Kindred Hospital East Greensboro
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensboro, North Carolina.
- Location
- 2401 South Side Boulevard, Greensboro, North Carolina 27406
- CMS Provider Number
- 345273
- Inspections on file
- 16
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Kindred Hospital East Greensboro during CMS and state inspections, most recent first.
Nursing staff failed to follow infection control policies during wound care and contact isolation. One resident with multiple pressure and lower extremity wounds received dressing changes in which an RN removed and discarded dressings from different sites together, cleansed and packed several wounds sequentially without changing gloves or performing hand hygiene between sites, treated bilateral heel wounds without glove changes, touched a newly identified leg wound with soiled gloves, repositioned the resident while still gloved, and did not disinfect the overbed table used as a work surface. In a separate case, a resident on contact precautions for MDRO pneumonia was cared for by an RN who entered the room and handled enteral feeding supplies wearing gloves but without donning a required gown, despite posted isolation signage and readily available PPE.
A resident with an initial Level I PASRR indicating no mental health diagnosis was later documented with major depressive disorder, bipolar disorder, and schizophrenia, but the facility did not submit a request for a Level II PASRR evaluation. Record review showed no evidence of a Level II request, and the MDS assessment reflected that the resident was not considered by the state Level II PASRR process to have serious mental illness. The social worker reported that she only reviewed PASRRs for new admissions or expiring Level I screens and did not routinely request Level II evaluations after new diagnoses, while the Administrator stated there was no established practice or clear responsibility for resubmitting PASRR information when new mental health conditions were identified.
A resident with documented diagnoses of major depressive disorder, anxiety, depression, and bipolar disorder was given an antipsychotic (haloperidol) for visual hallucinations, and a schizophrenia diagnosis was added to the active diagnosis list by a nurse based on a medication lacking a corresponding diagnosis. The nurse could not clearly identify which physician, if any, provided this diagnosis, and the MDS did not code the resident for schizophrenia. Review of electronic and paper records, as well as interviews with the consultant pharmacist, a physician, the DON, and the Administrator, revealed no clinical documentation or physician confirmation to support schizophrenia, and the resident’s care plan did not address this diagnosis.
A resident with severe cognitive impairment, respiratory failure, and a tracheostomy required ongoing respiratory services, including trach care. During an observed trach care procedure, an RT set up a trach care tray on an unclean overbed table, double-gloved, and repeatedly placed soiled gauze and other used items back into the tray containing clean supplies, including taking clean gauze from under used gauze to continue cleaning the site. The RT removed only the outer pair of gloves and did not perform hand hygiene before applying a clean dressing. In subsequent interviews, the RT reported misunderstanding training, while the supervisor, DOR, IP, DON, and a physician all described expectations for cleaning the work surface, avoiding contamination of clean items, using appropriate PPE, and performing hand hygiene between dirty and clean tasks.
A resident with major depressive disorder, bipolar disorder, generalized anxiety disorder, and schizophrenia was receiving multiple psychotropic medications, including an antipsychotic and antidepressants, but had no documented visits with a mental health provider over an extended period. The facility assessment showed there were no psychiatrists, psychologists, or licensed counselors available, and mental health services were instead handled by attending physicians and a social worker, despite most residents being on psychotropic medications. Staff reported that the resident experienced ongoing and worsening hallucinations and episodes of crying, and relied on verbal reassurance from CNAs and nursing staff, while the social worker acknowledged uncertainty in managing these hallucinations and confirmed the absence of a mental health provider, and the DON and administrator confirmed dependence on internists to manage behavioral health needs.
A resident receiving amiodarone for paroxysmal atrial fibrillation did not receive appropriate TSH monitoring despite a Consultant Pharmacist’s recommendation and a physician order. The pharmacist identified that no TSH level had been documented for at least six months and recommended obtaining one and repeating it every six months. A one-time TSH order was entered by the physician, but the lab did not draw the test, the order auto-discontinued after 24 hours, and the DON did not verify completion or re-order the lab. Review of the medical record confirmed that no TSH result was obtained and no prior TSH results were available.
A resident with a pressure ulcer had multiple weekly wound assessments and treatment orders incorrectly documenting the wound as being on the right buttock, with no documentation of a left buttock wound. The TAR contained ongoing physician orders and recorded treatments for a right buttock wound, and a nurse repeatedly signed off on these entries despite actually providing care to the left buttock. During surveyor observation, treatment was seen being given to the left buttock and no right buttock wound was present, and the nurse later admitted he had documented the wound location and corresponding treatment orders incorrectly since admission.
A nurse in an LTC facility was found to have misappropriated narcotic medications, affecting multiple residents. The nurse signed out medications like Oxycodone and Lorazepam without proper documentation on the MAR and at times when she was not present. Witness signatures for medication waste were also found to be incorrect or missing. The facility's investigation led to the nurse's suspension and termination.
The facility failed to report the misappropriation of controlled medications within 24 hours as required. An audit revealed discrepancies in medication records for six residents, with medications signed out by a nurse not recorded on the MAR and issues with witness signatures. The Administrator delayed reporting to the state agency due to uncertainty about the nature of the issue, notifying other entities only after misappropriation was suspected.
The facility failed to properly store and label food items, with observations revealing expired and improperly stored foods in the refrigerator and freezer, and dented cans mixed with usable ones in dry storage. The Kitchen Supervisor and RD acknowledged the issues, emphasizing the need for sealed containers and proper labeling.
The facility failed to provide required annual dementia management training for three NAs. The Staff Development Coordinator did not populate the necessary training modules, and the Administrator could not find documentation confirming the training was provided.
A facility failed to provide a four-ounce portion of pureed beef taco meat and did not prepare pureed foods according to the recipe for a resident with a diet order for pureed textured foods. The cook used an incorrect method to prepare the meal, and the recipe binder lacked necessary recipes for pureed foods. The RD and Administrator acknowledged that recipes should be followed to ensure correct portions and texture modifications.
A facility failed to provide written notification to a resident's responsible party regarding multiple hospital transfers for conditions like hypotension and altered mental status. Although phone notifications were made, no written notices were documented or mailed, contrary to regulatory expectations.
The facility failed to post accurate and consistent daily nurse staffing data at the beginning of shifts. Observations and record reviews revealed discrepancies in posted data and missing records for several days. Staff interviews indicated a lack of adherence to procedures, with the charge nurse admitting to forgetting to post data. The Administrator expected accurate postings and record maintenance, which was not achieved.
Failure to Follow Wound Care Aseptic Technique and Contact Precaution PPE Requirements
Penalty
Summary
The deficiency involves failures in infection prevention and control practices during wound care and contact isolation. Facility policies required hand hygiene before and after resident contact, before clean/aseptic procedures, after contact with body fluids or non-intact skin, after touching the patient environment, and before donning and after removing gloves. The clean dressing change policy required removal of soiled dressings with one pair of gloves, hand hygiene, then a new pair of gloves to cleanse each wound, with hand hygiene and glove changes between multiple wounds, and cleansing from least to most contaminated. During an observed wound care session for Resident #14, Nurse #3 did not follow these procedures. For Resident #14, who had multiple wounds to the sacrum, right ischium, left buttock, and bilateral heels, Nurse #3 removed dressings from the sacrum and right ischium together by rolling them into one bundle and discarding them, then removed the dressing from the left buttock separately. After performing hand hygiene and donning clean gloves, Nurse #3 cleansed the sacral, right ischial, and left buttock wounds using multiple gauze pads but did not perform hand hygiene or change gloves between each wound. Using the same pair of gloves, Nurse #3 then packed all three wounds and applied separate clean dressings without changing gloves between wounds. For the left and right heel treatments, Nurse #3 applied a protective barrier wipe to the left heel, then cut off the soiled bandage from the right foot, placed the scissors on the overbed table, and applied the same type of barrier wipe to the right heel, again without hand hygiene or glove change between heels. When a new wound on the outer right leg was identified during this process, Nurse #3 touched it with a gloved finger that had already been used for the heel treatments. Additional lapses occurred when Nurse #3 repositioned Resident #14 while still wearing the same soiled gloves and without performing hand hygiene before repositioning. After completing the treatment, Nurse #3 discarded supplies, removed gloves, and performed hand hygiene but did not clean the overbed table used as the work surface. In a separate observation involving Resident #13, who was on contact precautions for a multiple drug-resistant organism related to pneumonia, Nurse #2 entered the resident’s room and handled enteral feeding supplies on the overbed table while wearing gloves but without donning a gown, despite posted signage and available PPE indicating that both gown and gloves were required for every room entry. Nurse #2 later confirmed awareness that a gown was required and stated that wearing it had slipped her mind. The Infection Preventionist and Director of Nursing confirmed that facility policy and expectations required glove and gown use for contact precautions and hand hygiene with glove changes between wounds during dressing changes.
Failure to Request Level II PASRR Evaluation After New Serious Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident who developed serious mental health diagnoses after admission. The PASRR history detail dated 5/16/11 showed only a Level I PASRR had been completed, which at that time indicated no mental health diagnosis and did not meet Level II criteria. The resident was later admitted with a diagnosis that included major depressive disorder, and the active diagnosis list showed bipolar disorder, unspecified, added on 4/18/19 and schizophrenia, unspecified, added on 7/20/24. Review of the resident’s electronic and paper medical record revealed no evidence that a request for a Level II PASRR determination was ever submitted, and the MDS annual assessment indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability/related condition. In interviews, the social worker responsible for PASRR evaluations at the time of the new serious mental health diagnoses stated she typically only reviewed PASRRs for new admissions or when a Level I PASRR had an expiration date. She acknowledged that the resident’s new diagnoses of bipolar disorder and schizophrenia represented a significant change in mental health but confirmed it was not her normal practice to submit a request for a Level II PASRR evaluation. The Administrator reported that the facility received the resident’s Level I PASRR from the hospital and was unsure who was responsible for resubmitting PASRR information when new mental health diagnoses were identified. The Administrator further stated that it was not the facility’s normal practice to resubmit PASRR information after admission and that this was not something the facility was doing.
Unsupported Schizophrenia Diagnosis and Antipsychotic Use Without Clinical Documentation
Penalty
Summary
The facility failed to ensure that services met professional standards of quality when it did not have clinical documentation to support a diagnosis of schizophrenia for one resident who was reviewed for unnecessary medications. The resident was admitted with major depressive disorder and later readmitted from a hospital stay, with the hospital discharge summary not listing schizophrenia as a diagnosis. A provider progress note documented that the resident was seen for visual hallucinations and that haloperidol 1 mg every 6 hours as needed was added for continued hallucinations, but the note did not list schizophrenia as a diagnosis. The resident’s active diagnosis list showed schizophrenia, unspecified, as an admitting diagnosis active as of a specified date, with no onset date, and categorized under medical management. The schizophrenia diagnosis was entered into the record by a nurse, who stated she added it based on a medication that lacked a correct diagnosis and believed, but could not confirm, that a physician had given her this information. The resident’s care plan, last revised on a specified date, did not include a care plan for schizophrenia. The MDS quarterly assessment coded the resident for anxiety, depression, and bipolar disorder, but not schizophrenia. Review of the electronic and paper records revealed no clinical documentation supporting schizophrenia. The consultant pharmacist reported that the pharmacy had not requested adding a schizophrenia diagnosis, and a physician stated he had not given or written such a diagnosis and, to his knowledge, the resident did not have schizophrenia. The DON was unable to locate documentation from either physician supporting the diagnosis and only believed that one physician had reported a significant history of schizophrenia, while the Administrator could not recall whether the resident had that diagnosis and indicated she would discuss it with the clinical team.
Improper Tracheostomy Care and Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to provide tracheostomy care consistent with professional standards for one resident who required ongoing respiratory services. The resident was admitted with metabolic encephalopathy and respiratory failure and was documented on the quarterly MDS as severely cognitively impaired and receiving oxygen therapy, suctioning, respiratory services, and tracheostomy care. The resident’s care plan included a goal of having no abnormal drainage around the tracheostomy site and interventions such as instructing the resident or caregiver in tracheostomy care and suctioning. During an observed tracheostomy care procedure, the respiratory therapist (RT) performed hand hygiene and applied two pairs of clean disposable gloves, then opened a tracheostomy care tray on the resident’s overbed table without cleaning the work surface. The RT poured normal saline into the tray and used gauze saturated with saline to clean around the tracheostomy site, then placed the dirty gauze on a dressing package on the overbed table. The RT subsequently placed additional soiled gauze back into the tracheostomy care tray on top of remaining clean gauze and removed clean gauze from under used gauze to continue cleaning the site, thereby mixing clean and dirty supplies. The RT also used cotton-tipped applicators saturated with saline to clean around the site and continued to place used items in the same tray containing clean supplies. The RT removed the top pair of gloves before opening and applying a clean dressing but did not perform hand hygiene before applying the dressing. In interviews, the RT stated she had been trained to work from the tracheostomy care tray, was unaware she needed to clean the work surface before setup, and believed she had been instructed to double glove, although the third shift supervisor denied giving such a directive. The Director of Respiratory Therapy reported that the department followed Lippincott’s guidance for hand hygiene, had no written tracheostomy care policy, and that tracheostomy care was taught at the bedside. The Infection Preventionist and DON both stated expectations that staff should not contaminate clean areas, should perform hand hygiene, and should not go from dirty to clean during care. The physician interviewed stated he would expect clean gloves between dirty and clean tasks, that double gloving was not appropriate PPE, and that staff should not take shortcuts with hand hygiene.
Failure to Provide Necessary Behavioral Health Services for Resident on Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services to support a resident’s highest practicable mental and psychosocial well-being. One resident with major depressive disorder, bipolar disorder, generalized anxiety disorder, and schizophrenia was admitted to the facility and was receiving multiple psychotropic medications, including venlafaxine, cariprazine, and fluoxetine for bipolar disorder and major depressive disorder. A quarterly MDS assessment documented that the resident was cognitively intact, had psychiatric/mood disorders including anxiety, depression, and bipolar disorder, and was receiving antipsychotic and antidepressant medications, with self-reported feelings of being down, depressed, or hopeless on several days during the assessment period. Despite these diagnoses and ongoing psychotropic medication use, the facility was unable to provide any documentation of mental health provider visits for this resident since the last recertification survey. The facility assessment indicated that there were no behavioral or mental health providers such as psychiatrists, psychologists, or licensed counselors available, and that mental health and behavior services were instead provided by the attending physician and the social worker. The facility’s provider matrix showed that 16 of 20 residents were prescribed psychotropic medications, yet there was no dedicated mental health provider serving them. The resident reported being unable to recall the last time she spoke with a doctor specifically about her mental health and expressed a desire to talk to a doctor when she began to feel down. Staff interviews further demonstrated that the resident experienced ongoing and worsening hallucinations, including seeing animals and people who were not present, along with episodes of crying. A nurse aide and a nurse both reported that the resident had a history of hallucinations and that staff attempted to calm her by talking and reassurance. The social worker confirmed that the facility did not have a mental health provider, acknowledged that the resident’s hallucinations were worsening, and stated uncertainty about how to engage with the resident during these episodes, although she provided emotional and psychosocial support. The DON and the administrator both confirmed that there was no mental health provider currently seeing residents and that the attending internist physicians were relied upon to manage residents’ mental health needs and medications, with no clear indication of specialized behavioral health services being provided to address the resident’s ongoing symptoms.
Failure to Obtain Ordered TSH Monitoring for Resident on Amiodarone
Penalty
Summary
A deficiency occurred when a resident receiving amiodarone 200 mg daily for paroxysmal atrial fibrillation did not have appropriate thyroid monitoring as recommended. The Consultant Pharmacist reviewed the resident’s medications upon admission and identified that there was no TSH (thyroid stimulating hormone) level documented in the medical record for the previous six months, despite the resident’s ongoing amiodarone therapy. The pharmacist documented a recommendation on 10/27/25 for a TSH level to be obtained on the next convenient lab day and every six months thereafter. A physician order for a one-time TSH blood test was entered on 11/06/25, but the test was never drawn, and the order automatically discontinued within 24 hours. The DON stated that the TSH lab was not obtained as ordered, that the order was entered as a one-time order which auto-discontinued, and that she did not follow up to confirm that the TSH was drawn or re-order it when it was missed. Review of the resident’s electronic and paper records showed no TSH results from this order and no prior TSH results from the hospital discharge record. The physician later confirmed being notified that the TSH order had not been completed and stated he was not concerned because the test was for monitoring purposes.
Inaccurate Documentation of Pressure Ulcer Location and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record for a resident with a pressure ulcer. Weekly wound assessments dated 11/03/25, 11/11/25, 11/18/25, 11/25/25, and 12/02/25 documented multiple wounds, including a pressure ulcer to the right buttock, but contained no documentation of a wound to the left buttock. These assessments were completed by Nurse #3. Review of the December Treatment Administration Record (TAR) showed physician orders and documented treatments for a right buttock wound over multiple date ranges in December, with Nurse #3 signing off on those treatments on several days. There was no documentation of any wound treatment to the left buttock in the TAR. On observation on 12/17/25 at 8:46 a.m., Nurse #3 was seen providing wound treatment to the resident’s left buttock, and no wound was observed on the right buttock. In a subsequent interview, Nurse #3 acknowledged that since the resident’s admission he had incorrectly documented the wound location as the right buttock instead of the left buttock on both the weekly wound assessments and the treatment orders, and that he had continued to sign off treatments for a right buttock wound after actually treating the left buttock. The DON confirmed that Nurse #3 had informed her that the wound documentation and orders were incorrect and stated that she had not conducted rounds with Nurse #3 and that a process needed to be put in place.
Misappropriation of Narcotic Medications by Nurse
Penalty
Summary
The facility failed to protect residents from the misappropriation of narcotic medications, affecting six residents. Nurse #1 was involved in discrepancies related to the administration and documentation of narcotic medications, including Oxycodone, Hydrocodone, and Lorazepam. The Controlled Medication Utilization Records showed that medications were signed out as administered by Nurse #1, but these administrations were not documented on the Medication Administration Records (MAR). Additionally, there were instances where Nurse #1 signed out medications at times when she was not present in the facility, as evidenced by time punch records. Several residents, including those with severe cognitive impairments and chronic pain, were affected by these discrepancies. For instance, a resident with spinal stenosis and chronic pain was signed out as receiving Oxycodone multiple times without corresponding entries on the MAR. Another resident with spastic hemiplegia and respiratory failure had Oxycodone signed out at times when Nurse #1 was not on duty. Furthermore, there were questionable witness signatures for the waste of medications, with several nurses denying that the signatures were theirs or that they had witnessed the waste. The facility's investigation revealed a pattern of misappropriation by Nurse #1, who frequently marked narcotics as wasted with incorrect or missing witness signatures. The discrepancies were identified through audits and staff interviews, leading to the suspension and eventual termination of Nurse #1. The facility reported the incidents to relevant authorities, including the police department and the North Carolina Board of Nursing.
Failure to Timely Report Misappropriation of Medications
Penalty
Summary
The facility failed to submit an initial report to the state regulatory agency within 24 hours of discovering the misappropriation of resident property, specifically controlled medications. This deficiency involved six residents whose medication records showed discrepancies. The Director of Nursing (DON) was informed of a discrepancy in the Controlled Medication Utilization Record for two residents, which led to an audit revealing multiple instances where medications were signed out by a nurse but not recorded on the Medication Administration Record (MAR). Additionally, there were issues with witness signatures not matching the master signature log, and some nurses denied the handwriting was theirs. The Administrator did not send an initial report to the state regulatory agency within the required 24-hour timeframe because there was uncertainty about whether the issue constituted misappropriation of resident medications. Once misappropriation was suspected, notifications were made to various entities, including the corporate agency, pharmacy, law enforcement, Drug Enforcement Agency, and the North Carolina Board of Nursing. However, the report to the State Agency was delayed until ten days after the initial discovery, as the facility was conducting an investigation and wanted to ensure the problem was corrected.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to proper food storage and labeling protocols, as observed during a survey. In the walk-in refrigerator, a plastic bag of sliced turkey meat was found open to air with a use-by date that had already passed. The Kitchen Supervisor acknowledged that all refrigerated foods should be stored in sealed containers and discarded by the use-by date. Additionally, in the walk-in freezer, several opened food items, including diced potatoes, hash browns, breakfast sausage, diced chicken, and tater tots, were stored in plastic bags open to air without labels indicating the date opened or use-by date. The hash browns and diced chicken were noted to be freezer burned and were discarded by the Kitchen Supervisor during the observation. In the dry storage room, a canned product with a dent along the seal was stored with other canned foods available for use. The Kitchen Supervisor admitted that dented cans were usually placed on the first row of the rack, but due to the lack of labeling, a dented can was mistakenly stored with other usable cans. Interviews with the Kitchen Supervisor, Registered Dietitian (RD), and Food Service Director revealed that the facility received food deliveries twice a week, and staff were expected to monitor food storage for proper packaging and labeling. The RD conducted monthly sanitation rounds and re-educated staff when concerns were identified. The Administrator confirmed that the dietary department should store foods according to regulatory requirements.
Deficiency in Annual Dementia Training for Nurse Aides
Penalty
Summary
The facility failed to provide required annual training in dementia management and care for cognitively impaired residents for three nurse aides (NAs) reviewed. NA #4, NA #5, and NA #6, who were employed at the facility, did not receive this specific training as part of their annual education. The Staff Development Coordinator (SDC) acknowledged the absence of documentation for this training and admitted to not populating the necessary training modules in the electronic training management system, without providing a specific reason for this oversight. The Administrator expressed an expectation that all NAs receive the required annual training, including dementia management and care for cognitively impaired residents. However, she was unable to locate any documentation to confirm that this training had been provided to the NAs in question. The deficiency was identified through a review of records and staff interviews, highlighting a gap in the facility's training program for nurse aides.
Failure to Provide Correct Portions and Consistency of Pureed Foods
Penalty
Summary
The facility failed to provide a four-ounce portion of pureed beef taco meat per the approved menu and did not prepare pureed foods according to the recipe for a resident with a diet order for pureed textured foods. During a lunch meal tray line observation, it was noted that the resident received a 3 1/5-ounce portion of pureed beef taco meat with an applesauce consistency instead of the required four-ounce portion. Additionally, the pureed bean and corn salsa and cilantro lime rice were not prepared with the correct consistency as per the recipe instructions. The cook responsible for preparing the meal did not have a recipe to refer to and used an incorrect method to prepare the pureed foods, adding water and thickener without measuring. Interviews with the dietary staff revealed that the recipe binder did not include all necessary recipes for pureed foods, and the Registered Dietitian (RD) had not ensured that all texture modification recipes were included. The Patient Ambassador, who was responsible for compiling the recipe binder, admitted to not including recipes for pureed foods. The Kitchen Supervisor and Food Service Director acknowledged the oversight in recipe availability and preparation. The RD and Administrator both stated that recipes should be followed to ensure correct portions and texture modifications are served to residents.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to the responsible party (RP) regarding the reasons for hospital transfers of a resident with severe cognitive impairment. The resident was transferred to the hospital multiple times for conditions such as hypotension, fever, and altered mental status. Despite these transfers, there was no documentation that written notices were provided to the RP, although phone notifications were made. The facility's administrator confirmed that the RP was notified by phone, and a transfer/discharge form was sent with the resident to the hospital, but no written notice was mailed to the RP, which was against the regulatory expectations.
Inaccurate and Inconsistent Nurse Staffing Data Posting
Penalty
Summary
The facility failed to post daily nurse staffing data accurately and consistently at the beginning of shifts, as required. Observations on 9/15/24 revealed that the staffing data posted was for the previous day, and the actual staff present did not match the posted data. Additionally, records reviewed with the Staffing Coordinator showed missing or inaccurate postings on several occasions, including missing records for 8/3/24 and 8/17/24, and incorrect data for 8/12/24 and 8/20/24. The Staffing Coordinator admitted to errors in recording the shift dates and acknowledged the absence of records for certain days. Interviews with staff, including the Staffing Coordinator and a charge nurse, indicated a lack of adherence to the procedure of posting staffing data at the beginning of each shift. The charge nurse admitted to forgetting to post the data on 9/15/24, despite being aware of the responsibility. The Administrator expected the nursing staff to collaborate in posting accurate staffing data and maintaining records for 15 months, but this expectation was not met, leading to the deficiency.
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.
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.
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.
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.
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.
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 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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