The Greens At Hendersonville
Inspection history, citations, penalties and survey trends for this long-term care facility in Hendersonville, North Carolina.
- Location
- 1870 Pisgah Drive, Hendersonville, North Carolina 28791
- CMS Provider Number
- 345312
- Inspections on file
- 28
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at The Greens At Hendersonville during CMS and state inspections, most recent first.
Two residents had their MDS assessments inaccurately coded to reflect physician-prescribed weight loss regimens, despite no such orders being present. In both cases, staff responsible for completing the MDS did not verify the intent of weight changes or medication use with the RD or MDS Nurse, resulting in incorrect documentation of weight loss interventions.
The facility did not submit required Level II PASRR evaluations for three residents after new serious mental health diagnoses were identified, despite prior Level I determinations and clear indications for further screening. In each case, new psychiatric conditions such as delusional disorder and bipolar disorder were diagnosed, but no Level II PASRR requests were made due to lapses in communication and lack of a notification process between staff.
A resident with severe cognitive impairment was found with socks and rubber bands on their hands, causing swelling and blisters. The intervention was not documented or approved, and staff failed to question or remove the restraints over several days. The facility's policies on abuse and restraint were not followed, resulting in the resident's injuries.
A resident with Alzheimer's, dementia, and multiple sclerosis was found with socks and rubber bands on her hands, forming tourniquets, in a LTC facility. Despite visible injuries, multiple staff members failed to report the restraint, assuming it was a standard intervention. This oversight led to significant harm, revealing a breakdown in the facility's abuse and restraint policies.
A resident was found with socks and rubber bands tightly wrapped around her wrists, causing swelling and blisters. The initial report submitted by the DON inaccurately stated no apparent harm, as it was based on preliminary information. The report was submitted on time but lacked details about the injuries, which were to be included in a later investigation report.
The facility failed to maintain cleanliness and proper storage in its kitchen and nourishment areas. An opened soda bottle was improperly stored with resident food, and the milk cooler and ice machine were found unclean. The nourishment room refrigerator contained an undated opened nutritional supplement. The District Dietary Manager noted the absence of a cleaning checklist, and the Maintenance Director was unaware of the ice machine's condition.
A resident with dementia and diabetes continued to receive a higher dose of Trazadone despite a consultant pharmacist's recommendation for a Gradual Dose Reduction (GDR) and agreement from the NP. The order was not entered into the resident's chart due to oversight by the Unit Manager and confusion from a change in providers.
A resident with right-side paralysis and a healing fracture, who was 72 inches tall, experienced discomfort due to his feet pressing against the footboard when the bed was elevated. Despite reporting the issue to staff, no bed extender was provided. Observations and staff interviews confirmed the problem, but the maintenance department was not informed, although extenders were available. The DON and administrator acknowledged the oversight.
A resident with severe cognitive impairment was observed with a wheelchair armrest secured by tape, indicating a need for repair. Staff interviews revealed a communication breakdown, as the nurse aide did not notice the issue, and neither the Maintenance Director nor the Nurse Supervisor were informed. The DON and Administrator acknowledged that the repair should have been reported.
The facility failed to ensure air mattress settings matched the current weight of two residents, leading to a deficiency in pressure ulcer care. One resident's mattress was set at 182 pounds instead of 148.4 pounds, and another's was set at 252 pounds instead of 95.5 pounds. Nurses did not verify the settings despite initialing the MAR to confirm accuracy, as confirmed by the DON.
A facility failed to follow its infection control policy for Enhanced Barrier Precautions (EBP) during high-contact care for a resident with an indwelling catheter and MRSA history. Two nurse aides did not wear gowns while assisting the resident, despite clear signage and available PPE. The aides acknowledged their oversight, and the DON confirmed the requirement for gowns during physical assistance.
A resident with hemiplegia and cognitive impairment fell during incontinence care when a nurse aide turned him away from her without side rails or additional assistance. The resident, who was holding onto a dresser, let go and fell, sustaining head and limb injuries. The aide had been trained to provide care alone, contrary to safer practices for residents with hemiplegia.
A resident with a history of COPD, heart failure, and anxiety disorder experienced an acute change in LOC, becoming lethargic and difficult to arouse. Despite multiple neuro checks indicating drowsiness and confusion, the resident remained at the facility until EMS was called, resulting in a significant delay in treatment. The resident was hospitalized for acute metabolic encephalopathy, respiratory failure, and other conditions. The nursing staff failed to notify the MD promptly, leading to the deficiency.
A resident with severe cognitive impairment experienced a decline in level of consciousness, but the nursing staff failed to notify the physician, resulting in delayed treatment for a possible opioid overdose. Despite observing the resident's deteriorating condition throughout the day, the staff only called EMS late in the afternoon.
The facility failed to report an allegation of neglect within the required 2-hour timeframe after a resident was hospitalized for a suspected opioid overdose. The resident, who was not prescribed opioids, tested positive for opiates and received naloxone. The facility became aware of the neglect allegation on 4/3/24 at 11:45 AM but delayed reporting it to the state agency.
The facility failed to verify the competency and skills of an agency nurse before she provided care to residents. The nurse worked her first shift without prior verification of her competency, due to an emergency staffing situation and the recent loss of the Scheduler responsible for setting up employee files. The facility did not confirm with the staffing agency that the nurse's skills had been checked.
Inaccurate MDS Coding for Weight Loss Regimens
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments regarding weight loss for two residents. For one resident with a diagnosis of malnutrition and a care plan addressing nutritional concerns, the quarterly MDS assessment was incorrectly coded to indicate the resident was on a physician-prescribed weight loss regimen. However, there were no physician orders for weight loss, and both the Registered Dietitian (RD) and MDS Nurse confirmed that the resident was not intended to lose weight nor prescribed any weight loss medication. The Dietary Technician, who completed Section K of the MDS, did not communicate this coding with the RD or MDS Nurse, leading to the inaccurate documentation. Another resident, with diagnoses including dementia, chronic kidney disease, and diabetes, experienced significant weight loss while receiving a diuretic medication as prescribed by a physician. The resident's MDS assessment was also coded as being on a physician-prescribed weight loss regimen, despite the absence of any such order. The RD and MDS Nurse clarified that diuretic use for fluid management should not be coded as a weight loss regimen unless specifically prescribed for that purpose. The Dietary Technician appeared to have misunderstood the intent of the medication and did not verify the coding with the RD or MDS Nurse. Interviews with facility staff, including the RD, MDS Nurse, and Administrator, revealed a lack of communication and verification regarding the coding of weight loss regimens on the MDS assessments. The Administrator stated that accurate coding is expected and that the Dietary Technician should have consulted with the RD and MDS Nurse when coding weight loss as physician-prescribed. The absence of such communication contributed to the inaccurate MDS documentation for both residents.
Failure to Submit Level II PASRR Evaluations After New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit requests for Level II Preadmission Screening and Resident Review (PASRR) evaluations for three residents after new serious mental disorder diagnoses were identified, despite previous Level I PASRR determinations. For one resident, the medical record showed a Level I PASRR determination with instructions that further screening was only required if a significant change occurred. The resident was later diagnosed with generalized anxiety disorder, delusional disorder, and hallucinations, but no Level II PASRR request was submitted. The social worker acknowledged awareness of the requirement but could not provide a reason for the omission. Another resident had a Level I PASRR determination and was admitted with unspecified psychosis and anxiety disorder. The resident later exhibited increased agitation and aggression, leading to the addition of a delusional disorder diagnosis and the initiation of antipsychotic medication. Despite these changes, there was no documentation of a Level II PASRR request following the new diagnosis. The social worker confirmed responsibility for submitting such requests and noted the absence of a process to notify her of new mental health diagnoses, resulting in delays. A third resident had a Level I PASRR completed prior to admission, with recommendations to resubmit for Level II if a new mental health diagnosis was suspected. The resident was later diagnosed with bipolar disorder, but no Level II PASRR request was documented. Interviews revealed that while the MDS nurse was supposed to notify the social worker of new diagnoses, there was no consistent system in place to ensure this communication, contributing to the failure to submit timely PASRR requests.
Resident Found with Unauthorized Restraints Leading to Injury
Penalty
Summary
The facility failed to protect a vulnerable resident's right to be free from physical restraints when a resident was found with socks placed on each hand, secured by rubber bands wrapped around each wrist. This incident involved a resident with severe cognitive impairment due to Alzheimer's disease, dementia, and multiple sclerosis, who required total staff assistance for all self-care tasks. The resident was observed with swollen hands, blisters, and red ligature marks on the wrists, indicating the use of restraints without medical justification or physician orders. The resident's care plan did not include any intervention involving the application of socks or rubber bands to the hands, and there were no physician orders for such restraints. Staff interviews revealed that the socks and rubber bands were likely applied to prevent the resident from engaging in coprophagy, a behavior noted in the care plan. However, this intervention was not documented or approved, and staff members were unsure who applied the restraints or how long they had been in place. Multiple staff members, including nurses and nurse aides, observed the resident with socks and rubber bands on the hands over several days but did not question or remove them, assuming it was a standard intervention. The facility's Director of Nursing and Administrator were informed of the incident, and an investigation was initiated. The use of socks and rubber bands as restraints was not an approved practice, and the facility's policies on abuse and restraint were not followed, leading to the resident's injuries.
Failure to Report and Address Inappropriate Restraint Use
Penalty
Summary
The facility failed to implement its abuse policy and procedure when nursing staff did not identify and immediately report the use of a physical restraint on a resident. The resident, who had Alzheimer's disease, dementia, and multiple sclerosis, was found with socks placed on her hands, secured by rubber bands wrapped around each wrist, effectively forming tourniquets. This restraint was not medically necessary, and there was no assessment for its need. The incident was observed by multiple staff members over several days, but none reported it to the Administrator or Director of Nursing Services as required by the facility's policy. The resident's condition deteriorated due to the restraint, with her right hand becoming edematous and bright red, and several blisters forming on the top and palm of the hand. The rubber bands had to be cut to remove the socks, and a wound nurse practitioner evaluated the resident, noting a large fluid-filled blister on the palm of her right hand. Despite the visible signs of injury and the facility's policy against restraints, staff members, including nurse aides and nurses, failed to question or report the use of the socks and rubber bands, assuming it was a standard intervention to prevent the resident from playing with her feces. Interviews with staff revealed a lack of communication and understanding of the facility's abuse and restraint policies. Several staff members admitted to seeing the socks and rubber bands on the resident's hands but did not report it, either because they assumed it was an approved intervention or because they were following the lead of more experienced staff. This failure to report and address the inappropriate use of restraints resulted in significant harm to the resident, highlighting a breakdown in the facility's procedures for preventing abuse and neglect.
Removal Plan
- Resident #1 was observed with a sock on both hands and rubber bindings had been placed around each wrist to hold the socks in place. This intervention caused swelling, redness, and a blister on resident #1's right hand and redness and swelling on the left hand. The facility failed to comply with the abuse policy when staff members were aware of the socks and/or rubber bindings and failed to report this form of restraint to facility administration. Because of the failure to report, the facility did not protect a resident with severe cognitive impairment from abuse through unnecessary restraints.
- Staff members who admitted to knowledge of the socks and/or rubber bindings being on resident #1's hands and failing to report, were suspended pending investigation by the Director of Nursing (DON). Staff interviews attest that staff members began seeing the socks and/or rubber binding.
- 1:1 education was provided verbally by DON to staff who reported knowledge of socks and/or rubber binding on resident #1's hands regarding abuse policy, restraint policy and the requirement to report suspected or actual abuse to the administrator or DON.
- Immediately following identification of concerns, DON initiated investigation. Investigation is ongoing by Administrator, DON, and Assistant Director of Nursing (ADON) and Unit Managers.
- All perpetrators who were aware of the use of socks and/or bindings on resident #1's hands, failed to report, and failed to remove the coverings and/or bindings are being terminated.
- In an ad hoc Quality Assurance Process Improvement (QAPI) meeting, the abuse and reporting policy was reviewed by the administrator to ensure no changes were needed. In attendance at this meeting were the DON, ADON, and Unit Managers. It was determined that no changes were needed.
- The DON completed interviews with all residents having a Brief Interview for Mental Status (BIMS) of 10 or greater to ensure that they had not experienced any abuse that had not been reported. There were no new findings. Hard copies of these interviews reside in the facility.
- The DON completed skin assessment with all residents having a BIMS of 9 or less to ensure there was no visual indication of abuse that had not been reported. There were no new findings. Hard copies of these interviews reside in the facility.
- DON and Administrator completed interviews with all staff working over the last 5 days. These staff members were interviewed to determine if they were aware of any other incidents of using interventions that restrict movement or abuse that had not been reported. There were no new findings. Hard copies of these interviews reside in the facility.
- The Administrator reviewed all grievances and facility reported incidents for the last 30 days to ensure that there were no examples of a failure to report incidents as required by facility abuse and reporting policy. There were no new findings.
- The DON/Designee conducted all staff education in person and/or by telephone on the facility abuse and restraint-free policy to include a zero-tolerance for any type of resident abuse or failure to report an incident or suspected incident of abuse. Education also included that all residents have the right to be free from harm, including unnecessary or excessive physical restraint, including applying socks and bindings to hands to hinder manifestations of behaviors or for resident safety. Education focused not only on the requirement to report any unusual devices that could restrict movement, but to have open communication with the Administrator, DON, ADON, and Unit Managers about the resident population, asking questions or inquiring about any treatment or intervention that is new, uncommon, or suspected as possible abuse or a restraint. Newly hired or contracted staff will be educated prior to accepting an assignment and caring for residents. No staff will provide resident care without completing education. DON and ADON will be responsible for tracking education for all staff including new hires and contract staff. The administrator notified DON and ADON of these responsibilities.
- DON or designee educated all staff in person and/or by telephone to proper notification and appropriate intervention for unsafe or other unusual behaviors. Newly hired or contracted staff will be educated prior to accepting an assignment and caring for residents. No staff will provide resident care without completing education. DON and ADON will be responsible for tracking education for all staff including new hires and contract staff. The administrator notified DON and ADON of these responsibilities.
- During an ad hoc QAPI meeting, a root cause analysis was completed, and the root cause was identified as the need for additional staff education on the requirement to report unusual behavior or concerns about any intervention that restricts movement when visualized, as well as the requirement to report any incident or suspected incident of abuse immediately to the Administrator or DON. The decision was made to complete the following audits to maintain compliance with the plan of correction: DON/designee will interview 5 staff members weekly (on alternating shifts) for 8 weeks to identify any concerns for use of restraints, improper behavior management techniques, or abuse to ensure that reporting has occurred if present.
- DON/designee will review the 24-hour report (that includes Sbars) 5 x weekly for 8 weeks to identify any concerns for use of restraints, improper behavior management techniques, or abuse to ensure that reporting has occurred if present.
- DON/designee will make a walking round 5 x weekly for 8 weeks to identify any concerns for use of restraints, improper behavior management techniques, or abuse to ensure that reporting has occurred if present.
- The facility administrator will review findings of audits to identify patterns or trends and will present audits to QAPI for 2 months, adjusting the plan as needed to maintain compliance.
Inaccurate Initial Report on Resident Injury
Penalty
Summary
The facility failed to submit an accurate initial report to the State Agency regarding an incident involving a resident who was found with socks on her hands and rubber bands tightly wrapped around her wrists. This resulted in significant swelling and blistering of the resident's hands. The initial report, completed by the Director of Nursing (DON), inaccurately stated that there was no apparent harm to the resident, as the DON had not yet observed the resident's injuries firsthand and relied solely on the information provided by Nurse #1. The report was submitted within the required two-hour timeframe, but it lacked critical details about the extent of the resident's injuries. Photographic evidence and staff interviews revealed that the resident's hands were swollen and had developed fluid-filled blisters due to the tight binding. The DON was informed of the incident shortly after it occurred and initiated an investigation, but the initial report did not reflect the severity of the injuries. The Regional Director of Operations acknowledged that the DON prioritized timely submission over accuracy, intending to include the full extent of the injuries in a subsequent 5-day investigation report.
Deficiencies in Kitchen and Nourishment Area Cleanliness and Storage
Penalty
Summary
The facility failed to properly store and maintain cleanliness in its kitchen and nourishment areas, as observed by surveyors. An opened soda bottle belonging to a staff member was found in a refrigerator meant for resident food storage, indicating improper storage practices. Additionally, the milk cooler contained baking sheets with a dried white and fuzzy greenish to brownish substance, suggesting inadequate cleaning. The ice machine's plastic shield was unclean, with an orange/pink substance touching the ice, and the floor drain cover had a thick layer of slimy white and pinkish/red substance. Furthermore, the storage rack for baking sheets had a thick buildup of a yellow, waxy substance. The nourishment room refrigerator contained an opened nutritional supplement without an open date, which was placed by a nurse after the refrigerator had been checked for opened and expired items. The District Dietary Manager, who had recently taken over, acknowledged the lack of a cleaning sheet for staff to sign off on completed tasks and mentioned that the previous manager did not implement such a system. The Maintenance Director stated that the ice machine was cleaned monthly and as needed, but was unaware of the current state of the kitchen ice machine. The Administrator confirmed that dirty areas should be cleaned regularly and that items in the nourishment room refrigerator should be dated and disposed of when expired.
Failure to Implement Gradual Dose Reduction for Antidepressant
Penalty
Summary
The facility failed to follow up on a consultant pharmacist's recommendation for a Gradual Dose Reduction (GDR) of Trazadone for a resident with dementia and diabetes mellitus. The resident was admitted with severe cognitive impairment and was receiving an antidepressant. The consultant pharmacist recommended a GDR from Trazadone 50 mg to 25 mg, which was agreed upon by the Nurse Practitioner (NP) and signed on two occasions, but the order was not entered into the resident's chart in September 2024. Consequently, the resident continued to receive the higher dose until late October 2024. Interviews with the Consultant Pharmacist, NP, Unit Manager, Director of Nursing (DON), and Administrator revealed a breakdown in communication and responsibility. The Consultant Pharmacist provided recommendations to the DON, who then passed them to the providers. The NP, new to the facility, was unaware that the order was not entered after signing it. The Unit Manager admitted to overlooking the recommendation and failing to enter the order. The DON acknowledged confusion due to a change in providers, which contributed to the oversight.
Failure to Provide Bed Extender for Tall Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident who was 72 inches tall and required a bed extender to prevent his feet from pressing against the footboard. The resident, who was cognitively intact but dependent on staff for bed mobility due to right-side paralysis and a healing left fibula fracture, reported discomfort from his feet being pushed against the footboard when the head of the bed was elevated. Despite expressing his discomfort to staff shortly after admission, no action was taken to provide a bed extender. Observations confirmed the resident's feet were pressed against the footboard, and interviews with the physical therapist, occupational therapist assistant, and nursing assistant revealed awareness of the issue but no communication to maintenance for a bed extender. The maintenance director stated he had not been notified of the need for a bed extender, although extenders were available. The director of nursing and the administrator acknowledged the oversight, indicating that the need for a bed extender should have been reported and addressed.
Failure to Maintain Wheelchair Armrest in Good Repair
Penalty
Summary
The facility failed to maintain the armrest of a resident's wheelchair in good repair, compromising the resident's right to a safe, clean, and homelike environment. The resident, who had severe cognitive impairment, was observed on multiple occasions with the left armrest of their wheelchair secured by four rows of purple tape. Despite the armrest material not being cracked, broken, or frayed, the use of tape indicated a need for repair that was not addressed. Interviews with staff revealed a breakdown in communication regarding the repair needs of the wheelchair. A nurse aide, who regularly assisted the resident, admitted to not noticing the condition of the armrest and therefore did not report it. The Maintenance Director and Nurse Supervisor both confirmed they had not been informed of the issue, and the Director of Nursing acknowledged that staff should have reported the need for repair. The Administrator also expressed an expectation that the staff should have notified the Maintenance Director to ensure timely repairs.
Failure to Ensure Correct Air Mattress Settings for Residents
Penalty
Summary
The facility failed to ensure that the air mattress settings matched the current weight of two residents, leading to a deficiency in pressure ulcer care. Resident #41, who was admitted with an unstageable pressure ulcer that had reopened, had an air mattress setting that was incorrectly set at 182 pounds, despite the resident's actual weight being 148.4 pounds. The nurse responsible for Resident #41 admitted to not checking the weight settings on the air mattress, even though she initialed the Medication Administration Record (MAR) indicating that the settings were correct. Similarly, Resident #37, who was at risk for developing pressure ulcers due to dementia and malnutrition, had an air mattress setting of 252 pounds, while the resident's actual weight was 95.5 pounds. The nurse assigned to Resident #37 also failed to verify the weight settings, despite initialing the MAR to confirm the settings were correct. Both instances were confirmed by the Director of Nursing, who acknowledged that the nurses should have visually checked the weight settings to ensure they matched the residents' current weights.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection control policy and procedures regarding Enhanced Barrier Precautions (EBP) during high-contact care activities for a resident with an indwelling catheter. The policy required staff to wear gloves and gowns during high-contact activities such as transferring, toileting, and medical device care. However, during observations, two nurse aides did not follow these procedures. Nurse Aide #2 and Nurse Aide #3 were observed assisting a resident with transferring from bed to a wheelchair without donning gowns, despite the EBP signage posted on the resident's door and the availability of personal protective equipment outside the room. The resident involved had an indwelling urinary catheter and a history of methicillin-resistant staphylococcus aureus (MRSA), necessitating the use of EBP. During interviews, both nurse aides acknowledged their failure to wear gowns during high-contact activities, citing reasons such as not noticing the signage or being unaware of the resident's EBP status. The Director of Nursing confirmed the requirement for gowns during physical assistance, and the Administrator noted that staff had been educated on EBP requirements, indicating that the nurse aides should have followed the posted instructions.
Unsafe Incontinence Care Leads to Resident Fall
Penalty
Summary
The facility failed to provide incontinence care in a safe manner for a resident with a history of stroke, hemiplegia, repeated falls, and aphasia. The resident was moderately cognitively impaired and required assistance with bed mobility. During incontinence care, a nurse aide used a bed pad to turn the resident away from her while changing the bed sheet. The resident, using his unaffected arm to hold onto a dresser, let go and fell face-first onto the floor, hitting his head on the dresser. This resulted in a bruise on the left side of his head, a skin tear on the left knee and elbow, and injuries to his right hand. The nurse aide had been trained by other staff that the resident required only one-person assistance for incontinence care and linen changes, and to roll him away from her, despite the absence of side rails or additional staff assistance. The nurse's note confirmed the fall occurred during care with a CNA present. The resident was sent to the hospital for evaluation, where he was found to have a forehead hematoma and facial laceration, which did not require sutures. The physician who assessed the resident after the fall did not believe the delay in hospital transfer caused harm.
Failure to Initiate Timely Medical Services for Resident with Acute Change in LOC
Penalty
Summary
The facility failed to initiate timely medical services for a resident experiencing an acute change in the level of consciousness (LOC). The resident, who had a history of chronic obstructive pulmonary disease (COPD), heart failure, and anxiety disorder, was noted to be lethargic and difficult to arouse starting at 8:30 AM. Despite multiple neuro checks indicating drowsiness and confusion, the resident remained at the facility until emergency medical services (EMS) were called at 5:47 PM, resulting in a significant delay in treatment. The resident was subsequently admitted to the hospital for acute metabolic encephalopathy, acute on chronic hypoxemic respiratory failure with hypoxia, possible aspiration pneumonia, and pulmonary hypertension, and remained hospitalized for ten days. The report details that the resident's care plan included monitoring for side effects of pain medication and reporting any complaints of pain or requests for treatment. However, the resident was not on any opioid medications according to the Medication Administration Record (MAR). On the day of the incident, the resident received multiple medications, including Levothyroxine, Lidocaine patch, Diltiazem, Pregabalin, Torsemide, Albuterol sulfate, Diclofenac Sodium gel, Acetaminophen, Saline nasal gel, Fluticasone-Umeclidin-valiant, and Clonazepam. Despite the resident's deteriorating condition, the nursing staff did not notify the medical doctor (MD) until much later in the day. Interviews with the nursing staff revealed that the resident's lethargy and decreased LOC were observed throughout the day, but the severity of the condition was not adequately communicated to the Unit Manager or the MD. The Director of Nursing (DON) acknowledged that the nurses should have notified the MD immediately upon noticing the resident's decreased LOC. The hospital's urine drug screen was positive for opiates, leading to the administration of naloxone, which temporarily improved the resident's condition. The facility had naloxone available but did not suspect an opioid overdose due to the absence of opioid prescriptions in the resident's MAR. The delay in recognizing the severity of the resident's condition and initiating appropriate medical intervention led to the deficiency noted in the report.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the physician of a change in a resident's level of consciousness, resulting in a delay in the treatment of a possible opioid overdose. Resident #1, who had diagnoses including COPD, heart failure, and anxiety disorder, was noted to have a severely impaired cognition. On 3/31/24, neuro checks revealed a decline in the resident's level of consciousness from being alert at 7:00 AM to drowsy and confused by 8:30 AM. Despite further deterioration observed in neuro checks from 9:30 AM to 4:30 PM, there was no documentation that the physician was notified of these changes. The resident was eventually transferred to the hospital after emergency medical services were called at 5:47 PM. Interviews with the nursing staff revealed that Nurse #1 and Nurse #2 were aware of the resident's sleepiness and altered mental status but did not notify the physician. Instead, they monitored the resident's vital signs, which were normal, and placed the resident at the nurse's station for observation. Unit Manager #2 was informed of the resident's condition only after 5:00 PM, leading to the eventual call to EMS. The Director of Nursing acknowledged that the nurses should have notified the physician earlier when the resident's level of consciousness first decreased.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to submit an initial report to the state agency within the required 2-hour timeframe after receiving an allegation of neglect that resulted in hospitalization for a suspected opioid overdose for a resident who was not prescribed opioids. The resident was admitted to the hospital for drowsiness, altered mentation, and appeared disoriented and weak. A urine drug screen revealed the resident was positive for opiates, and the hospital administered two doses of naloxone. The facility became aware of the neglect allegation on 4/3/24 at 11:45 AM but did not report it to the state agency until after this time. The Police Detective contacted the facility on 4/2/24 and served a subpoena for the resident's medical records, indicating a potential or possible negligence related to medication. The Administrator was notified of the subpoena after 4:30 PM on 4/2/24 and was informed that a second Police Detective would return the next morning to explain the details. On 4/3/24 at approximately 11:45 AM, the Police Detective reported the family's allegation of neglect related to medication, prompting the Administrator to call the Department of Social Services and send the initial report to the state agency. The Administrator considered the incident a possible medication error rather than a report of abuse or neglect.
Failure to Verify Competency of Agency Nurse
Penalty
Summary
The facility failed to verify or check the competency and skills of an agency nurse (Nurse #3) before she provided care and services to residents. The employee file for Nurse #3 only contained verification of an active and unencumbered license to practice in the state, but there was no documentation confirming that her skills or competencies were checked. Nurse #3 worked her first shift at the facility on 3/30/24 without prior verification of her competency by the facility. This lapse occurred despite the facility's contract with the staffing agency, which stipulated that the agency should ensure the competency of their staff before sending them to the facility. The Director of Nursing (DON) and Administrator acknowledged that the competency check was not performed due to an emergency staffing situation on a holiday and the recent loss of the Scheduler responsible for setting up employee files, including competency checks for agency staff. The Administrator confirmed that the newly hired Scheduler, who was still in training, would be tasked with setting up these records in the future. However, at the time of the incident, the facility did not verify with the staffing agency that Nurse #3's skills and competencies had been checked before her shift on 3/30/24.
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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