Greenhaven Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensboro, North Carolina.
- Location
- 801 Greenhaven Drive, Greensboro, North Carolina 27406
- CMS Provider Number
- 345132
- Inspections on file
- 20
- Latest survey
- September 4, 2025
- Citations (last 12 mo.)
- 14 (2 serious)
Citation history
Health deficiencies cited at Greenhaven Health And Rehabilitation Center during CMS and state inspections, most recent first.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
A resident with severe cognitive impairment and a history of stroke received aspirin every other day without a specified dosage in the medication order. Nursing staff administered 81 mg based on assumption, and the DON confirmed the order lacked required clarification. The deficiency was identified during a surveyor review.
Three residents were not offered the pneumococcal 20-valent conjugate vaccine (PCV20) as recommended by CDC/ACIP guidelines. Facility records showed that these residents had either declined older pneumococcal vaccines or had no documentation of being offered PCV20, and the facility's immunization policy did not include PCV20. The DON/Infection Preventionist was unaware of the requirement to offer PCV20, resulting in the deficiency.
Over a four-month period, the facility did not act upon or resolve grievances raised by the Resident Council, including concerns about cleanliness, call bell response times, missing items, and staff conduct. Grievances were not documented, investigated, or followed up on as required, and residents were not informed of any actions taken, as confirmed by staff and resident interviews.
A resident with severe cognitive impairment and a history of intracerebral hemorrhage was admitted and had a baseline care plan completed, but the facility did not provide a copy of this care plan to the responsible party as required. Staff and leadership interviews confirmed the expectation to deliver the care plan within 48 hours, but there was no documentation or confirmation that this occurred.
A resident with severe cognitive impairment and a history of stroke received aspirin every other day without a specified dosage in the physician's order. Despite repeated consultant pharmacist recommendations to clarify the dosage, the facility did not address the issue, and nursing staff administered 81 mg aspirin based on assumption rather than a documented order. The DON was unaware of the unresolved recommendations until notified by surveyors.
A resident was not protected from the wrongful use of their belongings or money, as required. The facility failed to ensure proper safeguarding, resulting in unauthorized use.
A resident with a history of cardiac arrhythmia, dementia, and hypertension, who had documented bilateral cataracts and blurred vision, was not accurately coded for visual impairment on MDS assessments. Despite medical records and resident reports indicating vision problems, staff responsible for completing the MDS were unaware of the ophthalmology findings and coded the resident as having adequate vision, omitting necessary care plan interventions.
A resident who was non-ambulatory and dependent on staff for personal hygiene had overgrown, thick, and yellow toenails. Despite being unable to have her toenails trimmed by nursing staff and expressing a desire for podiatry care, no podiatry consult was arranged or documented. Communication lapses between a nursing assistant and nurse, as well as a missed opportunity to refer the resident to the podiatrist after she declined nail care, led to the deficiency.
A resident with severe cognitive impairment was sexually abused by his roommate, who was also cognitively impaired. Staff discovered the incident during rounds, finding one resident fondling the other's genitals while the latter was asleep and unable to defend himself. There was no prior history of sexually inappropriate behavior by the perpetrator, and both residents had significant dementia. The incident was directly observed and confirmed by staff, and the affected resident's family confirmed his inability to protect himself.
A nursing assistant observed a resident sexually assaulting another cognitively impaired resident and, instead of remaining in the room to protect the victim as required by facility policy, left to seek help from another staff member. The staff member was aware of the policy to stay with the resident and use available means to call for assistance but chose to leave the room, resulting in a failure to ensure immediate resident safety during the incident.
The facility failed to allow residents assessed as safe smokers to smoke independently at any time of their choice, enforcing a strict smoking schedule instead. This deficiency affected multiple residents who expressed dissatisfaction with the restricted smoking times, despite being assessed as safe smokers.
The facility failed to update care plans for four residents to reflect their current Smoking Evaluations and Advance Directives. Three residents had their Smoking Evaluations updated to show they could smoke independently, but their care plans still required supervision. Another resident's care plan was not updated to reflect a change to Do Not Resuscitate (DNR) status.
The facility's QAA Committee failed to maintain procedures and monitor interventions, resulting in repeated deficiencies in Grievances, Care Plan timing/revision, and Medication Storage. The facility did not investigate and resolve grievances for five residents, failed to update care plans for four residents, and improperly managed medication storage, including the removal of expired medications and proper labeling of inhalers and multidose vials.
The facility failed to monitor antibiotic usage for six months, from August 2023 to January 2024, as required by its Antibiotic Stewardship policy. The ADON could not locate the necessary information, and the previous ADON responsible for the program left in December 2023. The DON confirmed that the monitoring was not conducted as expected.
The facility failed to document COVID-19 vaccine education for five residents and did not offer the vaccine to three of these residents. Interviews revealed that consents and educational materials were missing from the records, indicating a lapse in documentation and infection control procedures.
A facility failed to apply a prescribed splint for a resident with a left-hand contracture. Despite physician orders and occupational therapy recommendations, the splint was not consistently applied, and staff were unaware of the resident's need for the splint. Observations confirmed the splint was not in place, and staff interviews revealed a lack of knowledge about the splint's application and location.
The facility failed to remove expired medications and supply kits from the medication storage room. Observations revealed expired multi-dose vials of Influenza Vaccine and Levemir insulin, as well as expired Secondary Administration Sets, Dressing Change Tray, Foley Catheter Insertion Tray, and Pivodon-Iodine Swab sticks. Staff interviews indicated that nurses were responsible for discarding expired items, but this was not consistently done.
The facility failed to administer influenza and pneumonia vaccines to two residents who had signed consent forms. Both the Infection Preventionist and the DON were unaware of why the vaccines were not given, despite the consents being in place.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Clarify Aspirin Dosage in Medication Order
Penalty
Summary
The facility failed to ensure that medication orders for a resident met professional standards of quality, specifically by not clarifying the dosage of aspirin to be administered. A resident with a history of dementia, cerebral stroke syndrome, and cerebrovascular disease was admitted with an order for aspirin to be given every other day, but the dosage was not specified in the Medication Administration Record (MAR) from January to July 2025. Despite this omission, nursing staff administered 81 mg of aspirin every other day from the facility's over-the-counter stock, based on the nurse's assumption and belief in a standing order, which was not present in the resident's physician orders. Interviews revealed that the nurse responsible for administering the medication was unaware of the missing dosage in the original order and relied on her understanding of typical practice for residents with a history of stroke. The Director of Nursing confirmed that there were two available dosages of aspirin in stock (81 mg and 325 mg) and acknowledged that the order should have been clarified to specify the correct strength. The issue was only identified after surveyor intervention, and the resident's physician was not available for interview during the survey.
Failure to Offer Pneumococcal 20-Valent Conjugate Vaccine to Eligible Residents
Penalty
Summary
The facility failed to offer the pneumococcal 20-valent conjugate vaccine (PCV20) to three out of five residents reviewed for pneumococcal immunizations. According to the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP), adults aged 65 years or older, and those aged 19-64 with certain underlying medical conditions, should be routinely offered PCV20 or PCV15 if they have not previously received a pneumococcal conjugate vaccine or if their vaccination history is unknown. Record reviews showed that residents had either declined older pneumococcal vaccines (PCV13 or PPSV23) or there was no documentation of being offered PCV20, and there was no evidence that PCV20 was offered or administered since the last recertification or prior to admission. The facility's immunization policy, last reviewed in March 2024, only referenced offering PCV13 or PPSV23, not PCV20. Documentation for the affected residents did not indicate that PCV20 was offered or declined, and there was no record of prior receipt of PCV20. During an interview, the DON/Infection Preventionist stated she was unaware of the need to offer PCV20 and confirmed that the facility had only been offering PCV13 and PPSV23 to residents.
Failure to Address and Communicate Resident Council Grievances
Penalty
Summary
The facility failed to act upon and resolve grievances reported by the Resident Council over a four-month period, as evidenced by record review, staff, and resident interviews. Resident Council minutes from March through June documented multiple grievances, including issues with cleanliness, call bell response times, missing personal items, staff attitudes, and inadequate assistance during certain shifts. Despite these concerns being voiced during meetings, there was no evidence that the grievances were recorded on the Facility Concern/Grievance Form, investigated, or resolved as required by the facility's grievance policy. Additionally, there was no documentation of follow-up or communication to the Resident Council regarding the status or resolution of their concerns. Interviews with the Activities Director and Administrator confirmed that while Resident Council minutes were provided to the Administrator, neither party completed grievance forms for council concerns nor documented actions taken to address them. The Activities Director was unaware of the requirement to follow up with the Resident Council, and the Administrator acknowledged that actions to address grievances were not documented or communicated. Residents reported that their repeated grievances were not addressed or followed up on, indicating a systemic failure to manage and resolve Resident Council concerns in accordance with facility policy.
Failure to Provide Baseline Care Plan to Responsible Party
Penalty
Summary
The facility failed to provide a copy of the baseline care plan to the responsible party for one resident who was admitted and later readmitted with a diagnosis that included non-traumatic intracerebral hemorrhage and was noted to be severely cognitively impaired. Documentation showed that a baseline care plan was completed by a unit manager within the required timeframe, but there was no evidence in the medical record that a copy of this care plan was given to the resident or the responsible party, despite the resident having a family member listed as the responsible party. Multiple attempts to interview the responsible party were unsuccessful, and staff interviews revealed that the admitting nurse did not complete or provide a summary of the baseline care plan. Further interviews with facility leadership, including another unit manager and the DON, confirmed that the expectation was for the baseline care plan to be developed and provided to the resident or responsible party within 48 hours of admission. However, the DON could not confirm that the summary was ever provided in this case. The administrator also stated that it was expected for the resident and/or responsible party to receive a written summary of the baseline care plan within 48 hours, but this did not occur for the resident in question.
Failure to Address Pharmacist's Recommendation for Aspirin Dosage Clarification
Penalty
Summary
The facility failed to address discrepancies identified by the consultant pharmacist regarding a resident's aspirin order. The resident, who had diagnoses including dementia, cerebral stroke syndrome, and cerebrovascular disease, was admitted with severe cognitive impairment and a history of stroke. The resident's Medication Administration Records over several months included an order for aspirin every other day, but the strength of the medication was not specified. The consultant pharmacist noted the missing dosage in multiple monthly reviews, but there was no documentation that the facility addressed or clarified the recommendation. Interviews revealed that a nurse administered 81 mg aspirin every other day from the facility's stock, believing it was the correct order, despite the absence of a specific physician's order for aspirin. The DON, who had recently assumed her role, discovered that several pharmacy recommendations, including the missing dosage clarification, had not been completed by previous nursing leadership. The DON was unaware of the missing dosage until it was brought to her attention by surveyors.
Failure to Protect Resident's Belongings or Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report notes that there was a failure to safeguard a resident's personal property or funds, resulting in unauthorized or inappropriate use. Specific details about the actions or inactions that led to this event are not provided in the report excerpt. No additional information about the resident's medical history or condition at the time of the deficiency is included.
Failure to Accurately Code MDS Assessment for Visual Impairment
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of vision for a resident with a history of cardiac arrhythmia, dementia, and essential hypertension. The resident's electronic medical record included an ophthalmology consultation that documented bilateral cataracts and blurred vision, with cataract surgeries scheduled but delayed due to a hospital stay. Despite this, both the Significant Change in Status and the most recent MDS assessments completed by two different MDS nurses indicated the resident had adequate vision and corrective lenses, with no mention of visual impairment or cataracts in the care plan. Interviews with the resident confirmed ongoing difficulty with vision, and staff interviews revealed that the MDS nurses were unaware of the ophthalmology findings at the time of assessment. Both nurses acknowledged that the resident should have been coded for visual impairment based on the available medical information. The administrator also confirmed that the MDS assessments should have accurately reflected the resident's medical condition.
Failure to Arrange Podiatry Care for Dependent Resident
Penalty
Summary
A resident with a history of cellulitis of the left lower limb, chronic kidney disease, and congestive heart failure was admitted to the facility and was dependent on staff for personal hygiene, including nail care. The resident was non-ambulatory and cognitively intact. During a quarterly assessment, it was noted that the resident's great toenails were long, thick, and yellow, extending beyond the end of the toes. The resident reported that nursing staff had not offered a podiatry consult and expressed a desire for a podiatry visit from the facility's onsite provider. There was no documentation in the medical record indicating that the resident had been seen by podiatry. A nursing assistant observed the resident's toenails to be overgrown and reported feeling unable to trim them, stating she notified a nurse of the need for a podiatry consult. However, the nurse was unaware of this report and had not initiated a consult. The DON stated that toenail care was to be provided by nursing staff, and if unsuccessful, a podiatry consult should be offered. The DON confirmed that although an attempt to trim the resident's toenails was made in May, which the resident declined, a podiatry consult was not offered at that time as required.
Failure to Protect Resident from Sexual Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment was not protected from sexual abuse by another resident. The incident involved two male residents, both diagnosed with dementia and significant cognitive deficits. One resident, who was dependent for most activities of daily living and unable to protect himself, was found in his bed with his brief open while his roommate was observed by staff to be fondling his genitals. The cognitively impaired resident was asleep and unable to respond or defend himself during the incident. Staff interviews and written statements confirmed that the inappropriate contact was directly observed by a nurse aide and a medication aide, who intervened to stop the behavior. Prior to this event, there was no documented history or care plan indication that the resident who initiated the contact had exhibited sexually inappropriate behaviors. Both residents had been roommates for approximately two weeks, and staff had not reported any prior concerns regarding inappropriate touching or aggression between them. The incident was discovered during routine rounds, and staff responded by separating the residents and assessing for injuries, of which none were found. The resident who was abused was severely cognitively impaired, unable to recall the incident, and had a history of behavioral disturbances but no recent behaviors. The other resident also had significant cognitive and intellectual deficits and was not aware of his actions. The family of the abused resident expressed that he would have been unable to defend himself and would have been upset by such an incident. The facility's failure to anticipate or prevent this event, despite both residents' vulnerabilities, resulted in a violation of the requirement to protect residents from all forms of abuse, including sexual abuse.
Failure to Follow Abuse Policy During Resident-to-Resident Sexual Assault
Penalty
Summary
The facility failed to follow its abuse prevention policy when a nursing assistant (NA) observed a resident-to-resident sexual assault and left the room to seek assistance, rather than remaining with the resident to ensure their immediate safety. The incident involved two residents who were roommates, both of whom had significant cognitive impairments. During routine rounds, the NA discovered one resident touching the genitals of the other, who appeared to be sleeping and had removed his own undergarment. The NA attempted to verbally redirect the resident but was unsuccessful, prompting her to leave the room to find help from another staff member. Upon returning to the room with a medication aide (MA), the staff intervened and separated the residents. The MA then called a nurse for further assistance. Interviews with staff confirmed that the NA was aware of the facility's policy, which required staff to remain with the resident and ensure their safety during incidents of abuse, using available means such as the call light, calling out for help, or using a phone. Despite this training, the NA chose to leave the room, believing it would be faster to get help in person rather than using the call light. The facility's abuse policy, last revised in 2017, specifically states that all necessary steps must be taken to prevent further acts of abuse and that staff are to be trained and retrained regularly on these procedures. Multiple staff interviews, including those with supervisory and administrative personnel, confirmed that the NA's actions were inconsistent with facility policy and expectations. The incident directly affected one of the two residents reviewed for abuse and was substantiated through record review and staff interviews.
Facility Restricts Smoking Times for Safe Smokers
Penalty
Summary
The facility failed to allow residents assessed to be safe smokers the ability to smoke independently at any time of their choice. This deficiency was identified through observations, resident and staff interviews, and record reviews. The facility's Smoking Policy, revised on 10/15/22, stated that residents identified as safe smokers could smoke unsupervised at any time. However, the facility enforced a strict smoking schedule, limiting smoking times to 11:00 AM, 2:00 PM, and 5:00 PM, even for residents assessed as safe smokers. Resident #47, with intact cognition and a history of diabetes and stroke, was assessed as a safe smoker on 3/2/24. Despite this assessment, the resident reported being restricted to the designated smoking times. Similarly, Resident #8, with intact cognition and a history of diabetes and cerebrovascular disease, was also assessed as a safe smoker but was limited to the same smoking schedule. Resident #69, with moderately impaired cognition and a history of non-traumatic spinal cord dysfunction, expressed dissatisfaction with the restricted smoking times despite being assessed as a safe smoker. Interviews with the Activities Director and the Interim Administrator confirmed that the supervised smoking schedule applied to all smokers, regardless of their assessment status. The Interim Administrator acknowledged that the issue needed to be addressed, indicating that the supervised smoking schedule was already in place when he assumed his role in mid-January. This practice of restricting smoking times for safe smokers was contrary to the facility's policy and the residents' rights to self-determination and choice.
Failure to Update Care Plans for Smoking Evaluations and Advance Directives
Penalty
Summary
The facility failed to review and revise the care plans for four residents as required. Resident #47, #8, and #69 had their Smoking Evaluations updated to reflect that they were safe, independent smokers, but their care plans were not revised accordingly. Resident #47's care plan still indicated the need for supervision while smoking, despite the evaluation showing they could smoke independently. Similarly, Resident #8's care plan continued to list them as an unsafe smoker requiring supervision, and Resident #69's care plan did not reflect their ability to smoke independently as per the latest evaluation. Interviews with the Director of Nursing and the MDS nurse confirmed that the care plans were not updated to match the Smoking Evaluations, and the MDS nurse acknowledged the need to modify the care plans to reflect the current evaluations accurately. Additionally, Resident #46's care plan was not updated to reflect a change in their Advance Directive. The resident had a physician's order to change their code status to Do Not Resuscitate (DNR) on 1/4/24, and a signed DNR form was present in the paper chart. However, the care plan revised on 1/25/24 still indicated a full code status. The MDS nurse confirmed that she missed updating the care plan to reflect the new DNR order. The facility's Administrator also acknowledged that the care plan should have been updated to reflect the correct code status. These deficiencies indicate a failure in the facility's process for ensuring that care plans are reviewed and revised in a timely manner to reflect significant changes in residents' evaluations and medical directives. The discrepancies between the Smoking Evaluations and the care plans, as well as the failure to update the code status in the care plan, were confirmed through staff interviews and record reviews.
Repeated Deficiencies in Grievances, Care Plan Timing/Revision, and Medication Storage
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions following recertification and complaint surveys. This resulted in repeated deficiencies in the areas of Grievances, Care Plan timing/revision, and Medication Storage. Specifically, the facility did not investigate and resolve grievances for five residents, failed to review and revise care plans for four residents, and did not properly manage medication storage, including the removal of expired medications and proper labeling of inhalers and multidose vials. These issues were identified during surveys conducted on 4/12/21, 1/13/23, and 3/14/24, indicating a pattern of the facility's inability to sustain an effective QAA program. For Grievances, the facility failed to investigate and resolve grievances for five residents and did not maintain evidence demonstrating the results of the grievances. In the area of Care Plan timing/revision, the facility did not update care plans to reflect changes in residents' conditions, such as smoking evaluations and advance directives. Regarding Medication Storage, the facility did not remove expired medications, label inhalers and multidose vials correctly, or store medications as per pharmacy instructions. These repeated deficiencies highlight the facility's ongoing challenges in maintaining compliance with regulatory standards.
Failure to Monitor Antibiotic Usage
Penalty
Summary
The facility failed to monitor antibiotic usage for six out of thirteen months reviewed, specifically from August 2023 to January 2024. The facility's policy on Antibiotic Stewardship, revised in March 2024, mandates the monitoring of antibiotic use as part of its infection prevention control program. During an interview, the Assistant Director of Nursing (ADON) was unable to locate antibiotic stewardship information for the specified months. The Regional Nurse Consultant indicated that the previous ADON, who was responsible for the antibiotic stewardship, left in December 2023, and attempts to contact her were unsuccessful. The Director of Nursing (DON) stated that the expectation was to monitor antibiotics and infections from the first day of antibiotic use, ensuring necessity, tracking, and trending infections, and reviewing specifics monthly. However, this monitoring was not conducted for the months in question.
Deficiency in COVID-19 Vaccine Documentation and Offering
Penalty
Summary
The facility failed to document the education regarding the benefits and potential side effects of the COVID-19 immunization for five residents and did not offer the COVID-19 vaccine to three of these residents. Specifically, the medical records for Residents #46, #14, #26, #33, and #54 lacked documentation of education about the COVID-19 vaccine. Additionally, Residents #26, #33, and #54 were not offered the vaccine, and their vaccination status was not recorded in their medical records. These deficiencies were identified through record reviews and staff interviews, revealing gaps in the facility's infection control practices. Interviews with the Infection Preventionist and the Director of Nursing (DON) highlighted the facility's inability to locate consents and educational documentation regarding the COVID-19 vaccine. The Infection Preventionist, who had been employed for 1.5 weeks, indicated that some consents were in the computer while others were on paper, but none could be found. The DON confirmed that the vaccine process was initiated upon admission, but the consents and educational materials were missing from the records, indicating a lapse in the facility's documentation and infection control procedures.
Failure to Apply Prescribed Splint for Resident with Contracture
Penalty
Summary
The facility failed to apply a prescribed splint for a resident with a left-hand contracture. Resident #33, who was admitted with diagnoses including hypertension, diabetes, cerebral vascular accident, and left-hand contracture/hemiparesis, was documented to require a left-hand splint as part of their care plan. Despite physician orders and occupational therapy recommendations, the splint was not consistently applied, and staff were unaware of the resident's need for the splint. Observations over several days confirmed that the splint was not in place, and staff interviews revealed a lack of knowledge about the splint's application and location. The occupational therapy discharge summary indicated that the resident tolerated the splint for up to four hours daily, and the physician order specified daily application of the splint. However, multiple observations showed the resident without the splint, and staff interviews confirmed that the splint was not being applied as required. The Director of Nursing and various nurse aides and nurses were unaware of the splint order, and the splint could not be located in the resident's room. The Medication Administration Records (MAR) for February and March 2024 documented the application of the splint, but physical checks during the survey period showed the splint was not in place. The Director of Nursing acknowledged the discrepancy and stated that the splint order would be placed on hold until the resident could be re-evaluated and staff trained on the application process. The lack of proper documentation and staff awareness led to the failure in providing the necessary care for the resident's contracture management.
Expired Medications and Supplies Found in Storage Room
Penalty
Summary
The facility failed to remove expired medications and supply kits from the medication storage room. During an observation of the medication storage room, it was found that there were two opened and undated multi-dose vials of Influenza Vaccine, one multi-dose vial of Influenza Vaccine opened on 11/8/23, and one expired multidose vial of Levemir insulin. Additionally, inside the cabinets, there were 18 expired sealed plastic bags of Secondary Administration Sets, one sealed plastic bag of Dressing Change Tray, one plastic bag of Foley Catheter Insertion Tray, and four Pivodon-Iodine Swab sticks, all of which were expired. Interviews with staff revealed that the nurses working on the medication carts were responsible for discarding expired medications from the medication storage room. However, Nurse #6 admitted that she had not checked the expiration date of medications at the beginning of her shift. The Director of Nursing (DON) and the Administrator both indicated that all nurses were responsible for checking and removing expired medications and supplies every shift, and they expected no expired items to be left in the medication storage room.
Failure to Administer Influenza and Pneumonia Vaccines
Penalty
Summary
The facility failed to administer the influenza and pneumonia vaccines to two residents who had signed consent forms for these vaccinations. Resident #33, who had moderate cognitive impairment, was admitted to the facility and had a consent form signed by their responsible party on 12/29/23. Despite the consent, there was no record of Resident #33 receiving the influenza or pneumonia vaccines. Similarly, Resident #54, who was cognitively intact, had a consent form signed on 01/17/24, but there was no documentation of the resident receiving the vaccines either. Both residents had signed consents indicating they were to receive the vaccines annually unless medically contraindicated, but the facility failed to follow through with the administration of these vaccines. Interviews with the Infection Preventionist and the Director of Nursing (DON) revealed that both were relatively new to their positions and were unaware of why the vaccines were not administered. The Infection Preventionist had recently audited the vaccinations and was preparing to obtain consents and administer the vaccines, while the DON confirmed that residents should have received the vaccines once the consent was signed. However, neither could provide an explanation for the oversight in administering the vaccines to Resident #33 and Resident #54.
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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