's systolic blood pressure (SBP) exceeded 120 mmHg. However, the Medication Administration Record (MAR) for July and August 2024 showed that the resident was administered midodrine multiple times despite having an SBP greater than the specified parameter. Interviews with several nurses involved in the administration of the medication revealed a lack of adherence to the physician's order. Nurse #5 confirmed that the medication should have been held based on the documented SBP readings, but could not explain why it was administered. Similarly, Nurse #4 acknowledged that the medication should have been held if the SBP was above 120 mmHg but could not recall the specific circumstances. Nurse #1 also stated that she would have checked the blood pressure before administering the medication but could not provide an explanation for the discrepancy. The Medical Director confirmed that the midodrine was ordered with a parameter to prevent the resident's blood pressure from becoming too high, which could pose a risk to the resident's health. The Interim Director of Nursing stated that nurses were educated on medication administration and the importance of adhering to order parameters, yet the medication was still administered outside of the specified guidelines.
Failure to Involve Resident in Care Plan Meeting
Penalty
Summary
The facility failed to involve a resident in the development and implementation of their person-centered care plan. Specifically, the facility did not hold a care plan meeting or invite the resident to participate in the care planning process for one resident. The resident, who had moderate cognitive impairment, was coded for active participation in assessment and goal setting. However, there was no documentation of a care plan meeting or invitation to participate between two specified dates, despite the resident expressing a desire to be involved in their care plan meetings. Interviews with facility staff, including the Director of Social Services and MDS Nurses, revealed a breakdown in the scheduling and documentation process for care plan meetings. The Director of Social Services was responsible for inviting residents to these meetings but could not find documentation that a meeting was held for the resident in question. MDS Nurse #1 was responsible for creating a care plan meeting calendar, but there was no confirmation that the resident was listed for a meeting during the relevant period. The Administrator confirmed that MDS Nurse #1 was responsible for ensuring the care plan meeting calendar was completed and communicated appropriately.
Inaccurate MDS Coding for Pressure Ulcer and CPAP Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their care needs. Resident #7, who was admitted with a physician order for a standard pressure ulcer redistribution mattress, was not coded for a pressure-reducing surface on their MDS quarterly assessment. Despite having moderate cognitive impairment and an unhealed, unstageable pressure ulcer, the MDS Nurse responsible for the assessment acknowledged the oversight and confirmed that the mattress should have been coded as a pressure-reducing surface. Similarly, Resident #95, who was admitted with obstructive sleep apnea and acute respiratory failure, was not coded for the use of a CPAP machine on their MDS assessment. Although the resident had an active physician order for CPAP use at bedtime and was observed with the machine at their bedside, the MDS Nurse failed to include this in the assessment. The nurse later discovered that the coding error was due to a misunderstanding of the assessment tool, which required selecting 'yes' to mechanical ventilation before coding for CPAP use. Both instances highlight the facility's failure to ensure accurate MDS coding, as confirmed by interviews with the MDS Nurses and the Administrator.
Failure to Revise Care Plans for Medication and Pain Management
Penalty
Summary
The facility failed to revise the care plans for two residents regarding antipsychotic medication use and pain management. Resident #62, diagnosed with Alzheimer's Disease and major depressive disorder, was recommended to start olanzapine for mood instability. Despite having an active physician order for the medication, the care plan was not updated to reflect this change. Interviews with the Interim Director of Nursing and MDS Nurses revealed that the responsibility for updating care plans lay with the MDS Nurses, but the new medication was not discussed in clinical meetings, leading to the oversight. Resident #101, diagnosed with Parkinsonism and having a stage 3 pressure ulcer, was on a scheduled pain medication, meloxicam, for chronic pain. However, the care plan did not include pain management despite the resident's report of aching pain in her right arm. Interviews indicated that the MDS Nurse responsible did not perceive the need to update the care plan as the resident did not report pain during the assessment. The Administrator expected care plans to be revised as needed, but this expectation was not met in these cases.
Failure to Conduct AIMS Assessment for Antipsychotic Medication
Penalty
Summary
The deficiency involves the failure of a licensed pharmacist to identify and report a medication irregularity for a resident prescribed Olanzapine, an antipsychotic medication. The resident, who was admitted with diagnoses including anxiety disorder and dementia with behavioral disturbance, was prescribed Olanzapine for mood instability and hallucinations. Despite being cognitively intact and not coded for behaviors, the resident was on antipsychotic medication for seven days during the assessment period. However, there was no documentation of an Abnormal Involuntary Movement Scale (AIMS) assessment in the resident's electronic medical record from August 2023 to September 2024. The Consultant Pharmacist conducted monthly medication regimen reviews but failed to recommend the completion of an AIMS assessment. Interviews with the Consultant Pharmacist and the Senior Vice President of Clinical Operations revealed that the facility was required to complete an AIMS assessment upon initiation of antipsychotic medication and every six months thereafter. The oversight was attributed to a breakdown in the facility's process and communication, as acknowledged by the facility's Administrator.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of Resident #66, who was readmitted with severe protein calorie malnutrition, failure to thrive, diabetes, and dysphagia. Despite a diet order specifying double portions, the resident did not receive these portions during meals. Observations on two separate occasions confirmed that the meal trays did not include double portions, and the meal tickets lacked this detail. Interviews revealed a breakdown in communication regarding the diet order change, as the Dietary Manager was not informed of the double portions requirement, and the meal tickets did not reflect this change. The Speech Language Pathologist had initiated the diet change, providing the necessary documentation to the kitchen staff and the nurse on duty. However, the Registered Dietitian noted that the order for double portions was vague and required clarification. The nurse interviewed could not recall receiving the diet order form. The Senior President of Operations acknowledged the need for a process to ensure clear communication of dietary changes, and the Administrator confirmed that dietary staff should have been alerted to the resident's preference for double portions.
Failure to Develop Dementia Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing dementia care for a resident diagnosed with Dementia and Insomnia. The resident, admitted on an unspecified date, exhibited behaviors such as refusing wound care and medications, and attempting to access the smoking area outside designated times. Despite these behaviors, the care plan updated on 8/7/2024 did not include a focus area for dementia. Interviews with staff revealed that the MDS Nurse acknowledged the oversight in updating the care plan, and the Administrator indicated that it was the Director of Nursing's responsibility to ensure care plans accurately reflected residents' conditions and diagnoses.
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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.
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