Great Oaks Rehabilitation and Healthcare Center failed to report the fractures affecting Resident #1, a cognitively impaired woman who has lived at the facility since November 2019. The resident cannot walk independently and requires assistance with transfers, according to her most recent assessment.
The fractures were discovered during a July 3 hospital visit for seizure-like activity. CT scans revealed bilateral displaced femoral neck fractures that imaging suggested may have been "subacute in nature given area of callus formation," indicating the breaks had occurred weeks earlier.
Administrator interviews revealed the facility believed the fractures were pathological and therefore didn't require state notification. But during a November 5 inspection interview, the administrator acknowledged "the cause of the fractures could not be determined and therefore met the definition of injuries of unknown origin that should have been reported."
The resident's injury timeline stretched back to May 28, when she experienced a syncopal episode and was transferred to the emergency room. The responsible party later told facility staff that Emergency Medical Services personnel "were not gentle" during the transfer from bed to stretcher, causing the resident to "yell out in pain."
Yet the facility's investigation file contained no staff witness statements, no record of conversations with the responsible party prior to the injury, and no supporting documentation verifying their conclusion that the fractures were pathological.
The facility's investigative summary listed three possible causes: pathological process, seizure activity, or rough EMS transfer. Despite this uncertainty, no report was filed with Mississippi authorities.
Director of Nursing interviews confirmed the resident was sent to the hospital on July 3 for evaluation of seizure-like activity, where imaging revealed the bilateral femur fractures. She stated that "the facility looked into it but was unable to determine the cause of the fractures."
The investigation wasn't initiated until July 3 when the fractures were identified, more than five weeks after the May 28 incident. The administrator confirmed that the responsible party had shared concerns about rough EMS handling during the May transport, which is why the facility dated their investigation to that earlier incident.
Additional injuries emerged in the record. A July 2 nurse's note documented that a nurse practitioner was "notified of bruising to face" for the same resident.
The resident's medical history includes malignant neoplasm of cervix uteri, protein-calorie malnutrition, and vitamin D deficiency. Her most recent mental status assessment scored one out of fifteen, indicating severe cognitive impairment.
Facility policy explicitly requires the abuse coordinator to "report injuries of unknown source with serious bodily injury within two (2) hours of the allegation" to the state agency. The policy also mandates reporting such allegations "in accordance with the state law."
The administrator's admission during the inspection interview directly contradicted the facility's handling of the case. He agreed that because the cause could not be determined, the bilateral femur fractures met the definition requiring state notification.
Federal inspectors found the facility failed to report an injury of unknown origin to the state agency for one of three residents reviewed for injuries during their complaint investigation.
The resident's functional abilities assessment showed complete dependence for transfers and inability to ambulate, making the circumstances surrounding her bilateral femur fractures particularly concerning given the facility's failure to conduct a thorough investigation or notify proper authorities.
The case highlights gaps in the facility's injury reporting and investigation procedures. Despite having written policies requiring prompt notification of serious injuries of unknown origin, staff failed to recognize that bilateral femur fractures with an undetermined cause warranted state agency involvement.
The facility's assumption that the fractures were pathological, without supporting medical documentation, led to a five-week delay in proper investigation and complete failure to notify state authorities as required by both facility policy and federal regulations.
The resident remains at Great Oaks Rehabilitation, where she continues to require assistance with all transfers and mobility. Her bilateral femur fractures, discovered more than a month after they likely occurred, represent injuries that may never be fully explained due to the facility's inadequate initial response and investigation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Great Oaks Rehabilitation and Healthcare Center from 2025-11-06 including all violations, facility responses, and corrective action plans.
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