Louisburg Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Louisburg, North Carolina.
- Location
- 202 Smoketree Way, Louisburg, North Carolina 27549
- CMS Provider Number
- 345358
- Inspections on file
- 22
- Latest survey
- March 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Louisburg Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not resolve grievances from Resident Council Meetings over four months, concerning limited beverage options and missing laundry items. Despite documentation of these issues, no follow-up actions were taken, as confirmed by resident interviews and staff acknowledgments.
The facility failed to provide RN coverage for 8 consecutive hours on two days, as required. A review of staffing data indicated low weekend staffing, and examination of staff postings and schedules revealed no RN on duty on these days, despite a census of 69 and 82. Interviews confirmed the absence of documentation for RN coverage, although the DON stated that the MDS nurse would fill open positions if needed.
The facility failed to maintain cleanliness of the convection oven, with significant grease buildup observed during two inspections. The oven was cleaned only once a month, with the last cleaning over a month prior, and charred food from a spill two weeks earlier remained unaddressed. This lack of regular cleaning could potentially affect food quality.
The facility failed to maintain the dignity of two residents during meals. A resident with severe cognitive impairment was observed with a urinal on the overbed table while eating, contrary to his preference. Another resident, who required limited assistance, was fed by staff standing over him instead of sitting at eye level, despite the availability of a chair. These practices violated the residents' rights to dignity and respect.
A facility failed to assess a resident for self-administration of medication, leading to a deficiency. The resident, who was cognitively intact, was found with medications left at her bedside, which she usually took herself. The Medication Aide forgot to return to ensure the medication was taken, and the DON confirmed no assessment was conducted for self-administration. The Administrator expected staff to ensure medications were taken before leaving the room.
A resident with Alzheimer's and dementia did not receive ordered foot care, as lotion was not applied to her feet despite a physician's order. The resident's care plan noted refusal of care, but there was no documentation of refusals related to foot care. A podiatry visit revealed severe dry skin, and staff interviews indicated a lack of awareness of the lotion application order. The DON and Administrator acknowledged the oversight in care and communication.
The facility failed to provide written grievance summaries for grievances filed by the Resident Council and a resident. Despite the facility's policy requiring a written response within 14 days, grievances concerning housekeeping, missing items, and staff conduct were not followed up with written summaries. The DON admitted to not being aware of the policy requirements until a mock survey, and the Administrator confirmed the need for timely written responses.
A resident with schizophrenia and breast cancer did not receive prescribed medications, Aripiprazole and Letrozole, on multiple occasions due to the facility's failure to ensure medication availability. Nurses did not notify the charge nurse or DON about the missing medications, nor did they follow up with the pharmacy or use a backup pharmacy. The pharmacist confirmed medication requests were made, but no follow-up calls were documented.
A resident with schizophrenia and breast cancer did not receive prescribed medications, Aripiprazole and Letrozole, on multiple occasions due to them being on order. Nursing staff lacked education on handling missing medications and did not follow up with the pharmacy or notify the charge nurse and DON. The Medical Director noted no side effects from missed doses.
Two residents in a facility were affected by an ant infestation due to ineffective pest control measures. One resident, with moderate cognitive impairment, was found with ants covering her bed and body, leading to itching and red marks. Another resident, requiring extensive assistance, was also found with ants in her room, necessitating a room change. Staff had previously observed ants, but the infestation's severity was unprecedented. The facility's pest control logs showed no prior ant activity, and the pest control company was called only after the incidents.
The facility failed to attempt a gradual dose reduction (GDR) of psychotropic medications for a resident, despite repeated recommendations from the Consultant Pharmacist. The resident was followed by an outpatient psychiatrist, but the facility did not obtain the necessary documentation to support this or to show that a GDR was clinically contraindicated. Interviews with staff revealed multiple attempts to secure the required records without success, leading to a deficiency in the care provided.
A resident with a diagnosis of schizophrenia was not referred for a PASRR level II screening due to a lack of notification to the responsible Social Worker. The resident's schizophrenia diagnosis was noted in the MDS annual assessment, but the Social Worker was unaware and did not submit the necessary review.
The facility failed to complete a baseline care plan within 48 hours for a resident with cancer, dialysis, and diabetes. Only the medication regimen section was completed on time, while other critical sections were delayed. Interviews revealed that the Social Worker was responsible for care plans, but the MDS Nurse only worked part-time, leading to the incomplete care plan for the severely cognitively impaired resident.
The facility failed to obtain and implement physician orders for a resident on hemodialysis, resulting in a lack of monitoring and necessary restrictions for the resident's AV fistula site. Nursing staff and administration were unaware of the missing orders, leading to inadequate care.
The facility failed to obtain outpatient psychiatrist visit notes for a resident prescribed psychotropic medication. Despite repeated requests from the Consultant Pharmacist and Nurse Practitioner, the facility did not have any documentation of the resident's outpatient psychiatric appointments, and attempts to contact the provider were unsuccessful.
The facility's QAA Committee failed to maintain procedures and monitor interventions, leading to deficiencies in labeling and storing drugs and administering vaccines. Issues included unlocked medication carts, expired medications, and failure to administer pneumococcal vaccines to eligible residents.
The facility failed to offer and administer the pneumococcal vaccine to two residents, despite having received consent from their responsible parties. One resident was admitted with intracranial injury, and another with encephalopathy. Both residents' immunization records indicated issues with vaccine administration and documentation.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to address and resolve grievances raised during Resident Council Meetings over a period of four months. Specifically, concerns about insufficient beverage options and clothes/items not being returned from the laundry were repeatedly noted in the meeting minutes for July, August, September, and October 2024. Despite these issues being documented, the follow-up/intervention sections of the meeting minutes were consistently left blank, indicating a lack of action taken to address the residents' concerns. Interviews with residents confirmed that these issues remained unresolved, as they continued to express dissatisfaction with the beverage options and the return of their laundry items. The Activities Director and Social Worker, who were responsible for facilitating the Resident Council Meetings, acknowledged that grievances were supposed to be communicated and addressed but could not explain why the issues were not resolved. The Administrator also confirmed that all complaints should have been followed by a grievance process, which was not adhered to in this case.
Failure to Provide RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours on two specific days, 9/15/24 and 12/07/24, as required. A review of the Payroll Based Journal (PBJ) staffing data for the first quarter of 2024 indicated excessively low weekend staffing. Further examination of the facility's daily staff postings and staffing schedules from 9/01/24 through 2/28/25 revealed that on 9/15/24, with a daily census of 69, and on 12/07/24, with a daily census of 82, there was no RN working on any shift. Interviews with the Director of Nursing (DON) and the Administrator confirmed the absence of documentation for RN coverage on these days, despite the DON's assertion that the MDS nurse, an RN, would fill open positions if needed.
Convection Oven Cleaning Deficiency
Penalty
Summary
The facility failed to maintain cleanliness of food service equipment, specifically the convection oven, during two separate kitchen observations. On 03/03/25, a large volume of grease buildup was observed inside the oven, on the door, and on the seals. This condition persisted during a second observation on 03/06/25. The Certified Dietary Manager admitted that the oven was cleaned only once a month, with the last cleaning occurring on 02/06/25. Additionally, it was revealed that charred food, identified as apples, had spilled over two weeks prior and had not been cleaned. These observations and admissions indicate a lack of regular cleaning and maintenance of the convection oven, which could potentially affect the quality of food served to residents.
Failure to Maintain Resident Dignity During Meals
Penalty
Summary
The facility failed to maintain the dignity of Resident #14 by not removing a urinal from the overbed table while the resident was eating. Resident #14, who had severe cognitive impairment and required assistance for toilet use, was observed on two occasions with a urinal on the table during meals. Despite the resident's preference for the urinal to be within reach but not on the table with his meal, staff did not adhere to this preference, leading to a dignity violation. Additionally, the facility did not promote the independence and dignity of Resident #35, who was cognitively intact and required limited assistance for eating. Observations revealed that staff stood over the resident while assisting with meals, despite the availability of a chair and the expectation that staff should be seated at eye level. This practice was observed on multiple occasions, indicating a failure to respect the resident's dignity during meal assistance.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medication, which led to a deficiency in medication administration practices. Resident #57, who was cognitively intact according to the quarterly Minimum Data Set, was observed with two cups of medication at her bedside. The resident stated that she had requested the staff to leave the medications on the bedside table as she was eating when they were brought in. She also mentioned that the staff usually left her medications at the bedside, and she would take them herself. However, there was no assessment in the medical record to determine if it was safe for Resident #57 to self-administer medications, and her care plan did not include self-administration of medication. Medication Aide #1 admitted to leaving the medications on the bedside table and forgetting to return to ensure Resident #57 took them. The Director of Nursing confirmed that the resident had not been assessed for self-administration and stated that all treatments should be completed by nursing staff. The Administrator expected staff to ensure all medications were taken before leaving the resident's room. This lack of assessment and oversight in medication administration led to the deficiency identified by the surveyors.
Failure to Provide Ordered Foot Care for Resident
Penalty
Summary
The facility failed to provide foot care as ordered for a resident diagnosed with Alzheimer's disease and dementia. The resident was readmitted to the facility with a physician's order to apply lotion to both feet for 90 days due to dry skin. However, a review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) from August 2024 to March 2025 revealed no documentation of lotion application to the resident's feet. The resident's care plan, last revised in October 2024, noted episodes of refusal to see a podiatrist and included interventions for managing care refusals, but did not document any refusals related to foot care. During a podiatry visit on January 30, 2025, the resident was found to have severe dry, peeling, and flaky skin on both feet, with poor pedal hygiene and crusty skin between the toes. The podiatrist recommended applying over-the-counter lotion twice daily for 90 days. However, interviews with staff revealed a lack of awareness of this recommendation. Nurse #1 and the Nurse Practitioner both observed the resident's feet to be extremely dry with excessive skin shedding, but neither could confirm regular lotion application. Nurse Aide #1, who worked part-time, stated she applied lotion during bed baths, but the resident often refused care, including bathing. The Director of Nursing (DON) and the Administrator acknowledged that the resident's foot care needs were not adequately addressed. The DON noted that lotion application should be a routine task and included in the care plan and activities of daily living (ADL) for nurse aides. The Administrator emphasized that all outside consultation summaries should be reviewed by the nurse on duty, and any recommendations should be communicated and implemented. The failure to apply lotion as recommended by the podiatrist was not documented or communicated effectively, leading to the deficiency in care.
Failure to Provide Written Grievance Summaries
Penalty
Summary
The facility failed to provide a written grievance summary for two grievances filed on behalf of the Resident Council and one grievance filed by a resident. The facility's Grievance Policy and Procedure required a written response within 14 days of filing, but this was not adhered to. For the grievance dated 9/23/24, concerning housekeeping issues, there was no evidence of a written summary provided to the Resident Council. Similarly, grievances dated 1/29/25, regarding missing socks, broken sinks, and other issues, also lacked written summaries. Interviews with the Social Worker and Activity Director revealed that the grievances were not followed up with written responses, and the Director of Nursing admitted to not being aware of the grievance policy requirements until a mock survey in February 2025. Resident #57, who was cognitively intact, filed a grievance on 2/7/25 regarding a nurse aide's refusal to assist with changing a resident. The facility's response involved educating the nursing team, but no written summary was provided to the resident. The Director of Nursing acknowledged the oversight, attributing it to a lack of awareness of the grievance policy. The Assistant Director of Nursing, who handled the grievance, was unavailable for interview. The Administrator confirmed that grievances should have been addressed with written responses in a timely manner.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medication was available and administered as ordered for a resident diagnosed with malignant neoplasm of the left breast and bipolar schizoaffective disorder. The resident was prescribed Aripiprazole for schizophrenia and Letrozole for breast cancer. However, the resident did not receive Aripiprazole on multiple occasions in July and August 2024, as documented in the Medication Administration Record (MAR). The nurses involved did not notify the charge nurse or Director of Nursing (DON) about the missing medication, nor did they follow up with the pharmacy or utilize a backup pharmacy. Interviews with the nurses revealed a lack of education on the process for handling missing medications. Nurse #1 attempted to order the medication but did not inform the charge nurse or DON when it was unavailable. Nurse #3 reordered the medication but did not follow up with the pharmacy or report the issue to the charge nurse or DON. The pharmacist confirmed that the medication requests were entered into the system, but there was no documentation of any calls from the facility regarding the unavailability of the medication. The Medical Director stated that there were no side effects from the missed doses of Aripiprazole and Letrozole. The DON expected that missing medications would be reported to the charge nurse and DON, and that the pharmacy should be notified to obtain the medication from a backup pharmacy. Despite these expectations, the facility did not ensure that the resident received the prescribed medications in a timely manner.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to prevent a significant medication error for a resident diagnosed with malignant neoplasm of the left breast and bipolar schizoaffective disorder. The resident was prescribed Aripiprazole for schizophrenia and Letrozole for breast cancer, but did not receive these medications on multiple occasions due to them being on order. Specifically, Aripiprazole was not administered on two days in July and two days in August, while Letrozole was missed on one day in August. The resident expressed concern about missing these medications, emphasizing their importance for daily intake. Interviews with nursing staff revealed a lack of education and awareness regarding the process for handling missing medications and the use of a backup pharmacy. Nurse #1 and Nurse #3 acknowledged the failure to follow up with the pharmacy or notify the charge nurse and Director of Nursing about the missing medications. The Medical Director confirmed that there were no side effects from missing doses of Aripiprazole and Letrozole. The Director of Nursing stated that the expectation was for nurses to notify the charge nurse and DON about missing medications and to utilize a backup pharmacy if necessary.
Ant Infestation in Resident Rooms Due to Ineffective Pest Control
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in an ant infestation affecting vulnerable residents. On June 23, 2024, a resident was found in bed with small black ants covering the floor, bedside table, bed linens, gown, inside her incontinence brief, and on her body. The resident, who had moderate cognitive impairment and required staff assistance to get out of bed, complained of itching and had numerous small, reddened areas on her body. The ants were identified as small black ants, and the resident was moved to another room after the infestation was discovered. Another resident, residing on the same hall, experienced a similar issue on June 26, 2024. This resident, who was cognitively intact but required extensive staff assistance to turn and reposition in bed, was found with small black ants all over the floor, furniture, bed linens, and clothing. Although the resident did not report any itching or bites, the presence of ants was significant enough to necessitate a room change. The facility's pest control logs indicated that a routine inspection had been conducted on June 17, 2024, with no ant activity noted, yet the infestation occurred shortly thereafter. Interviews with staff revealed that ants had been observed in the facility prior to these incidents, but the severity of the infestation in the residents' rooms was unprecedented. The Maintenance Supervisor was notified and took immediate action by spraying the affected areas, but the pest control company was not called until later. The pest control technician identified and treated fire ant mounds on the exterior of the facility, which were believed to be the source of the infestation. The facility's failure to promptly address the pest issue and ensure effective pest control measures led to the residents being exposed to the ant infestation.
Removal Plan
- Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.
- Clean and sanitize the room and check adjoining rooms for pests.
- Initiate daily inspection of all rooms for any signs of pests.
- Call Pest control to come to the facility and spray rooms. Proactively treat the exterior perimeter and treat fire ant mounds on the exterior of the facility.
- Complete ongoing pest control monitoring of all areas without additional identification of pests.
- Conduct skin checks on all residents to identify any skin concerns associated with pest/insect bites.
- Conduct room checks to identify any pests in the facility.
- Educate the Maintenance Supervisor to notify pest control immediately upon identifying any pests.
- Call pest control to do a thorough inspection and provide treatments as needed.
- Begin in servicing all staff on the need to provide effective Pest management to ensure residents are safe from ants and pests. This education will be provided to new hires during the orientation process. No staff shall work without this education. Monitor to ensure no staff works without completing the education.
- Maintain high standards of cleanliness and sanitation throughout the facility to eliminate food and water sources that attract pests. Ensure proper storage and disposal of waste to prevent attracting pests. Educate staff to ensure food is stored properly, waste is disposed of properly, and maintain cleanliness to reduce the risk of pest infestations.
- Inspect and repair any structural issues, such as cracks, holes, or gaps that could allow pests to enter the building.
- Conduct regular inspections of all areas of the facility, including resident rooms, common areas, kitchens, and storage areas to identify any signs of pest activity.
- Maintain detailed records of all pest control activities, including inspection reports, treatment records, and any actions taken to address identified issues.
- Educate staff to recognize signs of pest activity, understand the importance of maintaining a pest-free environment, and know how to report any pest sightings or concerns immediately. Report any pest sightings immediately to the Maintenance Supervisor or the on-call Administration.
- Address any concerns or complaints from residents or their families regarding pest control promptly and effectively.
Failure to Attempt Gradual Dose Reduction of Psychotropic Medications
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) of psychotropic medications for a resident, despite recommendations from the Consultant Pharmacist. The resident was admitted with diagnoses including anxiety, insomnia, and major depressive disorder, and was receiving antipsychotic, hypnotic, and antidepressant medications. The Minimum Data Set (MDS) annual assessment indicated that the resident had not undergone a GDR for the antipsychotic medication, and there was no documentation of clinical contraindications for such an attempt. The Consultant Pharmacist repeatedly notified the attending physician and Nurse Practitioner (NP) about the need for a GDR, but the responses indicated that the resident was followed by an outpatient psychiatrist, without providing the necessary documentation to support this claim or to show that a GDR was clinically contraindicated. The Consultant Pharmacist's notes from multiple dates highlighted the need for a GDR evaluation for the resident's medications, including zolpidem, bupropion extended release, and paliperidone. Despite these notifications, the facility did not obtain the required documentation from the outpatient psychiatrist to confirm that the resident's psychotropic medications were being appropriately monitored. Interviews with the Support Nurse, NP, and Medical Director revealed that they had all requested the outpatient psychiatric records but had not received any documentation. The Support Nurse mentioned attempts to contact the outpatient psychiatrist without success, and the NP and Medical Director both stated that they had asked the facility to obtain the necessary records multiple times. The lack of documentation and follow-up on the Consultant Pharmacist's recommendations led to the failure to attempt a GDR for the resident's psychotropic medications. The facility's inability to secure the outpatient psychiatric records and ensure proper monitoring of the resident's medication regimen resulted in a deficiency in the care provided to the resident. The Administrator acknowledged the issue and indicated that the Support Nurse was responsible for coordinating with the NP regarding the resident's outpatient psychiatric visits, but no resolution was achieved.
Failure to Refer Resident for PASRR Level II Screening
Penalty
Summary
The facility failed to refer a resident with a serious mental health diagnosis for a Preadmission Screening and Resident Review (PASRR) level II screening. Resident #38, who was admitted with diagnoses including major depressive disorder and anxiety, was later found to have a diagnosis of schizophrenia. This diagnosis was created on 10/20/23 with an active date of 6/23/23. Despite this, the PASRR Level I Determination Notification dated 3/24/23 indicated no further screening was required unless a significant change occurred. The Minimum Data Set (MDS) annual assessment also noted the resident's schizophrenia diagnosis. The Social Worker, responsible for submitting PASRR notifications, stated she was not aware of the schizophrenia diagnosis and therefore did not submit a review. The Administrator confirmed the Social Worker's responsibility for PASRR reviews.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure a baseline care plan was completed within 48 hours after admission for a resident with diagnoses of cancer, dialysis, and diabetes. The resident's medical record showed that the baseline care plan was started but only the medication regimen section was completed within the required timeframe. Other critical sections, including health conditions, dietary, therapy, and social services, were not completed. Interviews with the Director of Nursing, Administrator, and MDS Nurse revealed that the Social Worker was responsible for the care plans, but the MDS Nurse only worked part-time and checked the care plan for nursing team entries. This led to the incomplete baseline care plan for the resident, who was severely cognitively impaired, dependent on staff for activities of daily living, incontinent of bowel, and receiving dialysis.
Failure to Implement Physician Orders for Hemodialysis Care
Penalty
Summary
The facility failed to obtain and implement physician orders for the care and monitoring of a resident on hemodialysis. Resident #15, who was admitted with end-stage renal disease and dependent on dialysis, had an arteriovenous (AV) fistula placed in the right upper arm. Despite the dialysis center's request to note on the resident's chart that no intravenous (IV) or blood pressure (BP) should be taken in the right arm, the facility did not have active physician orders for monitoring the AV fistula site, nor for the restrictions on IV and BP in the right arm. Interviews with various nursing staff revealed a lack of awareness and follow-through regarding the necessary physician orders for Resident #15's AV fistula care. Nurse #2 and Nurse #5 both acknowledged the absence of specific orders for monitoring the AV fistula site and the restrictions on the right arm. The Registered Nurse (RN) Supervisor and the Director of Nursing (DON) confirmed that the nurse receiving the resident post-surgery should have entered the necessary orders and reviewed the dialysis communication book, but this was not done. The Medical Director and the Administrator also confirmed that the required orders for monitoring the AV fistula site and the restrictions on the right arm were not in place. The DON stated that the surgical discharge summary should have been reviewed and followed up on, but this did not occur. The deficiency was further highlighted by the fact that Resident #15, who was cognitively intact, reported that the nursing staff did not check her AV fistula site every shift, and there was no documentation in her medical record regarding the necessary care and restrictions for her AV fistula site.
Failure to Obtain Outpatient Psychiatrist Visit Notes
Penalty
Summary
The facility failed to obtain outpatient psychiatrist visit notes for a resident prescribed psychotropic medication. Resident #38, who was admitted with diagnoses including anxiety, insomnia, and major depressive disorder, was receiving outpatient psychiatric services. However, the facility did not have any documentation of these outpatient psychiatric appointments or supporting clinical documentation from the outpatient psychiatric provider. The Consultant Pharmacist had notified the provider about the lack of documentation and requested follow-up, but no records were obtained. The Support Nurse confirmed that the facility was unable to locate any information regarding the resident's telehealth visit with the outpatient psychiatrist and was unable to contact the provider's office. Interviews with the Consultant Pharmacist and the Nurse Practitioner revealed that both had repeatedly asked the facility to obtain the outpatient psychiatric visit records to ensure proper monitoring of the resident's psychotropic medications. Despite these requests, the facility did not have any of the necessary records. Attempts to contact the outpatient psychiatrist provider were unsuccessful, and the facility was unable to provide the required documentation for Resident #38's psychiatric care.
Failure to Maintain Medication and Immunization Protocols
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that were put into place following multiple surveys. Specifically, the facility was cited for deficiencies in the areas of labeling and storing drugs and biologicals, as well as administering influenza and pneumococcal vaccines. During the recertification and complaint investigation survey, the facility failed to keep medication and treatment carts locked, maintain medication cart drawers free of loose medications, and discard expired medications. These issues persisted during subsequent surveys, including the failure to discard expired controlled substances and properly date opened vials of insulin. Additionally, the facility failed to administer the pneumococcal vaccine to eligible residents. During the recertification and complaint investigation survey, it was found that the facility did not offer the Pneumococcal Polysaccharide Vaccine (PPSV23) a year following the Pneumococcal Conjugate Vaccine (PCV13) for residents who had consented to the vaccination. This failure was observed in two residents reviewed for immunizations. The Administrator confirmed that medication cart audits were performed daily, but an audit was missed due to the entrance of the state survey team.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer and administer the pneumococcal vaccine to two residents, despite having received consent from their responsible parties. Resident #19 was admitted with a diagnosis of intracranial injury with loss of consciousness. Although the responsible party gave authorization for the pneumococcal vaccine, the resident was not offered the vaccine, and the immunization record incorrectly showed consent refused. The Infection Preventionist later documented that Resident #19 declined the vaccine, but the responsible party insisted on its importance and confirmed that the resident had not received it at a previous facility. Resident #43, admitted with a diagnosis of encephalopathy, also did not receive the pneumococcal vaccine despite consent from the responsible party. The immunization record indicated that the vaccine was required but not given. The Infection Preventionist confirmed that the vaccine should have been administered, and the Administrator acknowledged that the nursing staff should have contacted the provider to ensure the vaccine's timely arrival and administration. Both cases highlight a failure in the facility's process for managing and documenting vaccinations.
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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