Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Laurels Of Chatham during CMS and state inspections, most recent first.
A dependent resident on anticoagulant therapy, requiring moderate to maximum assistance, became unresponsive while being showered by a NA. The NA left the resident unsupported on a shower bench without sides to seek help, rather than using the nearby emergency call bell. The resident slid off the bench, resulting in a laceration, significant bleeding, and a skin tear. Staff interviews and observations confirmed the resident was left in an unsafe position, directly leading to the fall and injuries.
A resident with a new diagnosis of unspecified psychosis and initiation of antipsychotic medication did not receive a required PASRR Level II referral. The social worker was unaware of the need for reassessment following the mental health diagnosis, and the resident's records and MDS did not reflect a Level II PASRR.
A resident on anticoagulant therapy with a DNR order became unresponsive during a shower and fell, sustaining a head laceration and skin tear. Staff failed to perform a head-to-toe assessment, check vital signs, or apply pressure to the bleeding wound before EMS arrived, leaving the resident unassessed and untreated for her injuries.
A resident with a feeding tube did not receive water flushes at the physician-ordered rate, as the pump was set to deliver less water than prescribed. The discrepancy was observed by staff, and the DON confirmed that water flushes were expected to be given as ordered.
A nurse did not maintain sterile technique while providing tracheostomy care and suctioning for a resident with chronic respiratory failure and a tracheostomy. The nurse failed to properly handle the suction catheter and did not reapply sterile gloves as required, resulting in a breach of infection control protocol during the procedure.
Nursing staff administered a blood pressure medication to a resident with severe cognitive impairment despite physician orders to hold the medication when systolic blood pressure was below a specified threshold. Multiple nurses gave the medication outside the ordered parameters on several occasions, acknowledging the errors during interviews.
A resident who fell and lost consciousness in the shower room was left nude and uncovered on the floor by staff until EMS arrived and provided a covering. Despite several staff being present, no one covered the resident, resulting in a failure to maintain the resident's dignity.
The facility failed to properly assess and manage the skin condition of a resident with a knee immobilizer, leading to an unstageable pressure ulcer. Additionally, another resident did not receive recommended protective skin care for a recently healed pressure ulcer due to a missed order.
The facility failed to address resident council concerns about night shift call bell response times and did not ensure the privacy of resident council meetings. Residents reported long wait times for call bell responses, and a nursing assistant interrupted a private meeting despite a sign indicating not to disturb.
A Consultant Pharmacist failed to identify the lack of documentation for monitoring side effects in a resident prescribed antipsychotic medications. Despite care plan interventions, there was no documentation of side effect monitoring in the nursing notes or MAR for three months. Interviews with staff confirmed the expectation for such monitoring, but it was not carried out, leading to a deficiency in care.
The facility failed to document the monitoring of side effects for a resident prescribed antipsychotic medications. Despite being care planned for the risk of adverse reactions, there was no documentation in the nursing notes or MAR for monitoring these side effects from August to October. Interviews with staff confirmed the expectation for monitoring, but the facility did not follow through.
The facility failed to maintain complete and accurate medical records for wound care in two residents. Interviews with the assigned nurses revealed that they had completed the wound care but forgot to document it. The DON confirmed that documentation is expected to be complete and accurate.
The facility's quality assurance process failed to sustain compliance, resulting in repeated deficiencies in dignity, activities of daily living, pressure ulcer care, and accurate medical records. Specific issues included inadequate incontinence care, poor communication, lack of nail and hair care, and failure to assess and protect skin, leading to pressure ulcers. The facility also did not maintain accurate medical records for wound care.
The facility failed to provide adequate stool incontinence care for a dependent resident, leading to feelings of anger and discomfort. Additionally, the facility failed to communicate effectively with a resident during care, resulting in resistance and aggressive behavior.
A resident with severe cognitive impairment and behavioral issues resisted care, but a Nursing Assistant continued to dress the resident despite physical and verbal signs of refusal. Interviews confirmed that staff should have stopped providing care when the resident resisted.
The facility failed to notify an orthopedic provider of a pressure ulcer caused by a knee immobilizer and did not inform the responsible party of a resident about the addition and increase of Depakote medication. These lapses in communication and protocol adherence led to inadequate management of the residents' health issues.
The facility failed to provide adequate personal care to two residents, including nail care, hair care, and facial hair shaving. One resident had greasy, matted hair and long, dirty nails despite preferring in-bed care, while another had discolored, thick, and long fingernails that were not trimmed. Staff and supervisory interviews revealed lapses in communication and oversight.
The facility failed to apply a knee immobilizer for a resident with a fractured femur as ordered and improperly handled a resident with a hip deformity after a fall. Management decided to leave the immobilizer off without consulting the orthopedic provider, and staff moved the resident with a hip deformity back to bed instead of calling for emergency services.
Failure to Provide Adequate Supervision During Shower Resulting in Resident Fall and Injury
Penalty
Summary
A dependent resident with a history of sacral fracture, aortic aneurysm, and lumbar radiculopathy, who was prescribed daily anticoagulant therapy, was involved in an incident during a shower. The resident required moderate to maximum assistance for bathing and transfers, and her care plan identified her as being at risk for falls and abnormal bleeding due to medication use. While being assisted by a nursing assistant (NA) on a shower bench without sides or railings, the resident suddenly became unresponsive and went limp. The NA responded by laying the resident across the shower bench, turning off the water, and leaving her side to seek help by running approximately 10 feet to the door to yell for assistance. During this time, the resident was left unsupported on the bench and subsequently slid off, falling to the floor and sustaining a laceration to her right eyebrow with significant bleeding, bruising, and a skin tear to her right elbow. The NA later acknowledged that an emergency call bell was present in the shower stall but did not use it, as it was behind her and she did not think to utilize it in the moment. Interviews with facility staff, including the Medical Director and Director of Nursing, confirmed that staff are expected to ensure residents are in a safe position before leaving them unattended. Observations of the shower room confirmed the lack of safety features on the bench and the location of the emergency call bell. The incident report and staff interviews corroborated that the resident was left unsupported, leading to the fall and resulting injuries.
Failure to Initiate PASRR Level II Referral After New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level II referral was made after a resident received new mental health diagnoses. Record review showed that the resident was originally admitted with a PASRR Level I completed, and a Level II PASRR was previously halted due to dementia being the primary diagnosis. However, the resident was later diagnosed with unspecified psychosis and started on an antipsychotic medication, but there was no documentation of a new Level II PASRR referral following this significant change in mental health status. Further review of the resident's comprehensive Minimum Data Set (MDS) confirmed that the resident was not coded for a Level II PASRR despite the new diagnosis. Interviews with facility staff revealed that the social worker was unaware of the need for a Level II PASRR referral after the new mental health diagnosis and cited difficulty keeping up with residents. The administrator acknowledged that the social worker was new to the role and required further education regarding PASRR requirements.
Failure to Assess and Treat Resident After Unresponsive Event and Fall
Penalty
Summary
A deficiency occurred when staff failed to thoroughly assess a resident who was prescribed a daily anticoagulant and had a do not resuscitate order, after she became unresponsive during a shower and subsequently fell, sustaining injuries. The resident, who had diagnoses including a sacral fracture, ascending aorta aneurysm, and lumbar radiculopathy, was sitting on a shower bench when she suddenly went limp and unresponsive. The nursing aide assisting her laid her across the bench and left her unattended to seek help, during which time the resident slid off the bench and hit her face on the floor, resulting in a laceration to her right eyebrow with significant bleeding and a skin tear to her right elbow. Upon arrival, the nurse did not perform a head-to-toe assessment, did not check vital signs, did not assess for pain or range of motion, and did not apply pressure to the bleeding laceration. The nurse only checked for a wrist pulse and did not attempt to cover the resident or address her injuries further. Multiple staff members were present in the shower room but did not assist in turning the resident over or providing basic first aid, such as applying pressure to the wound, before EMS arrived. The resident remained in the same position on the floor until EMS arrived and transported her. Interviews with staff and the medical director confirmed that the expected protocol after a fall included obtaining vital signs, assessing pain, and checking for bleeding or deformities, none of which were performed. The incident report and EMS documentation corroborated that the resident was left unassessed and untreated for her injuries in the minutes following the fall. The failure to provide appropriate assessment and care after the fall constituted the identified deficiency for this resident.
Failure to Administer Physician-Ordered Water Flushes via Feeding Tube
Penalty
Summary
A deficiency occurred when a resident with a history of severe protein-calorie malnutrition, cognitive communication deficit, and dysphagia, who was receiving nutrition and hydration via a feeding tube, did not receive water flushes at the physician-ordered rate. The resident's care plan included providing water as ordered, and the physician's order specified that the feeding tube should be flushed with 200 cc of water every 6 hours, totaling 800 cc per day. During an observation, it was found that the feeding tube pump was set to deliver water flushes at 100 cc every 4 hours, resulting in a total of 600 cc per day, which was less than the prescribed amount. The nurse present acknowledged the discrepancy between the pump settings and the physician's order but could not explain why the settings were incorrect. The DON confirmed that water flushes were expected to be administered at the prescribed rate.
Failure to Maintain Sterile Technique During Tracheostomy Suctioning
Penalty
Summary
Nurse #5 failed to follow sterile technique while providing tracheostomy care and suctioning for Resident #38, who had a history of chronic respiratory failure, traumatic brain injury, and a tracheostomy. During the observed procedure, Nurse #5 initially washed her hands and applied clean gloves to open the sterile tracheostomy care kit. After removing the resident's oxygen tubing and discarding her gloves, she washed her hands and applied sterile gloves. However, she then picked up the unopened suction catheter container from outside the sterile field and opened it with both hands. Without re-washing her hands or applying a new sterile glove to her dominant hand, she connected the suction catheter to the tubing and proceeded to suction the resident's tracheostomy. This sequence of actions did not maintain sterile technique as required for tracheostomy suctioning. The nurse admitted to forgetting the correct procedure due to nervousness during observation. Interviews with the unit manager, Director of Nursing, and Infection Preventionist confirmed that the expected protocol was not followed, specifically regarding the maintenance of sterility during the suctioning process.
Failure to Hold Antihypertensive Medication per Physician Order
Penalty
Summary
Nursing staff failed to follow physician orders regarding the administration of a blood pressure medication for a resident with hypertensive heart disease and heart failure. The physician's order specified that losartan potassium-hydrochlorothiazide should be held if the resident's systolic blood pressure (SBP) was less than 110. Despite this, medication administration records showed that the medication was given on multiple occasions when the resident's SBP was below the specified threshold. These instances occurred over several months and involved multiple nurses, who either acknowledged the oversight or could not recall the reason for administering the medication outside the prescribed parameters. The resident in question had severe cognitive impairment, as documented in the Minimum Data Set assessment. Interviews with nursing staff confirmed awareness of the medication parameters, yet the medication was still administered inappropriately. The nurse practitioner stated that, while no serious harm was expected from these incidents, she expected the nursing staff to follow the medication order as written. The Director of Nursing also confirmed that staff are expected to adhere to physician orders, including those with specific hold parameters.
Resident Left Uncovered After Fall in Shower Room
Penalty
Summary
A resident with intact cognition who required moderate assistance with bathing and transfers experienced a fall in the shower room while being assisted by a nurse aide. The resident lost consciousness, collapsed onto the floor, and sustained a laceration to her right eyebrow with significant bleeding, bruising, and a skin tear to her right elbow. Staff assessed the resident and found a faint pulse, then called EMS. During this time, the resident remained nude and uncovered on the shower room floor. Neither the nurse aide nor the nurse covered the resident with a towel or sheet after the fall, and both later stated in interviews that they did not think to do so. When EMS arrived, the resident was still nude and uncovered, and the paramedic covered her with a sheet before transferring her to the stretcher. The paramedic noted that there were five staff members present in the room and expressed embarrassment for the resident being left exposed. The Director of Nursing confirmed that the resident should have been covered to maintain dignity.
Failure to Properly Manage Pressure Ulcer Care
Penalty
Summary
The facility failed to properly assess and manage the skin condition of Resident #102, who was admitted with a fractured distal femur and required a knee immobilizer. Despite orders to remove the immobilizer for hygiene and skin checks, the immobilizer was not consistently removed, leading to the development of an unstageable pressure ulcer on the resident's right inner ankle. Multiple staff members, including nurses and aides, either did not remove the immobilizer or failed to report changes in skin condition, resulting in the pressure ulcer being identified only after it had become severe. Resident #102 had multiple risk factors for pressure ulcers, including severe cognitive impairment, limited mobility, and fragile skin due to conditions like bullous pemphigoid and psoriasis. The resident was on hospice care, further complicating her condition. Despite these risk factors, weekly skin assessments failed to identify any new wounds until the pressure ulcer was discovered on 4/3/24. Interviews with staff revealed inconsistencies in the removal and inspection of the immobilizer, contributing to the delayed identification and treatment of the pressure ulcer. Additionally, the facility failed to provide protective skin care for Resident #92, who had a recently healed pressure ulcer. Despite a recommendation from the wound care provider to apply skin prep every shift for at least seven days, this order was not transcribed or followed. The wound nurse admitted to missing the order, and the Director of Nursing confirmed that the wound nurse was responsible for transcribing such orders. As a result, Resident #92 did not receive the necessary protective care for his healed pressure ulcer, highlighting a lapse in the facility's wound care management protocols.
Failure to Address Call Bell Response Times and Ensure Privacy of Resident Council Meetings
Penalty
Summary
The facility failed to address resident council concerns regarding the response time to call bells on the night shift. Residents reported during council meetings in March and April 2024 that night shift nursing assistants were not rounding regularly and took hours to respond to call lights. Despite the facility's stated policy that call bells should be answered within 3 to 5 minutes, the issue persisted, and there was no documented response to the concerns raised in the April meeting. Interviews with the Activity Coordinator and the Director of Nursing confirmed that the problem was ongoing and that management was aware but had not effectively resolved it. Additionally, the facility failed to ensure the privacy of resident council meetings. During a resident council meeting in April 2024, a nursing assistant entered the meeting room unannounced despite a sign indicating that the meeting was in progress and should not be disturbed. This interruption was acknowledged as inappropriate by both the nursing assistant and the Activity Coordinator. The Director of Nursing confirmed that staff should not enter resident council meetings while they are in progress.
Failure to Monitor Adverse Side Effects of Antipsychotic Medications
Penalty
Summary
The Consultant Pharmacist failed to identify the lack of documentation for monitoring side effects in a resident prescribed antipsychotic medications. Resident #173, who had Alzheimer's Disease, dementia with behaviors, and Bipolar Disease, was admitted with orders for Zyprexa and later Seroquel. Despite the care plan's interventions to monitor for adverse reactions and side effects, there was no documentation of such monitoring in the nursing notes or medication administration records (MAR) for August, September, and October 2023. The Consultant Pharmacist's medication review notes on multiple dates indicated that there was nothing inconsistent with customary clinical approaches, yet failed to note the absence of side effect monitoring. Interviews with various staff members, including the Unit Manager, nurses, and the Consultant Pharmacist, revealed that there was an expectation for monitoring adverse side effects for residents on antipsychotic medications, but this was not carried out for Resident #173. The Director of Nursing and the Regional Nurse Consultant confirmed that the Consultant Pharmacist should have identified the need for observation to ensure Resident #173 was not experiencing any adverse side effects. The oversight was acknowledged by the Consultant Pharmacist, who attributed it to the facility's efforts to manage the resident's behaviors. The lack of documentation and monitoring for adverse side effects constituted a deficiency in the care provided to Resident #173.
Failure to Monitor Adverse Side Effects of Antipsychotic Medications
Penalty
Summary
The facility failed to document the monitoring of side effects for a resident prescribed antipsychotic medications. Resident #173, who had diagnoses of Alzheimer's Disease, dementia with behaviors, and Bipolar Disease, was admitted with orders for Zyprexa and later Seroquel. Despite being care planned for the risk of adverse reactions and side effects, there was no documentation in the nursing notes or medication administration record (MAR) for monitoring these side effects from August to October 2023. The resident exhibited various behaviors such as aggression, wandering, and rejection of care during this period, but no adverse side effect monitoring was recorded. Interviews with staff, including the Unit Manager, nurses, and the Physician, confirmed that there was an expectation for monitoring adverse side effects when a resident is prescribed antipsychotic medications. However, the facility did not follow through with this requirement. The Director of Nursing and the Regional Nurse Consultant acknowledged that the facility should have identified the need for observation to ensure the resident was not experiencing any adverse side effects associated with the antipsychotic medications.
Incomplete Documentation of Wound Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for wound care in two residents. For Resident #273, the Treatment Administration Record (TAR) for February 2024 showed that wound care for the left great toe amputation site was not signed as completed or refused on two occasions. Interviews with the assigned nurses revealed that they had completed the wound care but forgot to document it. The Director of Nursing (DON) confirmed that documentation is expected to be complete and accurate. For Resident #274, the TARs from April 2023 to July 2023 showed multiple instances where wound care for the left lower extremity pin sites was not signed off as completed or refused. Interviews with the assigned nurses indicated that they had performed the wound care but failed to document it. Multiple attempts to contact other nurses involved were unsuccessful. The DON reiterated the expectation for complete and accurate documentation.
Repeated Deficiencies in Quality Assurance and Resident Care
Penalty
Summary
The facility's quality assurance process failed to implement, monitor, and revise the action plan developed for the recertification survey dated 2/9/23, resulting in repeated deficiencies during the recertification survey on 4/14/24. The deficiencies were in the areas of dignity, activities of daily living, pressure ulcer care, and accurate medical records. Specifically, the facility failed to provide stool incontinence care on the night shift for a dependent resident, causing emotional distress, and failed to communicate adequately with another resident during care. Additionally, the facility did not provide proper nail care, hair care, and facial hair shaving for dependent residents, and failed to assess and provide protective skin care, leading to the development of an unstageable pressure ulcer in one resident and inadequate care for a recently healed pressure ulcer in another resident. The facility also failed to maintain complete and accurate medical records for wound care in two residents' closed records. During the previous recertification survey on 2/9/23, similar deficiencies were noted, including the failure to provide a dignified dining experience by using disposable food containers and plastic utensils, referring to a resident as a feeder, and not providing adequate nail care, shaving, and bathing assistance. The facility also failed to ensure that pressure reduction mattresses were set correctly and did not maintain accurate medical records for wound care. Despite hiring more staff and a new wound care company, the facility's quality assurance program was unable to sustain compliance, as evidenced by the repeated deficiencies in the subsequent survey.
Failure to Provide Adequate Incontinence Care and Communication
Penalty
Summary
The facility failed to provide adequate stool incontinence care for a dependent resident, leading to feelings of anger and discomfort. Resident #59, who was admitted with liver failure and required assistance with all activities of daily living, reported that night shift Nursing Assistants (NAs) did not round or respond to call lights in a timely manner. On the night of 4/14/24, Resident #59 was left sitting in stool for over two hours, causing a lingering smell and significant distress. The Director of Nursing (DON) acknowledged ongoing issues with night shift staff not answering call lights and providing care, despite previous attempts to address the problem through staff education. Additionally, the facility failed to communicate effectively with a resident during care. Resident #15, who was admitted with a diagnosis of seizure and exhibited behaviors of yelling and screaming due to confusion and psychotic disorder, was observed receiving care from NA #5. The NA did not inform the resident of the care being provided, leading to resistance and aggressive behavior from the resident. The DON confirmed that staff should direct residents during care and stop if the resident resists, indicating a lapse in proper communication and care protocols.
Failure to Honor Resident's Right to Refuse Care
Penalty
Summary
The facility failed to honor a resident's right to refuse care when a Nursing Assistant (NA) attempted to dress the resident in a gown despite the resident's physical and verbal behaviors resisting this care. The resident, who had diagnoses of seizure disorder and psychotic disorder with delusions, exhibited severely impaired cognition and verbal behaviors. During an observation, the resident resisted care by locking her elbow, yelling unintelligible words, and slapping the NA. Despite these clear signs of refusal, the NA continued to dress the resident, citing the need to prevent exposure and provide privacy. Interviews with the Unit Supervisor and the Director of Nursing (DON) confirmed that the staff should have stopped providing care when the resident resisted. The NA acknowledged that the resident's actions were a form of communication indicating refusal of care but continued with the dressing process to cover the resident. The DON stated that staff members are expected to stop providing care and address the reasons behind the resident's behavior when such resistance occurs.
Failure to Notify Providers and Responsible Parties of Critical Changes
Penalty
Summary
The facility failed to notify the orthopedic provider of a newly acquired pressure ulcer caused by a knee immobilizer and that the knee immobilizer was not being worn as ordered for a resident with a fractured distal femur. The resident was admitted with diagnoses including a right femur fracture, bullous pemphigoid, and psoriasis. Despite orders for the knee immobilizer to be worn at all times and removed only for hygiene, the immobilizer was not used on several occasions due to a pressure ulcer on the resident's right inner ankle. The orthopedic provider was not informed of the pressure ulcer or the decision to discontinue the use of the immobilizer until several days later. Interviews with staff revealed that the decision to stop using the immobilizer was made by management without consulting the orthopedic provider in a timely manner. Another deficiency involved the failure to notify the responsible party (RP) of the addition and increase of medication prescribed for a resident with Alzheimer's Disease, dementia with behaviors, and Bipolar Disease. The resident was prescribed Depakote for bipolar disorder, but there was no documentation that the RP was informed of the new medication or its increased dosage. The RP discovered the medication change only after the resident was diagnosed with drug-induced delirium at the hospital following a fall. Interviews with staff confirmed that the nurse responsible for notifying the RP did not follow procedure, leading to the RP's dissatisfaction and decision not to allow the resident to return to the facility. These deficiencies highlight significant lapses in communication and adherence to protocol within the facility. The failure to notify relevant medical providers and responsible parties about critical changes in resident care and condition resulted in inadequate management of the residents' health issues. The facility's management and nursing staff did not ensure proper documentation and timely communication, which are essential for maintaining the quality of care and safety of the residents.
Failure to Provide Adequate Personal Care
Penalty
Summary
The facility failed to provide adequate personal care to two residents, specifically in the areas of nail care, hair care, and facial hair shaving. Resident #59, who was admitted with diagnoses of post-traumatic stress disorder and depression, required staff assistance for bathing and personal care. Despite documentation indicating that personal care was provided daily, observations revealed that Resident #59 had greasy, matted hair, long nails with black soil underneath, and long facial hair. The resident expressed a preference for receiving care in bed and stated that he had not been offered hair washing or nail care in bed. Interviews with staff confirmed that the resident usually refused showers but accepted care in bed, yet his hair and nails remained unkempt over several days of observation. Resident #92, admitted with a diagnosis of moderate protein-calorie malnutrition, also did not receive proper nail care. The resident's Minimum Data Set indicated moderate cognitive impairment and required assistance with personal hygiene. Observations showed that Resident #92 had discolored, thick, jagged, and long fingernails. The resident stated that he would like his nails cut but had not been offered nail care. Staff interviews revealed that nursing assistants were responsible for nail care during showers and as needed, but no one had reported the condition of Resident #92's nails. The Director of Nursing was unaware that the resident's nail care had not been performed. Both residents' care plans included interventions to keep their nails trimmed and clean, yet these interventions were not consistently followed. The failure to provide adequate personal care, including nail trimming, hair washing, and facial hair shaving, was evident through multiple observations and interviews with residents and staff. The Director of Nursing and other supervisory staff were not aware of the deficiencies in personal care, indicating a lapse in communication and oversight within the facility.
Failure to Follow Medical Orders and Proper Protocols
Penalty
Summary
The facility failed to apply a right knee immobilizer for a resident with a fractured distal femur as ordered. Resident #102 was admitted with a diagnosis of a right femur fracture and had orders to wear a knee immobilizer at all times, except for hygiene purposes. Despite these orders, the immobilizer was not used on multiple occasions due to a pressure ulcer on the resident's right inner ankle. The facility's management decided to leave the immobilizer off without consulting the orthopedic provider, leading to a lack of consistent use of the immobilizer as prescribed. Interviews with staff revealed that the orthopedic provider was not informed of the decision to stop using the immobilizer until much later, and the facility did not follow up adequately with the provider regarding the new wound and the immobilizer's use. Another deficiency involved the improper handling of a resident with an obvious deformity and pain in the right hip/leg after a fall. Resident #30, who had severe cognitive impairment and was dependent on staff for most activities, was found on the floor with a misshaped right hip. Despite the visible deformity and the resident's complaints of pain, Nurse #10 and a Nursing Assistant moved the resident back to bed instead of leaving her on the floor and calling for emergency medical services. The nurse was aware that moving a resident with a possible hip fracture could cause additional damage and pain but proceeded to move her anyway. The Director of Nursing and the Regional Nurse Consultant later confirmed that the correct protocol would have been to assess the resident on the floor and call 911 if there was pain or deformity. These deficiencies highlight significant lapses in following medical orders and proper protocols for handling residents with serious injuries. The failure to apply the knee immobilizer as ordered and the improper handling of a resident with a potential hip fracture indicate a need for better communication and adherence to established medical guidelines within the facility.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pittsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Arbor | 6.3 mi | ★★★★★ | 0 | 0 |
| Sanford Health & Rehabilitation Co | 10.6 mi | ★★★★★ | 0 | 0 |
| The Cedars Of Chapel Hill | 15.7 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of Chapel Hill | 16.5 mi | ★★★★★ | 0 | 0 |
| Siler City Center | 17.4 mi | ★★★★★ | 8 | 1 |
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