Pine Acres Center For Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Lexington, North Carolina.
- Location
- 279 Brian Center Drive, Lexington, North Carolina 27292
- CMS Provider Number
- 345011
- Inspections on file
- 21
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Pine Acres Center For Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with extensive respiratory and cardiac comorbidities, recently hospitalized for sepsis, respiratory failure, influenza, and pneumonia, experienced a severe drop in oxygen saturation to 68% on room air while repeatedly removing prescribed oxygen. An NA documented the low saturation and, with a Medication Aide, reapplied oxygen and rechecked levels, which returned to the low 90s, and the resident became calmer. The Medication Aide continued intermittent checks and administered a breathing treatment but did not obtain a full repeat set of vitals or immediately notify the nurse of the critical desaturation, instead informing the nurse roughly two hours later, after the resident appeared stable. The deficiency is that the NA and/or Medication Aide did not request a timely nurse assessment at the time of the significant oxygen desaturation, contrary to the resident’s respiratory care plan and expectations for monitoring changes in condition.
A resident with COPD, chronic respiratory failure, obstructive sleep apnea, and recent hospitalizations for sepsis, respiratory acidosis, acute respiratory failure, influenza, and pneumonia was discharged from the hospital while oxygenating well on 2 L via nasal cannula, yet returned to the facility without a documented physician order for oxygen therapy. The care plan targeted maintaining SpO2 above 90% and normal respirations, and a provider note recorded multiple days of mid-90s oxygen saturations "on oxygen" after readmission, but the MDS did not code oxygen use and no oxygen order was found in the chart. Staff interviews revealed that the resident had been using oxygen more frequently since the latest hospitalization, was often observed wearing it, and at one point was found without oxygen with an SpO2 of 68% that improved to the low 90s after oxygen was reapplied, while the Medical Director described the oxygen need as PRN, all occurring in the absence of a formal oxygen order.
A nursing assistant was not trained on using the kardex system to identify resident care needs and instead relied on asking others. This lack of training led to an incident where a dependent resident with impaired gait was left unsupported during a transfer, resulting in a fall and fractures. Staff interviews and record review confirmed the NA had not received kardex training prior to the incident.
A dependent resident with a history of falls and impaired mobility was transferred from bed to the bathroom by a NA who did not follow the care plan requiring a mechanical lift and two-person assistance. The NA left the resident standing unsupported while disposing of a brief, resulting in the resident falling and sustaining a left wrist and hip fracture. Staff interviews confirmed the care plan was not followed and the resident was at high risk for falls.
Surveyors identified that MDS assessments were inaccurately coded for four residents, including errors in documenting anticoagulant and antibiotic use, oxygen therapy, hospice prognosis, and active diagnoses such as dementia and hypertension. These inaccuracies were confirmed by staff interviews and review of medical records, with staff acknowledging data entry errors and oversights.
Surveyors found that staff failed to discard expired milk and did not label or date several opened food items in the kitchen coolers. The Dietary Manager was on vacation, and the Social Worker, who was covering, identified and reported these issues to kitchen staff. The Administrator was unaware of these lapses until the survey.
Multiple residents receiving oxygen therapy did not have their oxygen administered according to physician orders, with one resident receiving a higher flow rate than prescribed and another using oxygen without a current order. Additionally, required oxygen-in-use signage was missing outside the rooms of two residents on continuous oxygen. Nursing staff and administration confirmed these lapses in respiratory care monitoring and documentation.
Two residents receiving enteral nutrition did not have their feeding formulas properly labeled with the date and time of change, and their enteral feeding syringes were stored with the plunger inside the barrel, contrary to infection control protocols. Nursing staff were unaware of the requirements for labeling and proper syringe storage, and the DON confirmed the correct procedures were not followed.
A resident with chronic pain and cancer was given oxycodone/acetaminophen instead of the ordered hydrocodone/acetaminophen due to a pharmacy labeling error. The error went undetected for multiple doses until a nurse noticed the pills did not match the label description. The resident reported poor pain control during this period, and the pharmacy later confirmed a breakdown in their verification process.
The facility did not provide written notification to the responsible parties for two residents who were transferred to the hospital after changes in condition. Although the DON and staff notified responsible parties by phone, there was no documentation of written notification being sent, and the facility lacked a process to ensure this requirement was met.
The facility did not consistently post accurate daily nurse staffing forms, with discrepancies found between posted information and actual staffing records, including outdated forms, incorrect staff counts, and missing staff. Staff interviews revealed confusion over who was responsible for updating the forms, particularly on weekends.
The facility failed to document education on the benefits and potential side effects of Influenza and Pneumococcal immunizations for five residents. Despite recent changes to the consent forms, the deficiency was identified during a review of the medical records.
The facility failed to resolve repeated Resident Council grievances regarding the delivery of evening snacks and ice water. Despite monitoring and re-education efforts by the DON, the issues persisted over several months, as confirmed by multiple residents and staff interviews.
The facility failed to accurately code the MDS assessment for a resident at high risk for falls. Despite documented falls and daily administrative meetings to review such incidents, the MDS Coordinator missed recording the falls in the quarterly MDS assessment, resulting in incorrect coding.
A resident with severe cognitive impairment received three doses of the Arexvy vaccine instead of the prescribed single dose due to an error in transcribing the physician's order into the electronic medical record. The MAR incorrectly indicated daily administration, leading to the resident receiving additional doses.
The facility failed to label and date four liquid medications in one of the medication carts. During an observation, it was found that Pro-stat, Chlorhexidine Gluconate, Valproic Acid Oral Solution, and Dextromethorphan/Guaifenesin were opened and undated. Nurse #8 confirmed that all opened medications should be labeled with the date they were opened, but did not know who placed the unlabeled medications in the cart. The DON and Administrator confirmed that staff had been educated on this procedure.
The facility failed to document education on the benefits and potential side effects of the COVID-19 vaccine for three residents. The issue was identified before the facility updated their consent forms to include this information.
Failure to Obtain Timely Nurse Assessment After Severe Oxygen Desaturation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a nurse was requested to assess a resident who experienced a significant drop in oxygen saturation to 68% on room air. The resident had extensive respiratory and cardiac comorbidities, including end stage renal disease on hemodialysis, COPD, chronic respiratory failure, obstructive sleep apnea, hypertension, bipolar disorder, anxiety disorder, recent sepsis, respiratory acidosis, acute respiratory failure, and a recent NSTEMI. The resident had also been recently hospitalized for influenza and pneumonia and was being monitored for thrombocytopenia. The resident’s care plan included goals to maintain oxygen saturation above 90% and interventions to monitor for signs and symptoms of respiratory distress, decreased pulse oximetry, abnormal breathing patterns, and to report such changes to the physician. On the evening in question, the resident’s vital signs earlier in the day had been within baseline, with oxygen saturations between 90% and 96%. At approximately 8:00 PM, the NA entered the resident’s room to obtain vital signs and found the resident without oxygen, yelling, and anxious about her health. The NA obtained vital signs and documented an oxygen saturation of 68% on room air. The NA notified the Medication Aide, who was just outside the room. The NA assisted the resident in putting her oxygen back on and rechecked the oxygen saturation, which increased to approximately 91–92% after a few minutes. The Medication Aide also checked the oxygen saturation with a manual oximeter and obtained a reading of 91–92% with oxygen applied. The NA reported that the resident’s color appeared normal and that the resident became calmer after about 10 minutes. The Medication Aide reported that the resident had been yelling frequently that night, which was typical for her, and had repeatedly removed and thrown down her oxygen tubing. The Medication Aide stated she had been in and out of the room multiple times to re-educate the resident and replace the oxygen. When called by the NA around 8:00 PM due to the low oxygen saturation in the 60s, the Medication Aide found that the NA had already reapplied the oxygen and that the saturation was rising. The Medication Aide confirmed oxygen saturations of 91–92% with oxygen on, administered a scheduled breathing treatment, and continued to check the resident with a manual oximeter several times, noting that the resident appeared normal, with no pallor or cyanosis, and calmer. The Medication Aide did not obtain a full set of repeat vital signs and did not immediately notify the nurse at the time of the 68% reading; instead, she informed the primary nurse shortly before 10:00 PM that the resident’s oxygen saturation had dropped to 68% on room air earlier but had since returned to normal with oxygen. Nurse #1, the primary nurse for the resident that evening, stated she had assessed the resident at the start of the shift and that the resident’s yelling and calling out were usual for her. Nurse #1 observed that the Medication Aide had been going in and out of the resident’s room to assist with oxygen but was not informed of the 68% oxygen saturation until just before 10:00 PM, approximately two hours after the event. Nurse #1 acknowledged that she did not go into the room when she passed by around 9:30 PM and only visually noted the resident was awake and calmer. She stated that when she was finally notified, she was told the resident had previously desaturated to 68% on room air but was now stable with normal vital signs after oxygen was reapplied and a breathing treatment was given. The Medical Director later stated he was not aware of the desaturation to 68% and would have expected the resident to be checked at that time and to be notified of a new oxygen desaturation level. The deficiency centers on the failure of the NA and/or Medication Aide to request a nurse assessment at the time of the critically low oxygen saturation, despite the resident’s care plan requirements and complex respiratory history.
Failure to Obtain Physician Order for Ongoing Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to obtain a physician order for oxygen therapy for a resident with significant respiratory comorbidities and recent hospitalizations for acute respiratory conditions. The resident had diagnoses including end stage renal disease on hemodialysis, COPD, chronic respiratory failure, obstructive sleep apnea, hypertension, bipolar disorder, and anxiety disorder. Hospital records from a recent stay documented sepsis, respiratory acidosis, and acute respiratory failure, with the resident discharged in stable condition while oxygenating well on 2 L via nasal cannula. Despite this, review of the facility medical record revealed no physician order for oxygen therapy upon the resident’s return. The resident’s comprehensive care plan, revised shortly after readmission, included focus areas for COPD, chronic respiratory failure, obstructive sleep apnea, and pneumonia, with goals to maintain oxygen saturation above 90% and normal breathing patterns. Interventions included monitoring for signs and symptoms of respiratory distress and reporting changes to the physician. A subsequent provider note summarized that during several days in January, the resident’s oxygen saturation readings were in the mid-90s "on oxygen," and the resident had recently been hospitalized again for influenza and pneumonia, returning to the facility on antibiotics. However, the Minimum Data Set assessment completed after this hospitalization did not code the resident as using oxygen, and there was still no documented oxygen order in the record. Staff interviews further described ongoing oxygen use without a corresponding physician order. A nurse aide reported that on one evening, the resident was found without oxygen in place and had an oxygen saturation of 68%; after the aide and a medication aide reapplied the oxygen, the saturation increased to around 91–92%. The nurse aide and medication aide both stated the resident had used oxygen before and had needed it more since returning from the hospital, though neither could recall the exact oxygen flow rate. The primary nurse for that shift confirmed that the medication aide had been in and out of the room assisting with oxygen because the resident frequently removed the tubing, and that the resident had been wearing oxygen most of the time since her recent hospitalization. The Medical Director stated that the resident’s oxygen need was on an as-needed basis, but there was no corresponding physician order documented for this oxygen therapy in the facility record.
Failure to Train NA on Kardex Use Leads to Resident Fall and Fractures
Penalty
Summary
A nursing assistant (NA) was found to be untrained and not competent in using the kardex system, which is a quick-reference tool for resident care information. The NA had not received education on what the kardex was or how to access it during orientation or while being trained on the floor. Instead, the NA relied on asking residents and other staff about care needs prior to learning about the kardex. The NA only received training on the kardex after an incident occurred, and review of the orientation packet confirmed there was no documentation of kardex training. This lack of training contributed to an incident where the NA attempted to assist a dependent resident with an impaired gait in ambulating to the bathroom. The NA left the resident standing unsupported while turning away to dispose of a brief, resulting in the resident falling and sustaining a left wrist fracture and a left hip fracture. Interviews with staff and review of records confirmed that the NA was not aware of the kardex or its use until after the incident, and the Director of Nursing was unaware of this training gap until it was brought to her attention.
Failure to Follow Transfer Protocols Results in Resident Fall and Fractures
Penalty
Summary
A dependent resident with a history of osteoporosis, lymphoma, breast cancer, previous fractures, and falls was admitted to the facility following a hospitalization for a fall that resulted in a subdural hematoma and right humerus fracture. The resident's care plan specified that she required two or more staff and the use of a mechanical lift for transfers due to her limited mobility, unsteady gait, and high risk for falls. The resident's fall risk assessment categorized her as high risk, noting her inability to walk without assistance and her tendency to overestimate her abilities. On the day of the incident, a nursing assistant (NA) who was unfamiliar with the resident's specific care needs attempted to assist her from bed to the bathroom by ambulating with her, rather than using the mechanical lift and two-person assistance as required by the care plan. During the transfer, the NA let go of the resident to dispose of a brief, leaving the resident unsupported and standing. The resident subsequently lost her balance and fell, resulting in a left wrist fracture and a left hip fracture. The NA later stated she was unaware of the resident's transfer requirements and had been told by other staff that the resident could ambulate with assistance, but could not provide the names of those staff members. Interviews with nursing staff and the physician assistant confirmed that the resident was to be transferred only with a mechanical lift and two staff members due to her poor balance and unsteady gait. The nurse who responded to the fall found the resident on the floor with injuries and confirmed that the care plan had not been followed. The director of nursing also stated that the care plan should have been followed and that the NA should not have left the resident unsupported during the transfer.
Inaccurate MDS Coding for Medications, Diagnoses, and Treatments
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for four residents in several key areas, including medication use, oxygen therapy, prognosis, and active diagnoses. For one resident with heart failure and pulmonary embolism, the MDS assessment incorrectly documented that the resident was not taking anticoagulant medications and was taking antibiotics, despite physician orders and medication administration records confirming ongoing warfarin therapy and no antibiotic prescriptions. The MDS nurse acknowledged this was a data entry error, having mis-keyed the information despite her own worksheet reflecting the correct medication. Another resident with chronic respiratory failure and chronic obstructive pulmonary disease was not coded for oxygen use on the MDS assessment, even though physician orders and medication records showed continuous oxygen therapy during the assessment period. The MDS nurse confirmed this omission was an oversight after reviewing the resident's orders and medication records. Similarly, a resident receiving hospice care for vascular dementia was not coded on the MDS for having a condition with a life expectancy of less than six months, despite a valid hospice certification and ongoing hospice care. The nurse responsible for the MDS assessment admitted this was also an oversight. Additionally, a resident with documented diagnoses of dementia and hypertension was not coded for these conditions on the MDS assessment, even though both diagnoses were active, included in the care plan, and supported by clinical documentation and vital sign monitoring. The MDS nurse stated she did not see the relevant documentation in the electronic medical record during the look-back period, resulting in the omission. In each case, the administrator confirmed that accurate MDS coding was expected.
Failure to Discard Expired Milk and Label Opened Food Items
Penalty
Summary
Surveyors observed that the facility failed to discard milk stored past its use by date in the reach-in cooler and did not label or date several opened food items in the walk-in cooler. Specifically, a partially consumed gallon of whole milk with a use by date that had passed, two opened bags of shredded cheese without labels or dates, an opened bag of hot dogs with no open date, a container of jelly with a use by date that had passed, a roll of bologna with no open date, and a bag of sliced cooked ham with a use by date that had passed were found during the kitchen inspection. These findings were confirmed through interviews with dietary staff and the Dietary Manager, who acknowledged the expectation for staff to label, date, and discard food items according to regulations. The Dietary Manager reported being on vacation during the period when the deficiencies occurred, and the Social Worker was assigned to make daily kitchen rounds using check-off sheets. The Social Worker noted undated and unlabeled food items on two occasions and reported these to kitchen staff, who stated they subsequently labeled and dated the items. The Administrator was unaware of the failure to properly label, date, and discard food items until informed during the survey. No information about specific residents or their conditions was provided in the report.
Deficient Oxygen Therapy Administration and Monitoring
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, as evidenced by multiple deficiencies in the administration and monitoring of oxygen therapy. One resident with chronic obstructive lung disease and respiratory failure was observed receiving oxygen at a flow rate of 5 liters per minute (LPM) on several occasions, despite a physician's order specifying 3 LPM. Nursing staff documented that the flow rate was checked, but interviews revealed that the checks may not have been performed as required, and the incorrect flow rate was not identified or corrected until observed by surveyors. Another resident with COPD, heart failure, and asthma was found to be using oxygen at 2 LPM via nasal cannula without a current physician's order. The resident and nursing staff confirmed that oxygen was used regularly, but a review of the medical record showed that the order for oxygen had expired and was not renewed after recent hospitalizations. The lack of a current order was acknowledged by both nursing staff and the physician assistant, who stated that an order should have been present for ongoing oxygen use. Additionally, two residents receiving continuous oxygen therapy did not have required signage posted outside their rooms to indicate oxygen use. Observations confirmed the absence of signage, and both nursing staff and administration acknowledged that the signage should have been in place. These deficiencies were identified through record reviews, direct observations, and staff interviews, affecting four of six residents reviewed for respiratory care.
Failure to Label Enteral Feedings and Improper Syringe Storage
Penalty
Summary
The facility failed to properly label enteral feeding formula and did not store enteral feeding syringes according to infection control protocols for two residents receiving enteral nutrition. For one resident with an anoxic brain injury and severe cognitive impairment, the enteral feeding was observed infusing without a label indicating the date or time it was changed. Additionally, the enteral feeding syringe used for medication administration was stored in a plastic bag with the plunger inside the barrel, and droplets of water were present in both the syringe tip and the bag. The nurse responsible was unaware of the requirement to label the feeding or to store the syringe components separately. For another resident with dysphagia and a history of stroke, the syringe used for medication and water flushes was also found stored in a plastic bag with the plunger inside the barrel, with visible droplets of liquid inside the syringe and bag. The nurse administering care was not aware that the plunger should be separated from the barrel during storage. The DON confirmed that the correct procedure is to label enteral feedings with the date and time and to store syringes with the plunger separated from the barrel to prevent bacterial growth.
Pharmacy Labeling Error Leads to Administration of Incorrect Opioid Medication
Penalty
Summary
A medication error occurred when a resident with a history of stroke, chronic pain, and ovarian cancer was administered oxycodone/acetaminophen instead of the hydrocodone/acetaminophen that was ordered by the physician. The error was traced to a pharmacy labeling mistake, where a blister package containing oxycodone/acetaminophen 5/325 mg was incorrectly labeled as hydrocodone/acetaminophen 5/325 mg. The tablets in the blister pack did not match the description on the pharmacy label, which was eventually noticed by nursing staff. The resident received a total of 18 doses of the incorrect medication over several days. The error was discovered when a nurse observed that the physical appearance of the pills did not match the label description. Upon further investigation, it was confirmed that the medication in the blister pack was not what was ordered. The pharmacy later determined that a technician had selected the wrong blister pack and the pharmacist failed to double-check the medication before it was dispensed to the facility. Interviews with the resident revealed that she did not experience adverse reactions but did report inadequate pain control during the period she received the incorrect medication. The incident was documented in the facility's records, and the physician was notified and assessed the resident. The pharmacy acknowledged the error and identified a breakdown in their verification process as the cause.
Failure to Provide Written Notification of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to the responsible party (RP) or resident regarding transfers to the hospital for two residents who experienced changes in condition. In multiple instances, nursing notes documented that residents were transferred to the hospital and later readmitted to the facility, but there was no evidence in the medical record of written notification being provided to the RP or the resident. The Director of Nursing (DON) confirmed that while the transfer form was sent with the resident to the hospital and the RP was notified by phone, she was unaware that written notification was also required to be mailed to the RP and given to the resident. One resident had diagnoses including respiratory failure and diabetes and was noted to be severely cognitively impaired. Another resident had a guardian for medical and financial concerns. In both cases, the RPs confirmed they were notified by phone but did not receive any written communication regarding the hospital transfers. The facility did not have a process in place to provide written notification of the reason for transfer, which was confirmed by staff interviews and review of the medical records.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to accurately post daily nurse staffing information for five out of eight reviewed dates. Observations revealed that on one occasion, the posted staffing form was outdated by two days, and the receptionist was unaware of who was responsible for updating it. Review of posted forms and corresponding schedules showed discrepancies, such as listing more LPNs and NAs than were actually scheduled or present, and omitting an RN who had worked a shift. In several instances, the number of staff listed on the posted forms did not match the actual staffing records, including both overstatements and omissions. Interviews with the scheduler and the Director of Nursing (DON) indicated confusion and lack of clarity regarding responsibility for updating the staffing forms, especially on weekends. The scheduler acknowledged making corrections during the week but was unsure why the receptionist had not updated the form on a weekend. The DON admitted that some errors may have been her responsibility and confirmed that the forms should be updated with any staffing changes. No specific residents or patient conditions were mentioned in relation to the deficiency.
Lack of Documentation for Immunization Education
Penalty
Summary
The facility failed to include documentation in the medical records of five residents regarding education on the benefits and potential side effects of the Influenza and Pneumococcal immunizations. Resident #10, who was cognitively intact, received the Influenza immunization but had no documentation of education provided. Similarly, Resident #21, who was severely cognitively impaired, received the Influenza immunization without documented education. Resident #34, who declined the Influenza immunization, also lacked documentation of education. Resident #35, who was cognitively intact, received the Influenza immunization without documented education. Lastly, Resident #41, who was moderately cognitively impaired, received the Influenza immunization without documented education in the medical record. The Director of Nursing (DON) explained that the facility had recently reviewed and adjusted their immunization protocol. They discovered that the consent forms used did not include information on the risks and benefits of the immunizations. New consent forms with the required information were obtained from the pharmacy and implemented starting in December 2023 for new admissions. However, the lack of documentation for the five residents reviewed indicated that the previous consent forms were still in use at the time of their immunizations. The Administrator confirmed that the facility had made changes to their immunization program and had started using new consent forms that included the necessary education on risks and benefits. Despite these changes, the deficiency was identified during the review of the medical records for the five residents, as there was no documentation of education provided regarding the benefits and potential side effects of the Influenza and Pneumococcal immunizations.
Failure to Resolve Resident Council Grievances
Penalty
Summary
The facility failed to provide resolution of Resident Council Meeting group grievances for four out of six monthly Resident Council Meetings. The Resident Council had repeated concerns regarding evening snacks and ice water being delivered in the evening. Despite the Director of Nursing (DON) monitoring and re-educating the evening shift staff, the issues persisted. The Resident Council Meeting minutes from 11/9/2023, 12/7/2023, 2/22/2024, and 3/21/2024 all noted ongoing issues with ice water not being passed out at night. The DON had monitored the situation and provided education but did not initiate a plan of correction or document her checks to ensure compliance. During the Resident Council Meeting on 3/21/2024, multiple residents voiced concerns about the inconsistency of evening snacks and ice water delivery, which had been brought up in previous meetings. Interviews with the Activity Director (AD) and the DON confirmed that the grievances had been communicated but not effectively resolved. The AD explained that the grievances were given to the DON, who had checked on the issues but did not document her findings or implement a corrective plan. The Administrator also confirmed that the Grievance Committee met with her to discuss resident complaints, but no other staff members or residents attended these meetings, and the grievances were reviewed as part of the facility's monthly Quality Assurance Program.
Failure to Accurately Code MDS Assessment for Falls
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident who was at high risk for falls due to deconditioning and psychoactive medication use. The resident experienced falls on two occasions, which were documented in the medical record but not recorded in the quarterly MDS assessment. The MDS Coordinator acknowledged missing these falls, resulting in an incorrect MDS coding. Despite daily administrative meetings to review falls, the MDS Coordinator did not update the MDS assessment accurately.
Resident Received Multiple Doses of One-Time Vaccine
Penalty
Summary
The facility failed to prevent a vaccine from being administered more than once when it was ordered for a one-time dose for a resident reviewed for unnecessary medications. Resident #71, who was admitted with diagnoses of stroke and chronic respiratory disease and was severely cognitively impaired, received three doses of the Arexvy vaccine instead of the prescribed single dose. The Medication Administration Record (MAR) indicated the vaccine was to be given once a day, leading to the resident receiving additional doses on 3/7/2024 and 3/15/2024, despite the order being for a one-time administration. Interviews with the nursing staff revealed that the error occurred due to the incorrect transcription of the physician's order into the electronic medical record. Nurse #14 administered the first dose as ordered, while Nurse #3 administered the second dose and mistakenly documented a third dose. The Director of Nursing confirmed that the order was incorrectly transcribed, resulting in the MAR indicating a daily administration instead of a one-time dose. The physician confirmed that the resident should have received only one dose but noted that no ill effects were observed from the additional doses.
Failure to Label and Date Opened Medications
Penalty
Summary
The facility failed to label and date four liquid medications that had been opened in one of the medication carts observed. During an observation of the 100-hall medication cart, it was found that Pro-stat, Chlorhexidine Gluconate, Valproic Acid Oral Solution, and Dextromethorphan/Guaifenesin were opened and undated. The Pro-stat label indicated it should be discarded three months after opening, while the other medications had no instructions regarding their discard dates after opening. This deficiency was identified during an observation on 3/20/2024 at 10:24 am. Nurse #8, who normally worked on the 100-hall, confirmed that all opened medications should be labeled with the date they were opened. Despite recent in-service education on this procedure, the nurse did not know who had placed the unlabeled medications in the cart. The Director of Nursing (DON) and the Administrator both confirmed that the nursing staff had been educated on labeling and dating medications, and that Nurse #8 should have ensured the medications were labeled and discarded if not properly dated.
Failure to Document COVID-19 Vaccine Education
Penalty
Summary
The facility failed to document education regarding the benefits and potential side effects of the COVID-19 immunization for three residents. Resident #10, who was cognitively intact, had no record of receiving this information in their medical file. Similarly, Resident #35, also cognitively intact, lacked documentation of such education. Resident #41, who was moderately cognitively impaired, also had no record of being informed about the benefits and potential side effects of the COVID-19 vaccine in their medical file. The Director of Nursing (DON) explained that the facility had recently reviewed and adjusted their immunization protocol. They discovered that the consent forms previously used did not include information on the risks and benefits of the COVID-19 vaccine. New consent forms with the required information were obtained from the pharmacy and implemented starting in December 2023 for new admissions. However, the lack of documentation for the three residents mentioned occurred before these changes were made. The Administrator confirmed that the facility had made changes to their immunization program after realizing the previous consent forms were inadequate. The new consent forms, which included the necessary risk and benefit information, were introduced in December 2023. Despite these updates, the deficiency was noted for the three residents whose records did not reflect the required education prior to the implementation of the new consent forms.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
