Pavilion Health Center At Brightmore
Inspection history, citations, penalties and survey trends for this long-term care facility in Charlotte, North Carolina.
- Location
- 10011 Providence Road West, Charlotte, North Carolina 28277
- CMS Provider Number
- 345563
- Inspections on file
- 17
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Pavilion Health Center At Brightmore during CMS and state inspections, most recent first.
A cognitively impaired resident with poor balance and confusion exited the facility unassisted through the front door while the receptionist was present but did not recognize the individual as a resident. The resident walked along a busy road, fell, and was later transported to a hospital after being found by strangers. The facility's risk assessment and care plan did not identify the resident as an elopement risk, and staff were unaware of the resident's exit until a family member arrived and reported the absence.
A resident with multiple neurological and cognitive diagnoses was administered Seroquel without a clearly documented or observed indication for its use. Despite care plan references to behavioral disturbances, staff interviews and observations did not confirm such behaviors or other symptoms like hiccups or nausea. Pharmacy review highlighted the lack of an allowable diagnosis, yet the medication continued to be ordered and administered.
The facility failed to accurately code MDS assessments for three residents, including incorrect discharge status, omission of hospice care, and failure to document oxygen use and functional status. Staff interviews confirmed that the errors were due to oversight and inaccurate information gathering, despite clear evidence in the residents' records and care needs.
Two residents did not have accurate, individualized care plans: one resident's care plan failed to address ongoing oxygen therapy despite physician orders and continuous use, while another resident's care plan incorrectly included hand mitts that were never used, instead of accurately reflecting the use of an abdominal binder for feeding tube protection. These deficiencies were confirmed through record review and staff interviews.
A resident admitted with a fracture, falls, and incontinence did not have a comprehensive care plan developed within 7 days of the MDS assessment. The care plan failed to address key areas such as ADL function, falls, incontinence, pressure ulcers, and nutrition, despite these being identified in the CAA. Staff interviews confirmed the care plan was incomplete due to oversight.
A nurse failed to use sterile gloves and did not perform hand hygiene while providing tracheostomy care to a resident with a tracheostomy and acute respiratory failure. The nurse used non-sterile gloves, did not sanitize hands between glove changes, and did not use a tracheostomy kit, contrary to the care plan and physician orders. Facility leadership expected proper infection control practices, but these were not followed during the observed care.
A resident with a PEG tube received medications in a manner inconsistent with physician orders, as a nurse combined and administered all medications together instead of separately with required flushes. This resulted in 5 medication errors out of 27 opportunities, leading to a medication error rate of 18.52%, which exceeds the acceptable threshold. The DON confirmed that staff are expected to follow all medication orders.
The facility failed to accurately code the MDS assessments for four residents in areas such as wounds, hospice services, range of motion, and tube feeding. Discrepancies were found between clinical findings and MDS documentation, as confirmed by interviews with staff and administrators.
The facility failed to ensure group activities were planned and executed for rehabilitation residents, leading to residents not being reminded or assisted to attend activities. The Activities Assistant did not have time to ask residents on the rehabilitation side if they wanted to attend activities due to the absence of the Activities Director. This resulted in residents with cognitive impairments not being invited to or informed about group activities, as confirmed by interviews with staff and residents.
The facility's QAA Committee failed to maintain procedures and monitor interventions, resulting in repeat deficiencies in resident's rights, accuracy of assessments, nutrition and hydration status, and infection control. Issues included rough treatment of a resident, inaccurate MDS coding, failure to follow dietary recommendations, and poor hand hygiene practices.
The facility failed to implement their infection control policy when a nurse aide did not perform hand hygiene between residents during meal delivery and another nurse aide failed to doff soiled gloves and perform hand hygiene before exiting a resident's room after checking for incontinence. Both aides had received prior training but did not follow the correct procedures.
The facility failed to recognize the use of an abdominal binder as a physical restraint for a resident with a G-tube and dementia. The binder was used to prevent the resident from pulling out the feeding tube, but there was no care plan, physician order, or documented consent for its use. Staff were unaware that the binder could be considered a restraint, leading to the deficiency.
The facility failed to develop comprehensive care plans for two residents. One resident with severe cognitive impairment and multiple diagnoses had necrotic wounds that were not included in the care plan. Another resident with severe cognitive impairment and knee contractures was recommended to use bilateral knee splints, but this was not reflected in the care plan.
A resident's care plan was not updated to reflect the discontinuation of IV antibiotics and catheter, despite the IV treatment ending and the catheter being removed. This oversight was confirmed by the MDS Nurse and acknowledged by the Administrator.
The facility failed to maintain accurate electronic records for three residents, leading to deficiencies in medication administration, weight documentation, and treatment application. Medications and treatments were administered but not properly documented, and weights were recorded on paper but not entered into the electronic system.
A resident with moderate dementia was without a functional call light for three days, impacting her ability to request assistance. Despite reporting the issue, the call light was not repaired promptly, leading to the resident attempting to manage her incontinence care independently.
The facility failed to post daily nurse staffing information in a prominent location accessible to residents. The staffing sheet was placed on the receptionist's desk in the front lobby, which required residents to manually open double doors to access. Interviews with the DON and Administrator confirmed the long-standing placement and acknowledged its inaccessibility to residents.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A severely cognitively impaired resident with a primary diagnosis of toxic encephalopathy, along with other significant medical conditions such as cardiac arrest, atherosclerotic heart disease, and chronic kidney disease, exited the facility without staff knowledge for over two hours. The resident, who required partial to moderate assistance with most activities of daily living and was known to be confused and unsteady on his feet, was last seen in his room by a nurse aide at approximately 9:30 AM. Video footage later revealed that the resident walked unassisted through the lobby and out the front door while the receptionist was present but engaged in conversation with a visitor. The receptionist did not recognize the resident as a resident and did not intervene as he exited the building. After leaving the facility, the resident walked along a heavily trafficked road, fell, and was assisted by strangers who transported him to a fire station 20 miles away. The facility staff became aware of the resident's absence only after a family member arrived for a visit and could not locate him. A search was initiated, and law enforcement was notified. The resident was eventually found and transported to the hospital, where he was noted to have abrasions and swelling consistent with a fall. Interviews with staff and family confirmed that the resident was consistently confused, required supervision for ambulation, and was not safe to walk unassisted. The facility's risk assessment and care plan for the resident did not identify wandering or elopement risk, as there was no prior history of such behaviors. However, the resident's cognitive impairment, confusion, and poor balance were documented. Staff interviews indicated that the resident typically remained in his room and had not previously attempted to leave the facility. The front entrance was unlocked due to the presence of a receptionist, but there was no effective process in place to ensure that residents could not exit unnoticed, especially when staff were unfamiliar with all residents or distracted.
Removal Plan
- A head count was completed by Nurse Supervisor #1 for 100% of residents. All residents in facility were accounted for with no issues identified.
- The Director of Nursing reviewed clinical alerts dashboard and nursing notes for all residents for the past 30 days to identify any exit seeking behaviors. No issues identified.
- The Director of Nursing audited 100% of residents wandering risk assessments. All residents with low wandering risk were reviewed for changes in condition/function that may put them at risk to exit the facility. No issues identified.
- Risk assessments are completed upon admission by the admitting nurse, quarterly and any time a change of condition is noted by staff nurse or nurse manager.
- All residents at high-risk for wandering charts were reviewed by the Director of Nursing to ensure that they had appropriate wander prevention strategies in place to include wander guard bracelet in place and functioning properly, daily battery checks and every shift placement checks were present on the MAR and that care plan was current and appropriate interventions were on the care plan.
- The Nurse Supervisor checked 100% of current residents with wander guards for placement and function by observing that wander guard was on resident's person and utilized the wander guard checker device to ensure proper function. No issues were noted.
- All exit doors were checked by the Director of Nursing and Nurse Supervisor #1 to ensure they were functioning properly.
- Staff interviews were initiated for all staff by the Director of Nursing to identify any exit seeking behaviors. Interviews identified no other new onset of exit seeking behaviors.
- The QA Nurse Consultant rechecked all entrance/exit doors to include door with wander guard system, squealer boxes and on/off switches for mag lock doors (doors with keypad entry/exit) and all were functioning properly. No issues were identified.
- A Quality Assurance Performance Improvement meeting held with the Interdisciplinary Team members to discuss incident findings and plan to correct.
- The Director of Nursing began education of all full time, part time, and as needed staff including agency on the following topics: Elopement Prevention and Missing Person Policy. Education included what to do if resident was exhibiting wandering/exit seeking behaviors especially for those residents who normally stayed in their rooms. Staff educated to stop and communicate with the resident and redirect, ensure safety of the resident and immediately notify the nurse.
- The Administrator will ensure that any of the above identified staff who did not complete the in-service training will not be allowed to work until the training is completed.
- This in-service was incorporated into the new employee facility orientation for the above identified staff and will be provided by the Staff Development Coordinator during orientation and prior to working in patient care areas.
- The Administrator educated all receptionists that all visitors will need to sign in and out and wear a badge to identify them as a visitor when entering the facility through main entrance designated for visitor entry.
- All other exit doors are locked with signage above directing visitors to go to the main entrance to enter and exit the facility.
- All receptionists and nurses were educated by the Administrator that receptionists are to lock the main entrance door upon leaving front desk for any reason and nurses are to let visitors into and out of facility in receptionist's absence from receptionist area.
- Receptionists were educated to have all persons exiting facility to be identified prior to them exiting by looking for visitor badge and asking person to identify themselves, checking sign in/out log for name and having them sign out once identified on sign in/out log prior to exiting facility to ensure they are not a resident displaying exit seeking behaviors.
- If the person is noted to be a resident, receptionist is to maintain resident safety and immediately notify nurse assigned to resident to come assist resident.
- The Administrator will ensure that any newly hired receptionist or nurse will receive this education prior to working and this in-service was incorporated into the new employee facility orientation for the above identified staff.
- Visitors will be required to sign in and out and wear visitor badge while in the facility.
- Receptionists were educated that they are to lock the main entrance door upon leaving front desk area for any reason and if no one is available to provide coverage until they return, they are to notify nursing staff via phone that they will be leaving front desk area prior to leaving.
- Upon hearing doorbell ringing, nurses are to go to front entrance area and let visitor into the facility, have visitor sign in and provide them with a visitor's badge.
- For visitors leaving facility, nurse is to identify person prior to them exiting by looking for visitor badge and asking person to identify themselves, checking sign in/out log for name and having them sign out once identified on sign in/out log prior to exiting facility.
- A receptionist is scheduled to work 7 days a week. In the event that there is no receptionist available, facility front entrance doors will be locked and nurses on duty will be responsible for allowing visitors entry or exit to facility.
Failure to Ensure Proper Indication for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident had an appropriate indication and diagnosis for the use of an antipsychotic medication, specifically Seroquel (Quetiapine Fumarate). The resident in question was admitted with multiple diagnoses, including cerebral infarction, hemiplegia, aphasia, benign neoplasm of cerebral meninges, adult failure to thrive, and vascular dementia with mood disturbance and anxiety. Physician orders for Seroquel were present, and the care plan referenced its use for dementia with behavioral disturbances. However, the quarterly MDS assessment did not indicate potential indicators of psychosis, and staff interviews revealed that the resident did not exhibit behavioral disturbances or symptoms such as yelling, hitting, or pulling at medical devices. Observations showed the resident was largely non-responsive, unable to move extremities, and required significant assistance with care. A pharmacy review noted that the resident lacked an allowable diagnosis to support the use of Seroquel, and the provider subsequently documented indications such as hiccups and nausea associated with cancer, though staff had not observed these symptoms. Orders for Seroquel were updated to reflect these indications, but staff interviews and observations did not confirm the presence of behavioral disturbances, hiccups, or nausea. The medication continued to be reordered upon each readmission without clear evidence of a supporting diagnosis or observed need, leading to the deficiency related to the use of unnecessary psychotropic medication as a potential chemical restraint.
Inaccurate MDS Coding for Discharge, Hospice, and Oxygen Use
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for three residents. One resident was discharged to an assisted living facility, but the discharge MDS was incorrectly coded as a discharge to a hospital. The MDS Coordinator, who was new to the role, acknowledged the error and stated that the discharge status should have reflected the actual destination. Both the DON and Administrator confirmed that the MDS should be coded accurately, but were unaware of the reason for the incorrect coding. Another resident was admitted to hospice services prior to admission, but the admission MDS did not reflect hospice care due to an oversight by the MDS Coordinator. Additionally, a third resident with a history of CVA, hemiplegia, and oxygen dependence was not coded for oxygen use on the quarterly MDS assessment, and their functional status was inaccurately documented. Staff interviews confirmed the resident's dependence on oxygen and total care needs, but these were not accurately captured in the MDS. The Administrator and clinical staff indicated that information from therapy, nursing, and physician orders should be used for accurate MDS coding.
Failure to Develop and Implement Accurate, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for two residents with specific clinical needs. For one resident with congestive heart failure, pneumonia, and a dependence on supplemental oxygen, the care plan did not include any interventions or care area addressing the resident's continuous oxygen therapy, despite physician orders and documentation showing ongoing use of oxygen since admission. This omission was confirmed by both the MDS Coordinator and the DON, who acknowledged that the resident's need for continuous oxygen was not reflected in the care plan due to oversight. For another resident with chronic respiratory failure, hypoxia, diabetes, and epilepsy, the care plan inaccurately included the use of bilateral hand mitts in addition to an abdominal binder for protection of a feeding tube. However, medical records, staff interviews, and the resident's MAR confirmed that only the abdominal binder was used, and there were no physician orders for hand mitts. The inclusion of hand mitts in the care plan was identified as a mistake by the MDS Coordinator, and staff confirmed that the resident never used them. The DON and Administrator both expected the care plan to accurately reflect the resident's current interventions.
Failure to Complete Comprehensive Care Plan After Assessment
Penalty
Summary
The facility failed to develop a comprehensive care plan within 7 days of completing a comprehensive assessment for one resident. The resident was admitted with multiple diagnoses, including a left humerus fracture, history of falls, and urinary tract infection. The admission MDS assessment indicated significant care needs, such as upper extremity impairment, partial to moderate assistance with ADLs, frequent incontinence, risk for pressure ulcers, and a history of falls. The Care Area Assessment (CAA) identified several triggered care areas, including ADL function, urinary incontinence, falls, pressure ulcers, and nutrition, with care plan decisions completed for these areas. However, a review of the resident's medical record showed that the care plan only addressed discharge planning, mood disorder, and activities, and did not include focus areas or interventions for the triggered care areas identified in the CAA. Interviews with the MDS Coordinator and the Administrator confirmed that the comprehensive care plan had not been completed as required, and the omission was acknowledged as an oversight by the responsible staff.
Failure to Use Sterile Technique and Perform Hand Hygiene During Tracheostomy Care
Penalty
Summary
Nurse #1 failed to use sterile gloves and did not perform hand hygiene while providing tracheostomy care to a resident with a history of acute respiratory failure and a tracheostomy. During the observed care, Nurse #1 set up supplies without a tracheostomy kit, donned non-sterile gloves, and removed the resident's dirty dressing. After doffing gloves, Nurse #1 did not sanitize her hands before donning new gloves and continued care, including removing and replacing the inner cannula, all without using sterile technique or performing hand hygiene between glove changes. Handwashing was only performed at the end of the procedure. The resident's care plan and physician orders required tracheostomy care with attention to infection prevention. Interviews with Nurse #1 revealed she was aware of the missed hand hygiene but was not aware that sterile gloves were required for tracheostomy care. The Infection Preventionist/ADON and DON both stated their expectations for proper infection control practices, including hand hygiene and sterile technique, but were not aware of the specific deficiencies observed during this incident.
Medication Error Rate Exceeds 5% Due to Improper PEG-Tube Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by 5 medication errors out of 27 opportunities, resulting in an 18.52% error rate. The deficiency involved a resident with a percutaneous endoscopic gastrostomy (PEG) tube, who had specific physician orders for medication administration. The orders required each medication to be dissolved separately in water, administered individually, and flushed with water between each medication, with a final flush at the end. During observation, the Unit Manager combined all prescribed medications into a single mixture, crushed and mixed them together, and administered them as a single solution through the PEG tube, contrary to the physician's orders. The Unit Manager admitted to not reviewing the resident's medication administration order prior to administering the medications and stated that her usual practice was to combine all medications for PEG-tube administration. The Director of Nursing confirmed that staff are expected to follow all medication orders as written. The observed practice resulted in multiple medication errors for the resident, as the administration did not comply with the specific instructions provided by the physician.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents in various areas, including wounds, hospice services, range of motion, and tube feeding. Resident #399 was admitted with multiple diagnoses, including a periprosthetic fracture and dementia. Despite having wounds on the right heel and great toe, the MDS assessment did not reflect these conditions. Interviews with the Nurse Practitioner (NP) and MDS Nurse revealed discrepancies between the clinical findings and the MDS documentation. The Director of Nursing (DON) and the Administrator both expressed expectations for accurate MDS coding based on the resident's clinical status. Resident #22 was admitted with diagnoses including venous insufficiency and type 2 diabetes. Although the care plan indicated palliative care, there was no documentation of hospice services in the medical record. The MDS assessment incorrectly coded hospice care, which was acknowledged as an error by the MDS Nurse. The Administrator reiterated the expectation for accurate MDS coding. Resident #11 had contractures in both knees and received physical therapy for limited range of motion. However, the MDS assessment did not reflect this condition. The Rehab Director and MDS Nurse confirmed the oversight. Resident #57, who was NPO and received nutrition via a PEG tube, was incorrectly assessed as requiring extensive assistance with eating instead of total staff assistance. The MDS Coordinator and Regional Quality Assessment & Assurance (QAA) Nurse identified the error, noting that the MDS was completed by a prn MDS staff member who no longer worked at the facility.
Failure to Include Rehabilitation Residents in Group Activities
Penalty
Summary
The facility failed to ensure group activities were planned and executed for rehabilitation residents, which was important to them. The March 2024 activity calendar showed daily activities at 11:00 AM and 2:00 PM, including an ice cream social and bingo twice a week. However, the Activities Assistant admitted that she did not have time to ask residents on the rehabilitation side if they wanted to attend activities due to the absence of the Activities Director since the beginning of March. This led to residents not being reminded or assisted to attend activities, as the Activities Assistant was also responsible for other duties, including resident admissions. Resident #37, who was moderately cognitively impaired and had a care plan indicating an interest in group bingo events, was not asked to attend activities after being readmitted to the facility. His Responsible Party (RP) stated that no staff members had come to the room to ask if he wanted to attend activities, and she had to personally take him to the ice cream social. Interviews with the Nurse Aide and Nurse assigned to Resident #37 confirmed that they had not asked him about attending activities, assuming that someone from the Activities Department would do so. Resident #85, who had severe cognitive impairment and indicated a desire to be invited to out-of-room activities, was also not asked to attend group activities. She stated that she loved being around people but could not recall being asked to join any activities. Similarly, Resident #88, who had moderately impaired cognition and expressed interest in group activities, was not informed about or invited to participate in activities. Both residents' medical records lacked activity notes, and the Nurse Aide assigned to them could not recall if they were asked or assisted to attend group activities. The Administrator was unaware of these issues and the arrangement between the Activities Director and Activities Assistant regarding resident activity participation.
Repeat Deficiencies in QAA Program
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 the recertification and complaint investigation survey. This failure resulted in four repeat deficiencies being cited again during the current recertification and complaint investigation survey. The deficiencies included issues related to resident's rights, accuracy of assessments, maintenance of nutrition and hydration status, and infection prevention and control. Specifically, a resident was treated roughly during personal care, causing her to cry, and another resident was left uncovered in bed in a soiled brief. Additionally, the facility failed to code the Minimum Data Set (MDS) assessment accurately in several areas, including wounds, hospice services, range of motion, and tube feeding for multiple residents. The facility also did not follow recommendations from the Registered Dietitian and Nurse Practitioner regarding reweighing a resident with significant weight loss and addressing subtherapeutic total protein lab results. Furthermore, the facility failed to implement their infection control policy, as observed with staff not performing hand hygiene between residents during meal delivery and assistance, and not doffing soiled gloves before exiting a resident's room to obtain incontinence care supplies. During the interview, the Administrator and the Regional QAA Nurse Consultant acknowledged the repeat deficiencies and attributed them to staff taking shortcuts, the use of agency staff, MDS staffing changes, and staff oversight despite continued efforts to re-educate staff. The Administrator stated that repeat deficiencies were reviewed during quarterly QA meetings, and re-education was provided if ongoing issues were identified. However, the continued failure to sustain an effective QAA Program was evident as the same deficiencies were cited during two federal surveys of record.
Failure to Implement Infection Control Policy
Penalty
Summary
The facility failed to implement their infection control policy when a nurse aide did not perform hand hygiene between residents during meal delivery and meal assistance. Specifically, the nurse aide was observed serving meal trays to multiple residents without sanitizing hands between each interaction, despite the presence of hand sanitizing dispensers in the hallway. The Assistant Director of Nursing (ADON) intervened and provided immediate hand hygiene education to the nurse aide, who acknowledged having received prior training on the matter. In another instance, a nurse aide failed to doff soiled gloves and perform hand hygiene before exiting a resident's room after checking for incontinence. The nurse aide was observed wearing the same soiled gloves while retrieving supplies from a clean linen closet, which is against the facility's infection control practices. The nurse aide admitted to knowing the correct procedure but did not follow it at the time. Interviews with the ADON, Director of Nursing (DON), and the Administrator confirmed that all staff had received hand hygiene education and were expected to follow the facility's infection control policies. The ADON, who is also the Infection Preventionist, stated that the staff would need re-education on proper hand hygiene and incontinence care procedures to prevent such deficiencies in the future.
Failure to Recognize Abdominal Binder as Physical Restraint
Penalty
Summary
The facility failed to recognize the use of an abdominal binder as a physical restraint for a resident admitted with diagnoses including intracranial hemorrhage, presence of a gastrostomy tube (G-tube), and dementia. The resident's baseline care plan did not include a care plan for the use of the abdominal binder as a restraint, and there was no physician order or documented consent for its use. Staff interviews revealed that the abdominal binder was used to prevent the resident from pulling out the feeding tube, but staff were unaware that it could be considered a restraint. The binder was unfastened during care but otherwise kept in place, and the resident was unable to remove it independently. Observations and interviews with various staff members, including nurses, nurse aides, the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and a Nurse Practitioner, confirmed the consistent use of the abdominal binder since the resident's admission. Despite its use for safety reasons, there was no documentation of a restraint assessment or consent in the medical record. The staff's lack of awareness regarding the classification of the abdominal binder as a restraint led to the deficiency identified in the report.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop an individualized, person-centered comprehensive care plan for two residents. Resident #399 was admitted with severe cognitive impairment and multiple diagnoses, including a periprosthetic fracture of the left hip and chronic embolism. Despite the presence of necrotic wounds on the right great toe and an open wound on the right heel, the care plan only addressed the risk for pressure ulcers and did not include the actual wounds. The MDS Nurse used the admission nursing assessment, which did not document any skin integrity issues, to complete the care plan and did not update it even after the Nurse Practitioner identified the wounds during an acute visit. Resident #11, who had severe cognitive impairment and contractures in both knees, was recommended to use bilateral knee splints by the Physical Therapy department. However, the care plan did not include this recommendation. The MDS Nurse acknowledged the oversight, and the Director of Nursing confirmed that the care plan should have been comprehensive and included the use of bilateral knee splints.
Failure to Update Care Plan for IV Medication
Penalty
Summary
The facility failed to revise the care plan for a resident receiving intravenous (IV) medication. Resident #22, who was admitted with diagnoses including diabetes and retention of urine, received Vancomycin via IV from 2/1/24 to 2/12/24. The IV catheter was removed on 2/14/24. However, the resident's care plan, last reviewed on 3/5/24, still included a focus area for receiving IV fluids via midline, despite the discontinuation of the IV antibiotics and catheter. This oversight was confirmed by the MDS Nurse during an interview on 3/14/24, who acknowledged that the care plan should have been updated. The Administrator also indicated that the care plan should accurately represent the resident's current status.
Failure to Maintain Accurate Electronic Records
Penalty
Summary
The facility failed to maintain accurate electronic records for three residents, leading to deficiencies in medication administration, weight documentation, and treatment application. For Resident #28, the Unit Manager administered an acid reflux medication but did not document it in the Medication Administration Record (MAR). The Director of Nursing confirmed that all administered medications should be documented in the MAR. Medication Aide #1, who was expected to sign off on the medication, was unavailable for an interview. Resident #71 had a physician's order for weekly weights, but the weights were not documented in the electronic medical record for the specified period. Nurse #10 recorded the weights on a report sheet but failed to enter them into the electronic system. For Resident #198, a physician's order specified the application of a medicated cream to the buttocks, but Nurse #12 applied the cream to a different area without proper documentation. The Director of Nursing stated that all treatments should be documented in the MAR and progress notes.
Failure to Provide Functional Call Light for Resident
Penalty
Summary
The facility failed to provide Resident #11 with a functional call light to request staff assistance for three consecutive days. Resident #11, who was admitted with moderate dementia and other conditions requiring extensive assistance, was observed on multiple occasions without a working call light. On 3/11/24, Resident #11 was found in her room with her pants and brief pulled down, stating she had used facial tissue due to a lack of toilet tissue and that her call light was not working. Despite pressing the call light, neither the wall panel light nor the light outside the room door turned on, indicating a malfunction. Nurse #6 confirmed the issue and reported it to the Maintenance Director, who acknowledged the problem and stated it was repaired on 3/13/24 after being reported on 3/12/24, although the nurse claimed to have reported it on 3/11/24. Interviews with various staff members, including Nurse Aides and the Maintenance Director, revealed that Resident #11 frequently used her call light for assistance but had been observed propelling herself into the hallway when the call light was not answered. The Maintenance Director admitted that the call light cord was burned out and replaced it, stating that call light audits were conducted monthly, with the last audit on 2/29/24. However, the malfunction was not identified until the call light was pressed and found to be non-functional. The Administrator and Regional Quality Assessment and Assurance Nurse Consultant confirmed that maintenance staff should ensure all call lights are functional for residents who use them. Despite the facility's procedures for daily room rounds and weekly call light audits, the deficiency in providing a functional call light for Resident #11 persisted for three days, impacting the resident's ability to request necessary assistance and maintain her activities of daily living.
Failure to Post Daily Nurse Staffing Information in Accessible Location
Penalty
Summary
The facility failed to post daily nurse staffing information in a prominent location that was readily accessible to residents on five consecutive days during the survey. Observations revealed that the daily nurse staffing sheet was placed on the ledge of the receptionist's desk in the front lobby, which was only accessible to residents by manually opening a set of double doors. This placement made the staffing information not readily visible or accessible to residents. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the current location of the posting had been in use for a long time and acknowledged that it was not in an area easily accessible to residents.
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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