Laurel Park Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Elizabeth City, North Carolina.
- Location
- 901 Halstead Boulevard, Elizabeth City, North Carolina 27909
- CMS Provider Number
- 345184
- Inspections on file
- 24
- Latest survey
- June 24, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Laurel Park Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A severely cognitively impaired resident with dementia and behavioral issues was physically restrained by a private caregiver, who forced medications into her mouth and held her down to prevent resistance. Despite the nurse's instruction to stop, the caregiver continued restraining the resident until the nurse returned and administered an IM antipsychotic as a chemical restraint. The resident was later found to have a small bruise on her lip, and staff interviews confirmed the use of both physical and chemical restraints during the incident.
A facility-wide assessment failed to include cultural considerations for residents, did not specify staffing needs for each shift or adjust for changes in the resident population, and omitted evaluation of contracted services for care provision. The Administrator was unaware of the requirements, and these deficiencies had the potential to affect all residents.
The facility did not provide written information or education about advance directives to most residents or their representatives, as required. Despite having residents with various serious medical conditions and both full code and DNR orders, there was no documentation of advance directive discussions or opportunities to formulate one. Staff interviews confirmed that advance directive education was not routinely offered during admission, and the responsibility for this process was unclear among staff.
Multiple resident rooms were found to be inadequately cleaned, with sticky floors, strong urine odors, and accumulated debris around baseboards and under furniture. Residents repeatedly voiced concerns about poor housekeeping practices, including insufficient sweeping and mopping, and unemptied trash. Staff interviews confirmed lapses in following cleaning schedules and communication gaps regarding maintenance issues.
Two residents were not given the opportunity to participate in their person-centered care plan meetings, as required. One resident with moderate cognitive impairment was not invited to a care plan meeting between quarterly reviews, and another cognitively intact resident could not recall ever attending a care plan meeting. The Social Worker, responsible for scheduling these meetings, admitted to being behind, and both the DON and Administrator confirmed the lapse in timely scheduling and invitations.
A resident with dementia and bipolar disorder was not accurately coded on the MDS for tobacco use and use of a wander/elopement alarm, despite documented assessments, care plans, and physician orders indicating the need for supervision while smoking and a wander guard device. The MDS Nurse missed these areas during assessment coding, and the error was confirmed through observation and interviews.
A resident with moderate cognitive impairment and new physician's orders for hearing aid use did not have her care plan updated to reflect this intervention. Despite daily clinical meetings and staff awareness of the resident's hearing aid use and refusals, the omission was not addressed, resulting in the care plan lacking necessary information about her hearing needs.
A resident admitted with a bone infection did not receive several scheduled doses of IV cefazolin as ordered due to delays in medication delivery from the pharmacy and lack of availability in the emergency dose kit. Nursing staff documented missed doses, contacted the pharmacy, and confirmed the medication was not on site, while the resident expressed concern about the missed antibiotics. The DON and Medical Director acknowledged the absence of an effective system to ensure timely access to IV antibiotics for new admissions.
A resident with a history of neuromuscular bladder dysfunction and a spinal fracture was readmitted with an indwelling urinary catheter, but the facility failed to obtain a physician order for the catheter's use and care. Nursing staff were unclear about who was responsible for reactivating or entering the order, and the omission was not identified during clinical review. Both the DON and Medical Director confirmed that a physician order was required.
A resident admitted with a bone infection did not receive four scheduled doses of IV cefazolin antibiotic because the medication was not available in the facility following admission. Nursing staff documented the missed doses, citing delays in pharmacy delivery and lack of availability in the backup medication system. The DON explained that medication orders for new admissions could not be activated until the resident arrived, leading to delays, especially for late evening admissions.
The facility did not provide required written transfer or discharge notices to residents or their representatives when residents were sent to the hospital, nor did it properly complete bed hold policy documentation or notify the Ombudsman as required. Staff interviews revealed confusion and lack of awareness regarding responsibilities for these notifications and documentation.
Two residents did not receive a written summary of their baseline care plan and medication list within the required timeframe after admission. One resident had severe cognitive impairment and the other was cognitively intact. In both cases, the Social Worker responsible for providing the documentation acknowledged falling behind, and neither the DON nor the Administrator were aware that the information had not been given.
The facility failed to conduct and document care plan meetings for three residents, including a cognitively intact resident with fractures, a moderately impaired resident post-stroke, and another resident who had not attended a meeting since 2021. The lack of meetings was due to scheduling and documentation issues, with responsibilities not clearly assigned after staff changes.
The facility was found to have unclean kitchen equipment, including skillets and baking sheets with grease buildup, and an ice scoop holder with mold. Observations were made over several days, and staff interviews revealed unclear responsibilities for cleaning tasks.
A facility failed to document a resident's prescribed medications, Apixaban and Humalog insulin, in the baseline care plan upon admission. Despite receiving these medications, the care plan was left unmarked, an oversight acknowledged by the nurse and the Assistant Director of Nursing. The DON confirmed the error, noting it could have been corrected during the 72-hour care plan meeting.
A resident with impaired vision did not receive meals in bowls as specified in their care plan, leading to a deficiency in nutritional care. Despite a physician's order and care plan instructions, the resident's lunch was served on a flat plate. Staff interviews confirmed the oversight, acknowledging that the care plan required meals to be served in bowls to aid the resident's self-feeding.
A resident with chronic heart and respiratory failure was admitted without a documented physician order for supplemental oxygen, despite receiving it to maintain oxygen saturation. The facility also failed to place required 'Oxygen in use, no smoking' signage outside the resident's room. Nursing staff and the DON confirmed these oversights, acknowledging the absence of necessary documentation and signage.
A resident with impaired vision did not receive meals in bowls as ordered by the physician, leading to a deficiency in care. Despite being aware of the requirement, the facility staff served the resident's lunch on a flat plate, and the nursing staff did not verify the meal setup before serving. The Director of Rehab and Dietary Manager confirmed the oversight, and the Director of Nursing acknowledged the failure to follow the care plan.
Resident Subjected to Physical and Chemical Restraint by Private Caregiver and Staff
Penalty
Summary
A severely cognitively impaired resident with diagnoses including metabolic encephalopathy, Alzheimer's disease, dementia with behaviors, and anxiety disorder was subjected to both physical and chemical restraint during an incident involving a private duty caregiver and facility staff. The resident, who had a history of refusing medications, was approached by a nurse to take her scheduled medication, which she refused. The private duty caregiver then intervened, attempting to force the medications into the resident's mouth, holding her hand over the resident's mouth to force her to swallow, and physically restraining the resident by placing her leg over the resident's legs to prevent kicking. The nurse instructed the caregiver to stop but left the room to call the on-call provider, during which time the caregiver continued to restrain the resident. Upon the nurse's return, the resident was still being physically restrained by the caregiver. The nurse then administered an intramuscular antipsychotic medication (Haldol) to the resident as a chemical restraint to calm her. Following the incident, a skin assessment revealed a small bruise on the resident's lower lip, and the resident was noted to have multiple bruises on her upper extremities, though some predated the incident. Interviews with staff confirmed the sequence of events, including the use of both physical and chemical restraints by the caregiver and nurse, respectively. The incident was witnessed by multiple staff members, including a nursing assistant who corroborated the use of force and restraint by the caregiver. The Director of Nursing and Medical Director were notified and assessed the resident after the event, noting the presence of bruising but no ongoing pain or decline in physical functioning. The administrator was also informed and confirmed the details of the incident, including the inappropriate actions of the private caregiver and the subsequent administration of a chemical restraint by nursing staff.
Incomplete Facility Assessment Omits Cultural, Staffing, and Contracted Service Considerations
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment as required. The assessment did not include any cultural considerations to address the specific needs of the resident population. Additionally, the staffing plan only listed the desired number of full-time equivalent (FTE) nurses and CNAs, without specifying staffing needs for each shift, including nights and weekends, or adjusting for changes in the resident population. The facility assessment also did not evaluate or document the contracted services used to provide necessary care, such as goods, medical services, facility management, emergency services, transportation, and dialysis. During an interview, the Administrator acknowledged missing the cultural consideration section and was unaware of the requirement to detail shift-specific staffing and contracted services in the assessment. These omissions had the potential to affect all 88 residents in the facility.
Failure to Provide Advance Directive Information and Education
Penalty
Summary
The facility failed to provide written information and education regarding advance directives to residents and their representatives, as required. Record reviews for 19 out of 22 residents revealed that there was no documentation indicating that residents or their representatives were given information about advance directives or offered the opportunity to formulate one. This deficiency was identified regardless of the residents' code status, which included both full code and do not resuscitate (DNR) orders, and spanned a range of medical conditions such as heart failure, diabetes, hypertension, chronic kidney disease, dementia, and others. Interviews with facility staff further confirmed the lack of compliance with advance directive requirements. The Admissions Director stated that while a blank template for advance directives was available, it was not routinely discussed with residents or their representatives during the admission process. Instead, the Admissions Director only reviewed existing advance directives from the hospital if provided and verified code status from the discharge summary. There was no process in place to ensure that all residents were educated about or given the opportunity to create an advance directive upon admission. The Social Services Director acknowledged only recently becoming aware that providing advance directive education was her responsibility. The Administrator also confirmed that the need for advance directive education had not been previously identified and that it had been missed. The responsibility for ensuring advance directive discussions and documentation was assigned to the Social Services Director, but this process was not being followed at the time of the survey.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents, as evidenced by multiple observations and resident interviews. Six resident rooms on one hall were found to have issues such as sticky floors, strong urine odors, encrusted brown matter, trash, and dust accumulation around baseboards and under furniture. Residents consistently reported concerns over several months in Resident Council meetings, noting that housekeeping staff were not adequately sweeping, mopping, or cleaning under beds and furniture, and that trash was sometimes left unemptied. Specific rooms were observed to have additional structural issues, including broken floor tiles, holes in walls, missing caulk, and damaged drywall. Interviews with residents confirmed dissatisfaction with the cleanliness of their rooms, with several stating that housekeeping did not clean thoroughly, particularly under beds and around furniture, and that floors remained sticky and stained. Some residents reported having to request that housekeepers clean specific areas, such as under bedside commodes, and noted persistent odors and visible debris. These concerns were echoed repeatedly in Resident Council meeting minutes over a period of nearly a year, indicating an ongoing problem rather than isolated incidents. Staff interviews revealed that the Housekeeping Director was responsible for ensuring cleanliness and described a daily cleaning routine that included sweeping, mopping, and bathroom cleaning, as well as a deep cleaning schedule that was not being accurately followed. The Maintenance Director stated that room issues were to be reported through an online system, but was unaware of some of the specific structural problems observed. The Administrator acknowledged that the deep cleaning schedule was not being properly implemented and that management staff were expected to report housekeeping and maintenance issues during daily rounds.
Failure to Involve Residents in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that two residents were given the opportunity to participate in the development and implementation of their person-centered care plans. For one resident with moderate cognitive impairment, there was no documentation of a care plan meeting or invitation to participate between two quarterly reviews, despite the resident expressing a desire to attend such meetings when able. The Social Worker acknowledged being behind in scheduling care plan meetings and confirmed that the required meeting had not been scheduled. The MDS Nurse and DON both indicated that the Social Worker was responsible for scheduling these meetings, but the process was not completed as required. For another resident who was cognitively intact, there was no documentation of a care plan meeting or invitation since admission, and the resident could not recall ever attending such a meeting. The Social Worker stated that the last care plan meeting attended by this resident was several months prior and admitted to being behind in scheduling meetings for the current year. Both the DON and Administrator confirmed that the Social Worker was responsible for scheduling and inviting residents to care plan meetings and acknowledged that meetings had not been held in a timely manner.
Inaccurate MDS Coding for Smoking and Elopement Alarm
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident in the areas of smoking and elopement alarms. The resident, who had diagnoses including dementia without behavioral disturbances and bipolar disorder, was assessed as requiring supervision while smoking and had a care plan updated to reflect this status. Additionally, there was a physician order and documentation for a wander guard (elopement alarm) device, with corresponding care plan interventions for elopement risk. Despite these documented needs and interventions, the MDS admission assessment did not reflect the resident's tobacco use or the use of a wander/elopement alarm. Observations and interviews confirmed the resident was a smoker and was wearing a wander guard device. The MDS Nurse acknowledged missing the coding for tobacco use and wander guard, stating she did not see the order for the wander guard and overlooked the tobacco use section during assessment coding. The Administrator confirmed that the MDS Nurse was responsible for ensuring the accuracy of the resident's assessment coding.
Care Plan Not Updated for Hearing Aid Use
Penalty
Summary
The facility failed to update the care plan to include the use of hearing aids for a resident who had recently been evaluated by audiology and received physician's orders for hearing aid use. The resident was admitted to the facility and subsequently assessed as having moderate cognitive impairment, with documentation indicating she wore hearing aids and had adequate hearing. Despite this, the care plan updated on 3/19/25 did not address hearing loss or the use of hearing aids, even though physician's orders specified the devices should be inserted each morning and removed at bedtime. Observations revealed the resident was not wearing her hearing aids, and interviews with the resident and staff confirmed she had recently started using them but often refused due to discomfort. The MDS nurse acknowledged missing the assessment and failing to update the care plan, despite daily discussions of resident assessments in morning meetings. Both the DON and Administrator confirmed that care plans were expected to be reviewed and updated during these meetings, but the omission was not identified or corrected.
Failure to Provide Timely IV Antibiotic Therapy for New Admission
Penalty
Summary
The facility failed to ensure that intravenous (IV) antibiotic medication was available and administered as ordered for a newly admitted resident with a diagnosis of osteomyelitis of the left ankle and foot. The resident was admitted with a physician's order for cefazolin 2 grams IV every 8 hours for 42 days. Upon admission, the resident had IV access in place, but the ordered antibiotic was not available for several scheduled doses. Documentation in the Medication Administration Record (MAR) indicated missed doses, with notes from nursing staff stating the medication was on order or awaiting delivery from the pharmacy. Multiple nursing staff interviews confirmed that the medication was not available at the facility at the time of admission and for subsequent scheduled doses. Nurses reported contacting the pharmacy, which indicated that the medication would be delivered on the next run, but it was not included in the initial deliveries. The emergency dose kit at the facility did not contain IV cefazolin, and staff were unaware of its availability in the kit. The resident expressed concern about missing several doses of the antibiotic and reported notifying nursing staff about the missed medication. Interviews with the pharmacist revealed that the pharmacy had a cut-off time for sending IV antibiotics for new admissions, and delays could occur if residents were admitted after this time or due to pharmacy staffing or documentation issues. The Medical Director and Director of Nursing acknowledged the lack of an effective system to ensure timely availability of medications for new admissions, particularly for IV antibiotics. The administrator was not aware of any issues with timely delivery of IV medications for new admissions.
Failure to Obtain Physician Order for Indwelling Urinary Catheter
Penalty
Summary
A deficiency occurred when the facility failed to obtain a physician order for the use and care of an indwelling urinary catheter for a resident who was readmitted with a history of neuromuscular dysfunction of the bladder and a spinal fracture. The resident had an indwelling urinary catheter in place during a recent hospital stay and at the time of discharge, and the care plan included interventions for catheter management. However, upon review of the facility's records, there was no physician order for the indwelling urinary catheter or its care after readmission. Interviews with nursing staff revealed confusion and miscommunication regarding responsibility for reactivating or entering the necessary orders for the catheter. One nurse believed the oncoming nurse would reactivate the orders, while the other nurse thought it was the first nurse's responsibility. Both the Medical Director and the DON confirmed that a physician order was required for the catheter, and the omission was acknowledged as an oversight during the facility's clinical morning meeting. The administrator also confirmed that nursing was responsible for ensuring physician orders were in place for catheter care.
Missed IV Antibiotic Doses Due to Medication Unavailability on Admission
Penalty
Summary
A deficiency occurred when a resident admitted with osteomyelitis of the left ankle and foot did not receive four scheduled doses of intravenous cefazolin antibiotic as ordered by the physician. The medication was to be administered every eight hours, but was not given at four scheduled times due to the medication not being available in the facility. Nursing staff documented the missed doses, citing reasons such as the medication being on order, not yet delivered from the pharmacy, or awaiting arrival. Multiple nurses confirmed in interviews that the cefazolin was not available for administration and that they either contacted the pharmacy or expected the medication to arrive later. The backup medication dispensing system did not contain cefazolin, and not all staff contacted the pharmacy to check on the delivery status. The resident, who was cognitively intact and had intravenous access, reported missing several doses of the antibiotic upon admission. The physician was notified of the missed doses and adjusted the medication schedule to ensure the total prescribed doses would be administered. The DON explained that new admission orders could not be activated until the resident arrived, which sometimes led to delays in medication delivery, especially for late evening admissions. The administrator confirmed that the DON was responsible for ensuring the availability of IV antibiotics as ordered.
Failure to Provide Required Written Notifications and Bed Hold Documentation During Hospital Transfers
Penalty
Summary
The facility failed to provide required written notifications and documentation related to resident transfers and discharges to the hospital. For three residents reviewed, there was no evidence that written transfer or discharge notices were given to the residents or their representatives at the time of hospitalization. In each case, the medical records lacked documentation of these notices, and interviews with staff confirmed that written notifications were not provided, although phone calls were sometimes made to inform resident representatives. Additionally, the facility did not properly complete the bed hold policy documentation. For one resident, the bed hold form was signed by the resident representative, but critical sections such as the dates of hospitalization and the acceptance or declination of the bed hold were left incomplete. The business office manager indicated that her involvement with the bed hold policy was limited to payment discussions if the resident or representative expressed interest, and that nursing staff sent the form with the resident by default. There was confusion among staff regarding responsibility for follow-up and completion of the bed hold process. The facility also failed to notify the Ombudsman in writing of resident transfers or discharges to the hospital. The social worker acknowledged that the required transfer/discharge list had not been sent to the Ombudsman for the relevant month, citing being behind on this task. Staff interviews revealed a lack of awareness regarding the requirement to send written notices to residents, representatives, and the Ombudsman, contributing to the deficiency.
Failure to Provide Baseline Care Plan and Medication List to Residents
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and medication list to residents or their responsible parties within the required timeframe for two out of four residents reviewed. One resident with severe cognitive impairment was admitted and neither the resident nor the responsible party received documentation regarding the care plan or medications. The responsible party, who visited almost daily, confirmed not receiving any information about the plan of care or medications. The electronic health record also lacked documentation of this requirement being met. Similarly, another resident who was cognitively intact did not receive a written summary of the baseline care plan or medication list after admission. The resident confirmed not receiving any documentation about the plan of care or medications. In both cases, the Social Worker, who was responsible for providing these documents, acknowledged falling behind in the process. The DON and Administrator were unaware that the required information had not been provided to the residents or their responsible parties.
Deficiencies in Care Plan Meetings for Residents
Penalty
Summary
The facility failed to conduct and document care plan meetings for three residents, leading to deficiencies in care planning. Resident #86, who was cognitively intact and admitted with multiple fractures, did not have a care plan meeting held within the required timeframe. Although a baseline care plan was signed by the Assistant Director of Nursing, there was no documentation of a 72-hour care plan meeting, and the MDS Nurse confirmed that no such meeting was conducted. The facility attempted to contact the resident's contact person but was unsuccessful, and the Admission Director was unable to provide evidence of a scheduled meeting. Resident #38, admitted with a stroke and later identified as moderately cognitively impaired, also did not have a documented care plan meeting following admission. The baseline care plan lacked signatures, and there was no record of a care plan meeting in the resident's electronic medical record. Interviews with the resident and staff revealed that no care plan meeting was held, and the Admission Director could not locate any documentation to confirm a meeting had occurred. Resident #26, who was cognitively intact and admitted with a stroke, had not attended or been invited to a care plan meeting since 2021, despite multiple MDS assessments being completed. The facility's previous Social Worker was responsible for scheduling these meetings, but after their departure, the meetings were not conducted. The Administrator was unaware of the lapse in care plan meetings until it was brought to her attention, and the Admissions Director was working to address the backlog of unscheduled meetings.
Facility Fails to Maintain Cleanliness of Kitchen Equipment and Ice Machine
Penalty
Summary
The facility failed to maintain cleanliness standards in their kitchen and ice machine areas, as observed during multiple inspections. Specifically, two out of four skillets and nine out of fifteen baking sheets were found with grease buildup, indicating they were not properly cleaned before being stored for use. These observations were made on three separate occasions, suggesting a persistent issue with maintaining dishware cleanliness. Additionally, an ice scoop holder was found with standing water and mold, which could potentially contaminate the ice served to residents. Interviews with facility staff revealed a lack of clarity regarding responsibilities for cleaning and maintaining equipment. The Certified Dietary Manager indicated that hall staff were responsible for the ice machine and scoop holder, while the Administrator stated that all staff were responsible for these tasks. This inconsistency in understanding roles may have contributed to the oversight in maintaining cleanliness, as evidenced by the repeated observations of unclean equipment.
Failure to Document Medications in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered baseline care plan for a resident who was admitted with diagnoses including Diabetes Mellitus, pulmonary embolism, and deep vein thrombosis. The resident had physician's orders for Apixaban, an anticoagulant, and Humalog insulin, a medication used to manage blood glucose levels. Despite these orders, the baseline care plan did not reflect the administration of these medications, as the medication section was left unmarked. Interviews with facility staff revealed that the resident was receiving the prescribed medications upon admission, and both the nurse responsible for completing the baseline care plan and the Assistant Director of Nursing acknowledged the oversight. The Director of Nursing confirmed that the medications should have been marked on the baseline care plan, and noted that the inaccuracy could have been corrected during the resident's 72-hour care plan meeting if it had been identified at that time.
Failure to Implement Individualized Care Plan for Visually Impaired Resident
Penalty
Summary
The facility failed to implement an individualized person-centered care plan for a resident with impaired vision, leading to a deficiency in nutritional care. The resident, who was cognitively intact but had highly impaired vision, was readmitted to the facility with a physician's order specifying that all meals should be served in individual bowls to aid in self-feeding. Despite this order being included in the resident's care plan, an observation revealed that the resident's lunch was served on a flat plate, contrary to the care plan's instructions. The resident confirmed that her meal should have been served in bowls, and although a new meal was offered, she declined it. Interviews with facility staff, including the Director of Rehab, Nurse Aide #1, the MDS Nurse, the Director of Nursing, and the Administrator, confirmed the oversight. The Director of Rehab had previously communicated the need for meals to be served in bowls to the Dietary Manager, and the MDS Nurse acknowledged that the care plan required meals to be served in bowls due to the resident's impaired vision. The Director of Nursing and the Administrator both stated that the care plan should have been followed, and the nursing staff should have ensured the meal was served as ordered.
Failure to Document Oxygen Orders and Signage
Penalty
Summary
The facility failed to obtain a physician order for the use of supplemental oxygen for a resident, identified as Resident #292, who was admitted with chronic heart failure and chronic respiratory failure. Upon admission, the resident was receiving oxygen at 2 liters per minute via nasal cannula, as per discharge orders to maintain oxygen saturation above 90%. However, there was no physician order documented in the resident's medical record for the use of oxygen therapy. On a subsequent occasion, the resident's oxygen saturation dropped to 80%, prompting an increase in oxygen to 3 liters per minute, which was also not documented in the physician's orders. Additionally, the facility failed to place appropriate signage indicating the use of oxygen outside the resident's room. Observations revealed that there was no 'Oxygen in use, no smoking' sign outside the resident's room, despite the resident continuously using oxygen. Interviews with nursing staff and the Director of Nursing confirmed the absence of the required physician order and signage, acknowledging that these should have been in place upon the resident's admission or when the need for oxygen was recognized.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide the necessary adaptive equipment for a resident with highly impaired vision, as ordered by the physician. The resident, who was cognitively intact, required all meals to be served in bowls to aid with self-feeding due to decreased vision. However, during an observation, it was noted that the resident's lunch was served on a flat plate, contrary to the physician's order. The resident confirmed that her meal should have been served in bowls, and although a new meal was offered, she declined. Interviews with staff revealed a breakdown in communication and adherence to the resident's care plan. The Director of Rehab had informed the previous Dietary Manager about the need for meals to be served in bowls, and the current Dietary Manager was aware of this requirement. Despite this, the lunch was not served correctly, and the nursing staff failed to double-check the meal before serving it. The Director of Nursing and the Administrator acknowledged that the plan of care was not followed, and the meal should have been provided in bowls as ordered.
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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