Resident #1 fell on October 16, 2025, breaking her right humerus. An X-ray the next day confirmed the fracture. Her responsible party declined aggressive treatment due to her declining health and hospice status, choosing comfort care instead.
But three weeks later, when state inspectors arrived on November 7, the facility still hadn't updated the resident's care plan to address the fracture.
The Director of Nursing acknowledged the oversight during the inspection. She told investigators that the resident's fracture "should have been care planned to enable staff to know what interventions to provide." She said the MDS nurse was responsible for updating the comprehensive care plan to reflect the fracture and necessary interventions.
The MDS nurse initially deflected responsibility. She told inspectors that floor nurses should have created an acute care plan for the fracture immediately after it occurred. "The floor nurses were responsible for doing the acute care plan and they should have done an acute care plan for Resident #'s fracture," she said.
Acute care plans, she explained, were for immediate issues like "falls, fractures and infections" where "interventions were listed right away." Comprehensive care plans were updated quarterly and annually during assessments.
But when pressed, the MDS nurse admitted the comprehensive care plan should have been updated. "I agree with you. [Resident #1's] comprehensive care plan should have been updated to reflect fracture of her right humerus," she told inspectors.
She noted that facilities have 14 days to update comprehensive care plans for significant changes, and acknowledged that fractures qualify as significant changes.
When inspectors requested to see acute care plans for the resident at 2:12 pm on November 7, none existed for the fractured arm.
The resident had moderate cognitive impairment, with a BIMS score of 09 on her quarterly assessment. She was receiving hospice services at the time of the fall and fracture.
On the day of the fall, staff had given the resident PRN morphine around 11:40 am for pain management. The hospice service called for clarification about the X-ray results on October 17, and a hospice nurse confirmed the fracture via email to the facility administrator.
The facility's own policy, revised in December 2016, requires comprehensive care plans that include "measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs." The policy mandates that interdisciplinary teams update care plans "when there has been a significant change in the residents' condition."
The policy also requires ongoing assessment, with care plans revised "as information about the residents and the residents' conditions change."
Despite having this policy in place for nearly nine years, staff failed to implement it when the resident sustained her fracture. The lack of an updated care plan meant staff had no formal guidance on how to position, move, or provide interventions for a resident with a broken arm.
During the inspection, the administrator had only just asked the MDS nurse to update the resident's comprehensive care plan to include "risk for fall and fracture" - three weeks after the actual fracture occurred.
The violation was classified as causing minimal harm or potential for actual harm, affecting few residents. But for this hospice patient with moderate cognitive impairment, the lack of coordinated care planning meant weeks without proper documentation of how staff should handle her fractured limb while keeping her comfortable in her final stage of life.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gracy Woods Nursing Center from 2025-11-24 including all violations, facility responses, and corrective action plans.