Woodhaven Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lumberton, North Carolina.
- Location
- 1150 Pine Run Drive, Lumberton, North Carolina 28358
- CMS Provider Number
- 345054
- Inspections on file
- 19
- Latest survey
- August 29, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Woodhaven Nursing Center during CMS and state inspections, most recent first.
Surveyors observed a medication error rate of 16.13% when a nurse administered medications by the wrong route to a resident with a G-Tube, based on inaccurate shift report information, and gave oral diabetes medication to another resident without food, contrary to physician orders. Both errors resulted from failure to verify current orders and assess residents prior to administration.
The facility did not ensure that food was served at a palatable and safe temperature, as evidenced by multiple residents consistently receiving cold meals, particularly at breakfast. A test tray confirmed that food items were cold to the touch and taste, and residents frequently requested reheating. The issue was linked to staff training gaps, staffing shortages, and equipment needing repair.
Surveyors found that dishware and food preparation areas were not properly cleaned, food items in storage were often unlabeled or undated, and staff failed to monitor and record food temperatures, resulting in hot food being served below required temperatures. The Food Service Supervisor and aides lacked adequate training and did not maintain temperature logs, and equipment issues further contributed to the deficiencies.
Two residents were left with medications at their bedside without proper assessment or physician authorization for self-administration. In both cases, nursing staff left medications for residents to take on their own, despite facility policy requiring witnessed administration and no completed assessments or orders permitting self-administration. The Medical Director and Administrator confirmed that no residents were authorized to self-administer medications and that the required process was not followed.
A medication aide placed an unlabeled cup containing several medications in a medication cart drawer after preparing them for a resident who was unavailable, instead of following proper medication storage procedures. The aide later acknowledged not knowing the correct protocol, and the administrator confirmed that medications are required to be properly labeled and not left unsecured.
A nurse failed to don a gown while administering medication via a G-tube to a resident on Enhanced Barrier Precautions, despite facility policies and signage requiring both gloves and gown for such high-contact care. The nurse, an agency staff member, acknowledged awareness of the requirement but did not comply during the observed care.
The facility did not accurately post the daily resident census on health care staff forms for over half of the days reviewed, with discrepancies between the posted numbers and the actual census. The Staffing Scheduler used census data from the admission Director based on the midnight count, which was not updated for admissions or discharges occurring afterward, leading to inconsistent and incorrect postings.
A resident with bilateral lower extremity edema did not receive ordered TED compression stockings and leg elevation in a timely manner. Despite orders from a Vascular NP, the facility delayed providing the necessary compression garments, and the resident's wheelchair lacked proper leg rests for elevation. The resident experienced symptoms such as feet discoloration and edema, and the Medical Director deemed the delay unacceptable.
The facility failed to manage medications properly, with expired medications found on the 1100 Long Hall and Memory Care Unit medication carts, and in the Rehab Unit's automated dispensing machine. A resident's medications were past their disposal dates, and another's inhaler lacked an opened date. Loose pills were also found in a medication cart drawer. Nurses acknowledged the issues, and the DON admitted responsibility for checking expired medications.
A facility failed to conduct a timely AIMS assessment for a resident on antipsychotic medication, despite a pharmacy recommendation. The resident, with schizophrenia and major depression, was on Risperdal. The Interim DON and Unit Manager did not ensure the assessment was completed, although it was last done ten months ago. The Administrator expected assessments every six months, but this was not met.
A facility failed to follow its abuse policy when a staff member witnessed a nurse slap a resident and did not report it, resulting in no protection or investigation. A second incident involved a nurse roughly removing a dressing, causing pain, and raising a hand to slap the resident, which was not reported by two aides. These failures placed residents at risk for further abuse.
A resident in a LTC facility was subjected to abuse by a nurse, who slapped the resident in one incident and roughly removed a dressing in another, causing a skin tear. Staff members witnessed these events but did not report them, and the facility failed to document the incidents. The nurse had a history of rough behavior and yelling at residents, but no prior complaints had been addressed by the administration.
A resident was found unresponsive and not breathing, but the LTC facility failed to immediately call EMS despite the resident being a full code. CPR was initiated by a nurse, but there was a delay in additional staff assistance and in contacting 911. The facility's locked doors and non-working doorbell further delayed EMS access. The resident was eventually transported to the hospital but was pronounced deceased. Interviews revealed confusion over who was responsible for calling 911 and ensuring EMS access.
The facility failed to perform daily wound care treatments as ordered for two residents with stage IV pressure wounds, leading to missed treatments and potential risk of infection. The treatments were not signed off on multiple days, and the nursing staff confirmed that the treatments were not completed due to being overwhelmed.
The facility failed to implement Enhanced Barrier Precautions (EBP) during high contact resident care activities. Two nursing staff members provided wound care to a resident with a stage IV pressure ulcer without wearing a protective gown, despite the facility's policy requiring both gloves and gowns. Interviews revealed that staff had been trained but either forgot or did not think to apply the gown due to the absence of PPE in the designated storage area.
A resident's neurology appointment was missed due to unavailable transportation and was not rescheduled for several months. The resident, who required extensive assistance and had significant medical conditions, expressed frustration over the delay. The facility's corrective action plan did not cover the period when the appointment was missed, and the issue was only identified months later.
The facility's QAPI failed to maintain procedures and monitor interventions, resulting in a resident missing a neurology appointment and another resident missing a post-operative appointment, leading to a necrotic wound. An interview revealed that the facility's corrective plan only reviewed missed appointments within a 30-day period, failing to identify the missed neurology appointment.
Medication Error Rate Exceeds 5% Due to Incorrect Administration Routes and Failure to Follow Orders
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 16.13% during a medication pass observation. Five medication errors were identified out of 31 opportunities, involving two residents. For one resident with a history of stroke, hypertension, depression, and respiratory failure, physician orders specified that multiple medications were to be administered via G-Tube. Despite accurate transcription of these orders in the electronic Medication Administration Record (eMAR), a nurse prepared and attempted to administer these medications orally, based on information received during the morning report that the resident no longer had a G-Tube. The nurse did not assess the resident prior to administration, and it was later confirmed by the resident and the unit manager that the G-Tube was still in place and medications should have been given via that route. In another instance, a resident with diabetes mellitus had an active physician order for Glucophage (metformin) to be administered with meals. During medication pass observation, the nurse prepared and administered the medication without providing food or a meal, as required by the order. The nurse later stated she was unaware of the specific instruction to give the medication with meals, as she had not read the entire medication order. This resulted in the medication being administered contrary to the physician's instructions. Both incidents were observed directly by surveyors and involved failures to follow physician orders as documented in the eMAR and on medication bottles. The errors were attributed to the nurse's reliance on verbal information from shift report without verifying the resident's current status or reviewing the full medication orders, as well as a lack of assessment prior to administration.
Failure to Serve Palatable and Properly Heated Food
Penalty
Summary
The facility failed to provide palatable foods at a safe and appetizing temperature for all seven residents reviewed for food palatability. Multiple residents, including one with severe cognitive impairment and diagnoses such as dementia and Type 2 diabetes, were affected. Observations revealed that breakfast trays were plated, placed in insulated domes, and loaded into a food cart for delivery to the dementia unit. However, when a test tray was sampled, the food items, including bacon, eggs, grits, and pancakes, were found to be cold to the touch and taste, with no steam or condensation present. The Food Service Supervisor confirmed the food was cold and admitted to not knowing how to maintain proper holding temperatures once trays were on the cart. Interviews with residents' representatives and during a Resident Council meeting indicated that complaints about cold food, especially at breakfast, were frequent and that residents often had to request staff to reheat their meals. The Food Service Supervisor was unaware of these complaints prior to the survey. The facility administrator acknowledged awareness of the issue, attributing it to new and insufficiently trained staff, staffing shortages, and the need for repairs to the steam table. No corrective or follow-up actions were described in the report.
Deficiencies in Food Service Sanitation, Food Storage, and Temperature Monitoring
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations, including the use of unclean and damaged dishware, improper storage of food, and inadequate cleaning of food preparation areas. During a kitchen tour, several steam pans, plates, dome lids, and serving trays were found with dried food residue, sticky substances, or were stacked while still wet. Some serving trays had peeling protective coverings, exposing the tray base. The Food Service Supervisor acknowledged that dietary aides were responsible for checking dish cleanliness, as there was no designated dish room staff. Further observations revealed that food preparation surfaces and equipment, such as the backsplash, stove ledge, steam table cover, and warmer oven, were covered with thick, greasy, and dried residues. Air vents in the kitchen had visible black and green matter, and a scoop was found submerged in a dry storage container of fish fry batter. In the walk-in refrigerator and freezer, several food items were found unsealed, unlabeled, or undated, including hot dogs, shredded cheese, tater tots, green beans, French toast, fried rice, and fish. The Food Service Supervisor stated that all food items should be sealed, labeled, and dated, but cited challenges due to limited staffing. During tray line observations, staff failed to monitor and record internal food temperatures, and hot food was served below the required 135°F. For example, meatloaf and pancakes were found at temperatures significantly below the standard, and staff either did not know the correct temperature requirements or did not consistently reheat food before serving. The Food Service Supervisor admitted to not keeping food temperature logs and not receiving in-house training on these procedures. The Administrator confirmed awareness of equipment issues and attributed the deficiencies to new staff, inadequate staffing, lack of training, and absence of routine deep cleaning schedules.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to assess and authorize the self-administration of medications before leaving medications at the bedside for two residents. For one resident with type 2 diabetes mellitus and chronic kidney disease, there was no documented assessment or physician's order permitting self-administration of medication. The resident was noted to be severely cognitively impaired according to the Minimum Data Set (MDS) assessment. During an observation, medications including Metformin, Amlodipine, and Jardiance were left at the bedside in a medication cup at the resident's request, and the nurse acknowledged this was not in accordance with facility policy. The nurse was not aware of any assessment or care plan allowing self-administration and later reported the incident to the Unit Manager after realizing the error. Another resident, diagnosed with type 2 diabetes mellitus and unspecified dementia, also did not have a self-administration assessment or physician's order for self-administration of medications. This resident was cognitively intact per the MDS assessment. During an observation, a nurse left multiple medications at the bedside while briefly leaving the room to retrieve a blood pressure machine. The resident self-administered the medications in the nurse's absence. The nurse later confirmed that she left the medications at the bedside and stated she was not concerned due to the resident's alertness but did not follow the required assessment and authorization process. Interviews with the facility's Medical Director and Administrator confirmed that the expectation is for medication administration to be witnessed and that no residents were authorized to self-administer medications. Both staff members involved were unaware of any completed assessments or orders for self-administration, and the facility's process requires an assessment and interdisciplinary team review before permitting self-administration, which was not followed in these cases.
Unlabeled Medications Left in Medication Cart Drawer
Penalty
Summary
A medication aide was observed storing an unlabeled cup containing multiple medications in the top drawer of a medication cart. The aide had prepared the medications for a resident but, upon realizing the resident was in the shower, placed the cup in the cart drawer with the intention of administering them later. The medications included a vitamin supplement, seizure medication, antidepressant, constipation medication, and a central nervous system stimulant. The cup was not labeled, and the medications were not secured according to facility policy or professional standards. During an interview, the medication aide admitted to not knowing the proper procedure for handling medications that could not be immediately administered, but acknowledged that medications should not have been left in the drawer. The administrator confirmed that the facility's process required medications to be properly labeled and not left out, and that periodic audits and staff education were in place regarding medication storage. The aide involved was new to the facility.
Failure to Follow Enhanced Barrier Precautions During G-Tube Medication Administration
Penalty
Summary
Nurse #2 failed to follow the facility's infection control policies by not donning a gown while administering medications via a gastrointestinal tube to Resident #37, who was on Enhanced Barrier Precautions (EBP) due to the presence of a G-tube. The facility's EBP signage and infection control policies required all healthcare personnel to wear gloves and a gown for high-contact resident care activities, including feeding tube care. During the observed medication administration, Nurse #2 entered the resident's room, donned gloves, and proceeded with the G-tube medication administration without wearing a gown, despite clear signage and available personal protective equipment at the door. Nurse #2, an agency nurse on her second shift at the facility, acknowledged awareness of the EBP requirements but stated she forgot to wear the gown. The Staff Development Coordinator/Infection Preventionist confirmed that agency staff receive infection control education, including EBP, either prior to or upon arrival at the facility, and provided documentation of Nurse #2's orientation and training. The Administrator and SDC/IP both confirmed that the facility's process and policies require staff to wear gowns and gloves for G-tube care, and that infection control education is routinely provided through meetings and huddles.
Inaccurate Daily Posting of Resident Census on Staffing Forms
Penalty
Summary
The facility failed to ensure the accuracy of the daily posting of health care staff census information for 15 out of 29 days reviewed. Record review showed that the posted census numbers on the daily staffing forms did not match the detailed census reports for multiple dates. The discrepancies included both over-reporting and under-reporting of the actual resident census. The daily posting was completed by the Staffing Scheduler, who relied on census numbers provided during the morning meeting by the admission Director. The census number used was based on the count at midnight and was not updated to reflect admissions or discharges that occurred after that time. Interviews with the Staffing Scheduler and the admission Director revealed a lack of clarity and consistency in how the census numbers were determined and reported. The Staffing Scheduler did not update the posted census if changes occurred after the initial count, and the admission Director confirmed that the number provided did not always include recent admissions or discharges. The Administrator was unaware of these discrepancies and confirmed that the posted census reflected the midnight count rather than the current census for the day.
Failure to Provide Compression Stockings and Leg Elevation
Penalty
Summary
The facility failed to provide Thromboembolic Deterrent (TED) compression stockings and elevation of the lower extremities for a resident with bilateral lower extremity edema, as ordered by the Vascular Nurse Practitioner. The resident, who was admitted with conditions including rheumatoid arthritis, diabetes mellitus type 2 with diabetic neuropathy, and atrial fibrillation, had been experiencing symptoms such as bilateral feet turning purple/black when sitting in a wheelchair. A consultation with the Vascular Clinic NP revealed moderate peripheral venous insufficiency, and orders were given for the resident to wear compression stockings during waking hours and elevate her legs when sitting. Despite these orders, the facility did not provide the necessary compression stockings in a timely manner. The resident reported not receiving the stockings until three months after the order was placed, and even then, only one stocking was initially provided. The resident had repeatedly inquired about the stockings with the Director of Nursing, who confirmed the orders but failed to ensure their timely arrival. Interviews with the LTC Support Nurse and Central Supply Supervisor revealed that the facility had ordered the stockings, but there were delays and issues with receiving the correct items. Additionally, the resident was not provided with a wheelchair that allowed for proper leg elevation, as the leg rests did not fit her wheelchair. This issue was only addressed after a physical therapist was consulted, who then provided a new wheelchair with elevating footrests. The Medical Director expressed that the delay in receiving the compression stockings was unacceptable, as they were crucial for managing the resident's condition and preventing further complications.
Medication Management Deficiencies
Penalty
Summary
The facility failed to properly manage medications in several areas, leading to deficiencies in medication storage and labeling. On the 1100 Long Hall medication cart, expired medications were found, including a Humalog insulin pen, an Incruse Ellipta inhaler, and a Timolol Maleate Ophthalmic solution, all of which were past their disposal dates according to the manufacturer's instructions. Additionally, an albuterol sulfate inhaler was not labeled with an opened date, and seven unidentifiable pills were found loose in the medication cart drawer. Nurse #9 acknowledged the presence of expired medications and loose pills, stating it was the nurse's responsibility to check for such issues, but she had not done so that morning. In the Memory Care Unit, an open box of Ipratropium Bromide nebulizer solution vials was found, which should have been disposed of after seven days, but was still present past its expiration. Nurse #8 admitted to missing the expired package during her check. In the Rehab Unit's medication storage room, expired insulin pens were found in the automated medication dispensing machine. The Rehab Nurse Manager was unsure of who was responsible for removing expired medications, while the DON admitted it was his responsibility to check the machine for expired medications. The DON acknowledged the need for staff to be more vigilant about expiration dates and following manufacturer's instructions.
Failure to Conduct Timely AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to act on a pharmacy recommendation to complete an Abnormal Involuntary Movement Scale (AIMS/discus) assessment for a resident who was receiving antipsychotic medication. Resident #57, who had diagnoses including schizophrenia, anxiety, and major depression, was prescribed Risperdal for his condition. Despite the care plan indicating the need to monitor for adverse side effects of antipsychotic medication, the AIMS/discus assessment, which was last completed ten months prior, was not conducted as recommended by the consulting pharmacist in July. The Interim Director of Nursing acknowledged that it was his responsibility to ensure pharmacy recommendations were addressed, but he failed to verify that the necessary actions were taken. Unit Manager #1 signed off on the pharmacy report, indicating the assessment was completed, but admitted to delegating the task without confirming its completion. The Administrator expected AIMS assessments every six months, but this was not adhered to for Resident #57. The Consulting Pharmacist confirmed notifying the facility of the overdue assessment, emphasizing the importance of regular evaluations for residents on antipsychotic medications.
Failure to Report and Address Abuse Incidents
Penalty
Summary
The facility failed to adhere to its abuse policy when a staff member, Confidential Staff #1, witnessed Nurse #3 slap a resident, Resident #3, and did not report the incident to the administration. This inaction resulted in no immediate protection for the residents, no investigation into the incident, and no notification to the state, adult protective services, or law enforcement. The incident occurred after Resident #3, who was receiving incontinence care, spat on Nurse #3, prompting the nurse to slap the resident across the face. Confidential Staff #1 acknowledged recognizing the act as abuse but failed to report it due to past experiences of inaction by the administration. A second incident of abuse involved Nurse Aide #2 and Nurse Aide #3, who did not identify or report abuse when they witnessed Nurse #3 roughly remove a dressing from Resident #3's forearm, causing pain and reopening a skin tear. Nurse #3 then raised her hand as if to slap the resident, but was stopped by Nurse Aide #2's intervention. Despite recognizing the potential for abuse, neither aide reported the incident, allowing Nurse #3 to continue working with vulnerable residents in the Alzheimer's unit, thereby placing them at risk for further abuse. The facility's failure to report and address these incidents of abuse placed residents at a high likelihood of suffering serious injury or harm. The administration was unaware of any complaints or issues regarding Nurse #3's behavior until the incidents were reported much later. The facility's abuse policy clearly outlined the steps to be taken in the event of suspected abuse, including immediate reporting, examination of the resident, and notification of authorities, none of which were followed in these cases.
Failure to Protect Resident from Abuse by Nurse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by two separate incidents involving a nurse. In March 2024, a staff member witnessed a nurse slap a resident across the face after the resident spat on the nurse twice. The staff member reported that the nurse had previously exhibited concerning behavior, such as yelling at residents and handling them roughly, but no action was taken by the administration at that time. There was no documentation of this incident in the facility's records. In July 2024, during a weekly skin check, two nurse aides observed the same nurse rip a dressing off the resident's forearm, causing a skin tear to reopen and bleed. The resident yelled in pain, and after spitting on the nurse, the nurse raised her hand as if to slap the resident, but was stopped by one of the aides. Again, there was no documentation of this incident in the facility's records. The nurse later claimed that the resident's actions caused the dressing to come off and that she did not intend to hit the resident. Interviews with other staff members revealed that the nurse frequently yelled at residents and was rough during treatments. The facility's administrator stated that no complaints had been made to her regarding the nurse's behavior, and she emphasized that all staff should follow the care plan for residents with behavioral issues. The facility was found to be out of compliance due to these incidents, which affected the resident's right to be free from abuse.
Failure to Initiate EMS for Full Code Resident
Penalty
Summary
The facility failed to immediately initiate emergency medical services (EMS) for a resident who was found unresponsive, pulseless, and not breathing, despite being a full code. The incident occurred when a nurse discovered the resident in this state and began cardiopulmonary resuscitation (CPR) while calling out for assistance. However, there was a delay in additional staff arriving to help, and no one immediately called 911. The nurse had to stop CPR to seek further assistance, which contributed to the delay in emergency response. The situation was further complicated by the facility's locked doors and non-working doorbell, which delayed EMS access to the resident. EMS was not contacted until approximately 17 minutes after the resident was found unresponsive, and they arrived at the facility 16 minutes later. Upon arrival, EMS personnel found the resident still pulseless and apneic, and despite continued resuscitation efforts, the resident was pronounced deceased at the hospital. Interviews with staff revealed a lack of clarity regarding who was responsible for calling 911 and ensuring EMS access to the facility. The facility's protocol did not clearly designate these responsibilities, leading to confusion and delays during the emergency. The Medical Director and Administrator acknowledged the failure to immediately activate EMS and the need for someone to be designated to wait at the ambulance door for EMS arrival.
Failure to Perform Daily Wound Care Treatments
Penalty
Summary
The facility failed to perform daily wound care treatments on a stage IV sacral wound and a deep tissue injury to the left heel for Resident #4, and a stage IV pressure wound of the right posterior medial heel for Resident #5, according to the physician's orders. Resident #4 was admitted with diagnoses including an open wound to the left foot, dementia, and a pressure ulcer to the left buttock. Despite the physician's order to clean the sacrum with normal saline and apply specific dressings daily, the Treatment Administration Record revealed multiple instances where the treatment was not signed off, indicating it was not performed. Nurse #1 confirmed that the treatments were not completed on several days due to being overwhelmed and falling behind on the unit. Additionally, the wound care nurse practitioner observed that the dressing on Resident #4's sacral wound was not changed daily as ordered, exposing the resident to potential infection due to the presence of drainage on the old dressing. Resident #4 also had a physician's order to apply skin prep to the left heel and cover it with a bordered foam dressing. However, the Treatment Administration Record showed that this treatment was also not signed off on multiple days, indicating it was not performed. Nurse #1 again confirmed that the treatments were not completed on those days. An observation of the wound care revealed that the dressing on the left heel was not changed daily as ordered, and an incorrect application of betadine was noted, which was not part of the physician's order. The wound care nurse practitioner emphasized the importance of adhering to the daily wound care order for effective treatment. Resident #5, who was admitted with a stage II pressure ulcer, also did not receive daily wound care treatments as ordered for a stage IV pressure wound on the right posterior medial heel. The Treatment Administration Record showed that the treatment was not signed off on several days, and Nurse #1 confirmed that the treatments were not completed due to being overwhelmed. An observation revealed that the dressing on Resident #5's right heel was not changed daily as ordered. The wound care nurse practitioner reiterated the necessity of daily dressing changes to promote wound healing. The Director of Nursing stated that the nursing staff is expected to complete wound treatments according to the physician's orders to avoid compromising the residents' wound healing potential.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement the Enhanced Barrier Precautions (EBP) policy regarding the application of Personal Protective Equipment (PPE) during high contact resident care activities. Specifically, two nursing staff members were observed providing wound care to a resident with a stage IV pressure ulcer without wearing a protective gown, despite the facility's policy requiring both gloves and gowns for such activities. The observation revealed that the PPE storage unit on the bathroom door was empty, contributing to the staff's non-compliance with the EBP policy. The resident involved had a pressure ulcer and a dialysis access device, necessitating strict adherence to EBP to prevent infection. Interviews with the involved staff members indicated that although they had been trained on the EBP policy, they either forgot to apply the gown or did not think to do so due to the absence of PPE in the designated storage area. The Director of Nursing confirmed that the resident was on Enhanced Barrier Precautions and that staff should have been using both gloves and gowns during care. The Administrator acknowledged that while an in-service training was conducted in April 2024 when the EBP was first initiated, additional education was needed to ensure compliance with the policy.
Failure to Ensure Resident Transportation for Neurology Appointment
Penalty
Summary
The facility failed to ensure a resident had transportation for a neurology appointment that was scheduled on 10/03/2023. The appointment was canceled due to the transportation provider being unavailable and was not rescheduled until 03/19/2024. This affected a resident who had been admitted to the facility with diagnoses including spinal stenosis of the lumbar region with neurogenic claudication, weakness of the lower extremity, and leg spasms. The resident required extensive assistance with daily activities and was always incontinent of bowel and bladder. Despite being cognitively intact, the resident's follow-up neurology appointment was missed and not rescheduled in a timely manner, leading to a significant delay in care. The physician's orders did not include a follow-up appointment for neurology until 03/19/2024, months after the initial missed appointment. The resident expressed frustration over the delay during an interview on 04/23/2024. The Transportation Coordinator admitted that the missed appointment fell through the cracks and was not rescheduled promptly. The Health Information Manager and the facility physician were also unaware of the missed appointment until months later. The facility had a corrective action plan in place for missed appointments, but it did not cover the period when the resident's appointment was missed. The facility has since changed transportation providers due to reliability issues with the previous provider. The facility provided a corrective action plan for medically related social services with a compliance date of 01/11/2024. This corrective action plan was not acceptable to the State Survey Agency for this deficiency. On 3/19/2024, the Department of Social Services notified the facility Resident #2 had not attended her neurology appointment that was scheduled for 10/03/2023. Prior to 03/19/2024, the facility had not identified the deficient practice for Resident #2. A corrective action plan with all required components was not developed to address this deficient practice for Resident #2.
Failure to Ensure Resident Transportation for Medical Appointments
Penalty
Summary
The facility's Quality Assurance and Performance Improvement Program (QAPI) failed to maintain implemented procedures and monitor interventions following a complaint investigation. This failure was evident in the case of a resident who missed a neurology appointment scheduled for October 3, 2023, due to the unavailability of a transportation provider. The appointment was not rescheduled until March 19, 2024. This deficiency was initially identified during a complaint investigation on December 15, 2023, when another resident missed a post-operative appointment with an orthopedic surgeon on October 4, 2023, and was not seen until November 17, 2023. At that visit, the resident was found to have a necrotic wound on her right knee. An interview with the Administrator on April 24, 2024, revealed that the facility's plan of correction for the initial deficiency only reviewed missed appointments within a 30-day period. This limited review failed to identify the missed neurology appointment for the second resident in October 2023. The continued failure to ensure transportation for medical appointments during two surveys indicates a pattern of the facility's inability to sustain an effective Quality Assurance Program.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
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