Autumn Care Of Marshville
Inspection history, citations, penalties and survey trends for this long-term care facility in Marshville, North Carolina.
- Location
- 311 W Phifer Street, Marshville, North Carolina 28103
- CMS Provider Number
- 345268
- Inspections on file
- 24
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Autumn Care Of Marshville during CMS and state inspections, most recent first.
A resident with a history of stroke, epilepsy, slurred speech, and dysphagia had an order for Atorvastatin 40 mg to be given orally once daily, whole and not crushed, consistent with the manufacturer’s instructions. An agency nurse on her first shift crushed and administered the resident’s nighttime medications, including Atorvastatin, without checking the physician’s order or consulting the provider or pharmacy. The resident’s POA observed the nurse crushing the medications, informed her that the order required the tablet to be given whole, and was told the medications had already been crushed and would be withheld until the next scheduled dose if refused. The cognitively intact resident confirmed receiving the Atorvastatin in crushed form and being told it would not harm her and would not be given again until the next scheduled time if she refused it.
The facility failed to maintain effective systems for shift-change narcotic reconciliation and secure storage of discontinued controlled substances, resulting in 80 missing oxycodone-containing tablets for two residents. One resident with PRN oxycodone/acetaminophen had a full card of tablets present one afternoon, but the next morning the oncoming MA and off-going nurse skipped the required physical narcotic count on one cart, relying on verbal confirmation instead; later that morning, when the resident requested pain medication, the MA found that the oxycodone/acetaminophen blister pack was missing. For a second, recently deceased resident with PRN oxycodone via gastric tube, a nurse removed the narcotics from the locked drawer and placed them in a pharmacy return bag left in the medication room; the next day the MA carried this bag to a nurse manager, who then stored it in an unlocked cabinet at the nurse’s station. When two nurses later attempted to count and scan the medications for return, they discovered that the oxycodone tablets for this resident were missing, confirming that discontinued narcotics had not been kept under the required double-lock system.
A resident with dementia, anoxic brain damage, and significant transfer and ADL assistance needs did not receive necessary dental services despite ongoing concerns reported by the POA about mouth pain and difficulty chewing. The care plan and MDS did not identify dental problems, and there was no documented dental exam for many months after admission. The POA arranged an initial visit at an outside dental office, where a dentist identified periodontal disease and the need for multiple extractions and placed a referral to an oral surgery office in the resident’s communication binder, but the specialist office reported never being contacted. A subsequent visit to another dental office resulted only in a cleaning and X-ray, and that office later declined treatment because the resident could not independently transfer to the dental chair. Staff interviews revealed lack of an established process to follow up on outside dental appointments, uncertainty about who was responsible for scheduling and communication, missing documentation of any in-house dental visit, and no equipment or plan to safely transfer the non-ambulatory resident for dental procedures, leading to prolonged delays in obtaining needed dental care.
A cognitively intact resident with epilepsy and prior stroke was given multiple anticonvulsant medications in crushed form by an agency nurse, despite physician orders and manufacturer directions that at least some of the tablets, including extended-release Brivaracetam and Lamotrigine, be swallowed whole. The nurse, on her first shift, relied on another nurse’s statement and her own assumption based on the resident’s stroke history, crushed the nighttime doses, and told the resident and POA that if the medications were refused, they would not be offered again until the next night. After taking the crushed medications, the resident experienced nausea, increased slurred speech, sweating, feeling hot, and weakness, reported these symptoms to staff, and later missed PT due to weakness. A NA observed increased sweating but did not obtain VS, and nursing staff did not notify the NP or physician at the time of the error; later interviews with the pharmacist, NP, and physician linked the symptoms to the crushed administration of the anticonvulsants.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and failing to provide adequate supervision to prevent accidents. The report highlights insufficient safety measures and lack of proper oversight, but does not specify individual residents or staff involved.
A resident with severe cognitive impairment experienced an unwitnessed fall, after which the facility failed to conduct ongoing comprehensive assessments or effectively communicate changes in the resident's condition. Despite signs of pain and abnormal limb positioning observed by staff, no immediate physical assessment was conducted. The resident was later diagnosed with a hip fracture requiring surgery and a clavicle fracture after being sent to the hospital at the family's request.
A nurse failed to disinfect a resident's glucometer according to the manufacturer's instructions, using a bleach wipe for only 10 seconds instead of the required 4 minutes. Despite having received training, the nurse was unaware of the correct procedure. The DON and SDC confirmed the nurse should have known the protocol, and the Administrator expected adherence to guidelines.
The facility inaccurately posted nurse staffing information by counting CMAs as LPNs over four days. The Staffing Coordinator, due to incorrect training, misreported the staffing levels, which the Administrator was unaware of.
A resident with a history of diabetes, anxiety, CHF, and dysphagia experienced a significant change in condition, including audible congestion and difficulty swallowing. Despite concerning vital signs, staff failed to notify the physician or take appropriate action. The resident was found not breathing and was pronounced deceased. Interviews revealed a lack of awareness and action regarding the resident's condition, with the Medical Director and DON indicating that the staff should have been notified.
A resident experienced neglect when staff failed to provide necessary care during a significant change in condition, leading to the resident being found unresponsive and not receiving immediate CPR. The nurse did not recognize the seriousness of the situation, failed to notify the physician, and did not verify the resident's code status promptly. The resident was later pronounced deceased by EMS.
A resident was found unresponsive and not breathing, but CPR was not administered immediately due to a nurse's assumption of a DNR status. The resident, who was a full code, did not receive timely CPR, and the code blue protocol was not activated. The delay and lack of coordination led to the resident being pronounced deceased by EMS upon arrival.
A resident with a full code status experienced a change in condition, including difficulty swallowing and audible congestion. Despite abnormal vital signs, the nurse did not notify the physician or initiate timely interventions. The resident was later found unresponsive, and CPR was delayed due to a failure to verify code status promptly.
Crushing and Improper Administration of Atorvastatin Against Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and physician orders for medication administration for one resident. The resident was admitted with diagnoses including cerebral infarction, epilepsy, slurred speech, and dysphagia, and had a physician’s order dated 02/07/2026 for Atorvastatin 40 mg to be administered orally once daily, with explicit instructions that the tablet was to be given whole and not crushed. The manufacturer’s prescribing information for Atorvastatin similarly stated that the tablets are to be swallowed whole and should not be crushed, chewed, or broken. The Medication Administration Record for 02/09/2026 at 9:00 PM showed that Atorvastatin 40 mg was administered and included instructions that it was not to be crushed, although it did not specify the form in which it was actually given. On the night of 02/09/2026, an agency nurse (Nurse #3), working her first shift at the facility and first time caring for this resident, crushed and administered the resident’s nighttime medications, including Atorvastatin 40 mg, without verifying the physician’s order. The resident’s POA, who stayed overnight, observed Nurse #3 crushing and administering the medications and informed her that the order specified the medication must be given whole, stating she had a copy of the order available. Nurse #3 responded that the medications had already been crushed and told the POA that if the resident refused the crushed medication, she would not receive it until the next scheduled dose. In a separate interview, the cognitively intact resident confirmed that Nurse #3 administered her nighttime medications, including Atorvastatin 40 mg, in crushed form and told her the medication would not harm her and that if she refused it, she would not receive it again until the next scheduled dose. Nurse #3 later acknowledged she crushed the medication based on her belief that it needed to be crushed due to the resident’s history of stroke and information from the previous shift nurse, and admitted she did not verify the physician’s order or contact the provider or pharmacy to clarify the order.
Failure to Reconcile and Secure Narcotics Resulting in Missing Oxycodone Tablets
Penalty
Summary
The deficiency involves the facility’s failure to maintain effective systems for shift-change narcotic reconciliation and to keep discontinued narcotic medications secured under two locks, resulting in missing controlled substances for two residents. For one resident, there was a physician’s order for oxycodone/acetaminophen 10/325 mg, one tablet by mouth twice per day as needed for moderate pain. The medication administration record showed that this resident received a dose on one morning for severe pain rated 9/10, administered by a medication aide (MA) and documented as effective. The MA reported that on the prior afternoon narcotic count, she recalled seeing a full card of 30 tablets of oxycodone/acetaminophen in the locked narcotic drawer for this resident. On the following morning, the MA was scheduled to work the day shift and received report and the medication cart from a nurse who had worked the prior afternoon and night shifts. The MA and the nurse counted narcotics on one hall’s cart and found the count accurate. However, when they went to count the narcotics on the second cart, the nurse told the MA that the count was the same as the previous afternoon and that they did not need to perform the count. The MA acknowledged that she knew she should not skip the narcotic count but relied on the nurse’s verbal assurance and signed the narcotic count sheet without physically counting the narcotics on that cart. Later that morning, when the resident requested pain medication, the MA opened the locked narcotic drawer and discovered that the resident’s oxycodone/acetaminophen blister pack was missing, despite her knowledge that a full card had been present the previous day. The facility’s internal investigation and interviews confirmed that the narcotic count for that cart had not been properly completed at shift change, and that the missing oxycodone/acetaminophen for this resident could not be located. Pharmacy records confirmed that 60 tablets had been delivered, and the facility determined that 50 tablets of oxycodone/acetaminophen 10/325 mg for this resident were missing. The former DON and unit manager both stated that nurses and medication aides, including the involved staff, had been trained to complete narcotic counts at every shift change, but in this instance the process was not followed, and staff relied on verbal confirmation rather than a physical count. A second deficiency involved discontinued narcotic medications for another resident who had a physician’s order for oxycodone 5 mg via gastric tube every four hours as needed for pain and who had died a few days before the events described. A nurse removed this resident’s narcotic medications from the locked narcotic drawer, placed them in a clear pharmacy return bag, and left the bag in the medication room. The next morning, the same MA was informed by the nurse that there were medications on the counter in the medication room that needed to be returned to the pharmacy. The MA, aware that the resident had died and that medications needed to be returned, took the bag from the medication room to the unit manager at the main nurse’s station but did not look inside the bag or verify its contents. The unit manager, who was occupied with investigating the first resident’s missing narcotics, placed the bag in an unlocked cabinet behind the nurse’s station instead of securing it under double lock as required. Later that day, when the unit manager and another nurse prepared to return medications to the pharmacy, they followed the process requiring two nurses to count and scan medications for return. At that time, they discovered that the oxycodone 5 mg tablets prescribed for the deceased resident were missing from the return bag. The unit manager acknowledged that she should have locked the medications in a locked cabinet in the medication room but failed to do so. The former DON stated that the unit manager was aware that narcotic medications needed to be locked, and the regional clinical leader stated that discontinued narcotics were to be kept under two locks until pharmacy retrieval with two nurses signing them out. The investigation determined that 30 tablets of oxycodone 5 mg for this resident could not be accounted for and that the medications had not been continuously secured under a double-lock system. Overall, the events leading to the deficiency consisted of staff failing to complete required shift-change controlled substance counts by physically verifying narcotics, relying instead on verbal confirmation, and failing to maintain discontinued narcotics under required double-lock security. These actions and inactions resulted in a total of 80 missing oxycodone-containing tablets for two residents, with the facility unable to substantiate the misappropriation or determine what happened to the medications.
Failure to Coordinate and Secure Necessary Dental Services for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure necessary assistance was provided to obtain routine and emergency dental services for a resident with significant cognitive and physical impairments. The resident was admitted with diagnoses including unspecified dementia, anoxic brain damage, unspecified intellectual disability, and hypertensive heart disease without heart failure, and required partial to substantial assistance with ADLs, including setup or clean-up assistance for oral hygiene and substantial assistance for transfers. The care plan dated 08/19/2025 did not identify any dental health problems, and the quarterly MDS documented no mouth or facial pain and no chewing discomfort, despite later reports from the POA that the resident complained of mouth pain and had difficulty chewing. Review of the EHR from 11/20/2024 through 07/09/2025 showed no evidence of a dental examination during that period. The sequence of events shows multiple missed opportunities and breakdowns in coordination to secure needed dental treatment. The POA reported raising concerns about the resident’s dental needs beginning in April 2025, including observed discomfort while eating and verbal complaints of mouth pain, and stated he repeatedly informed the Social Worker and other staff. The POA ultimately scheduled the first dental appointment himself at Dental Office #1 on 07/10/2025. A Unit Manager note for that date indicated the resident returned from Dental Office #1 and was not seen due to inability to ambulate, but the dentist at Dental Office #1 reported that the resident was in fact seen, was found to have periodontal disease, and needed multiple extractions due to tooth decay and cavities. The dentist stated the resident’s teeth appeared not to have been properly cared for and that, due to their condition, the resident would have experienced pain. The dentist further stated he referred the resident to an oral and maxillofacial specialist (Dental Office #2) and placed the referral and instructions in the communication binder for the facility to call and schedule the appointment, but Dental Office #2 reported having no record of any contact or treatment for the resident. Additional delays and failures occurred with subsequent dental arrangements. A Unit Manager note dated 07/29/2025 documented that the resident returned from Dental Office #3 with a diagnosis of gum disease and a need for multiple extractions, and a progress note dated 08/27/2025 indicated prior authorization was completed for Dental Office #3. However, the Chief Compliance Officer at Dental Office #3 stated the resident was only seen for a cleaning and X-ray at an initial appointment scheduled by the POA, and no treatment orders were communicated to the facility. The Social Worker stated she first learned of the dental concerns from the POA in July 2025, did not recall being told the resident was in pain, and believed dental services were being provided from August through September 2025 because she received no follow-up communication from nursing staff or the NP. She also stated there was no established process to follow up on outside dental appointments and could not provide documentation that the resident had ever been seen by the in-house dental provider, who visited quarterly and was present in October 2025. A Social Work note on 10/07/2025 documented that Dental Office #3 could not treat the resident unless he could transfer independently to the dental chair, and that an in-house dental appointment was scheduled for 10/17/2025, but the POA informed her of his intent to discharge the resident on 10/13/2025 due to delays in obtaining necessary dental services. Staff interviews further highlighted communication and process failures that contributed to the deficiency. Unit Manager #1 acknowledged family concerns about the resident’s teeth and stated the resident required assistance transferring to a dental chair, but the facility lacked appropriate resources to assist with transfers at dental offices. She indicated that nursing and Social Work attempted to locate dental offices that could accommodate the resident’s transfer needs and that the appointment scheduler handled communication with Dental Office #1, but she was unaware of any referral to Dental Office #2. NA #3, who transported the resident to some appointments, stated she did not transport the resident to Dental Office #1 because she was on leave, transported him to Dental Office #3 on 08/27/2025, did not stay for the appointment, and had no equipment to facilitate safe transfers, learning from the POA that Dental Office #3 declined treatment because the resident could not transfer to the dental chair. The NP stated she completed authorization in August 2025 and believed delays were related to finding a facility that could accommodate the resident’s physical needs and accept his managed insurance. The DON and Administrator, both hired after the resident’s discharge, reported that the referral to Dental Office #2 may have been lost in communication and that they were not aware of the resident’s dental concerns at the time, while the Administrator stated he expects nursing and Social Work to follow up on residents’ dental needs.
Crushing of Anticonvulsant Medications Contrary to Orders and Manufacturer Directions
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when multiple anticonvulsant medications ordered to be given whole were crushed and administered. The resident, who had diagnoses including cerebral infarction, epilepsy, slurred speech, and dysphagia, was cognitively intact and did not exhibit behavioral symptoms or rejection of care per a recent MDS. Physician orders specified that Brivaracetam 100 mg, Eslicarbazepine 800 mg, Lamotrigine 200 mg, and Xcopri 150 mg were to be administered orally and not crushed, with Brivaracetam explicitly ordered as “DO NOT CRUSH.” Manufacturer prescribing information for Brivaracetam and extended-release Lamotrigine stated that tablets should be swallowed whole and not chewed or crushed, while Eslicarbazepine and Xcopri could be administered whole. On the evening in question, an agency nurse (Nurse #3), working her first shift at the facility and first time with the resident, crushed and administered the resident’s nighttime doses of Brivaracetam, Eslicarbazepine, Lamotrigine, and Xcopri. The MAR reflected that the medications were given but did not specify whole versus crushed administration. According to the resident’s POA, she was present and informed Nurse #3 that the medications should not be crushed based on the physician’s orders she had in her possession. Nurse #3 responded that the medications had already been crushed and told the resident that if she did not take them, she would not receive them again until the next night. The resident reported that Nurse #3 told her the crushed medications would not hurt her, and she took them because they were important for seizure control and she was told she would otherwise miss the dose. Following administration of the crushed medications, the resident and her POA reported onset of symptoms including nausea, increased slurred speech beyond baseline, sweating, feeling extremely hot, and weakness within approximately 40 minutes to an hour. The POA stated she notified Nurse #3 of these symptoms and that Nurse #3 checked on the resident once during the night to obtain vital signs. NA #2, who cared for the resident that evening, reported the resident said she was scared when her medications were crushed and was noted to be sweating more than usual around the time of administration; NA #2 assisted with comfort measures but did not obtain vital signs. The pharmacist, NP, and facility physician each confirmed that crushing and administering these anticonvulsants together could alter their intended release and contribute to the symptoms described, and the NP stated the side effects the resident experienced were a direct result of the medications being crushed and administered all at once. Nursing staff did not notify the NP or physician at the time of the medication error, and the physician later reported he had been unaware of the incident.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential incidents. Specific actions or omissions by staff or management that led to this deficiency are not detailed in the report, nor are any particular residents or their conditions mentioned.
Failure to Assess and Communicate Changes in Condition After Fall
Penalty
Summary
The facility failed to complete and document ongoing comprehensive assessments for a resident after an unwitnessed fall and did not have effective systems in place for communicating changes in condition. The resident, who was severely cognitively impaired, experienced an unwitnessed fall from bed. Initially, a nurse assessed the resident and noted no pain or injury. However, this was the only documented nursing assessment following the fall. During subsequent shifts, staff observed signs of pain, such as wincing when the resident was turned, but these observations were not consistently reported to nursing staff or followed up with a physical assessment. On the day following the fall, the resident expressed pain in her lower right extremity to therapists, who observed that her right lower extremity was externally rotated and flexed. Despite these observations being reported to a nursing staff member, no immediate physical assessment was conducted. Later that day, a family member reported that the resident was in significant pain, leading to a physician being contacted and an x-ray being ordered. The family ultimately requested that the resident be sent to the hospital, where she was diagnosed with a closed right hip fracture requiring surgery and a non-operable right clavicle fracture. The deficiency occurred because the facility did not have effective communication and assessment protocols in place to identify and respond to changes in the resident's condition following the fall. The lack of timely and thorough assessments, as well as inadequate communication among staff, contributed to a delay in diagnosing the resident's injuries, which were only identified after the family intervened and requested hospital evaluation.
Improper Disinfection of Glucometer
Penalty
Summary
The facility failed to properly disinfect a resident's glucometer according to the manufacturer's instructions, as observed during a survey. Nurse #1 was seen removing a glucometer from an unsealed plastic bag, using it to check a resident's blood glucose level, and then placing it on the medication cart without following the correct disinfection procedure. The nurse used a germicidal disposable bleach wipe to clean the glucometer for approximately 10 seconds, contrary to the manufacturer's instructions that required the surface to remain visibly wet for 4 minutes and to air dry. Nurse #1 was unaware of the correct procedure and expressed uncertainty about how to keep the glucometer wet for the required time. Interviews with the Director of Nursing (DON) and the Staff Development Coordinator (SDC) revealed that Nurse #1 had received training and competency reviews on the disinfection procedure. Despite this, she did not follow the correct protocol during the observation. The DON and SDC confirmed that Nurse #1 should have known the proper procedure, and the Administrator expected all staff to adhere to the manufacturer's guidelines. The SDC noted that Nurse #1 felt nervous during the observation, which may have contributed to the oversight.
Inaccurate Nurse Staffing Information Posted
Penalty
Summary
The facility failed to post accurate nurse staffing information for four consecutive days. The discrepancies were identified during a review of the Daily Posted Nurse Staffing forms and the nursing schedule. On each of the days reviewed, the posted staffing information inaccurately listed the number of Licensed Practical Nurses (LPNs) and included Certified Medication Aides (CMAs) as LPNs. Specifically, on three of the days, the forms indicated three LPNs were staffed, while the schedule showed a combination of LPNs and CMAs. On the fourth day, the form inaccurately listed two LPNs instead of one LPN and one CMA. The Staffing Coordinator, responsible for updating the forms, admitted to counting CMAs as LPNs due to incorrect training received when she assumed her role four months prior. The Administrator was unaware of the inaccuracies and confirmed that CMAs should not have been recorded as LPNs.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician for a resident who experienced a significant change in condition. The resident, who had a medical history including type 2 diabetes mellitus, anxiety, chronic congestive heart failure, and dysphagia, was observed with audible congestion, difficulty swallowing, and was trying to cough up phlegm. Despite these symptoms, neither the Medical Director nor the Nurse Practitioner was notified. The resident's vital signs were concerning, with a low pulse, low oxygen saturation, and clammy skin, yet no medical intervention was sought. Throughout the evening and night shifts, various staff members interacted with the resident but failed to recognize the severity of the situation or take appropriate action. A nurse noted the resident's symptoms and even crushed medications due to the resident's difficulty swallowing, but did not notify a physician or take further steps to address the resident's declining condition. The resident was found not breathing in the early morning hours and was pronounced deceased shortly thereafter. Interviews with staff revealed a lack of awareness and action regarding the resident's change in condition. The Medical Director expressed that the staff should have contacted him or the Nurse Practitioner when the symptoms were first observed. The Director of Nursing also stated that the nurse should have applied oxygen and notified the physician due to the resident's low oxygen levels. The failure to act upon the resident's change in condition and notify the appropriate medical personnel led to a critical oversight in care.
Neglect and Failure to Administer CPR in a Timely Manner
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, as evidenced by the lack of necessary care and services provided to a resident who experienced a significant change in condition. The resident exhibited symptoms such as audible congestion, difficulty swallowing, and attempts to cough up phlegm, yet the nurse did not recognize the seriousness of the situation, failed to notify the physician, and did not conduct thorough and ongoing assessments. This neglect resulted in the resident being found not breathing and without a pulse, and subsequently pronounced deceased by emergency medical services. The facility also failed to ensure that Cardiopulmonary Resuscitation (CPR) was administered immediately and did not have an effective system in place for staff to respond to emergency situations. When the resident was found unresponsive, the nurse did not verify the resident's code status and resumed other duties. It was only after being informed of the resident's full code status that the nurse initiated CPR, but without following the code blue protocol. The nurse ceased CPR when fatigued, and the resident was later pronounced deceased. Additionally, the facility did not provide complete, thorough, and ongoing assessments, nor did it intervene when the nurse failed to recognize the seriousness of the resident's condition. Despite the resident's vital signs indicating a critical state, the nurse did not obtain another set of vital signs or initiate lifesaving resuscitative efforts. The Director of Nursing acknowledged the nurse's lack of competency in handling the situation, which included not notifying the physician, not monitoring the resident, and failing to verify the resident's code status immediately.
Failure to Administer Immediate CPR to Full Code Resident
Penalty
Summary
The facility failed to ensure that Cardiopulmonary Resuscitation (CPR) was administered immediately to a resident who was unresponsive, not breathing, and had no pulse. Nurse #1 was notified of the resident's condition but did not verify the resident's code status and assumed the resident was a Do Not Resuscitate (DNR). As a result, Nurse #1 did not initiate CPR immediately and resumed her duties elsewhere. It was only after being informed by another nursing assistant that the resident was a full code that Nurse #1 began CPR, but she did not activate the code blue protocol. The resident, who had been readmitted to the facility with diagnoses including type 2 diabetes mellitus, anxiety, chronic congestive heart failure, and dysphagia, was found unresponsive by a nursing assistant. Despite the resident's care plan indicating a full code status, Nurse #1 failed to act promptly. The delay in initiating CPR and the lack of a coordinated emergency response contributed to the resident being pronounced deceased by emergency medical services (EMS) upon their arrival. Interviews with staff revealed that Nurse #1 did not seek assistance from other staff members nor did she utilize the crash cart effectively. The crash cart was found to lack essential equipment such as an automated external defibrillator (AED), oxygen, tubing, or a suction machine. The emergency medical services report confirmed that CPR was not in progress upon their arrival, and the resident was found to be in asystole with no pulse or respiration.
Failure to Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to provide complete, thorough, and ongoing assessments for a resident experiencing a change in condition. The resident, who was a full code, exhibited symptoms of difficulty swallowing, audible congestion, and attempts to cough up phlegm. Despite these symptoms, Nurse #1 did not obtain vital signs or implement interventions to relieve the congestion. The resident's vital signs showed concerning levels, including a low pulse and oxygen saturation, but Nurse #1 did not take further action or notify the physician or Nurse Practitioner. On the morning of the incident, the resident was found with no pulse, and Nurse #1 did not verify the resident's full code status or initiate resuscitative efforts immediately. It was not until later that Nurse #1 became aware of the resident's full code status and began CPR, but by then, emergency medical services pronounced the resident deceased. Interviews with staff and record reviews indicated that there was a lack of timely response and communication regarding the resident's change in condition. The Medical Director and Nurse Practitioner both stated that they would have expected staff to obtain vital signs and notify them of the resident's symptoms. The Director of Nursing also indicated that Nurse #1 should have applied oxygen and notified the physician. The failure to act upon the resident's change in condition and the delay in initiating CPR contributed to the deficiency identified in the facility's care practices.
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.
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