Resident #3 fell on August 16 at Mayfair Village Nursing Care Center and was taken to the emergency room with left hip pain. Initial x-rays appeared negative, but a CT scan later revealed a nondisplaced greater trochanter fracture. Orthopedics recommended nonsurgical management with weight bearing as tolerated using a walker.
The fracture went undetected by facility staff for three days. CNP #270 discovered it only after MedOne physician services reviewed hospital notes on August 19 and found the CT scan results showing the break.
During those critical days following the fall, nursing staff failed to provide any pain relief despite the resident's ongoing complaints and available medication orders.
Medication records show acetaminophen was administered on August 16 for "no fever" but then nothing for pain management until August 20. On August 17, the resident reported pain levels of three and two. On August 19, pain remained at level three, yet no acetaminophen was given either day.
Progress notes from August 19 documented that the resident "had pain with turning and completing activities of daily living." CNP #270 was notified and gave a verbal order for stronger pain medication — oxycodone 5 mg every six hours as needed.
The resident's discomfort was evident to clinical staff. CNP #270's note from August 20 described the resident as appearing "uncomfortable and was unable to complete activities of daily living." She recommended using oxycodone "sparingly and only as needed due to concerns for falls."
Nursing reported the resident had "significant left hip pain and did not want to move too much."
When interviewed by inspectors on September 22, CNP #270 verified she had been concerned about prescribing opioids due to the resident's fall history. She confirmed noting the resident was in pain on August 18 and had expected facility staff to use the acetaminophen that had already been ordered to manage his discomfort.
"When the facility reported ongoing pain on August 19 she went ahead and ordered the oxycodone," inspectors wrote. "She was unaware the acetaminophen had not been used."
The Director of Nursing admitted the failure during her interview. She verified that "from August 17 to August 19 nursing did not attempt to give Resident #3 acetaminophen despite his reports of pain."
This included failing to provide any pain medication on August 19 even after the resident specifically requested stronger pain relief due to his ongoing discomfort.
Once oxycodone was finally administered starting August 20, records show it was given for pain levels ranging from four to six. The resident received the stronger medication on August 20 for pain levels of four, five, four, and six. It continued to be administered through the end of August for pain levels of five and six.
Certified Nursing Assistant #207 told inspectors she "could not recall the details but believed the resident may have reported pain once a little over a month ago."
The facility's own pain management policy, revised in April, required staff to ensure residents received treatment "in accordance with professional standards of practice" and "based on the resident specific assessment, preferences and choices."
The policy defined acute pain as "usually sudden in onset and time limited with a duration of less than a month" and "often caused by injury, trauma, or medical treatments." It mandated that the facility "identify and use specific strategies for preventing or minimizing different levels of sources of pain."
Federal inspectors cited the facility for failing to provide adequate pain management, finding that nursing staff had acetaminophen available by physician order but chose not to administer it during the three-day period when the resident was experiencing hip fracture pain.
The violation affected few residents but represented minimal harm or potential for actual harm, according to the inspection report.
The case illustrates how communication breakdowns between clinical providers and nursing staff can leave vulnerable residents suffering unnecessarily. While the physician expected existing acetaminophen orders to be used for pain control, nursing staff made no attempt to provide relief during the resident's most acute discomfort following his fracture.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mayfair Village Nursing Care C from 2025-09-23 including all violations, facility responses, and corrective action plans.
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