Deer Park Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Nebo, North Carolina.
- Location
- 306 Deer Park Road, Nebo, North Carolina 28761
- CMS Provider Number
- 345233
- Inspections on file
- 27
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 22 (5 serious)
Citation history
Health deficiencies cited at Deer Park Health And Rehabilitation during CMS and state inspections, most recent first.
Staff did not promptly inform a resident, the resident's doctor, and a family member about events such as injury, decline, or room changes that affected the resident, as required by regulation.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility's failure to follow the established care plan.
Two residents experienced deficiencies in care following falls: one was not promptly assessed or transferred after a hip fracture was identified on x-ray, and another was moved by unqualified staff after a transport van fall without a nurse's assessment, despite being on anticoagulation and fully dependent for ADLs.
A resident with severe cognitive impairment and limited mobility was not properly secured during van transport, resulting in a fall from a specialized wheelchair that was not designed for vehicle use. The transport driver did not follow manufacturer instructions for securement, and the resident slid out of the chair when the van hit a bump. In a separate incident, two residents were involved in a physical altercation over a television remote, leading to a minor injury. Both events reflect lapses in supervision and adherence to safety protocols.
A resident who fell and complained of hip pain had a right hip x-ray ordered, but the x-ray was not ordered stat and was completed the next day. The x-ray company faxed the positive fracture results and attempted to call the facility multiple times without success. The results were not communicated to the provider until the following day, delaying the resident's transfer to the hospital for evaluation and treatment.
A resident with a persistent vegetative state and chronic pain did not consistently receive a prescribed fentanyl patch for pain management due to the medication not being available. Documentation showed multiple missed doses over several months, with nursing staff demonstrating inconsistent understanding of the reordering process for controlled substances and, at times, failing to notify the provider when the medication was unavailable. The resident was unable to communicate pain, and the facility's processes for ensuring medication availability were not reliably followed.
The facility did not consistently follow planned menus, resulting in several residents receiving sandwiches instead of the scheduled hot dinner meals when the kitchen ran out of menu items. Staff interviews confirmed that this occurred multiple times, and residents were not offered choices for substitute meals. The issue was linked to inadequate training and oversight of kitchen staff, with cooks lacking clear guidance on meal preparation quantities and no formal skills assessment in place.
Surveyors found that staff failed to remove expired food and did not date perishable items in the walk-in cooler. Several opened food items, such as thickeners, muffins, and juice, were observed without proper labeling or dating, contrary to facility policy requiring all stored food to be sealed, labeled, and dated.
Staff failed to follow infection control protocols by not using PPE during high-contact care for a resident with multiple medical devices and by not properly disinfecting a shared glucometer between uses for two residents. These lapses occurred despite facility policies and manufacturer instructions requiring specific cleaning and disinfection steps, and were confirmed by interviews with the Infection Preventionist, DON, and Administrator.
The facility did not post required cautionary signage outside the rooms of multiple residents receiving oxygen therapy, despite physician orders and active administration of oxygen. Observations confirmed the absence of signage for several residents, and staff interviews revealed confusion about responsibility for ensuring signs were in place.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was prescribed Zyprexa, an antipsychotic, and did not receive the required AIMS assessment within the recommended six-month interval. Despite pharmacy recommendations and EMR alerts, the assessment was not completed or documented as expected by facility staff, including the DON and Administrator.
Several cognitively intact residents, including those with diabetes and malnutrition, reported that evening snacks were not consistently available when requested, especially during evening shifts and weekends. Staff interviews confirmed that nourishment rooms were often unstocked and that nursing staff lacked access to the kitchen after hours. The dietary manager and administrator were unaware of the issue, despite an adequate supply of snacks being ordered.
Two residents had inaccurate MDS assessments: one was discharged home but coded as discharged to a hospital, and another with end-stage kidney disease receiving regular hemodialysis was not coded for dialysis. These errors were attributed to keying mistakes and oversight by staff, including a remote nurse in training.
A resident with multiple fractures and chronic pain was receiving scheduled opioid and other pain medications, but the facility failed to develop a comprehensive care plan addressing pain management and opioid use. Despite documented medication orders and administration, the care plan did not include interventions for pain or opioid therapy, as confirmed by staff interviews and record review.
A resident with chronic pain and a history of multiple fractures did not receive a scheduled dose of Methadone because the medication was not available at the facility. Nursing staff did not notify the physician about the missed dose but contacted the pharmacy and reported the issue to the next shift. The resident reported feeling unwell that day, and both the DON and Administrator acknowledged that medications should be available and reordered before running out.
Surveyors found that multi-dose vials of Tuberculin and Acetylcysteine were not labeled with open dates and one was not stored per manufacturer instructions. Additionally, a nurse left medication cards containing midodrine and gabapentin doses for two residents unsecured and unattended on a medication cart during administration, contrary to facility expectations.
A resident with chronic pain and multiple fractures did not receive a scheduled dose of Methadone due to discrepancies in medication administration and documentation by a nurse. The nurse failed to follow proper procedures, including not contacting the physician about the missed dose and inaccurately recording medication times, resulting in a medication count discrepancy and the resident missing a dose.
A resident with end-stage kidney disease did not have a pressure dressing removed from a dialysis access site as ordered, resulting in swelling and a missed dialysis session. Despite repeated instructions from the dialysis nurse and a physician's order, the facility did not consistently remove the dressing or document the order prior to the incident. Additionally, the facility failed to provide a bagged meal or snack for the resident during dialysis appointments, with staff unaware of the need to do so.
A resident with multiple chronic conditions did not receive prescribed doses of guaifenesin and multivitamin because the medications were unavailable, and the nurse omitted the doses without notifying the provider. This resulted in a medication error rate of 6.67%, exceeding the acceptable threshold.
A resident with severe cognitive impairment and known wandering behaviors exited a facility unsupervised, walking 1/3 mile before being found in a ditch. The resident's blood sugar was critically high, requiring emergency medical care. Staff failed to notice the resident's absence promptly, and the facility's security measures were inadequate to prevent the elopement.
A gas grill with two propane tanks was found near the resident smoking area, posing an accident hazard. The facility's smoking policy did not address the storage and use of propane tanks in this area. The grill was placed by the Maintenance Director for an upcoming event, and both the Activity Director and Maintenance Director were unaware of regulations regarding its placement. The Administrator confirmed the policy's inadequacy in addressing this issue.
The facility did not adequately protect a resident with severely impaired cognition from sexual abuse by another resident with a history of sexually inappropriate behaviors. Multiple incidents occurred where the resident was inappropriately touched, including an instance of skin-to-skin contact causing distress. Additionally, the facility failed to prevent physical abuse when another resident was punched in the face. Despite the known history of sexually inappropriate behavior, the care plan for the offending resident was not revised following these incidents. Staff members involved did not consistently report or address the behaviors promptly.
A resident fell during a transfer at a dialysis center and was moved off the floor by NAs without being assessed for injuries, resulting in a clavicle fracture and right ankle strain. The NAs attempted to manually transfer the resident, leading to the fall. Despite the resident expressing pain, the NAs and a dialysis technician lifted the resident back into the chair without a nurse's assessment. The facility's policy required a nurse to assess a resident after a fall before moving them.
The facility failed to ensure a resident was transferred safely, resulting in a fractured clavicle and sprained foot. Additionally, another resident sustained skin tears after a nurse aide continued care despite the resident's combative behavior. Both incidents highlight the facility's failure to adhere to care plans and protocols for resident safety.
The facility failed to honor the smoking preferences of two residents, requiring them to vape instead of smoking tobacco cigarettes due to a policy change. The decision, made by the previous administration and the IDT, focused on safety and infection control without considering the residents' rights and preferences.
The facility failed to maintain a safe and homelike environment, with observations revealing damaged bathroom doors, scuffed metal door frames, and a rough, jagged footboard in several rooms. The Maintenance Director acknowledged the issues but cited delays due to remodeling and pending supplies.
A Consultant Pharmacist failed to identify drug irregularities and provide recommendations for a resident receiving Risperdal. Despite monthly medication regimen reviews, the required abnormal involuntary movements assessments were not conducted for over a year due to a transition to electronic medical records and frequent changes in leadership. The oversight was acknowledged by the Consultant Pharmacist.
The facility failed to limit the duration of a PRN psychotropic medication to 14 days and did not document the rationale for extending the order for a resident with anxiety disorder. Additionally, the facility did not monitor for abnormal involuntary movements in a resident on antipsychotic medication, with the last assessment conducted over a year ago. The issues were attributed to oversight and frequent changes in leadership.
The facility failed to properly label and manage medications, leading to deficiencies such as undated and expired insulin in the Seafoam Hall medication cart, expired OTC medications in the South medication storage room, and expired calcium citrate in the Silver Hall medication cart. Staff admitted to lapses in regular checks and attributed the issues to carelessness and distractions.
The facility failed to maintain cleanliness in the kitchen, with significant build-ups of debris and substances in the walk-in refrigerator, oil fryer area, circulatory fans in the walk-in freezer, and a storage shelf for ready-to-use cookware. The Dietary Manager and Administrator acknowledged these oversights.
The facility's QAA Committee failed to maintain and monitor interventions, resulting in repeat deficiencies in abuse prevention, accident hazards, and medication storage. Incidents included sexual abuse of a resident with impaired cognition, physical abuse between residents, unsafe transfer practices leading to injuries, and improper medication storage.
The facility failed to maintain the two-compartment sink in the kitchen, resulting in a leaking drainpipe. The Dietary Manager and assistant DM were unaware of the leak, and the sink had recently been used to rinse food. The Maintenance Manager and Administrator were also unaware of the issue, and no work order had been submitted prior to its discovery.
A facility failed to assess a cognitively impaired resident's ability to self-administer eye drops and a medicated cream. The resident had been self-administering these medications without a physician's order or an assessment, and the care plan did not address self-administration. Staff acknowledged the need for assessment and proper medication storage.
The facility failed to report incidents of resident-to-resident and employee-to-resident abuse within the required 2-hour timeframe. One incident involved a resident found with his hand inside another resident's brief, and another involved a resident with severe cognitive impairment who sustained skin tears during care. Miscommunication and misunderstanding of reporting requirements contributed to the delays.
The facility failed to accurately code the MDS assessments for two residents, leading to discrepancies in the documentation of behaviors and discharge status. One resident's wandering behaviors were not recorded, and another resident's discharge status was incorrectly documented.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Ensure Timely Clinical Assessment and Response After Resident Falls
Penalty
Summary
A deficiency occurred when a resident with a history of right femur fracture, muscle atrophy, and osteoarthritis experienced a fall while attempting to get out of bed. The DON witnessed the fall and assessed the resident, who complained of hip pain. Orders were obtained for a right hip x-ray and pain medication. The resident was transferred back to bed using a mechanical lift and later placed in a reclining chair near the nurse's station due to repeated attempts to get out of bed. The x-ray was not ordered stat, and the resident remained in the facility while awaiting imaging. The x-ray, completed the following day, revealed an acute right femoral intertrochanteric fracture, but the results were not reviewed or acted upon until the next day, resulting in a delay in transferring the resident to the hospital for treatment. Another deficiency involved a resident who was severely cognitively impaired, dependent for all ADLs, and on anticoagulation therapy. After returning from a dialysis appointment, the resident slid out of her wheelchair in a transport van when the driver hit a bump. Two nursing assistants responded to the driver's request for help and lifted the resident back into her wheelchair without notifying a nurse or having a qualified assessment for injuries prior to moving her. The nurse was notified only after the resident was brought back into the facility, at which point an assessment was performed and the resident was sent to the hospital for evaluation. In both cases, the facility failed to ensure that residents received timely and appropriate clinical assessments following falls. For the first resident, there was a failure to promptly review and act on diagnostic results, leading to a delay in necessary medical intervention. For the second resident, unqualified staff moved the resident after a fall without a nurse's assessment, which did not follow protocol for post-fall evaluation, especially given the resident's high risk for injury due to anticoagulant use and physical limitations.
Failure to Ensure Safe Transport and Supervision Resulting in Resident Fall and Altercation
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, limited mobility, and contractures was not safely secured during transport in a specialized wheelchair by a contracted transportation company. The driver failed to secure the resident in accordance with the manufacturer's instructions for the van's 4-point anchor tie-down system and seatbelt application. As the van entered the facility driveway and hit a bump, the resident slid out of the wheelchair and onto the van floor, with the seatbelt found around the wheelchair rather than properly restraining the resident. Facility staff assisted the resident back into the wheelchair, and the resident was subsequently assessed and transported to the emergency department, where no injuries were found. The resident involved had a history of end-stage kidney disease, encephalopathy, cerebral infarction, muscle weakness, and was on anticoagulant therapy. The resident required a mechanical lift for all transfers and was totally dependent on staff for activities of daily living. The specialized wheelchair used was not designed for vehicle transport, and both the transport company and facility staff noted challenges in securing the resident safely due to the wheelchair's construction. The transport company owner reported previous concerns about the safety of transporting this resident in the specialized chair, but there was no documentation of these concerns prior to the incident. Additionally, the facility failed to provide effective supervision to prevent a resident-to-resident altercation. In a shared room, one resident with severe cognitive impairment and behavioral issues struck another resident in the face during a dispute over a television remote. The altercation resulted in a small bruise on the hand of the resident who was struck, but no visible injury to the face or lip. Staff responded by separating the residents and assessing them for injuries. The incident was reported to the appropriate authorities, and the residents were interviewed about the event.
Delay in Provider Notification of Positive Hip Fracture X-ray Results
Penalty
Summary
A deficiency occurred when the facility failed to promptly notify the provider of x-ray results for a resident who had fallen and complained of hip pain. After the fall, the DON assessed the resident and contacted the PA, who ordered a right hip x-ray and pain medication. The x-ray was not ordered as stat, and the mobile x-ray company performed the x-ray the following day. The x-ray report, which showed an acute right femoral intertrochanteric fracture, was faxed to the facility and uploaded to the resident's EMR, but there was no documentation in the progress notes regarding the x-ray or the resident's right hip on the day the results were available. The mobile x-ray company attempted to call the facility five times to report the positive fracture results but was unable to reach anyone. The results were not communicated to the provider until the following day, when a nurse received a call from the x-ray company, checked the EMR, and found the report indicating a fracture. Only then was the provider notified, and the resident was transferred to the hospital for evaluation and treatment. Interviews with staff revealed that nurses are able to access x-ray results in the EMR and that the fax machine is accessible to all nurses, though agency nurses may not be aware of incoming faxes. The delay in provider notification resulted from a combination of the x-ray not being ordered stat, lack of documentation and follow-up in the EMR, unanswered phone calls from the x-ray company, and a lack of awareness among staff regarding the availability of the x-ray report. The administrator was unaware of the multiple failed attempts by the x-ray company to reach the facility, and the PA stated that ideally, the results should have been reported to a provider as soon as they were available.
Failure to Administer Pain Medication as Ordered Due to Medication Unavailability
Penalty
Summary
The facility failed to administer medications as ordered by the physician for a resident with complex medical needs, including a persistent vegetative state, chronic pain, and a stage 4 sacral pressure ulcer. The resident was prescribed a fentanyl transdermal patch to be applied every 72 hours for pain management, as well as scheduled oxycodone via PEG tube. Multiple instances were documented where the fentanyl patch was not applied as ordered due to the medication not being available at the facility. These missed doses were recorded in the Medication Administration Record (MAR) and progress notes across several months, with nurses documenting the unavailability and, in some cases, the steps taken to reorder the medication. Interviews with nursing staff revealed inconsistent understanding and execution of the medication reordering process, particularly for controlled substances. Some nurses reported reordering medications by clicking a button in the electronic MAR, while others described the need for a printed prescription to be signed by a provider and faxed to the pharmacy. Agency nurses, in particular, expressed unfamiliarity with the facility's specific procedures for reordering controlled medications. There were also instances where nurses did not notify the provider when the medication was unavailable, or failed to document such notifications. The facility's Director of Nursing and Administrator both stated expectations that medications should be available and reordered when supplies are low, and that providers should be notified if medications are unavailable. However, the transition to having unit managers oversee narcotic reordering had only recently begun, and gaps in the process were evident. The resident involved was non-verbal and unable to communicate pain, making adherence to the prescribed pain management regimen especially critical. Despite the presence of scheduled oxycodone, the failure to consistently administer the fentanyl patch as ordered constituted a deficiency in meeting professional standards of quality for medication administration.
Failure to Follow Planned Menus and Provide Scheduled Meals
Penalty
Summary
The facility failed to follow its planned menus for three residents who were reviewed for food preferences. Multiple staff interviews revealed that the kitchen repeatedly ran out of the prepared food items listed on the dinner menu, resulting in residents being served sandwiches instead of the scheduled hot meals. This issue was observed to occur several times, particularly during dinner, and residents reported not receiving the menu items on at least three occasions. Residents were not given choices for substitute meals and expressed a preference for hot meals over cold sandwiches. The dietary manager confirmed that a cook had been replaced due to frequent failures in preparing enough food, despite receiving training and guidance on using recipes and census data to determine appropriate quantities. The dietary manager and relief cook attempted to retrain the cook, but the problem persisted. The cook admitted to being inadequately trained and unaware of tools or formulas to calculate food amounts, leading to repeated shortages and the use of sandwiches as a substitute. Personnel records indicated the cook had been formally written up for not following the menu. Interviews with other staff, including a newly hired cook, revealed that training was primarily on-the-job, with no formal skills check-off or standardized method for determining food quantities. The DON and administrator acknowledged awareness of the issue, noting that residents always received three meals but not necessarily the items listed on the menu. The administrator confirmed that the previous cook did not feel comfortable in the position due to a lack of understanding about meal preparation requirements, and that training and oversight were based on observation rather than formal assessment.
Failure to Date and Remove Expired Food in Walk-In Cooler
Penalty
Summary
Surveyors observed that the facility failed to remove expired food and did not date perishable food items stored in the walk-in cooler. During a kitchen tour with the Dietary Manager, it was found that several opened food items, including cranberry thickener, lemon thickener, blueberry muffins, and orange-flavored juice, were not labeled with dates. The Dietary Manager confirmed that all food items should be sealed, labeled, and dated when stored, and that dietary aides are responsible for regularly checking and discarding any items that are not properly sealed, labeled, dated, or have expired.
Failure to Implement Infection Control Practices During Resident Care and Glucometer Use
Penalty
Summary
Facility staff failed to implement infection control policies and procedures during high-contact care activities and the use of shared medical equipment. Nurse #12 did not don personal protective equipment (PPE) as required for enhanced barrier precautions (EBP) when providing care to a resident with a gastrostomy tube, indwelling urinary catheter, and tracheostomy tube. During medication administration and tracheostomy care, Nurse #12 did not wear a gown, gloves, or mask, and also failed to perform hand hygiene between different care activities for the same resident. Interviews with the Infection Preventionist, Director of Nursing, and Administrator confirmed that PPE should have been used for such high-contact interactions and that hand hygiene was required before moving from one body part to another. Additionally, staff did not follow the manufacturer's instructions for cleaning and disinfecting a shared blood glucose meter between resident uses. Observations showed that Nurse #14 and Nurse #15, when performing blood glucose checks for two different residents, used only one EPA-approved germicidal wipe to clean the glucometer after use, instead of using two wipes as specified in both the facility policy and the manufacturer's instructions. The first wipe was intended for cleaning, and the second for disinfection, with the device to be left visibly wet for at least two minutes. Both nurses failed to use the second wipe, and one nurse did not clean the glucometer before use. At the time of the investigation, there were three residents in the facility with bloodborne pathogens, increasing the importance of proper disinfection practices. The Infection Preventionist, DON, and Administrator all confirmed that shared glucometers should be disinfected according to policy and manufacturer guidelines to prevent the spread of bloodborne infections. The deficient practices were identified for three of six staff members observed for infection control compliance.
Failure to Post Oxygen Safety Signage for Residents Receiving Oxygen Therapy
Penalty
Summary
The facility failed to post cautionary and safety signage outside the rooms of residents who were receiving oxygen therapy. This deficiency was identified for 13 out of 36 residents reviewed for respiratory care. Multiple observations confirmed that residents were either actively receiving oxygen via nasal cannula or had oxygen equipment present in their rooms, yet there was no signage at the entrance to indicate that oxygen was in use. The absence of such signage was consistent across several residents, regardless of whether the oxygen was being administered continuously, as needed, or only at night. Specific examples included residents with physician orders for continuous or as-needed oxygen therapy, who were observed with oxygen concentrators running or oxygen tubing in place, but without any cautionary signs posted on their doors. In some cases, the oxygen concentrator was present in the room but not running at the time of observation, yet the signage was still missing. The deficiency was observed on multiple occasions for each affected resident, indicating a pattern rather than isolated incidents. Interviews with staff, including nurses, the DON, and the Administrator, revealed a lack of clarity regarding responsibility for posting the required signage. Some staff members were unaware of who should apply the signs, while others believed it was the responsibility of the person bringing the concentrator into the room, but ultimately all staff were expected to ensure signage was in place. The Administrator acknowledged that she had not noticed the absence of signage and agreed that it should be present for all residents prescribed oxygen.
Failure to Complete Timely AIMS Assessment for Resident on Antipsychotic
Penalty
Summary
The facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident who was prescribed Zyprexa, an atypical antipsychotic, for mood disorders. The resident had a history of late-onset Alzheimer's disease with behavioral disturbance, dementia with mood disturbances, recurrent major depressive disorder, major neurocognitive disorder due to dementia, generalized anxiety disorder, and primary insomnia. Physician orders indicated the resident was to receive Zyprexa twice daily, and the Minimum Data Set (MDS) confirmed regular antipsychotic use with a clinically contraindicated Gradual Dose Reduction. The last documented AIMS assessment was completed over a year prior, despite recommendations from the Consulting Pharmacist for baseline and six-monthly AIMS assessments due to the risk of extrapyramidal side effects associated with the medication. Interviews with facility staff, including the Consulting Pharmacist, Psychiatric Nurse Practitioner, Physician, Weekend Supervisor, Director of Nursing (DON), and Administrator, confirmed that AIMS assessments were expected every six months for residents on Zyprexa. The Consulting Pharmacist had recommended the assessment in April, but the DON, who was responsible for completing or delegating the task, acknowledged that the assessment was not completed as required. The facility's electronic medical record system was designed to alert staff to due assessments, but the AIMS assessment for this resident was not performed or documented within the recommended timeframe, and no further AIMS assessments were provided for review.
Failure to Consistently Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to consistently provide evening snacks to residents who requested them, as observed and confirmed through resident and staff interviews. Six cognitively intact residents, some with diagnoses including type 2 diabetes and malnutrition, reported that evening snacks were either rarely offered or not available at all, particularly during evening shifts and weekends. Residents stated that when they requested snacks, staff often informed them that the nourishment rooms were empty or that they did not have access to additional snacks from the kitchen after hours. Staff interviews corroborated these accounts, with nursing assistants indicating that nourishment rooms were frequently unstocked during evening and weekend shifts, and that dietary staff were responsible for restocking but did not always do so. Nursing staff also reported not having access to the kitchen after hours to obtain snacks for residents. The dietary manager was unaware of the issue and had not been informed that nourishment rooms were not being stocked as required during all shifts. Observations confirmed that nourishment rooms were stocked at least once, but this was not done consistently, and the dietary manager only became aware of the deficiency after being interviewed. The administrator expected snacks to always be available and was not aware of the ongoing issue. Despite an adequate supply of snacks being ordered, the process for ensuring their consistent availability to residents was not followed, resulting in residents not receiving evening snacks upon request.
Inaccurate Coding of MDS Assessments for Discharge and Dialysis
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for two residents. One resident, who was discharged from the facility, had a progress note indicating discharge home with a friend and receipt of medications, but the discharge MDS assessment incorrectly documented discharge to a short-term general hospital. This miscoding was identified during staff interviews, where it was acknowledged as a keying error. Another resident with end-stage kidney disease and an active order for hemodialysis three times weekly was not coded for dialysis on the quarterly MDS assessment. The MDS Coordinator explained that the assessment was completed by a remote nurse in training, who had the correct information but failed to code dialysis on the assessment due to oversight. Interviews with facility leadership confirmed that MDS assessments are expected to accurately reflect residents' care needs.
Failure to Develop Comprehensive Pain Management and Opioid Use Care Plan
Penalty
Summary
The facility failed to develop an individualized, person-centered comprehensive care plan addressing pain management and opioid use for a resident with multiple fractures and chronic pain. The resident was admitted with significant injuries, including fractures of the clavicle, pelvis, hip, and leg, and had a diagnosis of chronic pain. Medication orders included scheduled doses of Methadone, Cyclobenzaprine, Gabapentin, and as-needed Tylenol for pain. Despite these orders and the resident's ongoing need for pain management, a review of the comprehensive care plan did not show any interventions or plans related to pain management or opioid medication use. Further review of the resident's Minimum Data Set (MDS) assessment confirmed that the resident had moderately impaired cognition and was receiving scheduled opioid and pain medications. Medication administration records indicated that all scheduled doses were given except for one missed dose of Methadone. Interviews with the MDS Nurse and Regional MDS Coordinator confirmed that the care plan should have included pain management and opioid use, but this was overlooked. The Administrator also acknowledged that the care plan was expected to reflect the resident's clinical condition and care needs, including pain management and opioid use.
Failure to Administer Scheduled Pain Medication Due to Unavailable Stock
Penalty
Summary
A significant medication error occurred when nursing staff failed to administer a scheduled dose of Methadone to a resident with a history of multiple fractures and chronic pain. The resident was prescribed Methadone 35 mg by mouth twice daily for pain management, but the morning dose on 04/16/2025 was not given because the medication was not available at the facility. The Medication Administration Record indicated the dose was missed, and pharmacy records showed the medication was delivered later that day. The resident, who had moderately impaired cognition and a history of severe injuries from an automobile accident, reported missing the morning dose and experiencing a lack of energy that day. The resident expressed confusion about why the medication was not kept in stock, especially since it was a long-standing prescription. Interviews with nursing staff confirmed the medication was unavailable during the morning pass, and the nurse did not contact the physician but did notify the pharmacy and the oncoming nurse. Further interviews with the physician and Physician Assistant revealed they were not initially aware of the missed dose, and both emphasized the importance of having medications available and reordering before supplies run out. The Director of Nursing and the Administrator acknowledged awareness of the missed dose and stated that medications should be available as ordered, with staff responsible for timely reordering to prevent such occurrences.
Failure to Label, Store, and Secure Medications as Required
Penalty
Summary
Surveyors observed that multi-dose medication vials in both the North and South Hall medication storage rooms were not labeled with open dates as required. Specifically, an opened vial of Tuberculin Purified Protein Derivative in the North Hall refrigerator and an opened vial of Acetylcysteine Solution in the South Hall medication room were found without open dates. The Acetylcysteine vial also had an illegible pharmacy label and was not stored in the refrigerator as recommended by the manufacturer. Interviews with the DON and Administrator confirmed that vials should be labeled with open dates and stored according to manufacturer instructions, but these procedures were not followed. Additionally, during medication administration, a nurse left medication cards containing doses of midodrine and gabapentin for two residents unsecured on top of the medication cart while attending to a resident behind a privacy curtain, leaving the medications unattended and out of sight. The nurse acknowledged being nervous during observation and did not realize the medications were left out until returning to the cart. Both the DON and Administrator stated that medications should not be left unattended during administration.
Failure to Protect Resident from Misappropriation of Controlled Substance
Penalty
Summary
A deficiency occurred when a resident with a history of multiple fractures and chronic pain, who was prescribed Methadone for pain management, did not receive a scheduled morning dose of Methadone. The medication was documented as not available, despite a pharmacy delivery of Methadone tablets to the facility that afternoon. The resident's medication administration record and declining inventory sheet showed discrepancies in the documentation of Methadone administration, including missing times and doses signed out at times when the assigned nurse was not on duty. Nurse assignment records indicated that the nurse responsible for administering the Methadone was present during the relevant shifts, but failed to document the administration times accurately. The nurse admitted to administering the medication at times not consistent with the physician's order and did not contact the physician for guidance regarding the missed dose. The resident reported only receiving one dose of Methadone that day and experienced discomfort, though it was unclear if this was directly related to the missed medication. The facility's investigation revealed that the nurse signed out two doses of Methadone on the inventory sheet, with one dose recorded at a time when the nurse was not present in the facility. The physician was not informed of the missed dose, and the resident's account was later credited for the missing medication. The incident was identified through a medication count discrepancy and reported by another nurse to the Director of Nursing, prompting an internal investigation.
Failure to Follow Dialysis Care Orders and Provide Meals During Dialysis
Penalty
Summary
The facility failed to follow physician orders regarding the care of a resident requiring hemodialysis, specifically in the removal of a pressure dressing from the resident's arterial venous fistula after dialysis treatments. Despite repeated written and verbal instructions from the dialysis nurse and a physician's order to remove the dressing at 9:00 PM on designated days, the dressing was not removed as directed. This resulted in swelling at the fistula site, which prevented the dialysis center from accessing the site and led to a missed dialysis treatment. Documentation and interviews confirmed that the facility had been notified multiple times about the importance of timely dressing removal, but the order was not consistently reflected in the medication administration record prior to the incident. The resident involved had a history of end-stage kidney disease, stroke, muscle weakness, and limited mobility, and was severely cognitively impaired. The care plan included specific interventions to monitor the dialysis access site and avoid complications. However, the failure to remove the dressing as ordered was attributed by facility leadership to possible ongoing bleeding, though there was no documentation or provider notification to support this. The dialysis nurse and physician assistant both confirmed that the extended presence of the pressure dressing caused swelling and prevented the scheduled dialysis session. Additionally, the facility did not provide a bagged meal or snack for the resident during dialysis appointments, despite the resident being scheduled for dialysis during meal times. Interviews with nursing, dietary, and transportation staff revealed a lack of awareness and practice regarding the provision of meals or snacks for residents attending dialysis, and the dietary manager was unaware that such a provision was necessary. The resident typically ate breakfast before leaving for dialysis, but no arrangements were made for food during the treatment period.
Medication Error Rate Exceeds 5% Due to Omitted Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors out of 30 opportunities, resulting in a 6.67% error rate. Specifically, a resident with chronic respiratory failure, iron-deficiency anemia, and a stage 4 pressure ulcer did not receive prescribed doses of guaifenesin and multivitamin via g-tube because the medications were not available on the medication cart or in the back-up supply. The nurse on duty prepared and administered the resident's other medications but omitted the unavailable medications without notifying the provider or obtaining an order to omit the doses. Documentation on the medication administration record indicated the omission, but there were no corresponding progress notes explaining the situation. During interviews, the nurse acknowledged awareness of the missing medications and stated that she typically would notify the provider but did not do so in this instance. The Director of Nursing confirmed that the nurse should have notified the provider and that the process for unavailable medications involves reordering by the unit manager.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to adequately supervise a severely cognitively impaired resident with known wandering behaviors, resulting in the resident exiting the facility unsupervised. The resident, who had a diagnosis of dementia and diabetes mellitus, was found by a neighbor lying in a ditch beside a road after walking approximately 1/3 mile from the facility. At the time of discovery, the resident's blood sugar level was critically high at 500 mg/dL, necessitating emergency medical intervention. The incident occurred during the night shift when the resident was allowed to walk in the hallway unsupervised after becoming agitated. Staff failed to notice the resident's absence until approximately 20-30 minutes later, initiating a search that lasted about an hour before notifying the Director of Nursing (DON). The facility's security camera footage later revealed that the resident had exited through the front door, which was supposed to be locked and required a code to open. However, staff were unable to determine how the resident managed to exit, as the door was found to be functioning correctly upon inspection. Interviews with staff indicated a lack of clarity regarding the timeframe for notifying administration in the event of a missing resident. The facility's elopement policy and procedures were not effectively implemented, as evidenced by the delayed notification and search efforts. The resident's care plan identified her as an elopement risk, yet the interventions in place were insufficient to prevent her unsupervised exit from the facility.
Accident Hazard in Resident Smoking Area
Penalty
Summary
The facility failed to remove an accident hazard from the resident smoking area, specifically a gas grill with two propane tanks. The grill was placed approximately six feet from the smoking area, which was occupied by 21 residents who were actively smoking and using vapes. The facility's smoking policy, last revised on 4/16/24, did not include guidelines for the storage and use of propane tanks in the resident smoking area. The Activity Director and Maintenance Director were unaware of any regulations regarding the proximity of the grill and propane tanks to the smoking area. The Maintenance Director had placed the grill in the area for an upcoming cookout and removed it after being informed of the potential hazard. The Administrator confirmed that the smoking policy lacked information about gas grills in the smoking area and acknowledged the need to move the grill for resident safety.
Failure to Protect Residents from Sexual and Physical Abuse
Penalty
Summary
The facility failed to protect Resident #3 from sexual abuse by another resident, Resident #52, who had a history of sexually inappropriate behaviors. Resident #3 had severely impaired cognition, while Resident #52 had moderately impaired cognition. Incidents on 3/25/23, 7/25/23, and 1/30/24 involved Resident #52 inappropriately touching Resident #3, including an incident where Resident #52 was found with his hand inside Resident #3's incontinent brief with skin-to-skin contact, causing Resident #3 to express distress. The facility also failed to prevent resident-to-resident abuse when another resident punched Resident #30 in the face. Immediate jeopardy was identified on 1/30/24 and removed on 4/22/24 after implementing measures to address the deficiency. Resident #52's care plan indicated a history of sexually promiscuous behaviors, with interventions to address such behaviors. However, no revisions were made to the care plan after the incidents involving Resident #3. Resident #52 was prescribed medications for depression and sexually inappropriate behavior, with observations of confusion and insomnia noted in the medical records. The facility's staff, including Nurse #2 and Nurse #3, were involved in incidents where Resident #52 was found inappropriately interacting with Resident #3, but there were gaps in reporting and addressing the concerning behaviors promptly.
Failure to Assess Resident After Fall
Penalty
Summary
The facility failed to assess a resident after a fall prior to moving them from the floor. Resident #103, who was severely cognitively impaired and totally dependent on staff for transfers, fell during a transfer at the dialysis center. The resident was moved off the floor by Nurse Aides (NAs) without being assessed for injuries, resulting in a clavicle fracture and right ankle strain. The incident occurred when the NAs attempted to manually transfer the resident from the dialysis chair to the transport chair, leading to the resident's knee buckling and the resident being assisted to the floor. Despite hearing a pop and the resident expressing pain, the NAs, along with a dialysis technician, lifted the resident back into the chair without a nurse's assessment. The Transportation Driver witnessed the incident and reported that the dialysis nurse initially refused to manually transfer the resident due to policy violations. The NAs were unable to use the lift sling they brought from the facility and decided to transfer the resident manually. During the transfer, the resident's knee buckled, and she was assisted to the floor. The NAs and a dialysis technician then lifted the resident back into the chair, during which the resident complained of pain and a pop was heard. The dialysis nurse assessed the resident afterward and called Emergency Medical Services (EMS), who transported the resident to the hospital. The hospital discharge summary confirmed that the resident sustained a left clavicle fracture and a right ankle strain. The Director of Nursing (DON) and the Medical Director both stated that the facility's policy required a nurse to assess a resident after a fall before moving them. However, the NAs present at the dialysis center did not assess the resident, and the DON was unaware of the dialysis center's protocols for handling falls or injuries. The resident returned to the facility with a sling for the clavicle fracture and was monitored for pain, receiving acetaminophen and later oxycodone for pain management.
Failure to Ensure Safe Transfers and Prevent Injuries
Penalty
Summary
The facility failed to ensure a resident was transferred safely, resulting in Resident #103 sustaining a fractured left clavicle and a sprained right foot. Resident #103, who was severely cognitively impaired and totally dependent on staff for transfers, was transferred manually by two nurse aides after her dialysis treatment without the use of a mechanical lift, contrary to her care plan. The incident occurred when the nurse aides were unable to place the lift sling under the resident and decided to transfer her manually, leading to the resident's knee buckling and her being assisted to the floor. During the lift from the floor, a pop was heard, and the resident complained of pain, leading to her being sent to the hospital where the injuries were confirmed. The facility's Director of Nursing (DON) and other staff acknowledged that the resident should have been transferred using a mechanical lift as per her care plan, and the nurse aides involved were provided with additional training on the use of slings and lifts after the incident. The facility also failed to prevent Resident #37 from obtaining skin tears when a nurse aide continued to provide care after the resident became combative. Resident #37, who had severe cognitive impairment and a history of being combative with care, sustained multiple skin tears on his arms after hitting them on the headboard and siderail while resisting care. The nurse aide involved admitted to continuing care despite the resident's resistance and not seeking assistance from another staff member. The incident was reported the following day, and the nurse aide was suspended and later counseled on the proper procedure for handling combative residents. Both incidents highlight the facility's failure to adhere to established care plans and protocols for resident safety and supervision. The deficiencies were identified through observations, record reviews, and interviews with various staff members, residents, and family members. The facility's policies and procedures for transferring residents and managing combative behavior were not followed, leading to preventable injuries for the residents involved.
Failure to Honor Residents' Smoking Preferences
Penalty
Summary
The facility failed to honor the residents' choice to smoke tobacco cigarettes, affecting two residents who preferred smoking tobacco over vaping. Resident #26, who was admitted to the facility and had intact cognition, expressed his preference for smoking tobacco cigarettes. Despite this, the facility's smoking policy change in February 2024 only allowed residents to vape using electronic cigarettes. The current Administrator, who was in training during the policy change, acknowledged that Resident #26 had voiced his preference during a Resident Council Meeting. The former Administrator stated that the decision was made by the Interdisciplinary Team (IDT) to ensure safety and infection control, as smoking required a higher level of supervision and staff involvement. However, the former Administrator did not recall any specific resident voicing a preference for tobacco cigarettes over vaping and did not consider the residents' rights in this decision. Resident #26 confirmed that he was waiting for a family member to bring him tobacco cigarettes and did not want to vape using an electronic cigarette. Resident #69, who had moderate cognitive impairment and used a manual wheelchair, was also affected by the policy change. Her smoking assessments indicated that she could smoke safely with supervision and had been smoking tobacco cigarettes when she first moved into the facility. However, after the policy change, she was observed smoking an e-cigarette. During an interview, Resident #69 indicated through gestures that she preferred smoking tobacco cigarettes over vaping. The current Administrator confirmed that the previous Administrator and Director of Nursing (DON) made the decision to change the smoking policy, and the previous Administrator reiterated that the decision was made for safety reasons and did not consider the residents' rights. Both residents' preferences for smoking tobacco cigarettes were not honored due to the facility's policy change, which only allowed vaping. The decision was made by the facility's governing body and the IDT, focusing on safety and infection control concerns without adequately considering the residents' rights and preferences. The current Administrator acknowledged the need to review the regulations related to smoking and indicated that the facility might need to change the smoking policy to allow residents who smoked tobacco cigarettes before the policy change to continue doing so.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents. Observations revealed that bathroom doors in several rooms had missing and splintered wood surfaces, and metal door frames had scuffed areas with exposed bare metal. Specifically, the bathroom doors in rooms 111, 215, and 219 were found to have significant damage below the doorknob and along the edges, with the metal door frames showing paint loss up to knee height. Additionally, the footboard of bed B in room 214 was damaged, with a rough and jagged surface area approximately 16 inches long, and the entrance door to the room was missing its smoother outer veneer, making it rough and splintered to touch. The Maintenance Director acknowledged the issues and explained that staff reported environmental concerns using an online maintenance reporting application. However, the main focus of the maintenance team was remodeling the therapy hall, which delayed repairs in resident areas. The Maintenance Director also mentioned that supplies needed for repairs had been on order for approximately one and a half months, but the list of rooms needing repairs did not include the identified rooms. The Administrator confirmed that the Regional Maintenance Director was on leave and that the facility would seek alternative solutions to address the repair needs promptly.
Consultant Pharmacist Failed to Identify Drug Irregularities
Penalty
Summary
The Consultant Pharmacist failed to identify drug irregularities and provide recommendations for a resident who was receiving Risperdal, an antipsychotic medication. The resident, diagnosed with non-Alzheimer's dementia, anxiety disorder, and depression, had been receiving Risperdal 0.5 mg three times daily since its initiation. Despite the requirement for abnormal involuntary movements assessments at least once every six months, the last documented assessment for the resident was on 01/08/23. The Consultant Pharmacist conducted monthly medication regimen reviews over the past 12 months but did not make any recommendations regarding the missing assessments. Interviews with facility staff, including a nurse, the Medical Record Coordinator, the Director of Nursing (DON), and the Administrator, revealed that the facility had not performed the required assessments due to a transition from paper-based to electronic medical records and frequent changes in leadership. The DON and Administrator both expected the Consultant Pharmacist to alert the facility when such assessments were not in place. The Consultant Pharmacist acknowledged the oversight and the importance of conducting these assessments to detect movement disorders early.
Failure to Limit PRN Psychotropic Medication Duration and Monitor for Abnormal Involuntary Movements
Penalty
Summary
The facility failed to limit the duration of a psychotropic medication ordered on an as-needed (PRN) basis to 14 days and did not document the rationale for extending the PRN order beyond 14 days for a resident with anxiety disorder. Despite recommendations from the Consultant Pharmacist to limit the PRN Lorazepam order to 14 days, the Physician Assistant and Medical Director continued the order without a stop date, citing the resident's need for the medication due to agitation and behaviors. The Director of Nursing acknowledged the oversight but was unsure if the Physician Assistant intended to review the order every 14 days. Additionally, the facility failed to monitor for abnormal involuntary movements in a resident receiving an antipsychotic medication for mood disorders. The resident had been on Risperdal for over a year, but the last documented assessment for abnormal involuntary movements was more than a year ago. Interviews with nursing staff and the Medical Record Coordinator confirmed the lack of recent assessments, and the Director of Nursing attributed the lapse to the transition from paper-based to electronic medical records and frequent changes in leadership. The Consultant Pharmacist emphasized the importance of conducting abnormal involuntary movements assessments at least every six months for residents on antipsychotic medications to prevent delays in detecting movement disorders. The facility's Administrator acknowledged the issue and attributed it to the frequent changes in the Director of Nursing position over the past year.
Medication Management Deficiencies
Penalty
Summary
The facility failed to properly label and manage medications, leading to several deficiencies. During a medication storage audit, it was found that an insulin Lantus pen in the Seafoam Hall medication cart was not dated when opened, and an insulin Lispro pen was expired. Nurse #4, who was present during the audit, confirmed these findings and admitted to not frequently working with the Seafoam Hall medication cart. Additionally, in the South medication storage room, expired Coenzyme Q-10 soft gels and zinc supplements were found, despite Unit Manager #1's responsibility to check the storage room weekly. She acknowledged the presence of expired medications and explained that they were rarely used by residents in recent months. Further deficiencies were noted in the Silver Hall medication cart, where an expired bottle of calcium citrate was found. Nurse #5, who was present during the audit, stated that she did not regularly work with the Silver Hall medication cart and usually checked her assigned cart in the Blue Hall weekly. The Director of Nursing (DON) and the Administrator both confirmed that nurses were instructed to date insulin upon opening and to audit medication carts weekly, attributing the lapses to carelessness and distractions. The expectation was for all expired medications to be removed promptly and for insulin to be dated when opened.
Facility Fails to Maintain Kitchen Cleanliness
Penalty
Summary
The facility failed to maintain cleanliness in several areas of the kitchen, which had the potential to affect all residents. Observations revealed a build-up of grey/black fuzzy substance in the walk-in refrigerator, which remained unchanged even after a follow-up observation. The Dietary Manager (DM) acknowledged that the refrigerator was on a cleaning schedule but admitted the substance was an oversight. Additionally, the oil fryer area had a significant build-up of food particles and grease, which was not cleaned as required. The DM confirmed that this area should have been cleaned nightly but was overlooked. Further observations found a thick build-up of crumbly debris on the circulatory fans in the walk-in freezer, which were not included in the cleaning schedule. The top shelf of a rack containing ready-to-use utensils and cookware also had a thick, fluffy, and crumbly substance, indicating it was not cleaned as per the routine schedule. The DM admitted these areas were overlooked, and the Administrator confirmed that the cleaning needed to be more detailed.
Repeat Deficiencies in Abuse Prevention, Accident Hazards, and Medication Storage
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to maintain and monitor interventions following multiple recertification and complaint investigation surveys. This resulted in repeat deficiencies in areas such as accident hazards/supervision, medication storage, and abuse. Specifically, the facility failed to protect a resident's right to be free of sexual abuse from another resident. One resident with severely impaired cognition was sexually abused by another resident with moderately impaired cognition and a history of sexual behaviors. Additionally, the facility failed to prevent physical abuse when a resident punched another resident, causing injury. These incidents affected multiple residents reviewed for abuse. The facility also failed to ensure safe transfer practices, resulting in a resident sustaining a fractured clavicle and a sprained foot. Another resident obtained skin tears due to improper handling during care. Furthermore, the facility did not adhere to proper medication storage protocols, failing to record the opening date for insulin, remove expired insulin, and discard outdated medications and supplements. The Administrator admitted to attending only one QAPI meeting since starting at the facility, attributing the repeat citations to changes in management and lack of consistency.
Leaking Drainpipe in Kitchen Sink
Penalty
Summary
The facility failed to maintain the two-compartment sink in the kitchen, as evidenced by a leaking drainpipe. During an observation with the Dietary Manager (DM), water was seen dripping from a pipe connection on the sink's drain trap onto the kitchen floor. The DM and the assistant DM were both unaware of the leak, and the sink had recently been used to rinse food. The Maintenance Manager, interviewed the following day, also stated he was unaware of the leak and confirmed that no work order had been submitted prior to the observation. The Administrator was similarly unaware of the issue and acknowledged that the leaking drainpipe should have been reported for repair.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess whether a cognitively impaired resident, diagnosed with dementia, had the ability to self-administer eye drops and a medicated cream. The resident had been self-administering cyclosporine eye drops and nystatin cream without a physician's order or an assessment to determine if it was clinically appropriate. The resident's care plan did not include any focus area for self-administration of these medications, and there was no documentation in the medical records to support the resident's ability to self-administer the medications. During observations, the medications were found on the resident's overbed table, and the resident confirmed self-administration. The assigned nurse and the Director of Nursing acknowledged that the resident's ability to self-administer medications needed to be assessed and that a physician's order was required. The Administrator also confirmed that the medications should be locked up and that the resident needed to be assessed by the Interdisciplinary Team for the ability to self-administer medications.
Failure to Timely Report Abuse Incidents
Penalty
Summary
The facility failed to file a report with the state agency within the required 2-hour timeframe for an incident of resident-to-resident abuse involving two residents and an allegation of employee-to-resident abuse involving another resident. Specifically, an incident occurred where one resident was found with his hand inside the brief of another resident, who was heard saying 'stop you're hurting me.' This incident was documented by a nurse, but the initial allegation report was not submitted to the state agency until several hours later. Additionally, there was no documentation regarding the notification of Adult Protective Services (APS) within the required timeframe. In another case, a resident with severe cognitive impairment alleged that a nursing assistant was rough during care, resulting in multiple skin tears. The initial allegation report for this incident was also not submitted within the required 2-hour timeframe. The nursing assistant involved stated that the resident became combative during care, which led to the injuries. The administrator, who was in training at the time, followed federal regulations as she understood them but did not adhere to the facility's abuse policy regarding timely notification of the state agency and APS. Interviews with the former Director of Nursing and the current Administrator revealed confusion and miscommunication regarding the reporting requirements. The former Director of Nursing was not present during the initial incident and assumed that the social worker would notify APS. The Administrator, who was in training, relied on federal guidelines rather than the facility's specific policy, leading to delays in reporting both incidents to the appropriate authorities.
Inaccurate MDS Coding for Behaviors and Discharge Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in the documentation of behaviors and discharge status. Resident #264, who was admitted with dementia and agitation, was monitored for wandering behaviors and had a physical altercation with another resident. However, the discharge MDS did not reflect these wandering behaviors, which was confirmed as an oversight by the Social Worker responsible for coding the MDS. The Director of Nursing and the Administrator both acknowledged that the MDS should have accurately reflected the resident's behaviors. Resident #113 was discharged home, but the discharge MDS incorrectly indicated that the resident was discharged to a short-term general hospital. The Director of Nursing, who was acting as the MDS Coordinator at the time, admitted to making an error by accidentally selecting the wrong discharge status. These inaccuracies in MDS coding highlight deficiencies in the facility's assessment and documentation processes.
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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