Blumenthal Nursing & Rehabilitation Center

F-F580: Based on record review and interviews with the Medical Director and staff, the facility failed to notify

the physician at the onset of pain and when the x-ray could not be completed stat (immediately) after Level of Harm - Immediate Resident #1 had an unwitnessed fall on 11/17/24 (Sunday). The x-ray was not performed 11/18/24 and the jeopardy to resident health or results indicated an acute nondisplaced (the bone does not break completely and there will be a crack on the safety bone) transverse (horizontal and perpendicular to the bone) left femur (thigh bone) fracture. The physician was not made aware of the fracture until 11/22/24 and was not notified the orthopedic consult ordered on Residents Affected - Few 11/19/24 was scheduled for 11/26/24. The facility also failed to notify the physician when the resident's pain was not manageable on night shift (11/20/24 and 11/21/24). Failure to notify the physician delayed orthopedic medical management, care and treatment and put the resident at high risk for complications such as deep vein thrombosis, pneumonia, bed sores, and increased risk for mortality. Resident #1 had an aspiration event (foods, stomach contents, or fluids are breathed into the lungs) while hospitalized which resulted in acute hypoxic respiratory failure (low levels of oxygen in your blood) and IV antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility on [DATE REDACTED]. This deficient practice affected 1 of 5 residents reviewed for notification of change (Resident #1).

F-F684: Based on record review and interviews from the Medical Director, the Nurse Practitioner (NP), Orthopedic Surgeon, Responsible Party (RP) and staff the facility failed to recognize the seriousness of the injury Resident #1 sustained from a fall and identify the need for urgent orthopedic evaluation. Resident #1 reported pain in her left hip on 11/17/24 following a fall. A STAT (with no delay) x-ray was ordered on Sunday 11/17/24, was not completed until 11/18/24, and revealed a nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (thigh bone) fracture. On 11/19/24 the NP ordered scheduled opioid medication for increased pain and ordered an orthopedic consultation at the request of Resident #1's RP. The resident remained in the facility awaiting an orthopedics consultation scheduled for 11/26/24. The Medical Director was not aware of the fracture until he saw Resident #1 on 11/22/24 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. Resident #1 was seen by the orthopedist on 11/22/24 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/24. While hospitalized , Resident #1 had an aspiration event (foods, stomach contents, or fluids are breathed into the lungs) which resulted in acute hypoxic respiratory failure (low levels of oxygen

in your blood) and Intravenous (IV) antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility on [DATE REDACTED]. The Orthopedic Surgeon indicated an injury like Resident #1's required an immediate transfer to the hospital for evaluation by an orthopedic specialist and that the risks of complications increased with the delay of care such as deep vein thrombosis (blood clots in veins deep in the body), pneumonia, and bed sores. This deficient practice affected 1 of 5 residents reviewed for falls (Resident #1).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0600

F-F714: Based on record review, and staff, Medical Director (MD) and Nurse Practitioner (NP) interviews, the NP failed to communicate and collaborate with the MD when Resident #1 was diagnosed on [DATE REDACTED] with an Level of Harm - Immediate acute nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse jeopardy to resident health or (horizontal and perpendicular to the bone) left femur (thigh bone) fracture following an unwitnessed fall on safety 11/17/24. The NP did not consult with the MD before making the decision the resident was probably not a surgical candidate and attempting to treat the resident in-house. Due to the lack of communication and Residents Affected - Few coordination the Medical Director (MD) was not aware of the fracture until he saw Resident #1 on 11/22/24 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. Resident #1 was seen by the orthopedist on 11/22/24 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/24. The lack of communication and collaboration between the NP and MD delayed orthopedic medical management, care and treatment and put the resident at high risk for complications such as deep vein thrombosis, pneumonia, and bed sores. Resident #1 had an aspiration event (foods, stomach contents, or fluids are breathed into the lungs) while hospitalized which resulted in acute hypoxic respiratory failure (low levels of oxygen in your blood) and IV antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days

after discharge back to the facility on [DATE REDACTED]. This failure affected 1 of 3 reviewed for accidents (Resident #1).

The Administrator was notified of immediate jeopardy on 1/3/25 at 8:48 AM.

The facility provided the following Acceptable Credible Allegation of Immediate Jeopardy removal.

Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of

the noncompliance:

An incident report was completed on 11/17/2024 at 11:05 am by the charge nurse, based on information obtained from certified nursing aide. Resident #1 was observed on the floor next to her bed sitting on her bottom. The resident was assessed by the charge nurse and no injuries were discovered during the initial assessment. The resident was assisted back to bed by the charge nurse and the certified nursing aide without incident. The charge nurse called the resident's Responsible Party (RP) and the Nurse Practitioner (NP) and no new orders were given. On 11/17/24 at 11:21 AM another progress note was entered in the electronic record which stated that the resident reported pain in her left hip and elbow when the RP arrived to

the facility. The facility failed to immediately notify the medical provider of the new onset of pain. The medical provider was not called until 2:14 PM and at that time the medical provider gave new orders for a stat x-ray and Tylenol 500mg every 6 hours as needed for pain. The Tylenol order was not entered until 3:05pm on 11/17/2024. The stat x-ray was not obtained on 11/17/2024. The nursing staff failed to notify the medical provider that the stat x-ray could not be obtained on 11/17/2024.

On 11/18/2024 the x-ray of the left hip was obtained at 9:23 am. The x-ray resulted on 11/18/2024 12:54 pm and the impressions were an acute transverse, nondisplaced intertrochanteric femur fracture. The resident's RP and NP were informed of the results on 11/18/2024 at 2:59 pm.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0600 On 11/19/2024 the NP assessed the resident after reviewing the x-ray and new orders were given for the resident to be seen by an orthopedic doctor. The NP elected not to send the resident out immediately after Level of Harm - Immediate conferring with the daughter who stated it was acceptable at the time. An orthopedic appointment was jeopardy to resident health or obtained for 11/26/2024. The NP ordered Tramadol 25 milligrams twice a day and to be given every 12 hours safety as needed for breakthrough pain.

Residents Affected - Few The Medical Director (MD) was not aware of the fracture until he saw Resident #1 on 11/22/24 at which time

he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day.

Resident #1 was seen by the orthopedist on 11/22/2024 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/2024.

The facility failed to notify the physician of an acute change in condition requiring emergent orthopedic medical treatment (x-ray results positive for fracture). The facility failed to notify the physician that an x-x-ray ordered stat was not going to be done stat. The facility failed to notify the physician that the orthopedic consult could not be scheduled ASAP. The facility failed to notify the physician when the resident's pain was not manageable on night shift on 11/20/2024 and 11/21/2024 when resident grabbed the aide and said stop.

The facility failed to identify the seriousness of Resident #1's left intertrochanteric femur fracture after a fall

on 11/17/2024 and identify the urgent need for orthopedic evaluation and surgical intervention. A STAT x-ray was ordered but not completed until 11/18/2024 and confirmed the fracture. The Nurse Practitioner ordered scheduled and as needed opioid pain medication and an orthopedic consultation on 11/19/2204 but failed to collaborate with the MD he was attempting to treat the fracture in- house.

The facilities neglect led to delayed treatment of Resident #1's left intertrochanteric femur fracture on 11/18/2024 causing Resident #1 to be sent to the hospital 11/22/2024. Resident #1 had surgery on 11/23/2024 to repair the left femur fracture.

To assist in identifying other residents who may have been affected by this deficient practice on 12/20/24 the Nurse Practitioner and Medical Director reviewed the previous 45 days of labs and radiology reports to ensure that all abnormalities have been addressed.

On 12/27/2024 the Nurse Managers reviewed residents who have fallen during the last 30 days to assess residents to include active and passive range of motion and pain assessment. This review also included examination of all recent incident reports to identify any patterns or recurring issues related to falls or delayed medical interventions.

The Director of Nursing and Regional Director of Clinical Services completed a review of all pain scales on 1/4/25 to assist in identifying any resident with unrelieved pain. Any opportunities identified during this audit will be corrected by the Nurse Managers by 1/4/25.

On 12/27/2024 the Nurse Managers reviewed residents who have fallen during the last 30 days to validate

the Medical Director had been notified. Any opportunities identified during this audit will be corrected by the Nurse Managers by 1/4/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0600 Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Level of Harm - Immediate jeopardy to resident health or On 12/20/24 the Director of Nursing/Staff Development Coordinator began in-person education for all facility safety staff in all departments including agency and contract staff. Education included review of policy regarding abuse/neglect. Residents Affected - Few - Recognizing signs of abuse and neglect

- Examples of neglect, including not providing necessary care and services.

- Reporting of abuse and neglect

- Facility policy and procedures for physician notification to include notification of physician to any complaints of unrelieved pain by residents to be reported to the physician immediately.

- Notification to physician of any delays in physician orders including stat orders and delay in any physician ordered appointments and x-rays.

- Education to certified nurse aides on reporting identified pain and other abnormal events identified during delivery of care.

Any nursing staff member that did not receive education on 12/20/2024 will receive education by the beginning of the next shift by the DON or designee. The Staff Development Coordinator will be responsible for tracking staff that still require education. Any staff that has not received education will not be allowed to work until education is received. All newly hired licensed staff will be educated by the Staff Development Coordinator on this policy. This education will be added to the orientation process. Staff Development was notified of this responsibility on 12/20/2024.

The DON or designee will verify the understanding of education through oral discussion and feedback with all staff and notate this on a tracking tool. The SDC will also do this in orientation.

In person education was completed on 12/27/2024 by the Director of Nursing to current medical providers including on-call providers, Nurse Practitioners and Medical Director. Education consisted of communication between all providers should be clear, concise and collaborative. Communication should include a discussion of treatment plans and seeking advice when necessary. Providers should participate in decision making in a timely manner.

On 1/3/2025 the Medical Director and the Physician Extenders agreed to meet with the Director of Nursing weekly to discuss abnormal labs, radiology or test results as a team.

On 1/3/2025 the Regional Director of Clinical Services informed the Staff Development Coordinator and/or

the Director of Nursing to complete monthly training on abuse and neglect for 3 months and then quarterly ongoing. Education will ensure abuse and neglect is explained to all staff per federal guidelines, Neglect as defined at 483.12, the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0600 Effective 1/4/2025 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Level of Harm - Immediate jeopardy to resident health or Alleged Date of Immediate Jeopardy removal: 1/5/2025 safety

An onsite validation was conducted on 01/09/25. A review of in-service records revealed that all facility staff Residents Affected - Few were educated on the facility's policy and procedures for abuse and neglect. This in-service training included: Recognizing signs of abuse and neglect, examples of neglect, including not providing necessary care and services, reporting of abuse and neglect, facility policy and procedures for physician notification to include notification of physician to any complaints of unrelieved pain by residents to be reported to the physician immediately, notification to physician of any delays in physician orders including STAT orders and delay in any physician ordered appointments and x-rays and education to nurse aides on reporting identified pain and other abnormal events identified during delivery of care. Interviews conducted with staff verified they had received training on abuse and neglect. The immediate jeopardy removal date of 01/05/25 was validated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm 43222

Residents Affected - Few Based on record review and Administrator interview, the facility failed to report an allegation of neglect to the state agency for 1 of 1 residents reviewed for neglect (Resident #1).

Findings included:

The Administrator was notified on 1/3/25 at 8:48 AM of an allegation of neglect after Resident #1 sustained a fall on 11/17/24 and did not receive necessary care and services for a fracture.

According to the Complaint Intake Unit (CIU), there was no evidence that an initial allegation report was submitted to the state agency until 1/6/25 at 2:15 PM.

The Administrator was interviewed on 1/6/25 at 10:08 AM. He revealed that the initial allegation report was not sent to the state agency on 1/3/25 because all parties involved, including the state agency, were aware of the allegation, so he assumed it was not necessary.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43222 jeopardy to resident health or safety Based on record review and interviews with the Medical Director, the Nurse Practitioner (NP), Orthopedic Surgeon, Responsible Party (RP) and staff, the facility failed to recognize the seriousness of the injury Residents Affected - Few Resident #1 sustained from a fall and identify the need for urgent orthopedic evaluation. Resident #1 reported pain in her left hip on 11/17/24 following a fall. A STAT (immediately) x-ray was ordered on Sunday 11/17/24, was not completed until 11/18/24, and revealed a nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (thigh bone) fracture. On 11/19/24 the NP ordered scheduled opioid medication for increased pain and ordered an orthopedic consultation at the request of Resident #1's RP. The resident remained in the facility awaiting an orthopedics consultation scheduled for 11/26/24. The Medical Director was not aware of the fracture until he saw Resident #1 on 11/22/24 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. Resident #1 was seen by the orthopedist on 11/22/24 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/24. While hospitalized , Resident #1 had an aspiration event (foods, stomach contents, or fluids are breathed into the lungs) which resulted in acute hypoxic respiratory failure (low levels of oxygen

in your blood) and Intravenous (IV) antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility on [DATE REDACTED]. The Orthopedic Surgeon indicated an injury like Resident #1's required an immediate transfer to the hospital for evaluation by an orthopedic specialist and that the risks of complications increased with the delay of care such as deep vein thrombosis (blood clots in veins deep in the body), pneumonia, and bed sores. This deficient practice affected 1 of 5 residents reviewed for falls (Resident #1).

Immediate jeopardy began on 11/18/24 when the facility failed to recognize the seriousness of the injury and identify the need for urgent orthopedic evaluation when x-ray results verified the resident sustained a transverse left femur fracture. The immediate jeopardy was removed on 1/9/25 when the facility implemented

an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems put into place and are effective.

Findings included:

Resident #1 was admitted to the facility on [DATE REDACTED] with diagnoses that included vascular dementia, muscle weakness, difficulty in walking, bradycardia (initiated 11/12/24), traumatic brain injury (TBI) in 1999, history of

a stroke, chronic obstructive pulmonary disease/asthma, and dysarthria (slurred speech).

Review of the annual Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed that Resident #1 had adequate vision/hearing, usually understood/understands, and was severely cognitively impaired. She did not have any falls since the previous assessment, and there was no pain presence or pain medication regimen in place at the time of the review period. Resident #1 was 62 inches tall and weighed 89 pounds.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0684 Review of physician orders for Resident #1 revealed that a pain assessment using 0-10 (0 = no pain, 10 = excruciating pain) scale or non-verbal scoring tool every shift was ordered on 11/9/24. Level of Harm - Immediate jeopardy to resident health or Review of an unwitnessed fall report dated 11/17/24 at 11:05 AM and completed by Nurse #1 revealed she safety was notified by Nurse Aide (NA)#1 that Resident #1 was on the floor next to her bed sitting on her bottom. Resident #1 denied hitting her head. The On-Call Provider and RP were notified. She was assessed, and no Residents Affected - Few injuries were noted. Vital signs were within normal limits. Resident #1 reported no pain or discomfort. She was then assisted back to her bed.

Review of a 72-hour post fall documentation note dated 11/17/24 at 11:21 AM and completed by Nurse #1 revealed that Resident #1 reported pain in her left hip when the RP arrived at the facility.

An On-Call NP note dated 11/17/24 at 2:32 PM revealed that Resident #1 had a fall at 11:00 AM. No injuries were reported, and Resident #1 denied pain. Now, Resident #1 reported left hip pain with tenderness to palpation (a method of feeling with the fingers or hands during a physical examination). Nurse #1 reports right facial swelling and concern for facial droop. A neurological check was performed by the NP via video and there were no acute deficits noted. A STAT x-ray of the left hip was ordered, as well as Tylenol 500 milligrams (mg) every 6 hours as needed (PRN) for pain. Neurological checks should be performed every 4 hours.

Review of physician orders for Resident #1 revealed that a one-time STAT x-ray of the left hip was ordered

on 11/17/24 at 3:04 PM. On the same day, Tylenol 500mg tablet given every 6 hours as needed for pain was also ordered.

Nurse #1 was interviewed on 12/19/24 at 11:14 AM. She revealed that on 11/17/24 around 11:00 AM, NA #1 told her that Resident #1 had fallen in her room. Nurse #1 went to the room and saw Resident #1 on her bottom next to her bed. Although Resident #1 was nonverbal, she could shake/nod her head to yes and no questions. Nurse #1 asked if she was ok, and she said yes. She then assessed Resident #1, including her extremities (limbs, hands, and feet), and asked if she hit her head. Resident #1 said no. She was then put back into bed with Nurse #1's assistance. Nurse #1 took vital signs and notified her supervisor at the time (name unknown). Nurse #1 was instructed to complete all documentation related to the fall and then called Resident #1's RP. The RP came later (45 minutes or so) and said Resident #1 complained of pain. Nurse #1 assessed her again, and Resident #1 said she was in pain. She assessed her left leg while she was laying

on her right side. When she pressed on it, Resident #1 winced with pain, and there was a bruise. She contacted the On-Call NP again and told her that there was new onset pain. The On-Call NP ordered an x-ray STAT. Nurse #1 stated she gave Resident #1 some Tylenol and then she left for the night at 7:00 PM.

A follow-up telephone interview was conducted with Nurse #1 on 12/19/24 at 6:05 PM. She revealed that radiology told her they would get to the facility on [DATE REDACTED] as soon as they could. Nurse #1 did not notify the On-Call Provider that the x-rays were not yet performed when she finished her shift at 7:00 PM on 11/17/24. Nurse #1 could not provide a reason as to why she did not notify the On-Call Provider of the STAT x-ray delay.

During a telephone interview with the Medical Director on 12/20/24 at 12:57 PM, he revealed that the expectation of a STAT x-ray was for it to be performed on the same day it was ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0684 The Director of Nursing (DON) was interviewed on 12/30/24 at 11:49 AM. She revealed that if a STAT x-ray was not performed within 2-4 hours after it was ordered or before a shift was completed, then Nurse #1 Level of Harm - Immediate should have contacted the On-Call Provider for further instructions on whether to wait or receive other orders. jeopardy to resident health or safety The RP was interviewed via telephone on 12/18/24 at 1:56 PM. She revealed that Nurse #1 called her on 11/17/24 when Resident #1 fell and said she was fine. She visited 45 minutes later, and when asked if Residents Affected - Few anything hurt, Resident #1 would say her left hip. The RP was told by Nurse #1 that an x-ray was ordered.

She waited until 8:00 PM, but no one came.

During a telephone interview with Nurse #3 on 12/19/24 at 11:41 AM, he revealed that when he arrived for

the night shift on 11/17/24, he was instructed by the day shift nurses to pay more attention to Resident #1 due to her trying to get up without assistance. Resident #1 needed assistance with transfers and was very unsteady on her feet.

Review of a medical progress note dated 11/18/24 at 10:00 AM and completed by the NP revealed that Resident #1 had a fall on 11/17/24. She denied hitting her head, injury, or pain following the fall. Resident #1 appeared at her baseline mental status and had tenderness to the left hip with palpation.

Review of a health status note dated 11/18/24 at 10:18 AM and completed by Nurse #2 revealed that radiology services were in the facility for Resident #1 to perform the STAT x-rays ordered on 11/17/24.

Review of a health status note dated 11/18/24 at 11:40 AM and completed by Nurse #2 revealed that Resident #1 continued to have pain/discomfort in her left hip.

Review of the x-ray results dated 11/18/24 revealed an acute transverse left femur fracture. The x-rays were taken at 9:23 AM and reported at 12:54 PM.

Review of a 72-hour post fall documentation note dated 11/18/24 at 2:18 PM and completed by Nurse #2 revealed that Resident #1 had a nondisplaced fracture to the left femur and reported a pain level of 4 in the left hip.

Review of the November 2024 medication administration record (MAR) revealed that Nurse #2 administered 500mg of as needed Tylenol to Resident #1 on 11/18/24 at 2:54 PM due to a pain level of 7.

Nurse #2 was interviewed on 12/19/24 at 12:09 PM. Nurse #2 revealed that she had worked with Resident #1 from 7:00 AM - 7:00 PM on 11/18/24. Resident #1 was not alert and oriented and was nonverbal but able to shake her head yes or no when asked a question. She stated Resident #1 had bruising on her left hip, and

an x-ray was ordered. On 11/18/24, it was found that Resident #1 had a left hip/leg fracture. Nurse #2 would ask Resident #1 how she was feeling during medication pass on 11/18/24 and if she was hurting, and she would nod yes if in pain. When working with her and turning her in bed, Nurse #2 noticed that Resident #1 would grimace some. It seemed she had pain from between a 4 to 7 out of 10 on the pain scale on 11/18/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0684 During a telephone interview with Nurse #3 on 12/19/24 at 11:41 AM, he stated he did not recall if he received any special instructions or was notified of the fracture when he arrived for the night shift on Level of Harm - Immediate 11/18/24. Resident #1 was nonverbal but would shake her head yes or no for responses. During the week of jeopardy to resident health or 11/18/24, he indicated that he could not recall if Resident #1 had any significant signs or symptoms of safety pain/discomfort.

Residents Affected - Few Review of a medical progress note dated 11/19/24 and completed by the NP revealed that Resident #1 had

an acute nondisplaced transverse intertrochanteric femur fracture. Resident #1's RP was waiting for the NP to contact her for consultation, which took place the same day. The RP requested an orthopedic evaluation.

The NP discussed complications about potential surgery with the RP and told her that orthopedics would consider Resident #1's overall health, specifics about the fracture, and new asymptomatic bradycardia.

An interview was conducted with the Unit Manager on 12/19/24 at 12:22 PM. She revealed that she spoke to

the RP on 11/19/24, and she wanted Resident #1 to be sent out to the hospital. The Unit Manager instructed her to speak to the NP, who then told her that Resident #1 was not a surgical candidate due to her low body mass. The Unit Manager indicated there was a non-verbal scoring tool with pain assessments on the MAR, and all nurses should have performed pain assessments during each shift.

Review of physician orders for Resident #1 revealed that on 11/19/24, an orthopedic surgery consultation for

a left hip/leg fracture was ordered.

An order note dated 11/19/24 at 10:16 AM by Nurse #2 revealed that new orders were received for an orthopedic consultation of Resident #1's left femur fracture after a fall.

Review of a health status note dated 11/19/24 at 11:43 AM by Nurse #2 revealed that Resident #1 continued to have pain/discomfort in her left hip. A consultation for orthopedics was ordered.

Review of a 72-hour post fall documentation note dated 11/19/24 at 2:29 PM and completed by Nurse #2 revealed that the note read in part: Current status of the resident's injuries or reports of pain from the fall: Acute transverse, nondisplaced intertrochanteric fracture femur is noted. No other acute fracture or dislocation. Interventions are currently in place to prevent additional falls: keep wheelchair beside bed, call bell within reach, bed in lowest/locked position, and Nurse Aides rounding every 2 hours. Resident's response to new interventions remains in the bed, Tylenol given for pain.

Nurse #2 was interviewed on 12/19/24 at 12:09 PM. Nurse #2 revealed that she had worked with Resident #1 from 7:00 AM - 7:00 PM on 11/19/24. The nurse stated she asked Resident #1 how she was feeling

during medication pass on 11/19/24 and if she was hurting, and she would nod yes if in pain. On 11/19/24,

an order for Tramadol was added.

Review of a health status note dated 11/19/24 at 2:40 PM and completed by the Unit Manager revealed that Resident #1's RP was at her bedside with some concerns of increased pain due to the left hip/leg fracture.

The RP stated that her family told her that Resident #1 needed to go to the hospital for 24-hour care. It was explained to the RP that Resident #1's pain could be managed at the facility; however, if she felt the pain was getting worse, the family could make the decision to send her out to the hospital. The Unit Manager spoke with the NP, who ordered scheduled Tramadol (treats moderate to moderately severe pain). The RP was made aware.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0684 On 11/19/24, a physicians order for Tramadol (opioid) 25mg twice daily due to the resident having increased pain. Level of Harm - Immediate jeopardy to resident health or During an interview via telephone on 12/18/24 at 1:56 PM the RP indicated they visited on 11/18/24 and safety found out about the left hip/leg fracture x-ray results. She requested to speak to the NP, but she was not contacted until 11/19/24. He (the NP) told her that Resident #1 had a broken hip and would not send her out Residents Affected - Few because she was not a surgical candidate due to her small body frame and the fracture could possibly heal

on its own. On 11/19/24, the RP stated she told the Unit Manager that Resident #1 was still in pain, and the RP wanted her to be sent out to the hospital. The RP stated she could not rate Resident #1's pain level due to her dementia but when she (the resident) reached for something she would say her left hip was hurting. When the RP asked if they could send Resident #1 to the hospital, the Unit Manager told her that the hospital would send her right back. The Unit Manager then ordered stronger pain medication. The RP stated her main concern was that Resident #1 was not sent to the hospital immediately after the fall.

During a telephone interview with the RP on 12/18/24 at 10:28 AM, she revealed on 11/19/24 when she spoke to the NP over the phone, he told her that he would not send Resident #1 to the hospital due to her small body frame, and it would be difficult for the surgeons to work on her. The RP recalled the facility scheduled an orthopedic appointment originally for 11/26/24.

During a follow-up telephone interview with the RP on 12/20/24 at 9:56 AM, she revealed that when she spoke to the NP over the phone on 11/19/24, he never spoke to her about the risks of not sending Resident #1 out to the hospital.

Review of a medical progress note dated 11/20/24 and completed by the Medical Director revealed that Resident #1 denied pain and neurological checks remain normal. The note indicated staff were to provide closer supervision and that fall protocols were in place. Laboratory results and radiology were reviewed.

The Night Nurse Supervisor was interviewed via telephone on 12/21/24 at 7:48 AM. She revealed that she did not assess Resident #1 for pain at all on 11/18/24, 11/19/24, or 11/20/24 She stated that she took the information in the 72-hour post fall documentation notes from the previous shift and copied the details into

the notes she wrote just so that some kind of documentation was completed during her shift. The Night Nurse Supervisor indicated that as a supervisor, she would review the documentation that needed to be completed by the nurses during her shift. If documentation was not completed, then she would have done it herself. Resident #1 was nonverbal, so she could not verbally provide a pain scale rating.

During a telephone interview with NA #3, who worked with Resident #1 during the night shift from 7:00 PM

on 11/20/24 until 7:00 AM on 11/21/24, she revealed that Resident #1 had fallen 3 days prior, and this was

the first time she had worked with Resident #1. When she arrived for her shift, she was notified by the off coming NA that Resident #1's left hip was hurt and to be cautious during care. NA #3 remembered that Resident #1 said ow during an incontinence care episode when she touched her left hip. She did not notify anyone of the pain because she was notified about the left hip at the beginning of her shift. She made sure not to change or move Resident #1 during the shift unless necessary.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0684 Review of a medical progress note dated 11/21/24 and completed by the Medical Director revealed that Resident #1 denied all pain and appeared comfortable. There was no injury since her last fall and fall Level of Harm - Immediate protocols were already in place. Laboratory results and radiology reviewed. jeopardy to resident health or safety A telephone interview was conducted with NA #2 on 12/19/24 at 10:53 AM. She worked with Resident #1

during the overnight shift from 7:00 PM on 11/21/24 until 7:00 AM on 11/22/24. NA #2 revealed that it Residents Affected - Few appeared Resident #1 was in a lot of pain during her shift because she would refuse care, was not willing to get out of bed, and was not willing to roll side to side. Resident #1 was nonverbal, but when NA #2 tried to turn her in the bed, Resident #1 would grab her arm as if she was telling NA #2 to stop.

Review of the MAR for November 2024 revealed that pain assessments were completed with a check mark from 11/19/24 - 11/22/24 without a numerical value or location for pain or a non-verbal pain scoring tool result in the medical record.

Review of a medical progress note date 11/22/24 and completed by the Medical Director revealed that at the time of Resident #1's last fall on 11/17/24, she denied injury and denied pain. Since her last clinical examination on 11/21/24, Resident #1 complained of pain to the nurses. A recent x-ray of the left hip indicated a left intertrochanteric femur fracture. The Medical Director documented an immediate referral to orthopedics was made for today (11/22/24).

A telephone interview was conducted with the Medical Director on 12/19/24 at 10:19 AM. He revealed that

he did not review Resident #1's x-ray results from 11/18/24 until 11/22/24, and he did not receive an update from the NP that entire week. When he saw Resident #1 on 11/22/24, Resident #1 was in pain, and the Medical Director told staff that she needed to be sent out immediately. The Medical Director indicated he was told that Resident #1 had an orthopedic appointment the following week, but he told them she needed to go that day (11/22/24). The Medical Director stated that Resident #1 should have gone to the hospital as soon as the x-ray results came in on 11/18/24, and the surgeon would have made the decision if she was a surgical candidate or not.

An interview was conducted with the Unit Manager on 12/19/24 at 12:22 PM. She revealed that she thought Resident #1 was not in pain the week after the fall because there was one day (date unknown) that she got out of bed into her wheelchair. However, for most of that week after the 11/17/24 fall, Resident #1 remained

in bed, even though she was usually up daily. Every time she (the Unit Manager) asked if Resident #1 was in pain, she shook her head no. The RP told nursing staff that Resident #1 was in pain, but when staff asked her themselves, she would shake her head no. On 11/22/24, after the Medical Director saw the x-ray results and evaluated Resident #1, he wanted her to be sent out to an orthopedic appointment that same day.

The RP was interviewed via telephone on 12/18/24 at 10:28 AM and 1:56 PM. She indicated Resident #1 remained in bed the entire week until 11/22/24, the day she went to the hospital. The Scheduler called the RP on 11/22/24 and told her that the orthopedics appointment was rescheduled for that same day. No reason was provided. The orthopedics office saw the fracture, and Resident #1 was then sent to the emergency department (ED).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0684 The NP was interviewed on 12/18/24 at 1:00 PM. The NP stated radiology took an x-ray of Resident #1's left hip on 11/18/24 and the results indicated a left femur fracture. He revealed that he was concerned whether Level of Harm - Immediate Resident #1 would be suitable for surgery due to asymptomatic bradycardia. The NP indicated on 11/19/24 jeopardy to resident health or he requested Resident #1 be sent to the first available appointment at an orthopedics office to determine if safety she was a surgical candidate. The RP told the NP that she wanted Resident #1 to go to surgery, which was why an orthopedic consultation was scheduled for the following week (11/26/24). The NP indicated that he Residents Affected - Few did not send Resident #1 to the emergency department (ED) because he was unsure if she was a surgical candidate or whether she would be better conservatively managed so that the fracture could heal on its own. Resident #1 was having a little bit of pain, which was managed with pain medication. The pain became unmanageable on 11/22/24, and she was seen by the orthopedics office on 11/22/24, who then sent her to

the emergency department (ED) for surgery.

Review of an Orthopedic Visit note dated 11/22/24 revealed that Resident #1 was in no acute distress, and

the left leg was warm and perfused (adequate blood flow). Resident #1 pointed to the left groin area as a source of pain. Due to the results of the x-rays taken during the visit (intertrochanteric fracture of the left femur), Resident #1 was sent to the hospital from the appointment.

Review of a Hospital Discharge Summary dated 11/26/24 revealed that Resident #1 had a closed intertrochanteric fracture of the left femur. She was seen in the orthopedic office on 11/22/24 for further evaluation, and an x-ray was obtained which showed an intertrochanteric fracture of the left femur. She was sent to the ED for further evaluation, and a left femur intramuscular nail surgery was performed on 11/23/24.

The discharge summary indicated Resident #1 had an aspiration event while hospitalized which resulted in acute hypoxic respiratory failure and IV antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility.

The Orthopedic Surgeon, who performed the left hip surgery for Resident #1 on 11/23/24 in the hospital, was interviewed on 1/2/25 at 5:22 PM. He revealed that the healing and the treatment of Resident #1's left hip/leg fracture would not change with the delay of surgery. However, the risk of complications would go up if there was a delay. Such complications could be deep vein thrombosis (blood clots in veins deep in the body), pneumonia, and bed sores. The Orthopedic Surgeon stated that if Resident #1 was lying completely still, then the left hip pain could be well tolerated. However, if she was transferred to a chair or back to bed or rolling in bed, that could be significantly painful for her. In general, the standard of care was that if someone broke a long bone (such as the femur), they would need to be evaluated by an orthopedic specialist, who would then make the final decision for surgery within 24-48 hours after the injury. An injury like this would need an immediate transfer to the hospital. If she came to the clinic to be seen, she would have been sent directly to the ED, and they would not let her go home and wait for surgery. If this type of fracture was not treated within 24-48 hours, there are good outcome studies that were done showing a 30% perioperative mortality rate. That mortality rate would decrease if the injury was treated with surgery within 48 hours.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0684 The DON was interviewed on 12/30/24 at 11:58 AM. She revealed that nurses should have used a non-verbal pain tool or a pain scale when assessing Resident #1 for pain. She believed that the nurses Level of Harm - Immediate chose N/A in the MAR when performing the pain assessments because Resident #1 denied pain. If a STAT jeopardy to resident health or x-ray was not done within 2-4 hours or before a shift was completed, then the nurse should have contacted safety the on-call provider for further instructions whether to wait or complete other orders. Resident #1 was noted

during that week without pain or discomfort. The providers made their decision, and if any pain or discomfort Residents Affected - Few was observed, the providers and managers would have agreed on further steps. The DON stated Resident #1 was not neglected, and the NP made his judgement call to keep her at the facility.

During an interview with the Administrator on 12/30/24 at 12:31 PM, he revealed that he could not speak on

this issue due to not having a clinical background.

The Administrator was notified of immediate jeopardy on 1/3/25 at 8:48 AM.

The facility provided the following Acceptable Credible Allegation of Immediate Jeopardy removal:

Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of

the noncompliance:

An incident report was completed on 11/17/2024 at 11:05 am by the charge nurse, based on information obtained from certified nursing aide. Resident #1 was observed on the floor next to her bed sitting on her bottom. The resident was assessed by the charge nurse and no injuries were discovered during the initial assessment. The resident was assisted back to bed by the charge nurse and the certified nursing aide without incident. The charge nurse called the resident's Responsible Party (RP) and the Nurse Practitioner (NP) and no new orders were given. On 11/17/24 at 11:21 AM another progress note was entered in the electronic record which stated that the resident reported pain in her left hip and elbow when the RP arrived to

the facility. The facility failed to immediately notify the medical provider of the new onset of pain. The medical provider was not called until 2:14 PM and at that time the medical provider gave new orders for a stat x-ray and Tylenol 500mg every 6 hours as needed for pain. The Tylenol order was not entered until 3:05pm on 11/17/2024.

On 11/18/2024 the x-ray of the left hip was obtained at 9:23 am. The x-ray resulted on 11/18/2024 12:54 pm and the impressions were an acute transverse, nondisplaced intertrochanteric femur fracture. The residents' RP and NP were informed of the results on 11/18/2024 at 2:59 pm.

On 11/19/2024 the NP assessed the resident after reviewing the x-ray and new orders were given for the resident to be seen by an orthopedic doctor. The NP elected not to send the resident out immediately after conferring with the RP who stated it was acceptable at the time. An orthopedic appointment was obtained for 11/26/2024. The NP ordered Tramadol 25 milligrams twice a day and to be given every 12 hours as needed for breakthrough pain.

The NP made a determination to treat the injury in-house because he considered the resident to not be a good surgical candidate.

The Medical Director was not aware of the fracture until he saw Resident #1 on 11/22/24 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0684 Resident #1 was seen by the orthopedist on 11/22/24 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/24. Level of Harm - Immediate jeopardy to resident health or The facility failed to identify the seriousness of Resident #1's left intertrochanteric femur fracture after the fall safety on 11/17/24, identify the urgent need for orthopedic evaluation and surgical intervention, obtain the x-ray stat as ordered by the medical provider. In addition, the facility also failed to explain to the RP the risk of not Residents Affected - Few sending the resident out for treatment versus managing the fracture in-house without a physician and/or orthopedic consultation. The delay in orthopedic medical management care and treatment put the resident at risk for complications such as DVT, PNA and bed sores.

On 12/27/24 the Director of Nursing, Unit Managers and Regional Director of Clinical Services, reviewed the last 30 days of diagnostic results and progress notes for all residents to identify any instances of delay in carrying out orders, changes in condition, abnormal results, refusals or other clinical conditions that had not been properly identified and acted upon. If there were instances identified, the Unit Manager completed proper assessment and follow-up with resident, medical providers and responsible party as needed.

Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete:

The Staff Development Coordinator, Regional Director of Clinical Services, and Unit Managers conducted in-person education for Licensed Nurses, including agency nurses, on recognizing when to seek medical treatment for residents with fracture and changes in condition and notification to the Physician/Medical Director following an incident or change of condition and when receiving ordered diagnostic test results. Requirements for notification included reporting of abnormal labs and x-ray results, if an order is not to be carried out as ordered by the physician or nurse practitioner, refusal of treatment plan by the resident or responsible party. Education also included knowing the risk and benefits of not sending a resident out for treatment when needed and how to effectively communicate this information to the RP or resident if they are responsible for making their own healthcare decisions. Risks include worsening condition, delayed treatment plan, increased pain or discomfort and complications associated with the disease process. The Director of Nursing will ensure that no staff member works without receiving this education. The Staff Development Coordinator is responsible for tracking that all staff received the required education. Any new hires, including agency staff, will receive education prior to the start of their shift. Education will be completed by 1/8/2025 by

the Staff Development Coordinator.

The Staff Development Coordinator, Regional Director of Clinical Services, and Unit Managers initiated in-person training for all Licensed Nurses, including agency nurses, to ensure they understand the requirements for orders received for diagnostic tests. The requirements included: If the diagnostic test is ordered stat and the mobile diagnostic company is unable to perform the study stat or in an acceptable time at the direction of the medical provider the resident is to be sent to the hospital. The Director of Nursing will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift. Education will be completed by 1/4/2025. The Staff Development Coordinator will be responsible for tracking all staff to make sure they have received the required education.

The Staff Development Coordinator was informed of her responsibility on 12/27/24. This education will also become a part of the new hire orientation process for all newly hired licensed nurses.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0684 On 12/27/24, the Staff Development Coordinator, Regional Director of Clinical Services, and Unit Managers conducted in-person education for all Licensed Nurses, including agency nurses, on the procedure for Level of Harm - Immediate handling abnormal x-ray results. The training emphasized that abnormal results must be reported to the jeopardy to resident health or Medical Director for further orders. Education will be completed by 1/4/2025. Any staff who did not receive safety the in-person training will be educated before their next scheduled shift. The Staff Development Coordinator is responsible for tracking that all staff receive the required education. This training will also be included in Residents Affected - Few the new hire orientation for all newly hired licensed staf [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43222

Residents Affected - Few Based on record review, and Medical Director, Nurse Practitioner, Responsible Party and staff interviews,

the facility failed to effectively intervene for complaints of pain, failed to provide thorough and ongoing pain assessments, and failed to effectively manage a resident's pain. This was for 1 of 1 resident reviewed for pain (Resident #1).

Findings included:

Resident #1 was admitted to the facility on [DATE REDACTED] with diagnoses that included vascular dementia, muscle weakness, difficulty in walking, bradycardia (a condition where the heart beats too slowly) (initiated 11/12/24), traumatic brain injury (TBI) in 1999, history of a stroke, chronic obstructive pulmonary disease/asthma, and dysarthria (slurred speech).

Review of the annual Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed that Resident #1 was severely cognitively impaired. She did not have any falls since the previous assessment, and there was no pain presence or pain medication regimen in place at the time of the review period.

Review of physician orders for Resident #1 revealed that a pain assessment using 0-10 (0 = no pain, 10 = excruciating pain) scale or non-verbal scoring tool every shift was ordered on 11/9/24.

Review of an unwitnessed fall report dated 11/17/24 at 11:05 AM and completed by Nurse #1 revealed she was notified by Nurse Aide (NA)#1 that Resident #1 was on the floor next to her bed sitting on her bottom. Resident #1 denied hitting her head. The on-call provider and responsible party (RP) were notified. Resident #1 was noted to have regular white socks on both of her feet. She was assessed, and no injuries were noted. Vital signs (VS) were within normal limits (WNL). Resident #1 reported no pain or discomfort. She was then assisted back to her bed.

Review of a 72-hour post fall documentation note dated 11/17/24 at 11:21 AM and completed by Nurse #1 revealed that Resident #1 reported pain in her left hip when the RP arrived at the facility.

Review of an On-Call Provider note dated 11/17/24 at 4:15 PM and completed by the On-Call Provider revealed that Resident #1 had a fall at 11:00 AM. No injuries were reported, and Resident #1 denied pain.

The RP visited the facility and now Resident #1 reported left hip pain with tenderness to palpation. A neurological check was performed via video and there were no acute deficits noted. A STAT (with no delay) x-ray of the left hip was ordered, as well as Tylenol 500 milligrams (mg) every 6 hours as needed for pain. Neurological checks should be performed every 4 hours.

Review of physician orders for Resident #1 revealed that a one-time STAT x-ray of the left hip was ordered

on 11/17/24 at 3:04 PM. On the same day, Tylenol 500mg tablet given every 6 hours as needed for pain was also ordered at 3:15 PM.

Review of Resident #1's vital signs from 11/17/24 - 11/22/24 revealed that she had a pain value of 0 on 11/17/24 at 11:08 AM and 4:14 PM. On 11/18/24, Resident #1 had pain values of 7 at 2:54 PM and 4 at 3:26 PM. Only numerical values were entered. Where the pain was located was not included.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0697 Nurse #1 was interviewed on 12/19/24 at 11:14 AM. She revealed that she completed all documentation related to Resident #1's fall and called the responsible party (RP). She was nonverbal. She checked on her Level of Harm - Actual harm multiple times after the fall, and she did not voice any pain/concerns. The RP came later that day and said Resident #1 complained of pain. She assessed her again, and Resident #1 said she was in pain. She Residents Affected - Few assessed her left leg while she was laying on her right side. When she pressed on it, she winced with pain and there was a bruise. She contacted the doctor again and told her that the pain had not been discovered until just then. She was instructed to order an x-ray ASAP. She told the RP that Resident #1 could go to the emergency room (ER) because the x-ray time was uncertain. The RP said no to the ER, and she would be ok waiting (not too long). She gave her some Tylenol and then she left for the night at 7:00 PM but the Tylenol was not documented as given.

Review of the November 2024 medication administration record (MAR) revealed that Nurse #2 administered 500mg of as needed Tylenol to Resident #1 on 11/18/24 at 2:54 PM due to a pain level of 7.

Review of a health note dated 11/19/24 at 2:40 PM and completed by the Unit Manager revealed that Resident #1's RP was at her bedside with some concerns of increased pain due to the left hip/leg fracture.

The RP stated that her family told her that Resident #1 needed to go to the hospital for 24-hour care. It was explained to the RP that Resident #1's pain could be managed at the facility; however, if she felt the pain was getting worse, the family could make the decision to send her out to the hospital. The Unit Manager spoke with the Nurse Practitioner (NP), who ordered scheduled Tramadol (treats moderate to moderately severe pain). The RP was made aware.

The NP was interviewed on 12/18/24 at 1:00 PM, and he revealed that Resident #1 was having a little bit of pain on 11/19/24 but was managed with pain medication.

Review of physician orders for Resident #1 revealed that on 11/19/24, 25mg of Tramadol was ordered twice daily and as needed every 12 hours.

Review of the MAR for November 2024 revealed that pain assessments were completed with a check mark from 11/19/24 through 11/22/24 without a numerical value or location for pain or a non-verbal pain scoring tool result in the medical record.

Review of a 72-hour post fall documentation note dated 11/19/24 at 2:29 PM and completed by Nurse #2 revealed that Resident #1 remained in bed and Tylenol was given for pain. However, this pain medication administration was not documented. An interview was not conducted with Nurse #2 related to this documentation.

Review of a 72-hour post fall documentation note dated 11/19/24 at 10:29 PM and completed by the Night Nurse Supervisor revealed that it read the same information from Nurse #2's 72-hour post fall documentation note at 2:29 PM.

Review of a 72-hour post fall documentation note dated 11/20/24 at 10:45 PM and completed by the Night Nurse Supervisor revealed that Resident #1 had a nondisplaced fracture to the left femur and reported a pain level of 4 in the left hip.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0697 The Night Nurse Supervisor was interviewed on 12/21/24 at 7:48 AM. She revealed that Resident #1 was not assessed for pain by the Night Nurse Supervisor on 11/18/24, 11/19/24, or 11/20/24. She stated that she Level of Harm - Actual harm took the information in the 72-hour Post Fall Documentation notes from the previous shift and copied the details into the notes she wrote just so that some kind of documentation was completed during her shift. The Residents Affected - Few Night Nurse Supervisor indicated that as a supervisor, she would review the documentation that needed to be completed by the nurses during her shift. If documentation was not completed, then she would have done

it herself. Resident #1 was nonverbal, so she could not quantify her pain a 4. She stated that Resident #1 was not in pain on 11/18/24 - 11/20/24 during the overnight shifts because a NA (name unknown) got her up out of bed and into the wheelchair without knowing she had a broken hip/leg. However, Resident #1 did not display any nonverbal expressions of pain.

Nurse #3, who worked with Resident #1 during the overnight shifts from 11/17/24 through 11/21/24, was interviewed on 12/19/24 at 11:57 AM. He revealed that during the week of 11/18/24, he could not recall a change in Resident #1's status or if she had displayed any signs/symptoms of pain or discomfort.

During an interview with NA #3, who worked with Resident #1 during the overnight shift from 7:00 PM on 11/20/24 until 7:00 AM on 11/21/24, she revealed that Resident #1 had fallen 3 days prior, and this was the first time she had worked with Resident #1. When she arrived for her shift, she was notified by the off going NA that Resident #1's left hip was hurt and to be cautious during care. NA #3 remembered that Resident #1 said ow during an incontinence care episode when she touched her left hip. She did not notify anyone of the pain because she was notified about the left hip at the beginning of her shift. She made sure not to change or move Resident #1 during the shift unless necessary.

An interview was conducted with NA #2 on 12/19/24 at 10:53 AM. She worked with Resident #1 during the overnight shift from 7:00 PM on 11/21/24 until 7:00 AM on 11/22/24. NA #2 revealed that it appeared Resident #1 was in a lot of pain during her shift because she would refuse care, was not willing to get out of bed, and was not willing to roll side to side. Resident #1 was nonverbal, but when NA #2 tried to turn her in

the bed, Resident #1 would grab her arm as if she was telling NA #2 to stop.

Review of a 72-hour post fall documentation note dated 11/22/24 at 2:24 AM and completed by Nurse #3 revealed that Resident #1 had a nondisplaced fracture to the left femur and reported a pain level of 4.

Nurse #3 was interviewed on 12/23/24 at 9:58 AM. He stated that he could not recall the 72-hour post fall documentation note dated 11/22/24, and no NA notified him that Resident #1 was in pain from 11/18/24 - 11/22/24.

The RP was interviewed on 12/18/24 at 10:28 AM. She revealed that Resident #1 continued to have pain

after the fall on 11/17/24. An x-ray was performed on 11/18/24, which resulted in a left leg/hip fracture.

During a follow-up interview with the RP on 12/18/24 at 1:56 PM, she revealed that on 11/19/24, Resident #1 was still in pain. She asked the Unit Supervisor to order stronger pain medication. Resident #1 remained in bed the entire week until 11/22/24 when she went to the hospital. The RP stated she could not rate Resident #1's pain level due to her dementia, but when she reached for something, she would say her hip was hurting.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0697 An interview was conducted with the Unit Manager on 12/19/24 at 12:22 PM. She revealed that she thought Resident #1 was not in pain the week after the fall because there was one day (date unknown) that she got Level of Harm - Actual harm out of bed into her wheelchair. However, for most of that week after the 11/17/24 fall, Resident #1 remained

in bed, even though she was usually up daily. Every time she (the Unit Manager) asked if Resident #1 was in Residents Affected - Few pain, she shook her head no. The RP told nursing staff that Resident #1 was in pain, but when staff asked her themselves, she would shake her head no. On 11/22/24, after the Medical Director saw the x-ray results and evaluated Resident #1, he wanted her to be sent out to an orthopedic appointment that same day.

Review of a medical progress note date 11/22/24 and completed by the Medical Director revealed that at the time of Resident #1's last fall on 11/17/24, she denied injury and denied pain. Since her last clinical examination on 11/21/24, Resident #1 complained of pain to the nurses. A recent x-ray of the left hip indicated a left intertrochanteric femur fracture. The MD documented an immediate referral to orthopedics was made for today.

During an interview with the Medical Director on 12/20/24 at 8:27 AM, he revealed that he saw Resident #1

on 11/20/24 and she denied pain. When the MD saw Resident #1 on 11/22/24, and she said she was in pain,

he went to look at the provider communication book and found out about the fracture on that day.

Review of an Orthopedic Visit note dated 11/22/24 revealed that Resident #1 was in no acute distress, and

the left leg was warm and perfused. Resident #1 pointed to the left groin area as a source of pain. Due to the results of the x-rays taken during the visit (intertrochanteric fracture of the left femur), Resident #1 was sent to the hospital from the appointment.

Review of the emergency department note dated 11/22/24 revealed that Resident #1 was seen for left hip pain after a fall 5 days prior. She was treated for pain with Tylenol and Tramadol at the facility. Resident #1 has had left hip pain for a while now but not if resting.

The DON was interviewed on 12/20/24 at 12:25 PM. She stated that she was unable to retrieve the results of

the twice daily pain assessments from 11/19/24 - 11/22/24 based on the MAR details. If the nonverbal pain assessment tool was entered and the pain was 0, it would show up in vital signs of Resident #1's medical record. The DON stated she was unsure why the pain assessment results were not included in vital signs from 11/19/24 through 11/22/24. If the pain assessment was checked off in the MAR but not displayed in vital signs, then the pain assessment results were not necessarily a 0.

During a follow-up interview with the DON on 12/20/24 at 12:47 PM, she revealed that the nurses who completed the pain assessments from 11/19/24 through 11/22/24 must have chosen not applicable as a response because the results did not show up in the medical record.

During a follow-up interview with the DON on 12/30/24 at 12:00 PM, she revealed that all nurses should have continued with the complete pain assessments after 11/18/24.

During an interview with the Administrator on 12/30/24 at 12:32 PM, he revealed that he could not speak on

the issue of missing pain assessment from 11/19/24 through 11/22/24 and delayed pain medication due to not having a clinical background.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0714 Ensure the physician properly assigns and delegates tasks to a physician assistant, nurse practitioner or clinical nurse specialist. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43222 safety Based on record review, and staff, Medical Director and Nurse Practitioner (NP) interviews, the NP failed to Residents Affected - Few communicate and collaborate with the Medical Director when Resident #1 was diagnosed on [DATE REDACTED] with an acute nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (leg) fracture following an unwitnessed fall on 11/17/24.

The NP did not consult with the Medical Director before making the decision the resident was probably not a surgical candidate and attempting to treat the resident in-house. Due to the lack of communication and coordination the Medical Director was not aware of the fracture until he saw Resident #1 on 11/22/24 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. Resident #1 was seen by the orthopedist on 11/22/24 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/24. The lack of communication and collaboration between the NP and Medical Director delayed orthopedic medical management, care and treatment and put the resident at high risk for complications such as deep vein thrombosis, pneumonia, and bed sores. Resident #1 had an aspiration event (foods, stomach contents, or fluids are breathed into the lungs) while hospitalized which resulted in acute hypoxic respiratory failure (low levels of oxygen in your blood) and IV antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility on [DATE REDACTED]. This failure affected 1 of 3 reviewed for accidents (Resident #1).

Immediate jeopardy began on 11/18/24 when the NP failed to collaborate and communicate with the Medical Director regarding medical management when x-ray results confirmed Resident #1 had an acute nondisplaced intertrochanteric femur fracture. Immediate jeopardy was removed on 1/5/25 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems put into place and are effective.

The findings included:

Resident #1 was admitted to the facility on [DATE REDACTED] with diagnoses that included vascular dementia, muscle weakness, difficulty in walking, bradycardia (a condition where the heart beats too slowly) (initiated 11/12/24), traumatic brain injury (TBI) in 1999, history of a stroke, chronic obstructive pulmonary disease/asthma, and dysarthria (slurred speech).

Review of the annual Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed that Resident #1 was severely cognitively impaired, had adequate hearing/vision, could speak clearly, and usually understood/understands.

Review of an Unwitnessed Fall Report dated 11/17/24 at 11:05 AM and completed by Nurse #1 revealed she was notified by Nurse Aide (NA) #1 that Resident #1 was on the floor next to her bed sitting on her bottom.

She was assessed, and no injuries were noted. Vital signs (VS) were within normal limits (WNL). Resident #1 reported no pain or discomfort and was then assisted back to her bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0714 Review of a 72 Hour Post Fall Documentation note dated 11/17/24 at 11:21 AM and completed by Nurse #1 revealed that Resident #1 reported pain in her left hip when the responsible party (RP) arrived at the facility. Level of Harm - Immediate jeopardy to resident health or Review of On-Call Provider progress note dated 11/17/24 at 4:15 PM and completed by the on-call provider safety revealed that Resident #1 had a fall at 11:00 AM on 11/17/24. No injuries were reported, and Resident #1 denied pain. The RP visited the facility and now Resident #1 reported left hip pain with tenderness to Residents Affected - Few palpation. A neurological check was performed via video and there were no acute deficits noted. A STAT (immediately) x-ray of the left hip was ordered, as well as Tylenol 500 milligrams (mg) every 6 hours as needed for pain. Neurological checks should be performed every 4 hours.

Review of physician orders for Resident #1 revealed that a one-time STAT x-ray of the left hip was ordered

on 11/17/24 at 3:04 PM.

Review of a medical progress note dated 11/18/24 at 10:00 AM and completed by the NP revealed that Resident #1 had a fall on 11/17/24. She denied hitting her head, injury, or pain following the fall. Resident #1 appeared at her baseline mental status and had tenderness to the left hip with palpation.

Review of a health status note dated 11/18/24 at 10:18 AM and completed by Nurse #2 revealed that radiology services were in the facility to perform the STAT x-ray ordered for Resident #1 on 11/17/24.

Review of a health status note dated 11/18/24 at 11:40 AM and completed by Nurse #2 revealed that Resident #1 continued to have pain/discomfort in her left hip.

Review of a health status note dated 11/18/24 at 3:00 PM and completed by Nurse #2 revealed Resident #1's x-ray results of the left hip were an acute nondisplaced intertrochanteric (where the hip and thigh meet) femur fracture.

Review of Resident #1's radiology results report in the electronic medical record revealed an entry on the x-ray results that noted the Medical Director reviewed the report on 11/18/24 at 6:29 PM.

During a telephone interview with the Medical Director on 12/20/24 at 11:13 AM, he revealed that the nurses always put the printout of x-ray results in his mailbox or provider book to review. The Medical Director stated

on 11/18/24 he had cleared all the lab and x-ray results from the computer without looking at the x-ray report for Resident #1. He did not review the x-ray results of any resident if he did not place the original order. He stated that he relied on the paperwork in his mailbox or provider book for further evaluation/orders.

Review of a medical progress note dated 11/19/24 and completed by the NP revealed that Resident #1 had

an acute nondisplaced transverse intertrochanteric femur fracture. Resident #1's RP was waiting for the NP to contact her for consultation, which took place the same day. The RP requested an orthopedic evaluation.

The NP discussed complications about potential surgery with the RP and told her that orthopedics would consider Resident #1's overall health, specifics about the fracture, and new asymptomatic bradycardia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0714 Review of a health note dated 11/19/24 at 2:40 PM and completed by the Unit Manager revealed that Resident #1's RP was at her bedside with some concerns of increased pain due to the left hip/leg fracture. Level of Harm - Immediate The RP stated that her family told her that Resident #1 needed to go to the hospital for 24-hour care. It was jeopardy to resident health or explained to the RP that Resident #1's pain could be managed at the facility; however, if she felt the pain safety was getting worse, the family could make the decision to send her out to the hospital. The Unit Manager spoke with the NP, who ordered scheduled Tramadol. The RP was made aware. Residents Affected - Few

Review of physician orders for Resident #1 revealed that on 11/19/24, an orthopedic surgery consultation for

a left hip/leg fracture was ordered.

Review of a medical progress note dated 11/20/24 and completed by the Medical Director revealed that Resident #1 denied pain and neurological checks remain normal. Staff to provide closer supervision and fall protocols were in place. Laboratory results and radiology reviewed.

Review of a medical progress note dated 11/21/24 and completed by the Medical Director revealed that Resident #1 denied all pain and appeared comfortable. There was no injury since her last fall and fall protocols were already in place. Laboratory results and radiology reviewed.

Review of a medical progress note date 11/22/24 and completed by the Medical Director revealed that at the time of Resident #1's last fall on 11/17/24, she denied injury and denied pain. Since her last clinical examination on 11/21/24, Resident #1 complained of pain to the nurses. A recent x-ray of the left hip indicated a left intertrochanteric femur fracture. The Medical Director documented an immediate referral to orthopedics that had been made for today.

A telephone interview was conducted with the Medical Director on 12/19/24 at 10:19 AM. He revealed that

he did not review Resident #1's x-ray results from 11/18/24 until 11/22/24, and he did not receive an update from the NP that entire week. When he saw Resident #1 on 11/22/24, Resident #1 was in pain, and the Medical Director told staff that she needed to be sent out immediately. The Medical Director indicated he was told that Resident #1 had an orthopedic appointment the following week, but he told them she needed to go that day (11/22/24). The Medical Director stated that Resident #1 should have gone to the hospital as soon as the x-ray results came in on 11/18/24, and the surgeon would have made the decision if she was a surgical candidate or not.

A telephone interview was conducted with the Unit Manager on 1/3/25 at 8:33 AM, and she revealed that the NP did consult with her and the Director of Nursing (DON) on 11/18/24 about the decision to keep Resident #1 in the facility and order an orthopedic consultation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0714 The NP was interviewed on 12/18/24 at 1:00 PM. The NP stated radiology took an x-ray of Resident #1's left hip on 11/18/24 and the results indicated a left femur fracture. He revealed that he was concerned whether Level of Harm - Immediate Resident #1 would be suitable for surgery due to asymptomatic bradycardia (asymptomatic). The NP jeopardy to resident health or indicated on 11/19/24 he requested Resident #1 be sent to the first available appointment at an orthopedics safety office to determine if she was a surgical candidate. The RP told the NP that she wanted Resident #1 to go to surgery, which was why an orthopedic consultation was scheduled for the following week (11/26/24). The NP Residents Affected - Few indicated that he did not send Resident #1 to the ER because he was unsure if she was a surgical candidate or whether she would be better conservatively managed so that the fracture could heal on its own. Resident #1 was having a little bit of pain, which was managed with pain medication. The pain became unmanageable

on 11/22/24, and she was seen by the orthopedics office on 11/22/24, who then sent her to the ER for surgery.

During a follow-up telephone interview with the NP on 12/20/24 at 8:09 AM, he revealed that he did not recall why the MD was not consulted prior to 11/22/24. The NP stated he made the decision to keep Resident #1 in

the facility from consultations with the unit supervisor and the DON.

During a follow-up telephone interview with the NP on 1/2/25 at 3:34 PM, he revealed that he was not trained to communicate with the Medical Director on specific topics. The NP and the Medical Director communicate

on things that require additional assessments or moderate to severe issues (for example: a suspected arterial blockage in the lower extremities). The NP stated the only time he would communicate to the Medical Director about x-rays, or a fracture, was if he had a question about the treatment.

During a follow-up telephone interview with the Medical Director on 12/20/24 at 8:27 AM, he revealed the NP consulted with him quite often, but he should have consulted with the Medical Director about the fracture when he found out on 11/18/24. The Medical Director stated that the NP had lots of experience and was qualified to look at x-rays and make decisions. However, in this case, the NP made the wrong decision. He should have sent Resident #1 out when the x-ray results were received. The Medical Director indicated that

he had seen Resident #1 on 11/20/24, and she denied pain. He was unaware of the fracture on that date, and he was unaware that an x-ray was ordered by the On-Call Provider. He became aware of the fracture on 11/22/24 from the provider communication book. When he saw Resident #1 on 11/22/24, and she said she was in pain, he went to look at the communication report and found out about the fracture on that day. The fracture report was not in the communication book the days prior.

During an additional telephone interview with the Medical Director on 1/2/25 at 3:09 PM, he revealed that the NP could have made the decision on his own to wait for surgery for Resident #1 because he had a lot of experience and was an independent practitioner. The NP made those types of decisions daily and well. The Medical Director stated that if the NP was comfortable managing those type of situations (fractures), then he did not need to consult with the Medical Director. The Medical Director indicated that he expected the NP to communicate with him when he was unsure/unclear about something or had a question, which the NP did regularly. The Medical Director indicated he and the NP spoke daily.

Review of an Orthopedic Visit note dated 11/22/24 revealed that Resident #1 was in no acute distress, and

the left leg was warm and perfused. Resident #1 pointed to the left groin area as a source of pain. Due to the results of the x-rays taken during the visit (intertrochanteric fracture of the left femur), Resident #1 was sent to the hospital from the appointment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0714 Review of a Hospital Discharge Summary dated 11/26/24 revealed that Resident #1 had a closed intertrochanteric fracture of the left femur. She was seen in the orthopedic office on 11/22/24 for further Level of Harm - Immediate evaluation, and an x-ray was obtained which showed an intertrochanteric fracture of the left femur. She was jeopardy to resident health or sent to the ER for further evaluation, and a left femur intramuscular nail surgery was performed on 11/23/24. safety The discharge summary indicated Resident #1 had an aspiration event while hospitalized which resulted in acute hypoxic respiratory failure and IV antibiotics were initiated on 11/24/24. The resident was prescribed Residents Affected - Few additional oral antibiotics for three days after discharge back to the facility.

During an interview with the DON on 12/30/24 at 12:03 PM, she revealed that she was unaware of the medical providers' communication protocol.

During a follow-up telephone interview with the DON on 1/6/25 at 8:54 AM, the DON recalled the NP giving

the order for the orthopedic consultation and an explanation why Resident #1 may not have been a surgical candidate but did not ask for her opinion.

An interview was conducted with the Administrator on 12/30/24 at 12:34 PM, and he revealed that he could not speak on the medical provider collaboration issue due to not having a clinical background.

The Administrator was notified of immediate jeopardy on 1/3/25 at 8:48 AM.

The facility provided the following Acceptable Allegation of Immediate Jeopardy removal.

An incident report was completed on 11/17/2024 at 11:05 am by the charge nurse, based on information obtained from certified nursing aide. Resident #1 was observed on the floor next to her bed sitting on her bottom. The resident was assessed by the charge nurse and no injuries were discovered during the initial assessment. On 11/17/24 at 11:21 AM another progress note was entered in the electronic record which stated that the resident reported pain in her left hip and elbow when the responsible party (RP) arrived to the facility. The on-call medical provider was called at 2:14 PM and at that time the medical provider gave orders for a stat x-ray.

On 11/18/2024 the x-ray of the left hip was obtained at 9:23 am. The x-ray resulted on 11/18/2024 at 12:54 pm and the impressions were an acute transverse, nondisplaced intertrochanteric femur fracture. The resident's responsible party (RP) and Nurse Practitioner (NP) were informed of the results on 11/18/2024 at 2:59 pm. The NP made a determination to treat the injury in-house, but did not consult with the Medical Director regarding this treatment plan before making the decision to treat in house because he considered

the resident to not be a good surgical candidate.

The Medical Director (MD) saw the resident on 11/20/24 and 11/21/24 but was unaware of the fracture because of the lack of communication and coordination from the facility and the NP.

On 12/20/2024, the MD reviewed the NP's notes for the previous 30 days, including the on-call providers, to ensure the plan of care was appropriate for the residents. Any opportunities identified during this audit were corrected by the MD on 12/20/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0714 On 12/20/2024, the Regional Director of Clinical Services, Nurse Practitioner, Medical Director, and the Director of Nursing reviewed Resident #1's plan of care and collaborated on what the best course of Level of Harm - Immediate treatment should have been for the resident. jeopardy to resident health or safety On 1/4/25 the Regional [NAME] President educated the Medical Director, NPs, and covering providers on collaborating/consulting following a fracture and/or a significant change of condition. The Medical Director, Residents Affected - Few Nurse Practitioners and covering providers will collaborate 3 times a week via phone, in-person, or virtual to discuss the plan of care for the residents that have obtained a fracture or a significant change in condition.

The Regional [NAME] President educated The Director of Nursing and the Administrator to participate in the meeting.

On 1/4/2025, the Medical Director reviewed the guidelines for how the Nurse Practitioners and other covering providers to communicate with the Medical Director. The Medical Director and Regional [NAME] President discussed this agreement with the NPs and other providers on 1/4/25.

The Regional Director of Clinical Services educated the Nurse Management Team and the Director of Nursing regarding the nurse practitioners' notes, including on call to ensure communication and collaboration is completed. The Director of Nursing, unit managers, staff development nurse and Assistant Director of Nursing will review and print the nurse practitioner notes, including the on-call providers daily and place them

in the Medical Director's communication book. When the Medical Director is not in the facility, he will receive

an electronic HIPAA compliant copy of the medical progress notes generated each day. Any new hires, including agency staff, will receive education prior to the start of their shift via telephone or in person. This education was completed on 1/4/2025 by the Regional Director of Clinical Services.

Effective 1/4/2025 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance.

Alleged Date of Immediate Jeopardy Removal: 1/5/2025

An onsite validation was conducted on 01/09/25. The in-service conducted by Regional [NAME] President with the Medical Director, Nurse Practitioners, and covering providers on collaborating/consulting following a fracture and/or a significant change of condition was reviewed. The Medical Director, Nurse Practitioners and covering providers will collaborate 3 times a week via phone, in-person, or virtual to discuss the plan of care for the residents that have obtained a fracture or a significant change in condition. Interviews completed with

the Medical Director and Nurse Practitioner verified knowledge of the new process for collaborating and consulting following a significant change in condition. The immediate jeopardy removal date of 01/05/25 was validated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43222

Residents Affected - Few Based on record review and staff interviews, the facility failed to ensure a medical record was accurate regarding post fall documentation. This was for 1 of 5 sampled residents whose medical record was reviewed for documentation (Resident #1).

The findings included:

Resident #1 was admitted to the facility on [DATE REDACTED].

Review of a 72-hour post fall documentation note dated 11/17/24 at 11:21 AM and completed by Nurse #1 revealed that Resident #1 reported pain in her left hip when the responsible party (RP) arrived at the facility.

Review of a 72-hour post fall documentation note dated 11/18/24 at 2:18 PM and completed by Nurse #2 revealed that Resident #1 had a nondisplaced fracture to the left femur and reported a pain level of 4 in the left hip.

Review of a 72-hour post fall documentation note dated 11/18/24 at 11:43 PM and completed by the Night Nurse Supervisor revealed that it read the same information from Nurse #1's 72-hour post fall documentation note dated 11/17/24 at 11:21 AM for Resident #1.

Review of a 72-hour post fall documentation note dated 11/19/24 at 2:29 PM and completed by Nurse #2 revealed that the note read in part: Current status of the resident's injuries or reports of pain from the fall: Acute transverse, nondisplaced intertrochanteric fracture femur is noted. No other acute fracture or dislocation. Interventions currently in place to prevent additional falls: keep wheelchair beside bed, call bell within reach, bed in lowest/locked position, and Nurse Aides rounding every 2 hours. Resident's response to new interventions remains in the bed, Tylenol given for pain.

Review of a 72-hour post fall documentation note dated 11/19/24 at 10:29 PM and completed by the Night Nurse Supervisor revealed that it read the same information from Nurse #2's 72-hour post fall documentation note dated 11/19/24 at 2:29 PM for Resident #1.

Review of a 72-hour post fall documentation note dated 11/20/24 at 10:45 PM and completed by the Night Nurse Supervisor revealed that it read the same information from Nurse #2's 72-hour post fall documentation note dated 11/18/24 at 2:18 PM.

The Night Nurse Supervisor was interviewed via telephone on 12/21/24 at 7:48 AM. She revealed that Resident #1 was not assessed for pain on 11/18/24, 11/19/24, or 11/20/24. She stated that she took the information in the 72-hour Post Fall Documentation notes from the previous shift and copied the details into

the notes she wrote just so that some kind of documentation was completed during her shift. The Night Nurse Supervisor indicated that as a supervisor, she would review the documentation that needed to be completed by the nurses during her shift. If documentation was not completed, then she would have done it herself. Resident #1 was nonverbal, so she could not quantify her pain a 4.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 36 345006 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345006 B. Wing 01/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Blumenthal Health and Rehabilitation Center 3724 Wireless Drive Greensboro, NC 27455

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 0842 Review of a 72-hour post fall documentation note dated 11/22/24 at 2:24 AM and completed by Nurse #3 revealed that it read the same information from Nurse #2's 72-hour post fall documentation note dated Level of Harm - Minimal harm or 11/18/24 at 2:18 PM. potential for actual harm Nurse #3 was interviewed on 12/23/24 at 9:58 AM. He stated that he could not recall the 72-hour post fall Residents Affected - Few documentation note dated 11/22/24, and no Nurse Aide (NA) notified him that Resident #1 was in pain on 11/22/24.

The Director of Nursing (DON) was interviewed on 1/6/25 at 8:54 AM. She revealed that the Night Nurse Supervisor and Nurse #3 should only enter documentation that was factual and accurate. The DON stated that each nurse was supposed to assess the pain of Resident #1 during each shift and record their

observations. The Night Nurse Supervisor and Nurse #3 should have assessed Resident #1 for each note entered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 36 345006