Mecklenburg Heath And Rehabilitation

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

received and indicated a left tibia and fibula fracture. She stated the ADON assisted her with interviewing staff and there were no reports of Resident #1 having an accident or incident that would have caused a fracture. The interim DON stated Resident #1 had a history of fractures and osteoporosis and due to no reports of a fall or trauma to her leg they determined the fracture was pathological. A phone interview with

the Medical Director indicated she was notified on 8/28/25 that Resident #1 obtained a left tibia and fibula fracture and was transferred to the ED for further evaluation. She stated on 8/29/25 she reviewed Resident #1's medical record and due to her history of fractures, diagnoses of osteoporosis and osteopenia and no reports of a fall or trauma to her leg she determined the fracture was pathological in nature. The Medical Director indicated she did not review Resident #1's ED or hospital records nor was she aware of the right tibia fracture however Resident #1 having bilateral leg fractures made it more evident that the fractures were pathological. An interview conducted with the Administrator on 9/17/25 at 2:30 PM revealed she was notified immediately on 4/28/25 of Resident #1's x-ray results and that she had a leg fracture. She indicated interviews were conducted with nursing staff to determine if there was an incident or accident that occurred to cause the fracture, and no incidents or accidents were reported. She stated on 4/29/25 the Medical Director reviewed Resident #1's medical record and determined the fracture was pathological. She stated

they determined the source of the injury was pathological, so an initial allegation report was not submitted to the state agency nor was a 5-day investigation report completed.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mecklenburg Heath and Rehabilitation

2415 Sandy Porter Road Charlotte, NC 28273

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and staff interviews, the facility failed to provide a safe transfer for 1 of 3 residents reviewed for accidents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE REDACTED] with diagnoses that included end stage renal disease, dependence on renal dialysis, and dementia. The resident care guide dated 8/27/24 indicated Resident #1 required 2-person assistance and the use of a mechanical lift for transfers. The significant change Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #1 was severely cognitively impaired and dependent on staff for assistance with activities of daily living (ADL) including transfers. A phone interview conducted with Nurse Aide (NA) #1 on 9/16/25 at 8:41 AM revealed she was Resident #1's Responsible Party (RP) and worked at the facility on night shift (7:00 PM to 7:00 AM). She stated she was not assigned to Resident #1 when she worked but would check on her and provide care as needed. She revealed on 8/26/25 at approximately 8:00 PM Resident #1 was complaining of leg pain during incontinence care. She stated Nurse Practitioner (NP) #1 was making rounds the next morning and assessed Resident #1 due to her complaints of leg pain. NA #1 revealed after NP #1 assessed Resident #1, NA #2 assisted her with transferring Resident #1 with the mechanical lift from the bed to the wheelchair. A phone interview was conducted with NA #2 on 9/17/25 at 7:45 AM. NA #2 revealed she was assigned to Resident #1 on 8/26/25 from 7:00 PM to 7:00 AM on 8/27/25. She stated NA #1 provided incontinence care for Resident #1 at approximately 8:00 PM and told her she would be back at the end of her shift to assist Resident #1 with morning care. NA #2 stated on the morning of 8/27/25 she did not assist NA #1 with transferring Resident #1 using the mechanical lift. A follow-up phone interview was conducted with NA #1 on 9/17/25 at 9:34 AM. She stated on 8/27/25 she transferred Resident #1 from the bed to the wheelchair with the mechanical lift without a second person.

She stated she wanted to ensure Resident #1 was transferred gently due to her leg pain and felt she would accomplish this by transferring her alone. NA #1 revealed the transfer was successful and without incident.

She indicated the facility's policy was to have a second person when transferring a resident with the mechanical lift and she should have requested for another staff member to assist her with the transfer. An

interview with the Assistant Director of Nurse (ADON) on 9/16/25 at 4:26 PM revealed she was aware that NA #1 reported on the morning of 8/27/25 NA #2 assisted her with transferring Resident #1 using the mechanical lift, however, NA #2 denied that she assisted with the transfer. The ADON indicated two staff members should assist with mechanical lift transfers to ensure resident safety An interview conducted with

the Administrator on 9/17/25 at 2:30 PM revealed two staff members should assist with all mechanical lift transfers to ensure the resident was safe.

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