Copperfield Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Concord, North Carolina.
- Location
- 515 Lake Concord Road Ne, Concord, North Carolina 28025
- CMS Provider Number
- 345130
- Inspections on file
- 25
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Copperfield Health & Rehabilitation during CMS and state inspections, most recent first.
A cognitively intact resident with bipolar disorder, schizophrenia, and a documented history of aggression repeatedly physically abused other residents when they entered or altered his environment. A severely cognitively impaired, wheelchair‑bound resident with Alzheimer’s dementia twice wandered into his room and, on each occasion, was struck in the face, resulting in a bruised, swollen, and lacerated lip, swelling to the jaw, and swelling and bruising around the eyebrow. Later, a newly admitted resident with Parkinson’s disease and normal cognition reported that, after using his call light to request a temperature change, the same aggressive resident approached his bed, yelled, cursed, spat at him, and struck him multiple times on the head and upper body, leaving him feeling unsafe and victimized. The psychiatric NP and Medical Director acknowledged that the aggressive resident was cognitively intact, aware of his actions, and had developed a pattern of striking out when others entered or changed his environment.
The facility failed to follow the planned menu for residents on mechanically altered diets when, on two observed lunch meals, a resident with dysphagia, protein calorie malnutrition, lipoprotein deficiency, and severe cognitive impairment received vegetables and desserts that did not match the therapeutic diet spreadsheet. Instead of the specified soft, fork-mashable vegetables and designated desserts, the resident was served alternate vegetables, fruit, and a cookie. The Dietary Manager and Regional Dietary Manager confirmed that all residents on mechanically altered diets received incorrect vegetables and desserts on those days due to the facility running out of food, and the Administrator stated that staff were expected to follow the menu and document and communicate any changes.
Surveyors found multiple open, unlabeled, and unsealed food items with signs of frostbite, discoloration, spoilage, and past use-by dates in the kitchen walk-in freezer and refrigerator. Items included chicken tenderloins and breasts, chocolate chip cookies, biscuit dough, shredded parmesan cheese, herb thyme, and pimento cheese spread. The Dietary Manager and Administrator acknowledged that facility practice requires all opened food to be labeled with an open date, kept closed and sealed, discarded if spoiled, and used or discarded according to use-by policies, and that the dietary department is responsible for daily food storage and safety.
A resident with CHF, COPD, and chronic respiratory failure had a physician order for continuous O2 at 3 L/min via nasal cannula, but repeated observations showed the bedside flowmeter set at 2 L/min. The cognitively intact resident reported that staff sometimes set her O2 at 2 L/min when she was in her wheelchair, despite her understanding that it should be 3 L/min. Nursing staff documented in the eMAR that O2 was given at 3 L/min on multiple shifts, while later stating they believed the ordered liter flow was being delivered and one nurse reported relying on the resident’s prior preference for 2 L/min and being unaware of an updated order. Unit management and leadership stated they were not aware of the incorrect liter flow and indicated that staff were expected to follow MD orders and verify correct O2 settings.
A resident with severe cognitive impairment was subjected to abuse and privacy violations by two nurse aides who live-streamed the resident's care to a prison inmate. The aides used vulgar language, failed to explain care, and exposed the resident's naked body, violating the resident's rights and dignity.
A resident's privacy was violated when two nurse aides live-streamed personal care to a prison inmate, exposing the resident without consent. The aides, despite being educated on privacy policies, engaged in this act, compromising the resident's dignity. The incident was captured on video, revealing a lack of effective monitoring and enforcement of privacy policies in the facility.
A resident in a LTC facility was subjected to abuse when two nurse aides failed to identify, intervene, or report the incident. The resident, who was severely cognitively impaired, was live-streamed naked from the waist up, with staff using profanity and physical aggression during care. The incident involved a prison inmate viewing the live stream, violating the resident's privacy and rights. The facility's inadequate abuse policy enforcement led to this immediate jeopardy situation.
A resident's oxycodone medication was misappropriated due to discrepancies in the narcotic count verification sheet, with signatures appearing forged and numbers overwritten. The facility's investigation revealed that one card of oxycodone was missing, and Nurse #2, responsible for the medication cart, refused to provide a statement. The pharmacy and police were notified, and the facility failed to protect the resident's medication from misappropriation.
A resident with limited range of motion and intact cognition did not receive necessary nail care and hand hygiene assistance from the facility. Despite requests, nursing assistants did not provide nail care due to time constraints, and the resident was observed scratching her skin without subsequent hand hygiene before meals. The Director of Nursing was unaware of these unmet care needs, indicating a deficiency in care practices.
The facility failed to conduct quarterly smoking assessments for two residents, one with severe cognitive impairment and another with moderate impairment, leading to a deficiency in accident prevention. Despite the care plan requirements and computer notifications, staff were unaware of the missed assessments, compromising supervision and safety.
The facility did not date three opened bottles of artificial tears in the B-hall medication cart, contrary to the manufacturer's recommendations that they be discarded after 28 days. Nurse #5 noted the absence of dates on the bottles, although the date was reportedly on the box the previous evening. Both the DON and the Administrator confirmed that the bottles or boxes should have been dated upon opening.
The facility failed to provide written transfer notifications to two residents or their representatives when they were sent to the hospital for medical issues. One resident, who was severely cognitively impaired, was transferred multiple times without notification, while another resident, who was cognitively intact, was also transferred without notification. The Social Worker had not been issuing these notices, and the Administrator was unaware of this deficiency.
Failure to Protect Residents From Repeated Physical Abuse by an Aggressive Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse by not adequately managing a cognitively intact resident with a known history of aggression toward others. This resident had diagnoses including anxiety, violent behavior, bipolar disorder, paranoid schizophrenia, dementia with mood disturbance, and insomnia, and was receiving antipsychotic, antianxiety, and antidepressant medications. His care plan documented a history of verbal aggression, poor impulse control, and threatening statements toward peers, with interventions such as 1:1 activity as needed, monitoring behavior episodes, explaining procedures, allowing time to adjust to changes, and psychiatric/behavioral services as needed. Despite this known history and care plan, the resident repeatedly engaged in physical aggression toward other residents. In the first incident, a severely cognitively impaired resident who was fully dependent for ADLs (except eating) and used a manual wheelchair entered the aggressive resident’s room. Staff did not witness the event, but the roommate called out for help, and staff found the cognitively impaired resident outside the doorway with a bruised, swollen, cut upper lip that had been bleeding. Nursing staff and the on‑call provider documented that the injuries were consistent with being struck in the mouth with a closed fist, and the aggressive resident told a nurse he hit the other resident because he did not want her in his room. The facility was aware of the aggressive resident’s past aggressive behaviors toward residents and staff prior to this event. In a subsequent incident involving the same two residents, the aggressive resident again spat on, cursed at, and punched the severely cognitively impaired resident when she wandered into his room. The cognitively impaired resident sustained swelling and bleeding of the lip and jaw, swelling and bruising of the upper lip, and swelling of the right eyebrow, and she was unable to reliably communicate pain. Documentation noted that she had been assaulted by the same resident two months earlier. Later, a newly admitted resident with Parkinson’s disease and normal cognition reported that, after activating his call light to request a lower room temperature, the same aggressive resident approached his bed, yelled, cursed, spat at him, and struck him multiple times on the head and upper body. The new resident reported feeling victimized, unsafe, and as though he had to sleep with one eye open. The aggressive resident told staff he spit on and punched this roommate because he believed he was going to be kicked. The Psychiatric NP and Medical Director both stated that the aggressive resident was cognitively intact, aware of his actions, and had developed a pattern of striking out when others entered or altered his environment, and that he would likely respond the same way again if not redirected by staff.
Failure to Follow Planned Menu for Mechanically Altered Diets
Penalty
Summary
The facility failed to follow the planned menu for residents prescribed mechanically altered diets during two observed lunch meals. A resident with protein calorie malnutrition, lipoprotein deficiency, dysphagia, and severe cognitive impairment was ordered a mechanically altered diet with thin liquids. The facility’s diet spreadsheet for therapeutic diets showed that residents on mechanically altered diets were to receive specific soft, cooked, fork-mashable vegetables and designated desserts for the lunch meals observed. However, during the first lunch observation, the resident’s tray ticket listed a regular mechanically altered diet, but the actual meal included broccoli with mixed vegetables and tropical fruit instead of the planned seasoned sautéed zucchini and applesauce. There was no evidence of the menu-specified vegetable or dessert on the tray. During the second lunch observation, the diet spreadsheet indicated that residents on mechanically altered diets, including this resident, should receive ground turkey cutlet with gravy, mashed potatoes, cut green beans, and cherry cobbler. Instead, the resident was served chopped turkey cutlet with gravy, red whole sliced potatoes, broccoli, and a cookie for dessert. The Dietary Manager acknowledged awareness of the resident’s mechanically altered diet and confirmed that the resident received the wrong vegetables and dessert, and that all 24 residents on mechanically altered diets received incorrect vegetables and desserts on both observed days. The Regional Dietary Manager stated the facility had run out of food, leading to menu changes, and confirmed that 24 residents on mechanically altered diets did not receive the correct vegetables or desserts. The Administrator stated her expectation that dietary staff follow the planned menu and log and communicate any menu changes to residents.
Improper Labeling, Storage, and Discarding of Food in Kitchen Walk-in Units
Penalty
Summary
The deficiency involves failure to properly label, date, seal, and discard food items in the facility’s walk-in freezer and refrigerator in accordance with professional standards. During an initial kitchen observation with the Regional Dietary Manager and the Dietary Manager, surveyors found in the walk-in freezer an opened, unsealed package of chicken tenderloins and an opened, unlabeled, unsealed package of chicken breasts, both with frostbite spots and grayish-brown discoloration. They also observed an opened, unlabeled, unsealed box of chocolate chip cookies with frostbite and grayish-brown discoloration, and an opened, unlabeled, unsealed package of biscuit dough with ice crystal formation. In the walk-in refrigerator, surveyors observed an opened, unlabeled 5-lb bag of parmesan fancy shredded cheese, an opened, unlabeled, unsealed box of herb thyme that appeared spoiled with brownish/blackish discoloration, and an open 1-quart container of pimento cheese spread with a use-by date that had already passed. In interviews, the Dietary Manager stated that open food items should be checked weekly, labeled with an open date, and kept closed and sealed, and acknowledged that the freezer items should not have been opened and needed to be discarded. The Administrator stated that all food and beverage items should be dated when opened, food showing signs of spoilage should be discarded, and items should be used or discarded according to use-by policies, confirming that the dietary department is responsible for daily food storage and safety.
Failure to Administer Ordered Oxygen Liter Flow and Accurate eMAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen as ordered by the physician for a resident with congestive heart failure, COPD, and chronic respiratory failure. The resident was admitted with these diagnoses and had a physician’s order dated 10/02/2025 for continuous oxygen at 3 liters per minute via nasal cannula for shortness of breath. The quarterly MDS indicated the resident was cognitively intact, received oxygen therapy, and used a non-invasive mechanical ventilator. On multiple observations on 02/16/2026, 02/17/2026, and 02/18/2026, the resident’s oxygen via nasal cannula connected to the bedside oxygen flowmeter was found set at 2 liters per minute instead of the ordered 3 liters per minute. During an interview, the resident stated that her oxygen was supposed to be set at 3 liters per minute and reported that when she was placed in her wheelchair, nursing staff sometimes set the oxygen at 2 liters instead of the prescribed 3 liters. She stated staff informed her of the oxygen setting and the amount remaining in the tank because the equipment was positioned behind her wheelchair. Review of the eMAR showed that Nurse #6 documented that the resident received oxygen at 3 liters per minute on 02/16/2026, 02/17/2026, and 02/18/2026 on first shift, and Nurse #7 documented that the resident received oxygen at 3 liters per minute on 02/17/2026 and 02/18/2026 on night shift, despite the observed setting of 2 liters per minute. Nurse assignment sheets confirmed that Nurse #6 and Nurse #7 were responsible for the resident’s care on the dates in question. In an interview, Nurse #6 acknowledged that the oxygen was set at 2 liters per minute and confirmed the physician’s order for 3 liters per minute continuously. She stated the resident had told her months earlier to set the oxygen at 2 liters based on home use and that the resident had been receiving 2 liters previously; she was unaware of the updated order for 3 liters per minute. Nurse #6 explained that the eMAR allowed her to document oxygen as administered by selecting yes or no and that she documented yes because she believed the resident was receiving 3 liters per minute. Nurse #7 similarly stated she documented oxygen as administered because she believed the resident was receiving 3 liters per minute. Unit Manager #1 stated that if oxygen was set at the wrong liter flow it was to be corrected immediately and that nursing staff should routinely check oxygen settings, but she had not previously noticed an incorrect setting for this resident. The NP stated that, due to the resident’s COPD, oxygen must be maintained at the prescribed liter flow, and the DON and Administrator both reported they were unaware that the resident’s oxygen was not being administered at the prescribed setting, while stating that staff were expected to follow physician orders.
Resident Abuse and Privacy Violation During Care
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving two nurse aides who provided personal care to a severely cognitively impaired resident while live streaming the event on a cell phone. The resident, who was naked from the waist up, was exposed to vulgar and profane language by the staff and a prison inmate who was watching the live stream. The staff did not explain the care being provided to the resident and were physically aggressive during the care process. The incident was captured on video footage provided by the Sheriff Department, which showed the staff's inappropriate behavior and the resident's exposure to the inmate and other inmates in the background. The resident involved in the incident was admitted to the facility with diagnoses including anxiety, Alzheimer's disease, dementia, and mood disturbance. The resident required extensive assistance with two-person support for bed mobility and transfers and was noted to be severely cognitively impaired. Despite having adequate hearing and vision and the ability to understand others, the resident was subjected to a lack of dignity and respect during the care process. The staff's actions, including undressing the resident without explanation and engaging in inappropriate conversations, violated the resident's rights and privacy. Interviews conducted with the involved staff members revealed that they had been educated on abuse and neglect policies but denied any wrongdoing. The Director of Nursing and Administrator were unaware of any staff using cell phones in care areas or taking pictures or videos of residents. The facility's failure to enforce policies prohibiting personal cell phone use in resident care areas and to protect the resident's privacy and dignity led to the deficiency. The incident was reported to Adult Protective Services and the local police department, highlighting the severity of the abuse and exploitation experienced by the resident.
Removal Plan
- All current facility staff were in-serviced on the Abuse, Neglect and Exploitation Policy, Resident Rights Policy and Cell Phone Policy.
- Education of proper resident care includes ensuring residents are not harmed physically or handled roughly during care.
- Facility is adopting a NO TOLERANCE Cell Phone Policy focusing on the strict prohibition of cellular phones and any type of electronic recording device use in resident care areas.
- Abuse questionnaires were completed with current facility staff to validate competency of education received and to identify any additional allegations or incidence of resident abuse.
- The Administrator, DON or designee will complete ongoing observational rounds of facility residents and staff to ensure that residents are free from abuse and resident rights to privacy is maintained.
- Facilities new hire screening process has been updated to include additional measures to better determine the candidate's probability of providing excellent resident care.
Resident Privacy Violated During Live Stream by Staff
Penalty
Summary
The facility failed to protect the privacy of a resident who was severely cognitively impaired. Two nurse aides, while providing personal care to the resident, live-streamed the event on a cell phone to a prison inmate. During this live stream, the resident was exposed, naked from the waist up, and the event was visible to multiple inmates and a guard in the prison's open area. The resident's privacy was violated as the live stream showed the resident being undressed and transferred without consent. The incident was captured on video footage provided by the Sheriff's Department, which showed the nurse aides engaging in the live stream while providing care to the resident. The video revealed that the aides were laughing and interacting with the inmate during the call, further compromising the resident's dignity and privacy. The aides did not use privacy curtains or take measures to ensure the resident's privacy during the care process. Interviews with the involved staff and facility administration revealed that the aides had been educated on resident privacy and the prohibition of cell phone use in care areas. Despite this, the aides denied taking part in the video call or recording the resident. The facility's Director of Nursing and Administrator were unaware of any staff using phones in care areas, indicating a lack of effective monitoring and enforcement of privacy policies.
Removal Plan
- The DON suspended NA #1 pending outcome of abuse investigation and notified the Medical Director of allegation.
- The Social Worker notified the local police department and adult protective services (APS) and obtained a police report number.
- The Administrator submitted the initial allegation report to North Carolina Department of Health Human Services (NCDHHS).
- The Administrator completed an observational round of facility residents and staff to ensure that resident's right to privacy is maintained.
- The DON, VPCO, VPRQA, Administrator and Medical Director held an Ad Hoc meeting to discuss incident to determine root cause analysis.
- The DON immediately suspended NA #2, notified Resident #2 resident representative(s) and the MD, and the VPRQA notified local law enforcement and APS with updated information.
- The VPCO assessed Resident #2 for physical injury, pain and signs or symptoms of psychosocial distress.
- The facility attempted to obtain information regarding the location of the prison to inquire on the security of the recording.
- All current facility staff were in-serviced on the Resident Rights Policy, CMS guidance 483.10(h) and the Cell Phone Policy.
- Questionnaires were completed following in-servicing with current facility staff to validate competency of education received.
- The Administrator, DON or designee will complete observational rounds of facility residents and staff to ensure that resident's right to privacy is maintained.
- Licensed nurses were educated and notified by the VPCO of their responsibility to complete observational rounds each shift for his/her unit.
- The Administrator is ultimately responsible for the implementation and completion of this removal plan.
Failure to Implement Abuse Policies Leads to Resident Abuse
Penalty
Summary
The facility failed to develop and implement effective abuse policies, resulting in a significant deficiency involving a resident. During an incident, two nurse aides were present in a room with a resident who was being abused. The aides did not identify the abuse, intervene to stop it, or report it immediately to licensed or administrative staff. This lack of action occurred while the resident was being live-streamed on a cell phone, exposing the resident to further abuse and violation of privacy. The resident involved was severely cognitively impaired, and the abuse included being shown naked from the waist up during a live stream. The staff involved used profanity and vulgarity, and the resident was subjected to physical aggression during care. The live stream was viewed by a prison inmate, further compounding the abuse and violation of the resident's rights. The reasonable person concept was applied, indicating that a reasonable person would have been traumatized by such treatment in their home environment. The facility's failure to protect the resident's right to be free from abuse was compounded by the staff's inaction and the lack of immediate reporting. The incident highlighted the facility's inadequate system for ensuring staff knowledge and enforcement of the Abuse, Neglect, and Exploitation Policy, as well as the Cell Phone Policy. This deficiency was identified as immediate jeopardy, indicating a severe risk to resident safety and well-being.
Removal Plan
- All current facility staff were in-serviced on the Abuse, Neglect and Exploitation Policy, Resident Rights Policy and Cell Phone Policy.
- Abuse training topics included preventing, reporting and identifying what constitutes abuse and NO TOLERANCE for failure to comply and ensure resident protection.
- Education of proper resident care includes ensuring residents are not harmed physically or handled roughly during care but are provided with care that is gentle, kind, dignified and that residents are free from offensive comments, profanities or other form of verbal abuse.
- The facility is adopting a NO TOLERANCE Cell Phone Policy focusing on the strict prohibition of cellular phones and any type of electronic recording device use in resident care areas.
- Training included examples of violation of residents' privacy and the potential effects on residents whose privacy is not maintained.
- Abuse questionnaires were completed with current facility staff to validate competency of education received and to identify any additional allegations or incidence of resident abuse.
- The Administrator, DON or designee will complete ongoing observational rounds of facility residents and staff to ensure that residents are free from abuse and resident rights to privacy is maintained.
- Licensed nurses were educated and notified of their responsibility to complete observational rounds for his/her unit and observe resident and staff interactions.
- The facilities new hire screening process has been updated to include additional measures to better determine the candidate's probability of providing excellent resident care.
- Human Resources (HR) and/or the Administrator, DON or SDC are responsible for the interview process, screening reference checks and screening social media platforms.
- The facility will NOT extend employment to any candidate with convictions or pending convictions involving elder abuse, neglect or exploitation.
- The Administrator is ultimately responsible for the implementation and completion of this removal plan.
Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of controlled medications. A resident with a diagnosis of chronic pain was prescribed oxycodone 10 mg every 6 hours. On a specific date, the facility received a delivery of four cards of oxycodone, each containing 10 tablets. However, it was discovered that one card of oxycodone was missing, and the shift change narcotic count verification sheet had been altered. The signatures on the sheet appeared to be forged, and the numbers were overwritten, indicating a discrepancy in the narcotic count. The investigation revealed that Nurse #2 was responsible for the medication cart on the day the discrepancy was noted. Despite attempts to contact her, Nurse #2 refused to provide a statement regarding the missing medication. The facility's Director of Nursing conducted a review and confirmed that one card of oxycodone was missing, and the shift change narcotic count sheet had been tampered with. The pharmacy and police were notified of the incident, and Nurse #2 was suspended pending further investigation. Interviews with other nursing staff indicated that the narcotic count was correct at the beginning of the day shift, but discrepancies were noted during the shift change. The facility's President of Quality confirmed that the Administrator and the Director of Nursing were no longer employed at the facility. The investigation concluded that the missing oxycodone card was not accounted for, and the facility failed to maintain accurate records and protect the resident's medication from misappropriation.
Failure to Provide Nail Care and Hand Hygiene for a Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care and hand hygiene for a dependent resident, identified as Resident #65, who required assistance with all activities of daily living. Resident #65, who had an intact cognition and a diagnosis of limited range of motion, was observed with long, uneven nails with black matter underneath, indicating a lack of proper nail care. Despite the resident's requests for nail care, the nursing assistants (NAs) assigned to her care did not provide the necessary assistance due to time constraints and heavy workloads. The resident was also observed scratching her skin, including inside her undergarment, without subsequent hand hygiene being offered before meals. Interviews with the NAs and the Director of Nursing (DON) revealed a lack of communication and awareness regarding the resident's need for nail care and hand hygiene. The NAs admitted to not providing nail care during bed baths and not informing the nurse of the resident's condition. The Activity Assistant also noted that a scheduled manicure activity was not completed due to time limitations. The DON was unaware of the resident's unmet care needs and the lack of hand hygiene provided before meals, highlighting a deficiency in the facility's care practices for dependent residents.
Failure to Conduct Quarterly Smoking Assessments
Penalty
Summary
The facility failed to complete quarterly smoking assessments for two residents, leading to a deficiency in ensuring a safe environment free from accident hazards. Resident #31, who was admitted with diagnoses including hypertension, muscle weakness, dementia, and blindness in one eye, was identified as a supervised smoker due to severe cognitive impairment and non-compliance with the smoking policy. Despite the care plan's requirement for regular smoking assessments, only one assessment was completed since the last recertification, indicating a lapse in monitoring the resident's smoking habits. Similarly, Resident #72, with diagnoses of hypertension and unsteadiness of feet, was assessed as an independent smoker. However, the facility failed to conduct quarterly smoking assessments as required, with a significant gap between assessments. Interviews with staff, including a nurse, unit manager, and the Director of Nursing, revealed a lack of awareness and oversight regarding the missed assessments, despite the computer system's notifications for pending assessments. This oversight contributed to the deficiency in maintaining adequate supervision to prevent accidents related to smoking.
Failure to Date Opened Bottles of Artificial Tears
Penalty
Summary
The facility failed to properly date three opened bottles of artificial tears stored in the B-hall medication cart, as observed during a survey. According to the manufacturer's recommendations, these bottles should have been discarded 28 days after opening. During an observation, Nurse #5 revealed that the bottles were found without an open date, although she mentioned that the date was on the box the previous evening. Both Nurse #5 and the Director of Nursing acknowledged that either the bottle or the box should have been dated when the bottle was opened. The Administrator also confirmed this requirement during an interview.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide timely written notification of hospital transfers to residents or their representatives, as required by regulations. This deficiency was identified for two residents who were transferred to the hospital for medical issues. Resident #27, who was severely cognitively impaired, was transferred to the hospital on multiple occasions for various health concerns, including difficulty swallowing, a fall with head pain, and intractable nausea and vomiting. Despite these transfers, there was no documentation of written transfer notifications in the resident's medical record. Similarly, Resident #28, who was cognitively intact, was sent to the hospital for cellulitis, elevated white blood cells, and elevated kidney function. The medical record for this resident also lacked a written transfer notification. Interviews with the Social Worker revealed that she had not been providing written notices of transfer, despite being informed by the previous administrator that it was necessary. The current Administrator was unaware of this lapse and expected that such notifications were being provided.
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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