Siler City Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Siler City, North Carolina.
- Location
- 900 W Dolphin Street, Siler City, North Carolina 27344
- CMS Provider Number
- 345143
- Inspections on file
- 20
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Siler City Center during CMS and state inspections, most recent first.
A resident with a left patella fracture was admitted with hospital instructions that a knee immobilizer be worn when bearing weight and removed when not weight-bearing, but facility staff transcribed the order as requiring the immobilizer to be in place at all times, with removal only for bathing and skin checks. Admission notes documented existing skin concerns and redness at the left knee, yet the MDS and care plan did not reflect these findings or include specific interventions for the immobilizer. Over several weeks, nurses and NAs often did not fully remove the immobilizer for skin assessments, some documented normal skin or no external device, and one nurse later admitted seeing redness and indentations from the brace without reporting or documenting them. Eventually, an NA noticed drainage on the bed sheet, opened the immobilizer, and found an open wound on the back of the resident’s lower leg at the edge of the device; the wound was documented as a new, in-house acquired pressure ulcer, while the immobilizer remained in place and continued to press on the wound until it was removed days after a verbal order from an orthopedic NP.
Surveyors found multiple food service sanitation deficiencies, including a flour scoop stored directly in a flour bin instead of being kept to avoid contact with the food, a steam table hood with visible orange-brown residue and a slick surface that had not been cleaned recently, and plastic plate bases stacked while still wet on the tray line. The Dietary Manager acknowledged the issues with the scoop placement, the lack of recent cleaning under the hood, and that she had not checked the plastic plate bases for dryness, while the Administrator reported being unaware of why these conditions occurred.
A cognitively intact resident with a physician’s order for fluticasone nasal spray for allergies was observed multiple times with the prescribed nasal spray left on the overbed table for self-use, without any documented assessment, physician order, or care plan for self-administration. The resident reported that a nurse had left the spray in the room and acknowledged it was not supposed to be there, but that it made use easier. A nurse assigned to the resident stated she was unsure of the self-administration process, believed no residents on that hall self-administered medications, and had not noticed the spray earlier when giving medications, only discovering and removing it during an interview. The DON and Administrator described a process requiring evaluation, orders, a lock box, and care plan interventions for self-administration and indicated these steps had not been completed for this resident, despite the medication being kept at bedside.
A resident with multiple comorbidities, including CHF and Alzheimer’s disease, was admitted with documented skin issues such as a dark spot on the coccyx, an open area on the spine, and knee redness. The care plan identified risk for skin breakdown and outlined general preventive skin care measures, but did not specifically address the documented open area or dark spot. The admission MDS inaccurately recorded that the resident had no pressure ulcers, scars over bony prominences, or other skin problems, and did not indicate the need for a pressure-relieving device, repositioning/turning program, or nutrition/hydration program for skin, resulting in an inaccurate MDS skin assessment.
A resident with a physician order prohibiting self-administration of medications and requiring monitored swallowing was found with a cup containing seven pills left on the bedside table after the assigned nurse had finished passing meds on the hall. The nurse reported these were the resident’s lunch meds, stated that the resident usually took them when handed to him, and admitted she trusted the resident to take them after he said he would, despite later refusal in her presence. The nurse acknowledged knowing the resident was not to have meds at the bedside and that she was required to monitor and document swallowing. The physician confirmed he expected staff to follow orders, and the DON stated that only one resident in the facility was authorized to self-administer medications, while all others, including this resident, were not.
Surveyors found that the trash compactor area, located behind the kitchen entrance, was not properly maintained, with multiple plastic bottles, disposable cups, gloves, and straws scattered in the grassy area beside the compactor. The DM stated that kitchen staff cleaned only the cement platform weekly and that the surrounding grassy areas were not being picked up, despite the compactor being used by all departments. The Administrator acknowledged he did not know why the area had not been cleaned and stated he would want the area free of debris.
A resident with dementia and a history of physical aggression toward others repeatedly struck other residents, including one cognitively impaired resident at the nurses’ station, a cognitively intact roommate during a dispute over television volume, and another severely cognitively impaired resident who approached too closely, even while the aggressive resident was on 1:1 supervision. Care plans for the involved residents documented behavioral symptoms, mood disturbances, and wandering, and called for monitoring for aggression, removal from triggering environments, and diversion. However, staff at the nurses’ station were unable to separate residents in time to prevent a slap, the assault with a reaching device in a shared room was unwitnessed, and NAs assigned to 1:1 supervision reported they were not informed of the aggressive resident’s specific triggers or the reasons for the 1:1, contributing to the failure to prevent these resident-to-resident abuse incidents.
Two cognitively impaired male residents, both lacking capacity to consent, were involved in an incident where one was observed grasping and moving the other's exposed penis in a shared room. Neither had a prior history of sexually inappropriate behavior, and their care plans did not address such risks. The event was discovered by a nurse aide who intervened immediately, but the absence of prior identification or monitoring for sexual behaviors contributed to the deficiency.
A resident with COPD, diabetes type 2, and hypertension was found with medications left unsecured on their over the bed table without a physician's order for self-administration. The resident, who was cognitively intact, did not indicate an intention to take the medications. A nurse left the medications assuming the resident would take them, but later retrieved them when the resident refused. The DON confirmed that medications should not be left unsecured without an order.
The facility failed to ensure privacy in mail delivery for three cognitively intact residents, who reported receiving opened mail related to their financial status. The Business Office Manager admitted to opening all mail without verifying the addressee, especially if it was financial. The Administrator was unaware of this practice, which breached residents' privacy.
A resident with a feeding tube was not receiving water flushes at the physician-ordered frequency. The order specified 110 ml every 3 hours, but observations showed it was set for every 4 hours. The discrepancy was acknowledged by a nurse, and the DON expected adherence to the prescribed rate.
A resident with low blood pressure received Midodrine despite having systolic blood pressure readings above the prescribed threshold. The medication was administered on multiple occasions contrary to the physician's order, which specified it should only be given if the SBP was less than 120. Nursing staff acknowledged the oversight, and the DON and Medical Director expected adherence to the order.
A resident with moderate cognitive impairment experienced a lack of dignity due to staff failing to empty urinals in a timely manner, particularly before meals. Despite the resident's requests and the DON's expectations, urinals with urine were observed on the nightstand during meal times, indicating a deficiency in maintaining the resident's dignity.
The facility failed to provide written notification to residents or their responsible parties regarding hospital transfers, affecting four residents. Despite sending necessary medical documents with residents during transfers, the facility did not include written notices. Interviews with staff revealed a lack of awareness about this requirement, indicating a systemic issue in the notification process.
Failure to Follow Knee Immobilizer Orders and Monitor Skin, Leading to Device-Related Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to follow physician and hospital discharge orders for a knee immobilizer and to provide adequate skin assessment and monitoring, resulting in a facility-acquired pressure ulcer under the device. The resident was admitted after a left patella fracture with hospital discharge instructions specifying that the knee immobilizer should be worn when bearing weight and could be removed when not bearing weight for comfort. However, when the order was transcribed into the facility’s EMR by a house supervisor, it was entered as “left knee immobilizer in place at all times. May remove for bathing and skin checks every day and night shift,” which did not match the hospital discharge instructions. Neither of the two house supervisors who handled admissions could explain where the “at all times” language originated, and no documentation was produced to support that wording. The resident was admitted with multiple diagnoses including left patella fracture, A-fib, CHF, hypothyroidism, Alzheimer’s disease, and later-documented moderate protein-calorie malnutrition. On admission, nursing documentation noted a dark spot on the coccyx, an open area on the spine, and redness to the left knee, but these findings were not reflected on the admission MDS, which indicated no pressure ulcers, no other skin problems, and no malnutrition or risk for malnutrition. The care plan identified risk for skin breakdown and nutritional risk but did not include specific interventions related to the knee immobilizer or to the coccyx and spinal skin issues noted on admission. Subsequent Braden and advanced skin checks at various dates documented normal skin findings and, on at least two occasions, incorrectly indicated that the resident did not have an external device, despite the presence of the immobilizer. Throughout October and early November, the TAR carried the order for the immobilizer to be in place at all times, with removal allowed for bathing and skin checks, and nurses consistently initialed that the order was carried out. Multiple nurses and NAs reported that they either did not fully remove the immobilizer or could not recall doing so, and some stated they believed the order did not require full removal except for baths. One nurse later acknowledged seeing redness and indentations from the brace on the lower leg or back of the thigh on at least two days but did not document or report these findings, considering them not significant. Another staff member documented that the splint was removed and inspected and that no concerning changes were seen, while other staff described only partially opening the brace or being able to see the skin “fine” without fully removing it. On a follow-up visit, the orthopedic NP recommended that the resident be weight bearing as tolerated with the immobilizer and to continue the immobilizer when sitting and lying, with PT allowed to remove it for range of motion up to 60 degrees of flexion. Later, an NA providing a bed bath observed yellow drainage on the bed sheet and, upon opening the immobilizer and lifting the leg, found an open, dark-colored wound on the back of the left lower leg at the point where the immobilizer ended, with indentations all over the leg from the brace. The nurse who assessed the wound documented it as a new, in-house acquired pressure ulcer and initially mis-located it on the front lateral lower leg due to confusion with directions. The wound was described by staff as open, with red and yellow tissue and “yellowy-red” drainage, and another nurse noted that the immobilizer remained in place and was pushing into the wound. The facility contacted the orthopedic NP days later to ask about removing the immobilizer; the NP gave a verbal order to remove it and requested to see the resident the same day, but the visit was delayed due to transportation issues, and interviews indicated the immobilizer was not actually removed until several days after the verbal order, during which time it potentially continued to exert pressure on the ulcer.
Improper Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food storage and sanitation practices in the facility’s kitchen. During an initial kitchen tour with the Dietary Manager, a large bin of flour was observed with the scoop stored directly inside the flour, rather than in a manner that prevented contact with the food product. The Dietary Manager explained that the hook intended for hanging the scoop was inside the container and that when the lid was slid closed, it often knocked the scoop back into the flour. No residents or their specific medical conditions were mentioned in relation to this observation. Further observations showed additional sanitation issues. The underside of the steam table hood was found to have orange and brown residue and felt slick to the touch, and the Dietary Manager acknowledged that while the steam table was cleaned between meals, the underside of the hood had likely not been cleaned for some time. On a follow-up kitchen tour, surveyors observed that 20 of 30 plastic plate bases on the tray line were stacked while still wet and ready for use. The Dietary Manager stated she had checked other dishware for dryness but had not checked the plastic plate bases. The Administrator later stated he did not know why the hood was not clean or why the scoop was left in the flour and indicated he would want the kitchen kept clean and dishware clean and dry before use.
Failure to Assess and Authorize Resident Self-Administration of Nasal Spray Kept at Bedside
Penalty
Summary
The facility failed to assess and authorize a cognitively intact resident’s ability to self-administer a prescribed steroid nasal spray that was kept at bedside. The resident had a physician’s order for fluticasone propionate nasal suspension, 50 micrograms, two sprays in both nostrils twice daily for allergies. The quarterly MDS documented that the resident was cognitively intact, and the DON and Medical Director both acknowledged the resident had the potential or ability to self-administer medication. However, the resident’s care plan contained no goals or interventions related to self-administration of medications, and the medical record did not contain any assessment for self-administration or an order permitting the resident to keep the nasal spray at bedside. Surveyors observed the resident’s prescribed nasal spray on the overbed table on multiple occasions over two consecutive days, and the resident stated that a nurse had left it in the room and that she knew she should not have it there, but it made it easier to use when needed. A nurse assigned to the resident stated she was unsure of the process for residents who self-administer medications, believed no residents on that hall self-administered, and said she would remove any medication found in a resident’s room, yet she had not noticed the nasal spray earlier that day when administering medications. During an interview and concurrent room observation, this nurse then discovered the nasal spray on the overbed table behind a tissue box and removed it. The DON and Administrator both described a facility process requiring an assessment, an order, a lock box, and care plan interventions for self-administration, and both stated they were not aware of residents on that hall self-administering medications, confirming that these required steps had not been completed for this resident despite the medication being left at bedside.
Inaccurate MDS Skin Assessment for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to complete an accurate MDS assessment regarding skin conditions for one resident. The resident was admitted with diagnoses including a left patella fracture, A-fib, CHF, hypothyroidism, and Alzheimer’s disease. On admission, a nurse documented a dark spot on the coccyx, an open area on the spine, and redness to the left knee. The resident’s care plan, initiated the day after admission, identified her as being at risk for skin breakdown and included general preventive skin care interventions such as patting the skin dry, observing for signs of breakdown, using barrier creams, and checking the skin weekly by a licensed nurse. Despite these documented skin findings and risk factors, the admission MDS indicated that the resident was severely cognitively impaired and required extensive assistance with ADLs but did not accurately reflect her existing skin issues. The MDS stated that the resident did not have a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing or device, and under other ulcers, wounds, and skin problems, it indicated none were present. The MDS also did not indicate the need for a pressure-relieving device in the chair, participation in a reposition/turning program, or inclusion in a nutrition and hydration program for skin, resulting in an inaccurate assessment of the resident’s skin condition and related care needs.
Unsecured Bedside Medications Left With Resident Despite No Self-Administration Order
Penalty
Summary
The deficiency involves the facility’s failure to secure medications and prevent unauthorized self-administration for a resident who had explicit physician orders prohibiting self-administration. The resident was admitted on a specified date and had a physician’s order dated 6/25/2025 stating that he may not administer his own medications, as well as an order for staff to monitor his swallowing during medication passes and document any coughing, pain, or difficulty swallowing. During an observation on 2/24/2026 at 2:50 PM, surveyors found a medication cup containing seven pills on the resident’s bedside table while the assigned nurse was no longer passing medications on the hallway. The resident stated he would take the medications in the cup when they let him out of the facility. At 2:55 PM the same day, the assigned nurse confirmed that the cup contained the resident’s lunch medications, which she had given him at approximately 1:30 PM, and acknowledged that he usually took them when handed to him. When the nurse asked the resident to take the medications, he refused, repeating that he would take them when he got up out of there, and did not take them at that time. The nurse then removed the medication cup and later stated she had trusted the resident would take the medications and recognized this as a lapse in judgment, acknowledging she knew he was not to have medications left at the bedside and that she was required to monitor and document his swallowing. The physician later stated he did not recall the no self-administration order but agreed that if such an order existed, the resident probably should not self-administer, and he expected staff to follow physician orders. The DON confirmed that only one resident in the facility had an order to self-administer medications and that all others, including this resident, had orders that they may not self-administer medications.
Failure to Maintain Clean Trash Compactor Area
Penalty
Summary
Surveyors observed that the facility failed to keep the area around the trash compactor free of accumulated trash and debris. During an observation of the dumpster area with the Dietary Manager, the trash compactor was seen in a fenced area behind the kitchen entrance, with a cement platform in front and grassy areas to the left and back. In the grassy area on the left side of the compactor, surveyors noted four plastic bottles, six disposable cups, four disposable gloves, and seven straws that had not been removed. The Dietary Manager reported that a member of the kitchen staff cleaned only the cement platform on a weekly basis and confirmed that the trash and debris on the left side and back of the trash compactor were not being picked up. The Dietary Manager stated she did not know why those areas were not attended to and noted that all departments in the facility used the same trash compactor. In a separate interview, the Administrator stated he did not know why the trash compactor area had not been cleaned and indicated he would want the area free of debris.
Failure to Prevent Repeated Resident-to-Resident Physical Abuse Despite Known Behavioral Risks
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse, specifically resident-to-resident altercations involving one resident with dementia and behavioral symptoms. This resident had diagnoses including dementia, psychotic and mood disturbances, and anxiety, and was assessed as severely cognitively impaired with no physical limitations. His care plan, revised multiple times, documented a history and risk of physical behaviors toward others, including prior resident-to-resident incidents. Despite this, his MDS assessments did not reflect behaviors directed toward others during the lookback periods, and the care plan interventions relied on staff recognizing triggers, observing for non-verbal signs of aggression, and removing or diverting the resident as needed. On one occasion, an altercation occurred between this resident and another cognitively impaired resident with dementia and depressive disorder. The second resident’s care plan documented physical behaviors such as grabbing, pushing, and aggression, as well as verbal behaviors including threatening, cursing, agitation, and delusions. Staff accounts and the facility’s investigation showed that the first resident reported finding the second resident in his room going through his belongings, after which an unwitnessed altercation occurred in the room. Shortly afterward, in front of the nursing station, staff observed the first resident, visibly upset and speaking in broken English, approach the second resident and strike him in the face with an open hand. Staff present at the nursing station were unable to separate the residents quickly enough to prevent the slap. In a separate incident, the same resident with dementia shared a room with another resident who was cognitively intact but had psychiatric diagnoses including schizoaffective disorder, major depressive disorder, bipolar disorder, PTSD, and a history of hallucinations. This roommate’s care plan noted fluctuating mood, agitation, and anxiety, with interventions focused on redirection and observation for worsening psychiatric symptoms. Staff reported that the two roommates had argued over television volume earlier in the day, with a nursing assistant notifying a nurse about the dispute. Later, a nurse responding to the resident with dementia observed the shared room in disarray and found the cognitively intact roommate with blood on his forehead. The injured resident stated he had been struck on the head with a reaching device by his roommate, and continued to complain about the television volume. The actual assault was not witnessed by staff. Another incident involved the same aggressive resident and a severely cognitively impaired resident with vascular dementia, insomnia, and anxiety, who was known to wander, enter other residents’ rooms, and show poor awareness of personal space. This resident’s care plan included interventions such as gently guiding him from environments and diverting him with alternative activities. On the date of the incident, the aggressive resident was under 1:1 supervision near the nursing station. Witnesses, including a nurse and the nursing assistant assigned to 1:1, reported that the wandering resident approached and leaned in close to the supervised resident while speaking. Within seconds, the supervised resident stood or reached up and struck the approaching resident across the face with an open hand. The nursing assistant providing 1:1 supervision stated she was within arm’s reach but did not anticipate an altercation and was unable to intervene in time. Interviews with nursing assistants assigned to provide 1:1 supervision revealed they were not informed of the specific reasons for the supervision or of the resident’s known triggers for aggression, such as others touching his belongings or entering his personal space. One assistant reported only being told to notify a nurse if the resident became upset, and another stated she had not received instructions about triggers or what to avoid. The DON acknowledged being unaware whether NAs assigned to 1:1 supervision were educated about the resident’s triggers, while the ADON stated that staff were supposed to be told triggers but could not recall any formal in-service specific to this resident’s aggression. These gaps in communication and implementation of individualized interventions contributed to repeated resident-to-resident physical abuse incidents involving the same resident, including one that occurred while he was on 1:1 supervision.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a cognitively impaired male resident was not protected from sexual abuse by another cognitively impaired male resident. The incident took place in a shared room within the memory care unit, where a nurse aide overheard unusual laughter from one resident and, upon entering the room, observed one resident lying in bed with his penis exposed while the other resident was standing beside the bed, grasping and moving the exposed penis in an up and down motion. Both residents were severely cognitively impaired and lacked the capacity to consent to sexual activity. The nurse aide immediately intervened by instructing the resident to stop and separated the two individuals. Prior to the incident, neither resident had a documented history of sexually inappropriate behaviors. Both residents had care plans that addressed other behavioral symptoms such as wandering, disrobing in public, and physical or verbal behaviors, but there were no interventions or monitoring in place for sexually inappropriate conduct. The residents were both independent with eating, bed mobility, and transfers, but required staff assistance for other activities of daily living. One resident was being treated for a urinary tract infection and had been observed pulling at his groin area earlier that morning, but this behavior had not previously been associated with sexual activity. The facility's staff, including the nurse aide, nurse, unit manager, DON, and administrator, confirmed that neither resident had previously exhibited inappropriate sexual behaviors. The incident was witnessed directly by the nurse aide, and subsequent interviews with staff and responsible parties indicated that the event was unexpected and not anticipated based on the residents' prior behavior or care plans. The lack of identification and intervention for potential sexually inappropriate behaviors in the care planning process contributed to the failure to protect the resident from abuse.
Removal Plan
- Both residents were separated and placed on one-to-one supervision by facility staff.
- Staff that witnessed the event were interviewed by the Nurse Supervisor and statements were obtained.
- The Nurse Supervisor interviewed both residents regarding the occurrence.
- Resident #2 was moved to a different room.
- Responsible Parties for both residents were notified by the licensed nurse.
- The Medical Director and Nurse Practitioner were notified of the occurrence.
- The local Police Department was notified by the Nurse Supervisor.
- Licensed Nurse conducted skin assessments on both residents.
- An initial report was sent to the North Carolina Department of Health and Human Services.
- Adult Protective Services was notified of the allegation of resident abuse.
- Psychiatric services was notified for Resident #1; a telehealth and follow-up in-person visit were conducted.
- Medication changes were recommended and implemented for Resident #1 (increased Depakote, Hydroxyzine as needed).
- Resident #2’s Zoloft was increased to decrease libido.
- A chart review was completed for both residents by the Director of Nursing.
- Skin assessments were completed on all non-alert/oriented residents by licensed nursing staff.
- Social Worker Director and Assistant Social Worker interviewed all alert and oriented residents regarding resident abuse.
- Residents with roommates were interviewed to ensure roommate compatibility.
- Medical record audit of all residents was completed to identify residents with behaviors and review for sexual behaviors.
- Residents identified as having behaviors are reviewed in clinical morning meetings to ensure appropriate interventions are in place.
- Interventions for residents with behaviors include medication regimen review, one-to-one supervision, psychiatric consultation/visit, physician notification and assessment, and roommate compatibility.
- Education was provided to all facility staff (including agency staff) on the abuse policy with emphasis on sexual behaviors, management of symptoms, and ensuring resident safety by reporting, identifying, preventing, and managing behavioral symptoms.
- Any staff not receiving abuse education will not be allowed to work before receiving education.
- All newly hired staff, including new agency staff, will be educated on the facility's abuse prohibition policy in new hire orientation.
- The Director of Nursing and Nurse Practice Educator are tracking abuse education to ensure no staff works prior to receiving education.
Failure to Obtain Physician's Order for Self-Administration of Medications
Penalty
Summary
The facility failed to assess and obtain a physician's order for the self-administration of medications for a resident diagnosed with chronic obstructive pulmonary disease, diabetes type 2, and hypertension. The resident was cognitively intact and displayed no behaviors or rejection of care according to a quarterly Minimum Data Set assessment. However, a review of the resident's medical record did not reveal an order to self-administer medications. During an observation, medications were found in a medication cup on the resident's over the bed table, which the resident stated had been left there since breakfast. The resident did not indicate an intention to take the medications. An interview with a nurse revealed that she had left the morning medications on the over the bed table for the resident to take, assuming the resident would do so. When the nurse returned, the resident stated he did not want to take them at that time, leading the nurse to retrieve the medications and mark them as refused on the Medication Administration Record. The Director of Nursing confirmed that medications should not be left unsecured at the bedside unless there is an order for self-administration, which the resident did not have.
Breach of Resident Mail Privacy
Penalty
Summary
The facility failed to ensure that residents had reasonable access to and privacy in their use of communication methods, specifically regarding the delivery of mail. Three residents, all cognitively intact, reported receiving mail that had been opened prior to their receipt. These residents were unable to provide specific dates but indicated that the opened mail was related to their financial status. The Activity Director confirmed that mail was sometimes delivered taped closed, indicating it had been opened previously. The Business Office Manager admitted to opening all mail without checking the addressee, especially if the mail was related to financial matters. She stated that she opened mail for residents with impaired cognition but acknowledged that she should not open mail for cognitively intact residents. The Administrator was unaware of this practice and confirmed that mail should only be opened if addressed to the facility or if the resident was cognitively impaired. The improper handling of mail led to a breach of privacy for the residents involved.
Failure to Administer Water Flushes at Prescribed Rate
Penalty
Summary
The facility failed to administer water flushes via a feeding tube at the physician-ordered flow rate for a resident with a feeding tube. Resident #22, who was admitted with diagnoses including dysphagia and the presence of a feeding tube, was observed to have her feeding tube connected to a continuous bottle of formula with a standby bag of water. The physician's order specified that the feeding tube should be flushed with 110 milliliters of water every 3 hours during continuous feedings. However, observations revealed that the water flush was set to run every 4 hours instead of the prescribed 3-hour interval. During an observation with Nurse #1, it was confirmed that the water flush settings were incorrect, with the frequency set at every 4 hours instead of the ordered 3 hours. Nurse #1 acknowledged the discrepancy after reviewing the physician orders but was unable to explain why the settings differed from the physician's order. The Director of Nursing later stated that she expected water flushes to be administered at the prescribed rate, indicating a failure in adhering to the physician's orders for Resident #22's care.
Failure to Adhere to Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to adhere to a physician's order regarding the administration of Midodrine, a blood pressure medication, for a resident diagnosed with low blood pressure. The order specified that the medication should only be administered if the resident's systolic blood pressure (SBP) was less than 120. However, a review of the Medication Administration Records (MARs) for October and November 2024 revealed that the resident received the medication on multiple occasions when the SBP was above 120. Specific instances included SBP readings of 122, 124, and even as high as 134, yet the medication was still administered. Interviews with nursing staff indicated that the failure to hold the medication as per the physician's order was an oversight. Nurse #5, who was responsible for administering the medication on several dates, acknowledged the error upon reviewing the MARs. Similarly, Nurse #3 also recognized the oversight during their interview. Attempts to contact other nurses involved were unsuccessful. The Director of Nursing and the Medical Director both expressed that they expected the medication to be administered according to the physician's orders, although the Medical Director noted that the deviation did not result in serious harm to the resident.
Failure to Maintain Resident Dignity by Not Emptying Urinals Timely
Penalty
Summary
The facility failed to maintain the dignity of a resident by not ensuring urinals were emptied in a timely manner, particularly before meals. Resident #41, who was moderately cognitively impaired and required assistance with toileting, was observed with urinals containing urine on his nightstand on multiple occasions. Despite expressing his desire for the urinals to be emptied more frequently, especially before meals, the staff did not consistently fulfill this request. Observations revealed that the urinals remained unemptied for extended periods, even when meals were served, which the resident found unsanitary. Interviews with nursing assistants and the Director of Nursing (DON) highlighted a lack of adherence to the expected practice of emptying urinals before meals and as needed. Nursing assistants either failed to notice the urinals or did not respond to inquiries about their last emptying. The DON acknowledged the expectation for staff to ensure urinals were emptied regularly and before meals, but this was not consistently practiced, leading to the deficiency in maintaining the resident's dignity.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents or their responsible parties (RPs) regarding hospital transfers, as required by regulations. This deficiency was identified for four residents who were transferred to the hospital on multiple occasions without receiving the necessary written notices. The facility's practice involved sending a copy of the face sheet, physician orders, medication list, DNR information, and bed hold policy with the resident during transfers, but did not include a written notice of the transfer to the resident or RP. Resident #22, who had severely impaired cognition, was transferred to the hospital twice without written notification being provided to her RP. Similarly, Resident #58, who was cognitively intact, was transferred twice without receiving the required written notices. Resident #111, with moderately impaired cognition, experienced three hospital transfers without written notification to the RP. Lastly, Resident #132, who was cognitively intact, called 911 himself for a hospital transfer, and although his POA and hospice were notified, no written notice was provided. Interviews with staff, including Nurse #2 and the DON, revealed a lack of awareness regarding the requirement for written notifications. The DON confirmed that phone notifications were made to RPs, but written notices were not sent. The Administrator was also unaware of this oversight and expected the regulation to be followed, indicating a systemic issue in the facility's transfer notification process.
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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