Pruitthealth-neuse
Inspection history, citations, penalties and survey trends for this long-term care facility in New Bern, North Carolina.
- Location
- 1303 Health Drive, New Bern, North Carolina 28560
- CMS Provider Number
- 345357
- Inspections on file
- 29
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Pruitthealth-neuse during CMS and state inspections, most recent first.
A resident with hemiplegia and hemiparesis, moderate cognitive impairment, and documented nutrition/hydration risk had a physician order and care plan specifying use of a spouted cup with handle at all meals, but was repeatedly served beverages in regular cups with lids and straws. Observations showed that staff delivering meal trays did not properly check diet slips against tray contents, and one NA admitted she did not verify accuracy and would leave incorrect trays as they were, despite training. The resident reported spilling drinks with regular cups and finding the spouted cup easier to use, while the DON and Dietary Manager confirmed that staff were expected to verify trays and that appropriate adaptive cups were available in stock.
A moderately cognitively impaired resident with multiple comorbidities was found with a half-full 40-ounce bottle of multipurpose cleaner on the bedside table, which the resident had ordered and used for cleaning spills. The product’s label warned of eye, skin, and respiratory irritation and adverse effects if ingested. Direct care staff and a nurse reported they were unaware the cleaner was in the room and stated it should have been removed if seen. The DON and Administrator acknowledged the resident’s pattern of ordering items to the room and stated hazardous products should not be kept at the bedside and should be removed and reported when observed.
A resident's Responsible Party, who held Power of Attorney, repeatedly requested medical records from the Medical Records Director over several months but did not receive them within the required 2 working days. The records were eventually mailed after legal intervention, with the delay attributed to the Medical Records Director's misunderstanding of the release timeframe following the resident's discharge and death.
A resident with a history of bipolar disorder and documented tobacco use was incorrectly coded as a non-smoker on the MDS assessment, despite care plan and observation records indicating otherwise. Staff interviews confirmed the resident's smoking status and attributed the error to oversight during the assessment process.
A resident with a history of bipolar disorder and assessed as a safe, independent smoker was observed lighting and smoking a cigarette inside the facility lobby, contrary to the facility's no-smoking policy. Staff intervened by escorting the resident outside and attempting to secure her smoking materials, resulting in a combative incident and police involvement. The resident had previously been permitted to keep smoking materials in a lock box in her room due to a grandfathered policy.
A resident with diabetes experienced elevated blood sugar levels exceeding 500 mg/dL on multiple nights. Despite physician orders to notify the MD for levels over 400 mg/dL, the responsible party was not informed until the resident was hospitalized. The nurse involved did not notify the RP due to the time of night and perceived non-life-threatening nature, although the Director of Nursing acknowledged the RP should have been informed.
A resident with a history of UTI did not receive scheduled doses of ciprofloxacin due to a failure in verifying the physician's order. The order was not sent to the pharmacy or added to the MAR, leading to missed doses. Nursing staff were unaware or did not verify the order, and the facility's system for medication administration was not followed.
A resident with anxiety disorder did not receive 10 doses of prescribed lorazepam due to an error by the DON, who mistakenly discontinued the medication on the MAR. This led to increased anxiety for the resident, who was observed crying and asking for his medication. The error was compounded by confusion among nursing staff and a misunderstanding regarding the family's request, resulting in the resident not receiving either the scheduled or PRN lorazepam during this period.
A resident with respiratory failure and muscle weakness was transferred without a mechanical lift, despite being assessed as requiring one. The nursing assistants were unaware of this requirement due to a lack of communication between therapy and nursing staff. The resident experienced pain and shortness of breath during the transfer.
A facility failed to maintain a medication error rate below 5%, resulting in a 7.41% rate due to errors involving a resident's medication administration. A nurse crushed and administered medications in applesauce against orders, including an enteric-coated aspirin and Metoprolol Succinate extended-release, which were to be given whole. Interviews confirmed the errors and highlighted the risks of altering medication properties.
The facility failed to include estimated costs on SNF/ABN forms for two residents, as required. Medicare coverage ended for both residents, but the forms lacked the necessary cost information. Staff interviews revealed a lack of awareness about this requirement.
A facility failed to accurately code a significant change in status MDS for a resident who elected hospice care. The resident, with acute respiratory failure, acute pneumonitis, and Alzheimer's dementia, was admitted to hospice, but the MDS did not reflect this change. The MDS nurse was aware of the hospice admission but did not include it in the MDS, and the administrator confirmed this oversight.
A treatment cart was found unlocked and unattended in a hallway, with a resident nearby and staff and visitors passing by. The MDS Nurse locked the cart upon noticing it. Treatment Nurse #1, responsible for the cart, acknowledged it should be locked when unattended but had no explanation for the oversight. The cart contained various medications and ointments.
A nurse failed to perform hand hygiene before donning gloves and after glove removal during medication administration and a blood glucose test for a resident. Despite facility policies requiring hand hygiene at these times, the nurse did not comply, citing nervousness and a headache. The Infection Preventionist and DON confirmed the breach in protocol.
A facility failed to protect a resident's controlled medication, resulting in 30 Oxycodone 5mg pills being unaccounted for. The resident was unaware of the missing medication, and an internal investigation involving the DON, Administrator, and pharmacist could not locate the pills. The facility covered the cost to replace the medication.
The facility failed to report an incident of misappropriation of a resident's narcotic medication to the state regulatory agency, APS, and law enforcement in a timely manner. The DON and Administrator did not realize the incident was reportable, leading to delays and failures in required notifications.
The facility's QAA failed to maintain procedures and monitor interventions, leading to deficiencies in providing a homelike environment, reporting alleged violations, and infection control. Issues included strong urine smells in rooms, unreported misappropriation of resident property, and staff not wearing PPE during resident care.
The facility failed to implement enhanced barrier precautions when three nursing staff members did not wear PPE while providing care to a resident with chronic wounds, a urinary catheter, a gastrointestinal tube, and a tracheostomy. Despite training and infection control signage, the staff did not don gowns during high-contact care activities.
The facility failed to maintain a clean and homelike environment due to a strong urine odor in the 300 hallway and specific rooms. Despite multiple attempts to clean, residents' refusal to allow housekeeping contributed to the persistent smell. Staff and administration were aware of the issue, with suggestions to replace floor tiles to address the odor.
Failure to Provide Ordered Adaptive Drinking Equipment and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed adaptive drinking equipment and to ensure staff verified diet slips against meal trays. A resident with hemiplegia and hemiparesis following a nontraumatic intracranial hemorrhage had a physician’s order, dated 7/31/25, for a spouted cup with handle with all meals. The resident’s care plan, last reviewed 9/25/25, identified nutrition/hydration risk and included an approach to provide adaptive equipment with meal trays as ordered, specifically a spouted cup with handle. The quarterly MDS documented moderate cognitive impairment, impairment of one upper and one lower extremity, and independence with eating after tray setup. On observation, the breakfast tray diet slip specified a spouted cup with handle, but the tray contained only regular cups with lids and straws, and the beverages appeared untouched. Later observation of the lunch meal showed a nurse aide delivering the tray, placing it on the overbed table, removing the plate lid, and attempting to leave without checking the diet slip. When questioned, the aide initially stated she had not checked the diet slip and that they “didn’t really say anything,” then, after looking, failed to notice the spouted cup order and incorrectly stated the resident was not supposed to have one before correcting herself. She acknowledged that when a tray does not match the diet slip, she “just leaves it and hopes for the best,” despite having been trained on tray passing at hire. The resident reported sometimes spilling drinks when using a regular cup with lid and straw and that the spouted cup with handle was easier to use. The DON stated that staff passing trays were responsible for checking diet slips and returning incorrect trays to Dietary, and the Dietary Manager reported that multiple staff checked trays before carting and that there was adequate stock of spouted cups, yet the resident still received breakfast and lunch without the ordered assistive device.
Hazardous Cleaning Product Left at Resident Bedside
Penalty
Summary
The facility failed to maintain an environment free of hazards when a moderately cognitively impaired resident with diagnoses including diabetes, depression, and chronic kidney disease was observed with a 40-ounce bottle of multipurpose cleaner, approximately half full, on her bedside table. The cleaner’s warning label stated it could cause moderate to serious eye irritation, skin irritation, and respiratory tract irritation from vapors, and that ingestion could cause stomach distress, nausea, and vomiting. The resident reported she used the cleaner to clean spills in her room and had ordered it from a local retailer that delivered it directly to her room. The resident’s roommate was described as non-ambulatory, not self-propelling in a wheelchair, and severely cognitively impaired. Staff interviews revealed that direct care staff and nursing staff were unaware that the resident had the multipurpose cleaner in her room. A nurse aide stated she did not know the cleaner was present and acknowledged the resident should not have had it because it could cause harm if consumed or if splatter got into the eyes. A nurse reported she did not recall seeing the cleaner and stated that if aides, housekeepers, or nurses had seen it, they should have removed it immediately. The DON and Administrator both stated the resident should not have had the cleaner at the bedside, acknowledged the resident’s history of ordering items for delivery to her room, and indicated that any staff member who observed such a product should remove it and report it to leadership. North Carolina Poison Control confirmed that ingestion or eye contact with the cleaner could cause adverse effects, and the Medical Director stated she had no concerns about the resident’s exposure because she did not believe the resident would ingest it, but would call poison control if ingestion occurred.
Failure to Timely Provide Medical Records to Resident's Responsible Party
Penalty
Summary
The facility failed to provide copies of a resident's medical records to the resident's Responsible Party (RP) within 2 working days after a formal request was made. The RP, who was also the Power of Attorney, began requesting the records from the Medical Records Director several months prior to the resident's death, but the records were not provided despite repeated assurances. The RP eventually engaged legal assistance and submitted a signed consent for the records, but the Medical Records Director delayed mailing the records, believing that a 90-day timeframe applied since the resident was no longer at the facility. Interviews with facility staff, including the Medical Records Director, prior Administrator, and current Administrator, confirmed that the request was received and not fulfilled within the required 2 working days. The Senior Nurse Consultant acknowledged that not providing the records within this timeframe was a problem. The deficiency was identified for one resident who had expired, and the delay in providing records was attributed to a misunderstanding of the required timeframe for record release after discharge or death.
Inaccurate MDS Coding for Tobacco Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of tobacco use. The resident, who had a diagnosis of bipolar disorder with manic delusions, was admitted to the facility and was documented in the care plan and observation records as a smoker who understood and followed the facility's smoking policy. However, the annual MDS assessment incorrectly indicated that the resident did not use tobacco. Staff interviews revealed that the MDS was completed by a nurse from the corporate office during the regular coordinator's absence, and both the Case Mix Coordinator and the DON confirmed that the resident was a smoker and should have been coded as such. The error was attributed to oversight during the assessment process.
Resident Smoked Indoors in Violation of Facility Policy
Penalty
Summary
A deficiency occurred when a resident with a diagnosis including bipolar disorder with manic delusions was observed smoking a cigarette inside the facility lobby, in violation of the facility's smoking policy that prohibits smoking indoors at any time. The resident had been assessed as cognitively intact, able to self-propel in a wheelchair, and was care planned as a safe, independent smoker who could keep smoking materials in a lock box in her room. Staff interviews confirmed that the resident had previously understood and agreed to the smoking policy, and there were no prior incidents of indoor smoking reported for this resident. On the day of the incident, the resident was seen lighting and smoking a cigarette in the lobby area, away from other residents with oxygen. Staff intervened by escorting the resident outside and attempting to retrieve her smoking materials, which led to the resident becoming combative and the police being called. The resident was subsequently sent to the emergency room for evaluation due to escalating behaviors and later returned to the facility under one-to-one supervision. The facility's policy allowed certain residents, grandfathered in from a previous administration, to retain smoking materials in their rooms if assessed as safe smokers, which applied to this resident prior to the incident.
Failure to Notify Responsible Party of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's change in condition when the resident's fingerstick blood sugar (FSBS) levels exceeded 500 milligrams per deciliter on multiple occasions. The resident, who was admitted with diagnoses including diabetes, dementia, and a femur fracture, had a physician order for insulin lispro to be administered according to a sliding scale. Despite the elevated FSBS levels recorded on 10/01/24, 10/02/24, and 10/03/24, there was no documentation that the RP was informed of these critical changes. Nurse #3, who was responsible for monitoring the resident's FSBS levels, did not notify the RP of the elevated readings, citing the time of night and the non-life-threatening nature of the situation as reasons. The nurse did notify the on-call provider and administered additional insulin as instructed, which temporarily reduced the blood sugar levels. However, the RP was only informed of the elevated levels when the resident was transferred to the hospital on 10/05/24, after becoming unresponsive. The Director of Nursing confirmed that the RP should have been notified of the elevated blood glucose levels.
Missed Antibiotic Doses Due to Unverified Physician Order
Penalty
Summary
The facility failed to administer scheduled antibiotic medication to a resident, resulting in three missed doses. The resident, who had a history of urinary tract infection (UTI), was admitted to the facility with a discharge diagnosis that included a UTI. However, it was unclear if the resident had been treated for the UTI during a prior hospital stay. A physician order for ciprofloxacin, an antibiotic, was written to treat the UTI, but the medication was not administered as scheduled. The deficiency occurred because the physician order for ciprofloxacin was not verified by the nursing staff, which prevented the order from being sent to the pharmacy and appearing on the Medication Administration Record (MAR). Multiple nurses involved in the resident's care were unaware of the order or did not verify it in a timely manner. The order was eventually verified by a nurse, but not until after the scheduled doses had been missed. Interviews with the nursing staff and facility management revealed a lack of clarity and responsibility in verifying physician orders. The Director of Health Services stated that the nurses or the Unit Manager were responsible for verifying orders, but the order for ciprofloxacin was not verified, leading to the missed doses. The Medical Director and Nurse Practitioner were not informed of the missed doses, and the facility's system for verifying and administering medications was not followed, resulting in the deficiency.
Failure to Administer Prescribed Lorazepam Leads to Increased Anxiety
Penalty
Summary
The facility failed to administer prescribed medications to a resident, identified as Resident #45, who was diagnosed with hypertension, anxiety disorder, and asthma. The resident was prescribed lorazepam, an anti-anxiety medication, to be taken four times a day, as well as a PRN dose. However, due to an error by the Director of Nursing (DON), the scheduled lorazepam was erroneously discontinued on the Medication Administration Record (MAR) from 7/29/24 to 8/1/24, resulting in the resident missing 10 consecutive doses. This error led to the resident experiencing increased anxiety, as noted by the Nurse Practitioner (NP) on 8/1/24, who observed the resident crying and asking for his medication. The error occurred when the pharmacy sent an alert indicating that Resident #45 had two lorazepam orders. The DON mistakenly discontinued the scheduled lorazepam, believing it was a duplicate order. Despite the availability of PRN lorazepam, it was not administered during this period. Interviews with nursing staff revealed confusion and lack of clarity regarding the administration of the medication, with some nurses unaware of the discontinuation and others believing the family had requested the medication to be stopped. The resident's family member confirmed that they had only requested a single dose to be held for a visit and had not asked for the medication to be discontinued. The Psychiatric Nurse Practitioner and the Pharmacist both indicated that lorazepam should not have been abruptly stopped, as it could lead to increased anxiety and other withdrawal symptoms. The facility's Administrator acknowledged the error, attributing it to the medication re-order system setup, which led to the oversight in medication administration.
Failure to Use Mechanical Lift for Resident Transfer
Penalty
Summary
The facility failed to provide a safe transfer for a resident who required a mechanical lift, as assessed by a physical therapist. The resident, who was moderately cognitively impaired and dependent on staff for transfers, was transferred from bed to chair by two nursing assistants without the use of a mechanical lift. This occurred despite the resident's care plan indicating a risk for falls and the physical therapist's assessment that a mechanical lift was necessary due to the resident's inability to stand safely. The incident involved a resident with acute and chronic respiratory failure, anxiety, muscle weakness, and pneumonia, who was admitted to the facility with a need for supplemental oxygen. On the day of the incident, the resident informed the nursing assistants to use a mechanical lift, but they proceeded with a manual transfer, causing the resident to feel as though she was falling and resulting in pain and shortness of breath. The nursing assistants were unaware of the requirement for a mechanical lift, as the care card only indicated a two-person assist. Interviews with staff revealed a lack of a formal communication process between therapy and nursing staff regarding transfer methods. The physical therapist had verbally communicated the need for a mechanical lift to a nurse, but this information was not documented or relayed to the nursing assistants. The Director of Nursing acknowledged the absence of a set system for communicating transfer requirements, which led to the unsafe transfer of the resident.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a rate of 7.41% due to two medication errors involving a single resident. The errors were identified during an observation of medication administration by Nurse #1, who crushed and administered medications in applesauce contrary to the resident's orders. The resident was prescribed a 325 mg aspirin and a 50 mg Metoprolol Succinate extended-release tablet, both of which were to be given whole in puree. Nurse #1 admitted to crushing the medications because the resident had difficulty swallowing them whole, and she used an enteric-coated aspirin instead of a regular one due to availability in her cart. The errors were further confirmed through interviews with the nurse, pharmacist, Director of Nursing (DON), and the physician. The pharmacist and DON highlighted that crushing Metoprolol Succinate extended-release alters its release properties, potentially affecting the resident's blood pressure and pulse. The physician confirmed that the resident did not have an order for medications to be crushed and emphasized the risks associated with crushing enteric-coated aspirin. The facility's failure to adhere to the prescribed medication administration method led to these errors.
Failure to Include Estimated Costs on SNF/ABN Forms
Penalty
Summary
The facility failed to provide a complete Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF/ABN) by omitting the estimated cost of services for two residents. Resident #286 was admitted to the facility and began receiving Medicare Part A services on December 27, 2023. A Notice of Medicare Non-Coverage (NOMNC) was issued to Resident #286's representative on March 11, 2024, indicating that Medicare coverage would end on March 13, 2024. However, the SNF/ABN form dated March 11, 2024, did not include the estimated cost of services. Similarly, Resident #287, who began Medicare Part A services on June 14, 2024, received a NOMNC on August 12, 2024, stating that coverage would end on August 16, 2024. The SNF/ABN form for Resident #287, dated August 12, 2024, also lacked the estimated cost of services. Interviews with facility staff revealed a lack of awareness regarding the requirement to include estimated costs on the SNF/ABN forms. Nurse #2, responsible for completing the forms for both residents, stated she was unaware of the need to include estimated costs and would do so in the future. The Administrator in Training acknowledged that if estimated costs were required, they should have been included for both residents. The Administrator was also unaware that the estimated costs had not been completed for the residents and agreed that they should have been included.
Failure to Accurately Code Hospice Admission in MDS
Penalty
Summary
The facility failed to accurately code a significant change in status Minimum Data Set (MDS) assessment for a resident who elected hospice care. The resident, who was readmitted to the facility with acute respiratory failure, acute pneumonitis, and Alzheimer's dementia, was admitted to hospice on August 19, 2024. However, the MDS completed on the same day did not reflect this significant change. During an interview, the MDS nurse acknowledged awareness of the resident's hospice admission but was unsure how the information was omitted from the MDS. The facility's administrator also confirmed that the MDS should have captured the hospice admission.
Unattended and Unlocked Treatment Cart
Penalty
Summary
The facility failed to ensure that medications were securely stored in a locked treatment cart, as observed with Treatment Cart #1. On the specified date, the treatment cart was found unlocked and unattended in the 100 hall. During this time, a resident approached the cart and stopped approximately five feet away, while a nurse aide, a restorative aide, and a visitor walked past the unlocked cart. The MDS Nurse, upon noticing the cart was unlocked, proceeded to lock it. Interviews with staff revealed that the treatment cart was under the responsibility of Treatment Nurse #1, who acknowledged that the cart should be locked when unattended but could not provide a reason for it being left unlocked. The cart contained various medications and ointments, including calmoseptine ointment, triamcinolone acetonide cream, and nystatin ointment. The Director of Nursing confirmed that treatment carts are required to be locked when not in use.
Failure to Follow Hand Hygiene Protocols During Medication Administration
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies during medication administration, as observed with Nurse #1. The nurse did not perform hand hygiene before donning gloves and after glove removal while administering medications and conducting a blood glucose test for a resident. The facility's policy, dated 10/17/2023, clearly states that hand hygiene should be performed before and after glove use during medication administration. However, during an observation on 9/10/24, Nurse #1 was seen putting on gloves without prior hand hygiene and removing gloves without subsequent hand hygiene after completing the tasks. In interviews conducted on the same day, Nurse #1 acknowledged her failure to perform hand hygiene, attributing it to nervousness and a headache. The Infection Preventionist confirmed that hand hygiene should have been performed after glove removal. The Director of Nursing also stated that nurses receive infection control training upon hire and annually, and confirmed that Nurse #1 should have followed the hand hygiene protocol before and after glove use during the procedure.
Misappropriation of Controlled Medication
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of a controlled medication. Specifically, 30 Oxycodone 5mg pills prescribed for pain management were unaccounted for. The resident, who was moderately cognitively impaired, was unaware of the missing medication and did not recall any disruption in his pain management. The issue was discovered during a narcotic count at shift change, and the Director of Nursing (DON) was notified. The facility conducted an internal investigation, notified law enforcement and the pharmacy, and searched all medication carts and med rooms, but the medication was not found. Interviews with the DON revealed that the narcotics were kept double-locked, and both the nurse and an orientee working that night passed voluntary drug screening tests. The Administrator confirmed that the narcotic count sheet had been moved within the binder, and the medication cart was parked out of camera view for part of the shift. Despite these efforts, the missing medication was not recovered, and the facility covered the cost to replace it. The pharmacist also assisted in the investigation but was unable to locate the missing medication.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to submit an initial or investigation (5-day) report to the state regulatory agency and did not notify Adult Protective Services (APS) regarding an allegation of misappropriation of resident property. Specifically, the Director of Nursing (DON) received a phone call from a nurse on 9/7/23 reporting that a card of narcotic medication belonging to a resident was unaccounted for during a shift change medication count. The facility did not notify law enforcement until 9/13/23, and there was no indication that APS was notified at all. The DON admitted to not sending the required reports to the state regulatory agency and not notifying APS, as she did not realize the incident was reportable. The Administrator also failed to report the incident, thinking it was more of a diversion issue rather than misappropriation of resident property. The DON and the Administrator both acknowledged their failure to report the incident to the appropriate authorities. The DON spent five days searching for the missing medication before notifying law enforcement. The Administrator confirmed that no initial or 5-day investigation report was sent to the state regulatory agency and that APS was not notified. Both the DON and the Administrator did not categorize the missing medication as misappropriation, leading to delays and failures in reporting the incident as required by regulations.
Quality Assurance Failures in Multiple Areas
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor interventions that were previously put in place following recertification and complaint investigation surveys. This failure was evident in three recited deficiencies: Safe/Clean/Comfortable/Homelike Environment (F584), Reporting of Alleged Violations (F609), and Infection Control (F880). Specifically, the facility failed to provide a room free of a strong smell of urine, failed to report an allegation of misappropriation of resident property to the state regulatory agency and Adult Protective Services (APS), and failed to implement their policies and procedures for wearing Personal Protective Equipment (PPE) when providing care to a resident. These deficiencies were observed during multiple surveys, indicating a pattern of the facility's inability to sustain an effective Quality Assurance Program. In the case of F584, the facility was cited for failing to keep walls, resident furniture, and sinks in good condition, and for not addressing water damage, leaking plumbing, and black substances on walls. For F609, the facility did not report an allegation of misappropriation of resident property within the required time frame. For F880, nursing staff members were observed not wearing PPE when providing care to a resident, despite the facility's policies and procedures. The Administrator acknowledged these issues and mentioned that overcoming certain citations is difficult due to the need for corporate approval for funds to fix walls and replace resident furniture. Additionally, a citation for failure to report was attributed to a fax issue, which has since been resolved by using a different fax machine.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement their enhanced barrier precautions policies and procedures for wearing Personal Protective Equipment (PPE) when three nursing staff members were observed not wearing PPE while providing care to a resident. The resident had chronic wounds, a suprapubic urinary catheter, a gastrointestinal tube, and a tracheostomy, all of which required enhanced barrier precautions. Despite the infection control signage on the resident's door and the facility's guidelines, the staff did not don gowns during high-contact care activities such as wound care, catheter care, tube feeding, and tracheostomy care. Interviews with the nursing staff revealed that they had received enhanced barrier precautions training but failed to follow the protocols due to nervousness and falling out of practice. The Administrator and the Director of Nursing confirmed that the staff had been trained but were unsure why the protocols were not followed. The deficiency was observed during multiple instances of care provided to the resident, highlighting a lapse in adherence to infection control measures.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a room free of a strong smell of urine, which extended into the hallway. This issue was observed in two rooms on the 300 hall. During observations on multiple days, a strong urine odor was detected in the 300 hallway and specific rooms. Interviews with residents, staff, and the Housekeeping Director confirmed the persistent urine smell. The Housekeeping Director noted that the residents in the affected rooms refused to allow housekeeping to clean their rooms, and one resident was known to urinate in trashcans and on furniture. Nursing assistants and nurses working in the area corroborated the presence of the strong urine odor and the residents' resistance to care and room cleaning. The Maintenance Director suggested that the floor tiles might need replacement to eliminate the odor. The Administrator and Director of Nursing were aware of the issue, with the Administrator mentioning plans to retile the floor in one of the rooms. Despite multiple attempts by the facility to clean the rooms, the residents' refusal to permit cleaning contributed to the ongoing problem. The deficiency was evident in the strong urine odor that permeated the 300 hall and specific rooms, affecting the residents' right to a safe, clean, and homelike environment.
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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