Life Care Center Of Hendersonville
Inspection history, citations, penalties and survey trends for this long-term care facility in Hendersonville, North Carolina.
- Location
- 400 Thompson Street, Hendersonville, North Carolina 28792
- CMS Provider Number
- 345463
- Inspections on file
- 21
- Latest survey
- August 27, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Life Care Center Of Hendersonville during CMS and state inspections, most recent first.
The facility did not ensure RN coverage for at least 8 consecutive hours on multiple days, as confirmed by staffing records and staff interviews. Scheduling gaps occurred, particularly on weekends, and documentation was lacking for required RN presence on several dates.
Surveyors identified expired milk in the walk-in cooler, unlabeled and undated chicken in the freezer, open and undated food items and supplements stored on the floor in dry storage, a dirty ice machine, and an unclean nourishment refrigerator. Staff interviews confirmed these practices did not meet facility expectations for food safety and sanitation.
Two residents did not receive their physician-ordered therapeutic diets and nutritional supplements. One resident with diabetes and malnutrition was not given double portions as ordered, and another resident at risk for weight fluctuation did not receive a prescribed frozen nutritional supplement due to it being out of stock. Staff failed to ensure orders were followed and did not notify nursing when supplements were unavailable.
A treatment nurse failed to follow infection control protocols by not wearing a gown during wound care for a resident with a diabetic foot ulcer and during tracheostomy and feeding tube care for another resident on Enhanced Barrier Precautions (EBP). The nurse also did not remove gloves and perform hand hygiene between dirty and clean tasks during a feeding tube dressing change, contrary to facility policy. The DON and Administrator confirmed that EBP and hand hygiene protocols were expected to be followed during these care activities.
The facility did not ensure that daily nurse staffing sheets accurately matched the actual nursing staff who worked, as shown by discrepancies between posted sheets and time clock records. Staff interviews revealed inconsistent processes for updating and posting staffing information, leading to inaccurate documentation of RN and LPN coverage on multiple days.
A resident developed a stage 2 pressure ulcer, but the nurse failed to notify the Physician or PA and did not document the occurrence or treatment. The facility's protocol required such notification and obtaining treatment orders, which was not followed, leading to a deficiency.
A resident at risk for pressure ulcers did not receive timely care due to the facility's failure to complete weekly skin assessments and obtain treatment orders for a newly identified sacral ulcer. The ulcer was discovered by a nurse who did not document the occurrence or notify the PA for treatment orders, resulting in a five-day delay in care. The DON and Administrator expected nurses to follow protocol by contacting the Physician or PA for treatment orders, which was not adhered to in this instance.
The facility failed to properly manage medication storage, with an opened bottle of Latanoprost eye drops stored beyond the manufacturer's recommended period and an expired Povidone Iodine solution found in medication carts. Nurses acknowledged the oversights, and the DON expressed confusion over the missed expired medications despite previous training and audits.
A facility failed to complete a comprehensive MDS assessment within 14 days of the ARD for a resident. The delay was due to the absence of a permanent MDS Coordinator, with staff from other facilities focusing on current assessments to prevent further delays. The Administrator identified the issue during an audit and attributed it to having only one permanent MDS Coordinator, with plans to address the backlog by hiring an additional coordinator.
The facility failed to complete quarterly MDS assessments within the required timeframe for three residents. The delay was due to the absence of a permanent MDS Coordinator, with staff from other facilities focusing on current assessments to prevent further delays. The issue was identified during an audit, and the facility has since hired an additional MDS Coordinator.
A facility failed to complete a discharge-return anticipated MDS and an entry tracking record within the required timeframe for a resident. The delay was due to the absence of a dedicated MDS Coordinator, leading to a backlog of assessments. The issue was identified during an audit, and the facility had been relying on staff from other facilities to assist, which was insufficient to address the backlog.
A resident with multiple diagnoses requiring total assistance for transfers fell and sustained a hip fracture after a nurse aide attempted an independent transfer without a mechanical lift. The care plan lacked clear documentation of the resident's transfer needs. In another case, a resident with multiple sclerosis was transferred without the required mechanical lift and two-person assistance, contrary to the care plan.
The facility failed to maintain cleanliness and proper labeling in the kitchen and nourishment areas. Observations revealed debris on a kitchen fan and in the walk-in cooler, along with undated and expired food items. The Dietary Manager and Administrator expected cleanliness and proper labeling, but the Dietary Manager was unaware of cleaning responsibilities. Unlabeled and undated items were also found in nourishment rooms, with dietary aides responsible for labeling and discarding items.
A facility failed to accurately code MDS assessments for several residents, leading to documentation deficiencies. A resident's fall and resulting fracture were not recorded, another's anticoagulant use and hand contracture were omitted, and significant weight loss in a third resident was not documented. Additional errors included unrecorded bowel incontinence and a colostomy. The Corporate MDS Consultant attributed these inaccuracies to the health issues of the MDS Coordinator.
The facility failed to date open bottles of latanoprost eye drops and multi-dose vials of tuberculin, and did not remove expired medications and vaccines from medication room refrigerators. Staff interviews revealed a lack of awareness and responsibility for these tasks.
The facility did not provide all food items as specified by the planned menu for residents on a pureed diet. During a lunch meal observation, pureed chicken and dumplings and pureed beets were served, but pureed bread was missing. The Dietary Manager and RD were unsure why the bread was not prepared, and the Administrator expected the menu to be followed unless an RD-approved substitution was made.
A facility failed to ensure a resident's physician's order for an advanced directive matched the MOST form signed by the family. The resident was admitted with a full code status, but the family changed it to DNR with limited interventions. The electronic health record still showed a full code status due to an oversight in the review process. The ADON, DON, and Executive Director acknowledged the discrepancy and the expectation for records to match.
A resident with anemia and malnutrition was not provided yogurt with meals despite multiple requests, as confirmed by observations and interviews. The Dietary Manager was aware of the request but had not audited meal trays to ensure compliance. The facility's Administrator expected food preferences to be followed.
The facility failed to provide nighttime snacks for three residents, who reported a lack of variety and availability in the nourishment rooms. Observations confirmed limited snack options, and interviews revealed unclear responsibilities for stocking snacks. The practice of preparing labeled snack trays was discontinued.
A resident with severe cognitive impairment and dependency on staff for daily living activities did not receive necessary oral hygiene assistance. Observations showed dirty dentures and teeth with a white buildup, indicating a lack of care. Staff interviews revealed a lack of awareness and communication about the resident's needs, despite expectations for daily assistance.
A resident with dysphagia and diabetes, dependent on staff for care, did not receive the correct tube feeding as per physician's order. The RD recommended specific settings to meet nutritional needs, but observations showed the feeding was set incorrectly. The DON confirmed the error, and the Physician Assistant emphasized the importance of following RD's recommendations. Attempts to interview the responsible nurse were unsuccessful.
Failure to Provide Required RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least 8 consecutive hours per day on five specific dates within the reviewed period. Review of daily nurse staffing sheets and time clock reports revealed that on these dates, there was no documentation of an RN being present for the required duration. Staff interviews confirmed that there were times when no RN was scheduled for the full 8 to 12 hours, and the Central Supply Manager, who was responsible for scheduling, would notify the Former Administrator when this occurred. The Former Administrator acknowledged awareness of the issue, particularly on weekends, and described attempts to address it by alternating the MDS Nurse and Treatment Nurse, both RNs, on weekends, but could not recall when this system was implemented. The Regional Director of Clinical Operations also confirmed the lack of documentation for RN coverage on the identified dates and noted that there may have been instances of call-outs or staff working at a sister facility, which contributed to the deficiency. The report does not mention any specific residents affected or provide details about their medical conditions at the time of the deficiency. The deficiency was identified through record review and staff interviews, which consistently indicated that the facility did not meet the regulatory requirement for RN coverage on the specified dates.
Deficiencies in Food Storage, Labeling, and Sanitation Practices
Penalty
Summary
Surveyors observed multiple deficiencies in food storage, labeling, and sanitation practices within the facility. In the walk-in cooler, a box of 2% milk cartons was found with a use-by date that had already passed, and both the Dietary Manager and Administrator confirmed that expired items should be discarded by the use-by date. In the walk-in freezer, a bag of boneless chicken breasts was found without a label or date, contrary to facility expectations. The dry storage room contained open and undated bags of powdered sugar and graham crackers, as well as boxes of nutritional supplements stored directly on the floor, all of which were acknowledged by staff and administration as not meeting facility standards for labeling, dating, and storage. Further observations revealed sanitation issues with equipment and nourishment storage. The dining room ice machine had a visible build-up of gray debris on the left vent, and while a contract company handled quarterly deep cleaning, the Maintenance Director was responsible for routine cleaning and had not been notified of the issue. Additionally, the nourishment room refrigerator on the 500/600 hall had a large area of dried white substance with cardboard stuck to the middle shelf, which staff and administration stated should be checked and cleaned daily. These findings were confirmed through staff interviews, indicating lapses in routine monitoring and adherence to established food safety and sanitation protocols.
Failure to Provide Physician-Ordered Therapeutic Diets and Supplements
Penalty
Summary
The facility failed to follow physician diet orders for two residents with specific nutritional needs. One resident, admitted with diabetes and malnutrition, had a physician order for a mechanical soft diet with double portions as an intervention for weight loss. Despite this, observations during a lunch meal revealed the resident did not receive a double portion of beef as ordered. Staff interviews confirmed that the dietary aide responsible for checking meal trays overlooked providing the double portion, and the dietary manager and registered dietitian both stated that double portions were expected to be provided as ordered. Another resident, admitted with a history of stroke and at risk for weight fluctuation, had a physician order for a frozen nutritional supplement twice daily. Observations on two consecutive days showed that the resident did not receive the ordered supplement with her lunch meal because the kitchen was out of the product. Staff interviews revealed that dietary staff did not notify nursing staff or the dietary manager about the unavailability of the supplement, and the registered dietitian confirmed that staff should have notified nursing so an appropriate substitute could be ordered. The administrator also stated that she expected residents to receive supplements as ordered and for nursing to be notified if they were unavailable.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to follow its infection control policy and procedures regarding Enhanced Barrier Precautions (EBP) and hand hygiene during care for residents with chronic wounds and indwelling medical devices. Specifically, a treatment nurse did not wear a protective gown while providing wound care for a resident with a diabetic foot ulcer, despite the facility's EBP policy indicating that diabetic foot ulcers are considered chronic wounds and require EBP during high-contact care activities. The nurse and the Director of Nursing (DON) both stated that EBP was not implemented because the wound was not present for three months, although the policy listed diabetic foot ulcers as chronic wounds regardless of duration. The Administrator later confirmed that EBP should have been implemented for this resident during wound care. Additionally, the same treatment nurse did not don a gown while providing tracheostomy and feeding tube care for another resident who was on EBP, as indicated by signage and supplies at the resident's door. The nurse performed multiple steps of tracheostomy and feeding tube care, including handling soiled dressings and cleaning around the devices, without wearing a gown as required by the facility's EBP policy. The nurse acknowledged this omission as an oversight during an interview, and both the DON and Administrator confirmed that staff are expected to follow EBP protocols during such care. The facility also failed to follow its hand hygiene policy during a dressing change for a resident with a feeding tube. The treatment nurse did not remove gloves and perform hand hygiene after removing a soiled gauze and before cleaning around the feeding tube, contrary to the facility's policy and CDC guidelines. The nurse stated she would only remove gloves and perform hand hygiene if the gloves were visibly soiled, while the DON and Administrator both indicated that hand hygiene should be performed when moving from a dirty to a clean task.
Inaccurate Daily Nurse Staffing Sheets
Penalty
Summary
The facility failed to ensure that daily nurse staffing sheets accurately reflected the nursing staff who worked on four out of six days reviewed. Record review showed discrepancies between the posted staffing sheets and the actual time clock reports. On several occasions, the staffing sheets indicated that a Registered Nurse (RN) was present during the day shift, while the time clock reports revealed that only Licensed Practical Nurses (LPNs) were present and no RN had worked. On another occasion, the staffing sheet did not list an RN, but the time clock report showed that an RN had worked for three hours during the shift. Interviews with facility staff revealed inconsistencies in the process for completing and updating the daily nurse staffing sheets. The Assistant Director of Nursing (ADON) was responsible for updating the sheets during the week, while the weekend nursing supervisor was responsible on weekends. However, the Central Supply Manager reported that she sometimes completed the sheets in advance for the weekend, and the receptionist would post them, with nursing staff expected to update them as needed for call-outs or schedule changes. The Administrator confirmed these responsibilities and stated that the expectation was for the sheets to be updated to accurately reflect the staff who worked each shift.
Failure to Notify Physician of New Pressure Ulcer
Penalty
Summary
The facility failed to notify the Physician or Physician Assistant (PA) about a newly identified pressure ulcer for one of the residents. Resident #3, who was admitted with diagnoses including dementia and protein-calorie malnutrition, developed a stage 2 pressure ulcer on the sacrum, first identified on 10/18/24. Nurse #1, who completed the wound observation tool on 10/24/24, was aware of the new wound but did not document the occurrence or treatment, nor did she inform the PA about the wound. This lack of communication and documentation led to a failure in obtaining necessary treatment orders. Interviews with the PA, Director of Nursing (DON), and the Administrator revealed that the facility's protocol required nurses to notify the Physician or PA and obtain treatment orders when a new wound is discovered. The PA expressed a preference for being notified as soon as possible about skin issues that could result in pressure ulcers. The DON and Administrator both confirmed that Nurse #1 did not follow the established protocol, which was an expectation for addressing new wounds in the facility.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident. The resident, who was admitted with diagnoses including dementia and protein-calorie malnutrition, was at risk for pressure ulcers due to decreased mobility. Despite being identified as at risk, the facility did not complete weekly skin assessments or obtain treatment orders for a newly identified pressure ulcer on the resident's sacrum. The pressure ulcer was first identified on October 18, 2024, but there was no documentation of its discovery or initial treatment until October 24, 2024, when a physician's order was finally obtained. Nurse #1, who discovered the wound, did not document the occurrence or treatment of the wound and failed to notify the Physician Assistant (PA) to obtain treatment orders. The PA indicated that while treatment orders would have been beneficial, the delay did not impact the outcome due to the resident's poor nutrition and refusal to offload. The Director of Nursing (DON) and the Administrator both expressed that their expectation was for nurses to contact the Physician or PA and obtain treatment orders when a new wound is discovered, which was not done in this case.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication storage guidelines, resulting in deficiencies related to expired and improperly stored medications. During a medication storage audit, an opened bottle of Latanoprost eye drops was found in a medication cart, having been stored at room temperature since 04/28/24, contrary to the manufacturer's guidelines which allow room temperature storage for only up to six weeks. Nurse #1, who was present during the audit, acknowledged the oversight, mistakenly believing the medication could be stored until its expiration date in June 2026. Additionally, another audit revealed an expired antiseptic wound care solution, Povidone Iodine 10%, in a different medication cart. The solution had expired on 10/31/23 but was still present and ready for use. Nurse #2, who was present during this audit, admitted to missing the expired solution during her morning check. The Director of Nursing expressed confusion over the oversight, despite previous in-service training and audits, and emphasized the expectation for the facility to remain free of expired medications.
Failure to Complete MDS Assessment Timely
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date (ARD) for one of the sampled residents. The resident was admitted to the facility, and their annual MDS assessment was noted as in progress with an ARD of 08/01/24. The Corporate MDS Consultant confirmed that the assessment was not completed within the regulatory timeframe due to the facility being without a permanent MDS Coordinator for some time. Staff from other facilities had been assisting but focused on current assessments to prevent further delays. The Administrator became aware of the issue during an audit for the Plan of Correction from a previous recertification survey. The delay was attributed to having only one permanent MDS Coordinator, and the facility had recently hired an additional coordinator to address the backlog. The Administrator expected MDS assessments to be completed within the regulatory timeframes.
Delayed Completion of MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required 14 days of the Assessment Reference Date (ARD) for three residents. Resident #2's quarterly MDS assessment, with an ARD of 07/23/24, was still in progress as of 08/22/24. Similarly, Resident #5's assessment with an ARD of 07/26/24 and Resident #3's assessment with an ARD of 08/06/24 were also noted as in progress. The Corporate MDS Consultant confirmed that these assessments were not completed within the regulatory timeframe. The delay in completing the MDS assessments was attributed to the facility being without a permanent MDS Coordinator for some time. Staff from other facilities had been assisting, focusing on current MDS assessments to prevent further delays. The Administrator acknowledged the issue during an audit for the Plan of Correction from a previous recertification survey and attributed the breakdown to having only one permanent MDS Coordinator. The facility has since hired an additional MDS Coordinator to address the backlog.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to complete a discharge-return anticipated Minimum Data Set (MDS) within 14 days of the discharge date and an entry tracking record within 14 days of admission for one of the sampled residents. Resident #5 was admitted to the facility, and upon review of their electronic health record, it was found that both the discharge-return anticipated MDS assessment and the entry tracking record were still in progress beyond the regulatory timeframe. This deficiency was confirmed during a telephone interview with the Corporate MDS Consultant, who acknowledged the delay and attributed it to the absence of a dedicated MDS Coordinator. The Administrator became aware of the issue during an audit for the Plan of Correction from a previous recertification survey. The delay in completing MDS assessments was primarily due to having only one permanent MDS Coordinator, which led to a backlog. The Administrator discussed the issue with the Corporate MDS Consultant, who was focusing on current assessments to prevent further delays. The facility had been relying on staff from other facilities to assist, but this was insufficient to address the backlog in a timely manner.
Failure to Follow Transfer Protocols Leads to Resident Injuries
Penalty
Summary
The facility failed to include a resident's transfer status in the comprehensive care plan, leading to an unsafe transfer attempt by a nurse aide. Resident #44, who had multiple diagnoses including muscle weakness and hip contractures, required total dependence for transfers due to lower extremity weakness. On the evening of 05/17/24, Nurse Aide #1 attempted to transfer Resident #44 from a motorized wheelchair to the bed without assistance or a mechanical lift, resulting in the resident falling to the floor. The resident sustained an acute left intertrochanteric fracture and was admitted to the hospital for surgical repair. The incident was compounded by the lack of clear documentation and communication regarding Resident #44's transfer needs. The nurse aide was not aware of the resident's transfer status and did not seek assistance or clarification before attempting the transfer. The care plan was only updated after the incident to reflect the need for total staff assistance with transfers. Interviews with staff and the resident revealed inconsistencies in the nurse aide's account of the incident, and the facility's investigation determined that the fall was due to the nurse aide's failure to follow proper transfer protocols. In a separate incident, Resident #8, who was dependent on staff for transfers due to multiple sclerosis, was transferred by NA #2 without the use of a mechanical lift and two-person assistance as required by the care plan. The aide used one-person physical assistance, believing it was safe due to the resident's ability to bear weight on one leg. This action was contrary to the care plan, which specified the use of a total mechanical lift with two-person assistance. The aide had not recently checked the care plan and did not inform therapy or nursing staff of the resident's ability to bear weight and pivot with one-person assistance.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to maintain cleanliness and proper labeling in the kitchen and nourishment areas, as observed during a survey. A fan in the food preparation area was found with gray debris on its covers, and the walk-in cooler had a thick build-up of gray debris near the ceiling light and entry door wall. The Dietary Manager, who had been employed for about a month, was unaware of any deep cleaning schedule or who was responsible for cleaning these areas. The Administrator expected all kitchen fans and the walk-in cooler to be clean and free of debris. In the walk-in cooler, several food items were found opened and undated, including sliced cheese, cottage cheese, shredded cheese, loaves of bread, and a bag of shredded carrots. Additionally, iceberg lettuce showed signs of spoilage, and collard greens were past their best-by date. Manufactured milkshakes were not labeled with the date they were removed from the freezer. The Dietary Manager expected all food items to be labeled and dated, and spoiled or expired food to be discarded. The Administrator shared these expectations, including the use or disposal of milkshakes within 14 days of thawing. Further observations revealed an opened and undated bag of French fries in the walk-in freezer and expired food items on a food preparation table. In nourishment rooms, various food and beverage items were found unlabeled and undated, including milkshakes, water, pineapple juice, diet soda, salad, and cake. The Dietary Manager stated that dietary aides were responsible for labeling, dating, and discarding items each shift. The Administrator expected all food and beverage items to be labeled and dated, with milkshakes used or discarded within 14 days of thawing.
Inaccurate MDS Coding Leads to Documentation Deficiencies
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for several residents, leading to deficiencies in the documentation of their medical conditions and treatments. Resident #44, who was admitted with diagnoses including abnormal gait and muscle weakness, experienced a fall resulting in a hip fracture. However, the MDS assessment did not reflect this fall or the fracture, indicating a significant oversight in the documentation process. The Corporate MDS Consultant acknowledged that the MDS should have accurately recorded the fall and fracture. Resident #17, admitted with hemiplegia and hemiparesis following a stroke, was prescribed Xarelto, an anticoagulant medication. Despite this, the MDS assessment failed to document the use of anticoagulant medication and the impairment of the resident's upper extremities due to a right-hand contracture. Similarly, Resident #13, who experienced a significant weight loss over six months, was not accurately coded in the MDS assessment to reflect this weight loss. The Corporate MDS Consultant confirmed these inaccuracies, attributing them to the health problems of the facility's MDS Coordinator. Additional coding errors were identified for Resident #7, whose bowel incontinence was not documented, and Resident #2, whose colostomy was not recorded in the MDS assessment. These omissions were also confirmed by the Corporate MDS Consultant, who cited the MDS Coordinator's health issues as a contributing factor. The facility's Administrator expressed an expectation for accurate MDS assessments, highlighting a gap between expected and actual documentation practices.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and store medications and biologicals according to professional standards. Specifically, two open bottles of latanoprost eye drops were found on a medication cart without being dated, which is necessary to track their usage duration. Nurse #1, who was interviewed, was unaware of how long the eye drops had been in use and admitted to not being the usual nurse assigned to that medication cart. The Director of Nursing (DON) and the Administrator confirmed that the expectation was for the nurse who removed the eye drops from refrigeration to date them when placed on the cart. Additionally, the facility did not date three multi-dose vials of tuberculin purified protein derivative, which were stored in the medication room refrigerators. These vials should be discarded if in use for more than 30 days. Furthermore, expired medications and influenza vaccines were found in the medication room refrigerators. The DON and the Infection Preventionist were responsible for checking these items, but the Infection Preventionist was unaware of her responsibility to check the expiration dates of the influenza vaccines. The Administrator expected regular checks of the medication rooms to ensure expired items were removed.
Failure to Follow Pureed Diet Menu
Penalty
Summary
The facility failed to provide all food items as specified by the planned menu for residents receiving a pureed diet. During an observation of the lunch meal tray line, it was noted that pureed chicken and dumplings and pureed beets were served using a 4-ounce serving utensil, but no pureed bread was provided on the pureed meal trays. The menu for the lunch meal specified that a 4-ounce serving of pureed chicken and dumplings, a 4-ounce serving of pureed beets, and one serving of pureed bread mix were to be served. The Dietary Manager was unable to explain why the pureed bread was not prepared, and the Registered Dietician expected the menu to be followed as planned. The Administrator also expected the menus to be followed unless a substitution approved by the RD was provided.
Mismatch Between Physician's Order and MOST Form for Resident's Code Status
Penalty
Summary
The facility failed to ensure that the physician's order for an advanced directive matched the Medical Orders for Scope of Treatment (MOST) form signed by the resident's family for one resident. The resident, who was moderately cognitively impaired, was admitted to the facility with a full code status as per the hospital's SBAR report. However, upon admission, the resident's family decided to change the code status to Do Not Resuscitate (DNR) with limited interventions, as documented in the MOST form. Despite this change, the electronic health record still reflected a full code status, leading to a discrepancy between the physician's order and the MOST form. The Assistant Director of Nursing (ADON) acknowledged that the facility's interdisciplinary team was responsible for reviewing new residents' code statuses to ensure accuracy, but this review was overlooked for the resident in question. The Director of Nursing (DON) and the Executive Director both stated that their expectation was for the code status in the electronic health record to match the MOST form. The oversight occurred because the resident was admitted on a Friday, and the review was supposed to take place the following Monday, but it was missed. Staff were trained to check the physical chart for the MOST form for the most up-to-date code status before providing medical intervention.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as Resident #9, who was admitted with diagnoses including anemia and malnutrition. Despite being cognitively intact and having a regular diet order, Resident #9 expressed a preference for yogurt with each meal, which was not provided. This issue was identified through record reviews, observations, and interviews with the resident and staff. The resident's nutrition care plan, last revised in June 2024, did not reflect this preference, and observations over several days confirmed the absence of yogurt on her meal trays. The Dietary Manager acknowledged awareness of the resident's request for yogurt and confirmed its availability in the kitchen. However, he admitted to not conducting audits of meal trays to ensure compliance with residents' food preferences since his employment began a month prior. The facility's Administrator stated an expectation that residents' food preferences should be followed, indicating a lapse in the facility's adherence to dietary preferences for Resident #9.
Failure to Provide Nighttime Snacks
Penalty
Summary
The facility failed to offer and provide nighttime snacks for three of four sampled residents, as observed during a resident council meeting. Residents reported not being offered nighttime snacks and noted a lack of variety in the available snacks in the nourishment rooms. They expressed a desire for healthy snacks in the evenings, as they often felt hungry between their early dinner and the next morning's breakfast. Observations confirmed that the nourishment rooms had limited snack options, with only peanut butter crackers and saltine crackers available. Interviews with the Dietary Manager and the Administrator revealed a lack of clarity and responsibility regarding the stocking of nourishment rooms. The Dietary Manager indicated that snacks were available upon request before dietary staff left for the day, but was unsure who ensured the nourishment rooms were stocked. The Administrator, unaware of the limited snack availability, stated that all staff had access to the nourishment rooms to provide snacks upon request. However, the practice of preparing a tray of snacks labeled with residents' names, as done previously, was no longer in place.
Failure to Provide Oral Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary oral hygiene assistance to a resident with severe cognitive impairment and dependency on staff for daily living activities. Resident #64, who was admitted with diagnoses including dementia and seizure disorder, required setup assistance for oral hygiene as per their care plan. However, observations on multiple occasions revealed that the resident's dentures and teeth were visibly dirty with a white buildup of debris, indicating a lack of proper oral care. Interviews with staff, including the Director of Nursing (DON) and a nursing assistant (NA #3), highlighted a lack of awareness and communication regarding the resident's need for oral hygiene assistance. NA #3 was unaware that the resident had dentures and confirmed that no assistance was provided on specific dates. The DON acknowledged the need for cleaning but was unsure when the resident last received oral hygiene care. This deficiency in care was noted despite the facility's expectation for staff to provide daily oral hygiene assistance.
Failure to Follow Physician's Order for Tube Feeding
Penalty
Summary
The facility failed to adhere to a physician's order regarding the administration of a high protein, fiber-fortified nutritional supplement for a resident who was receiving tube feeding. The resident, who had multiple diagnoses including dysphagia following a stroke and diabetes, was dependent on staff for all self-care tasks and received more than half of her total calories and fluid intake via tube feeding. The Registered Dietitian (RD) had recommended specific tube feeding settings to meet the resident's nutritional and hydration needs, which were not followed as per the physician's order. Observations revealed that the tube feeding was set at 50 ml/hr instead of the prescribed 55 ml/hr, with water flushes at 20 ml/hr. The Director of Nursing (DON) confirmed the discrepancy in the tube feeding settings and suggested that the nurse might have misread the order. The RD stated that her recommendations were based on the provider's agreement and the resident's tolerance, but she did not observe the incorrect settings herself. Attempts to interview the responsible nurse were unsuccessful, and the Physician Assistant expressed a preference for staff to follow the RD's recommendations. The facility administrator, not being clinical, could not comment on the expectations without consulting the nurse involved.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
