Trinity Elms
Inspection history, citations, penalties and survey trends for this long-term care facility in Clemmons, North Carolina.
- Location
- 7449 Fair Oaks Drive, Clemmons, North Carolina 27012
- CMS Provider Number
- 345565
- Inspections on file
- 20
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Trinity Elms during CMS and state inspections, most recent first.
Multiple MDS assessments were inaccurately coded when one resident admitted with pneumonia and meningitis, who had documented IV access, midline catheter use, and IV ceftriaxone therapy, was not coded for IV access or IV antibiotics on the MDS. Another resident with Type 2 DM receiving subcutaneous Tirzepatide was incorrectly coded as having received an insulin injection after the MDS nurse mistakenly assumed Tirzepatide was insulin, despite no insulin being documented on the MAR. A third resident with anxiety disorder had multiple documented behaviors such as yelling, hitting, aggression, agitation, exit seeking, and refusing care during the MDS look-back period, but was coded as having no behaviors because the social work staff relied only on direct observation and did not review the electronic medical record for documented behaviors.
A resident with chronic pain, mild dementia, severe neurocognitive disorder, debility, and impaired mobility was admitted with documented high fall risk and physician orders for PRN acetaminophen ER and a daily lidocaine patch for pain. Within 48 hours, the MDS nurse completed a baseline care plan that addressed transfer status, therapy, and dietary needs but omitted goals and interventions for pain management and did not include fall prevention measures, despite the fall risk evaluation indicating that prevention protocols should be initiated and documented. The resident’s representative reported ongoing pain and perceived high fall risk and wanted staff to be aware of these needs, while the DON and Administrator later acknowledged that the baseline care plan should have contained this essential information.
A resident with documented episodes of grabbing, hitting, physical aggression, agitation, anxiousness, and exit-seeking did not have communication or behavior needs addressed in the comprehensive care plan. Although the admission MDS showed adequate hearing with hearing aids and no behaviors at that time, the CAA identified communication as a triggered area to be care planned. The Social Work Assistant completed the CAA based only on the resident’s behavior during the assessment, did not review the EMR behavior monitoring reports, and was unaware of the need to do so. As a result, no communication or behavior interventions were added to the care plan, a lapse later acknowledged by both the Social Work Assistant and the DON.
A resident with dementia, failure to thrive, a fall history, and HTN was found on the floor by an RN, who assessed for pain and injury but did not notify the NP, responsible party, DON, or Medical Director of the fall and entered the event in the EMR as an injury rather than a fall. Two days later, the resident reported new right knee pain and swelling; the NP and family were informed only of the pain, not the prior fall, and an x-ray was ordered. Over the following days, the resident continued to report pain, received multiple analgesics, and underwent imaging, culminating in a CT that showed multiple right hip and pelvic fractures. The NP, Medical Director, and resident representative all reported they were not made aware of the fall until after the CT results and subsequent internal review, and hospital records later documented admission for a displaced right acetabular fracture and severe pain with functional decline after a fall at the facility.
A resident with dementia, gait abnormalities, and a history of falls was found on the floor in front of a wheelchair and assessed by an RN, who documented no pain or injury and returned the resident to a wheelchair. The RN entered the event in the EMR as an injury rather than a fall, did not complete required fall risk and post‑fall evaluations, and did not report the fall in shift report, so management and the primary provider were not promptly notified and automated fall protocols were not triggered. Over subsequent days, the resident repeatedly complained of right leg pain with documented pain scores and received PRN analgesics while outside imaging orders were delayed and not clearly communicated to the NP. When the NP later assessed the resident for persistent discomfort and limited ROM, a hip/pelvis x‑ray and then a CT scan were ordered, ultimately revealing multiple right hip and pelvic fractures. Interviews and record review showed that the fall was not disclosed to the NP or family until after the CT results and internal investigation, demonstrating a breakdown in communication, documentation, and interdisciplinary coordination around the resident’s fall and subsequent pain complaints.
A medication aide mistakenly administered a set of medications intended for another resident to a resident with severe cognitive impairment after misidentifying her during a medication pass. The error involved multiple medications, including antihypertensives and psychotropics, and was discovered after the aide realized the mistake and reported it. The resident was monitored and found to be stable, with no acute distress or adverse reactions noted.
The facility failed to submit accurate PBJ data to CMS, missing RN hours and 24-hour licensed nursing coverage for several days in a quarter. Despite having the required staffing, errors in reporting led to the deficiency, which was later corrected.
A facility failed to maintain consistent advance directive information for a resident, resulting in a discrepancy between the EMR and paper medical record. The resident's EMR indicated a full code status, while the paper record showed a signed DNR form. Staff interviews confirmed the inconsistency, with the DON and Administrator expecting records to match.
The facility failed to post required cautionary and safety signage for three residents receiving oxygen therapy. Despite physician orders for continuous oxygen administration, observations revealed that these residents were receiving oxygen without any signage indicating its use. Interviews with the DON and Administrator confirmed that signage was expected but not implemented.
A resident, not approved to self-administer medications, was found with medications left unsecured on their overbed table. The nurse mistakenly believed the resident could self-administer, leading to a breach in medication storage protocols. The DON confirmed this was against facility policy.
A nonverbal resident with diabetes in an LTC facility developed skin wounds during a shower, which were not promptly reported to the medical provider. The resident's condition worsened overnight, leading to a diagnosis of deep partial thickness burns. The delay in notification increased the risk of infection, especially given the resident's diabetes.
A resident with severe cognitive impairment was left unattended in a shower by a nurse aide, resulting in deep partial thickness burns to her thighs and mons pubis. The resident, who required total assistance for care, was found with peeling skin after being left with running water. The incident highlighted a lack of supervision and failure to follow proper procedures, leading to the resident's hospitalization and treatment.
Inaccurate MDS Coding for IV Therapy, Insulin Use, and Behaviors
Penalty
Summary
The deficiency involves inaccurate coding of Minimum Data Set (MDS) assessments for multiple residents, resulting in failure to capture IV therapy, IV antibiotic use, insulin use, and behavioral symptoms. One resident was admitted with pneumonia and meningitis requiring IV access and IV antibiotic medications. Documentation showed the resident arrived with IV access in the right antecubital fossa, had physician orders for IV ceftriaxone every 12 hours, and received IV antibiotics and saline flushes over several days, with notes indicating use of a midline catheter. However, the discharge return not anticipated MDS assessment did not indicate the presence of a midline IV access or that IV antibiotics were received upon admission, during the stay, or at discharge. The MDS Nurse later acknowledged that IV access and IV antibiotic use were not marked and that this was an error. Another resident with Type 2 diabetes mellitus with hyperglycemia had a physician order for Tirzepatide to be administered subcutaneously once weekly, and the Medication Administration Record confirmed that this medication was given as ordered. There was no indication on the MAR that the resident received any insulin injections. Despite this, the admission MDS assessment coded that the resident had received one insulin injection. The MDS Nurse who completed the assessment stated she coded one insulin injection because she believed Tirzepatide was considered insulin and later realized this was incorrect, confirming that the MDS had been inaccurately coded. A third resident admitted with an anxiety disorder exhibited multiple documented behaviors during the MDS assessment look-back period, including grabbing others, hitting, physical aggression, agitation, anxiousness, exit seeking, yelling, throwing medication, refusing care, restlessness, and wandering. These behaviors were recorded on behavior monitoring reports and in progress notes by nursing staff and the Administrator. Despite this documentation, the admission MDS with an Assessment Reference Date within this period coded the resident as having no behaviors, although it did indicate severe cognitive impairment and receipt of antianxiety medication. The Social Work Assistant responsible for coding behaviors on the MDS stated she did not observe these behaviors during the assessment period, was not aware she needed to review the electronic medical record for documented behaviors, and was unaware that such behaviors had been documented, leading to the omission of behaviors on the MDS.
Failure to Include Fall Risk and Pain Management in Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan that addressed a newly admitted resident’s immediate needs related to fall prevention and pain management. Record review showed the resident had diagnoses of chronic neck pain, chronic pain syndrome, mild dementia, severe major neurocognitive disorder, debility, and impaired mobility. Hospital documentation indicated a recent cognitive and functional decline, increased confusion, difficulty ambulating with a walker, generalized weakness, and reduced mobility. On admission, the facility’s fall risk evaluation identified the resident as being at high risk for potential falls, with instructions that fall prevention protocols should be initiated immediately and documented on the care plan. Physician orders at admission included PRN acetaminophen extended release for pain and a daily lidocaine 4% patch for lower back pain. Despite this information, the baseline care plan completed within 48 hours of admission did not include goals or interventions for the resident’s chronic pain syndrome and did not address the resident’s immediate needs related to fall risk prevention. The MDS nurse who completed the baseline care plan stated it included transfer status, therapy, and dietary information and believed it met minimum requirements for basic safety. The resident’s representative reported that the resident had a history of chronic pain requiring medication for comfort, that his pain continued after admission, and that she believed he was at high risk for falls due to his physical and mental condition, and wanted staff to be aware of these issues. The DON and Administrator both stated that a baseline care plan should include the minimum healthcare information necessary to meet a resident’s needs, and the DON acknowledged that the resident’s high fall risk and pain should have been included, but they were not.
Failure to Develop Communication and Behavior Care Plans for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive care plan addressing communication and behavioral needs for one resident. The resident was admitted on a specified date, and behavior monitoring and intervention reports documented multiple episodes of problematic behaviors, including grabbing others, hitting others, physical aggression toward others, agitation, anxiousness, and exit-seeking on consecutive days. The admission MDS assessment indicated the resident had adequate hearing with hearing aids, was usually understood and usually understood others, and showed no behaviors at that time. The Care Area Assessment (CAA) summary, completed shortly after admission by the previous Social Work Assistant, showed that communication was a triggered care area and stated that communication would be addressed in the care plan. Despite these findings, review of the resident’s care plan, dated shortly after admission with a later revision date, revealed no care plan or interventions in the areas of communication or behaviors. In a telephone interview, the previous Social Work Assistant confirmed she completed the communication CAA summary and acknowledged the resident should have had a communication care plan, but she did not know why one had not been developed. She stated she based her CAA answers solely on the resident’s behavior during the assessment, when no behaviors were observed, and she did not review the electronic medical record’s behavioral monitoring and intervention report because she did not know she needed to do so. The DON also stated that the resident should have had communication and behavior care plans and was unsure why they had not been completed.
Failure to Notify Provider and Representative of Resident Fall and Subsequent Pain
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify the nurse practitioner (NP) and the resident representative of a resident’s fall and to clearly communicate the occurrence of that fall when later reporting new pain symptoms. The resident, who had non-Alzheimer’s dementia, adult failure to thrive, a history of falling, and hypertension, was found on the floor in front of her wheelchair on 1/28/26. Nurse #7, who had just started her shift, assessed the resident for pain and injury, checked range of motion, and documented that the resident denied pain and had no apparent injury. Nurse #7 did not notify the provider, the family, or the DON of the fall on that date and believed the fall was witnessed by the Scheduler. The DON later stated that the incident was entered in the electronic medical record as an “injury” rather than a “fall,” which prevented the system from triggering the facility’s fall risk and post-fall evaluations. On 1/30/26, the resident began complaining of right knee pain, rated 4/10, and was given acetaminophen. A health status note by Nurse #11 documented that the NP was notified of the resident’s knee pain and slight swelling, and an x-ray was ordered. The resident’s family, who visited that day, was also notified of the complaint of right knee pain, but neither the NP nor the family was informed that the resident had been found on the floor two days earlier. The NP later confirmed she was never officially notified of the 1/28/26 fall and ordered the x-ray based solely on the reported pain. The NP stated she typically would be called when a resident fell and that she did not learn of the fall until 2/11/26, after CT results were available and the facility began an internal investigation. In the days following the onset of pain, the resident continued to report pain of varying intensity, including right lower extremity thigh/knee pain, and received acetaminophen, tramadol, and hydrocodone-acetaminophen. An x-ray could not be completed on one date due to snow, and the family initially requested waiting to send the resident out, later agreeing to further evaluation when the pain migrated to the hip. An x-ray of the knee was eventually done and was reported as fine, with a recommendation for CT if pain persisted. A CT scan performed on 2/9/26 revealed multiple serious fractures of the right hip and pelvis and flattening of the superior lateral right femoral head. The resident representative stated she was not notified of the 1/28/26 fall and only became aware of it in February when discussing CT results with the NP. The Medical Director also reported not being informed of the fall until 2/11/26, learning of it through record review. Hospital records documented that the resident was admitted with a displaced transverse-posterior fracture of the right acetabulum and severe pain with functional decline after experiencing a fall at the nursing facility.
Failure to Document and Communicate Fall Led to Delayed Identification of Fractures and Ongoing Pain
Penalty
Summary
The deficiency involves the facility’s failure to implement effective systems for communication, collaboration, assessment, and documentation following a resident fall, resulting in delayed recognition and response to injury and ongoing pain. Resident #33, who had hypertension, non‑Alzheimer’s dementia, adult failure to thrive, generalized muscle weakness, gait and mobility abnormalities, a history of falls, and used a wheelchair, was care planned as being at moderate risk for falls with interventions such as a wing‑tip mattress and prompt response to assistance needs. On the afternoon of 1/28/26, the Scheduler observed the resident already on the floor, sitting on her buttocks in front of her wheelchair, and summoned a nurse and a medication aide. Nurse #7 assessed the resident, checked range of motion, obtained vital signs, and asked about pain; the resident denied pain, and no apparent injury was noted. The resident was assisted back into her wheelchair and taken to the nurse’s station for brief observation before returning to routine activities. Despite this event, Nurse #7 did not document the occurrence as a fall in the electronic medical record, instead entering it as an “injury” incident type, which did not trigger the facility’s fall‑related User‑Defined Assessments (Fall Risk and Post Fall Evaluations). There was no contemporaneous Post Fall Evaluation or Fall Risk Evaluation completed for the 1/28/26 event, and the fall was not included in the shift report. As a result, management, the primary provider, and the resident’s representative were not promptly informed of the fall. The DON later confirmed that the misclassification of the event in the EMR prevented automatic initiation of the fall assessments and associated management investigation. The NP stated she was never officially notified of the 1/28/26 fall at the time it occurred and that she typically expected a call from the facility when a resident fell. Following the 1/28/26 incident, the resident began complaining of right knee pain on 1/30/26, with documented pain scores and administration of acetaminophen and later tramadol and hydrocodone‑acetaminophen. Nursing staff notified the NP of knee pain and slight swelling, and a right knee x‑ray was ordered on 1/30/26; due to weather and scheduling issues with the outside imaging company, this x‑ray was delayed, and the NP was not made aware of the delay until a later facility visit. The 1/30/26 knee x‑ray, when eventually completed, showed no acute fracture. On 2/4/26, during an on‑site visit, the NP observed the resident to be uncomfortable, irritable, frequently repositioning, and apparently not bearing weight on the right side, with complaints of pain and limited ROM of the right leg; staff at that time reported “no known injury.” Based on this assessment, the NP ordered a right hip/pelvis x‑ray, which showed arthritic changes and osteopenia but recommended CT if clinical suspicion for fracture persisted. A CT scan performed on 2/9/26 revealed multiple serious fractures of the right hip and pelvis. Throughout this period, the resident had repeated documented pain scores, and the NP and Medical Director both reported that they and the family only became aware of the 1/28/26 fall after the CT results and subsequent internal investigation, underscoring that the initial fall event and subsequent pain complaints were not effectively communicated or linked by staff to a potential injury from the fall. A late entry Post Fall Note was created by the ADON on 2/12/26, backdated to 1/28/26, describing the resident on the floor in front of her wheelchair, the assessment with no apparent injury, and the use of the PAINAD scale, but this documentation occurred only after the CT scan identified fractures and after the facility began investigating the cause of the injuries. Interviews with the DON, Unit Manager, NP, Medical Director, and other staff confirmed that the fall was initially treated as a non‑injurious event, that required fall assessments and notifications were not completed at the time, and that there were gaps in communication about both the fall and the delays in obtaining imaging. The surveyors concluded that the facility failed to implement effective systems to ensure timely communication and collaboration regarding the resident’s care, including accurate classification and documentation of the fall, prompt notification of the provider and resident representative, and timely follow‑up on persistent pain and imaging orders. Hospital records later documented that the resident was admitted after a fall at the nursing facility with a serious right hip socket fracture and severe pain and difficulty moving. The Medical Director’s first post‑fall visit with the resident occurred on 2/11/26, well after the 1/28/26 fall, and she reported that at that time the resident did not appear to be in pain but was agitated. The NP stated that had she known about the fall when it occurred, she might have ordered different or more extensive imaging earlier and would have considered sending the resident to the emergency department if injury was suspected. The deficiency centers on the facility’s failure to recognize, document, and communicate the 1/28/26 fall as such, failure to complete required fall‑related assessments, and failure to effectively coordinate provider notification and diagnostic follow‑up in the context of the resident’s ongoing pain and functional changes. Overall, the events show that the resident’s fall was not properly reported or documented in real time, the EMR entry did not trigger the facility’s fall management protocols, and key clinical staff and the resident’s representative were not promptly informed of the fall. Subsequent pain complaints, behavioral changes, and functional limitations were managed without clear linkage to a known fall event, and imaging orders were delayed or not effectively followed up, contributing to a prolonged period before the resident’s fractures were identified. These actions and inactions, as documented by staff interviews, record reviews, and practitioner statements, constitute the basis of the cited deficiency for failure to provide treatment and care in accordance with orders, resident preferences, and goals through effective communication and collaboration.
Medication Error Due to Resident Misidentification
Penalty
Summary
A medication error occurred when a medication aide administered a set of medications intended for one resident to another resident with severe cognitive impairment. The aide had previously given the correct morning medications to the resident, but later, due to changes in the resident's appearance and a case of mistaken identity, she addressed the resident by another's name and administered the wrong medications. The aide realized the error about an hour later and reported it to the nurse on duty. The resident who received the incorrect medications had a complex medical history, including hypertensive heart disease with heart failure, atrial fibrillation, and dementia with behaviors. The medications erroneously administered included multiple antihypertensives, an antipsychotic, an antidepressant, an antibiotic, and other medications not prescribed for her. At the time of the error, the resident was alert, at her baseline, and did not exhibit any acute distress or adverse reactions, though her blood pressure was monitored and found to be slightly low but stable. The incident was confirmed through interviews with the medication aide, the nurse, the nurse practitioner, and the medical director, as well as a review of the resident's medical records, EMS, and hospital documentation. The facility's DON stated that staff are expected to follow the six rights of medication administration, which were not adhered to in this case, resulting in the administration of another resident's medications to the wrong individual.
Inaccurate PBJ Reporting of RN Hours and Nursing Coverage
Penalty
Summary
The facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) regarding Registered Nurse (RN) hours and licensed nursing coverage for 24 hours per day. This issue was identified for one of the three quarters reviewed, specifically Quarter 4 of 2024. The PBJ report indicated that there were no RN hours recorded for several days in September 2024, and the facility also failed to have licensed nursing coverage for 24 hours per day on multiple days during the same month. Upon review of the Posted Daily Nursing Staffing Forms, Daily Staffing Sheet, and nursing staff time detail reports, it was found that there were indeed RN hours and 24-hour licensed nursing coverage for the days in question. An interview with the Human Resources Payroll Manager revealed that the PBJ data file submitted for September 2024 was initially rejected due to errors, which were later corrected and resubmitted successfully. The Administrator confirmed that the facility had the required RN hours and licensed nursing staff, attributing the issue to a reporting error.
Inconsistent Advance Directive Information for Resident
Penalty
Summary
The facility failed to maintain consistent and accurate advance directive information for a resident, leading to a discrepancy between the electronic medical record (EMR) and the paper medical record. The resident, who was moderately cognitively impaired, had a physician's order in the EMR indicating a full code status dated 12/12/24, while the paper medical record at the nurse's station contained a signed Do Not Resuscitate (DNR) form dated 12/16/24. This inconsistency was identified during staff interviews and record reviews. Nurse #1 confirmed the discrepancy and stated that in an emergency, she would first check the paper medical record. If there was a discrepancy, she would consult with the Director of Nursing (DON). The DON and the Administrator both expressed that their expectation was for the EMR and paper medical records to match. However, the inconsistency remained, indicating a failure in the facility's process to ensure that critical information regarding the resident's code status was accurately reflected across all records.
Failure to Post Oxygen Safety Signage
Penalty
Summary
The facility failed to post cautionary and safety signage outside the rooms of three residents who were receiving oxygen therapy. Resident #57, admitted with pneumonia due to hemophilus influenzae, had a physician's order for continuous oxygen administration via nasal cannula at 1 Liter/minute. Observations on two separate occasions revealed that Resident #57 was receiving oxygen without any cautionary signage posted at the entrance to her room. Similarly, Resident #69, admitted with acute respiratory failure with hypoxia, had orders for oxygen titration up to 2 Liters/minute. Observations showed that Resident #69 was receiving oxygen at varying levels without the required safety signage outside his room. Resident #48, who was admitted with pneumonia, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease, also had a physician's order for continuous oxygen at 2 Liters/minute. Observations confirmed that Resident #48 was receiving oxygen without any safety signage posted at the entrance to her room. Interviews with the Director of Nursing and the Administrator revealed that it was their expectation that the required oxygen signage be posted for residents receiving oxygen, indicating a lapse in adherence to safety protocols.
Failure to Secure Medications for Resident
Penalty
Summary
The facility failed to secure medications for a resident who was not approved to self-administer medications. Resident #77, who was admitted with diagnoses including cerebral infarction, hypertension, and anxiety, was assessed on 9/13/24 and found to require assistance with oral medications. Despite this assessment, medications were observed on the resident's overbed table during a survey on 1/13/25. The resident confirmed that it was common practice for the nurse to leave medications on the table for later consumption. Nurse #1, who left the medications on the table, mistakenly believed that the resident was approved to self-administer. The medications included Gabapentin, Labetalol, Clopidogrel, Zetia, Lasix, Isosorbide, Cozaar, a multivitamin, and Zoloft. The Director of Nursing confirmed that the medications should not have been left at the bedside, indicating a lapse in following the facility's medication storage protocols.
Failure to Notify Medical Provider of Resident's Condition Change
Penalty
Summary
The facility staff failed to notify the medical provider of a change in condition for a nonverbal resident with diabetes when new skin wounds were observed. The resident, who was severely cognitively impaired and nonverbal, was found to have skin tears on both thighs during a scheduled shower. The nurse on duty assessed the resident and noted redness and skin peeling on the thighs and mons pubis. Despite the visible injuries, the nurse did not notify the medical provider due to time constraints and instead passed the information to the oncoming nurse. The subsequent nurse also failed to notify the medical provider, assuming the previous nurse had done so. The resident's condition worsened overnight, with increased redness and irritation observed by the morning shift nurse. It was only after the wound nurse's assessment that the Assistant Director of Nursing was notified, who then contacted the medical provider. The resident was sent to the emergency department and diagnosed with deep partial thickness burns. Interviews with the medical director and dermatologist confirmed that the facility should have contacted the medical provider immediately upon noticing the change in the resident's condition. The dermatologist's assessment indicated that the injuries were consistent with thermal burns, possibly from hot water or a hot washcloth. The delay in notifying the medical provider increased the risk of infection, especially given the resident's diabetes and the severity of the burns.
Resident Left Unattended in Shower Results in Burns
Penalty
Summary
The facility staff failed to adequately supervise a severely cognitively impaired and nonverbal resident during a shower, leading to significant injuries. On the specified date, a nurse aide left the resident unattended and naked on a shower bed with the water running. Upon returning, the aide found the resident with a pool of water over her thighs and genital area, and the top layer of her skin was peeling off. The resident was subsequently diagnosed with deep partial thickness burns to her thighs and mons pubis, requiring hospitalization and treatment. The resident involved had a complex medical history, including lumbar degenerative disc disease, fibromyalgia, diabetes, heart failure, chronic kidney disease, and vascular dementia. She was severely cognitively impaired, nonverbal, and required total assistance for all care. Despite these needs, the care plan did not address behaviors such as scratching, which was noted during the incident. The nurse aide's decision to leave the resident unattended in the shower room without supervision or a call for assistance contributed to the incident. Interviews and documentation revealed inconsistencies in the reporting and assessment of the resident's condition before and after the incident. The nurse aide initially reported no skin issues, but later noted skin alterations after the shower. The facility's response included multiple interviews and assessments, but the initial lack of supervision and failure to follow proper procedures in the shower room were critical factors leading to the resident's injuries.
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.
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.
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.
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.
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.
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 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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