The Greens At Lincolnton
Inspection history, citations, penalties and survey trends for this long-term care facility in Lincolnton, North Carolina.
- Location
- 515 S Generals Boulevard, Lincolnton, North Carolina 28093
- CMS Provider Number
- 345250
- Inspections on file
- 23
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at The Greens At Lincolnton during CMS and state inspections, most recent first.
The facility failed to request required Level II PASRR evaluations for four residents who developed new mental health diagnoses after admission. Each resident had a pre-admission Level I PASRR that directed the facility to resubmit paperwork for a Level II if new mental health conditions or significant changes occurred, yet subsequent MDS assessments documented new active diagnoses such as psychotic disorder, major depressive disorder, anxiety disorder, schizoaffective disorder, bipolar type, and autism without any corresponding Level II PASRR requests. The SW reported she was responsible for PASRR paperwork but had not received training on when and how to complete and submit Level II requests and was unaware they were required for new mental health diagnoses or significant changes, while the Administrator confirmed the SW’s responsibility and acknowledged that Level II PASRR evaluations had not been completed as expected for these residents.
During a COVID-19 outbreak, the facility failed to follow its own policies and CDC guidance for infection prevention and control. Staff entered a COVID-positive resident’s TBP room and performed COVID specimen collection without required eye protection, despite clear signage and available PPE. The facility did not have a specific policy for PPE during COVID specimen collection, and a UM reported uncertainty about eye protection requirements. Staff with COVID-19 were allowed to return to work before 10 days from symptom onset without documented negative viral tests on both day 5 and day 7, and there was no systematic logging or oversight of staff self-testing. COVID-positive residents were removed from TBP after 7–9 days based on a single negative antigen test on day 5, contrary to the policy requiring 10 days or two negative tests 48 hours apart. The facility also used expired COVID-19 test kits for staff and resident testing, despite manufacturer confirmation that the printed expiration dates were final and that results from expired tests would not be valid.
Surveyors found that the facility failed to educate cognitively intact residents on the benefits and potential side effects of the COVID-19 vaccine, did not consistently offer the vaccine, and did not document offers, consents, or declinations in the medical record. Multiple residents had MDS assessments indicating they were not up to date on COVID-19 immunization, with no vaccination history or related education documented, and they reported not recalling any discussion or offer of the vaccine. The IP nurse used an informal list to track interest, lacked a defined process for new admissions, and did not provide risk-versus-benefit education, while the formal admission and documentation processes in place for flu and pneumonia vaccines did not include COVID-19, resulting in absent medical record documentation for COVID-19 vaccination activities.
A resident with bladder neck obstruction and an indwelling urinary catheter had care plan interventions and medical orders in place, including securing the catheter to prevent excess tension and routine flushing for sediment. During observation, the catheter was connected to a bedside drainage bag with visible urine and sediment, but no catheter stabilization device was present. A NA had noticed the missing device earlier and reported it to the assigned nurse, who assessed the catheter but delayed replacing the device while awaiting input from the NP about a possible catheter change. The ADON later assessed the resident and confirmed the absence of the stabilization device, while the NP and Administrator both indicated the resident should have had a device in place to prevent pulling of the catheter tubing.
A resident with chronic pain and atrial fibrillation was recommended a sleep study by a pulmonologist due to respiratory issues. Despite scheduling attempts, the facility repeatedly canceled the sleep study appointments, resulting in no study being conducted. Facility staff were unaware of the orders, and the previous scheduler responsible for appointments had left, leading to a deficiency in providing necessary medical services.
The facility failed to issue the required SNF ABN to two residents before their discharge from Medicare Part A services. Although the NOMNC was provided, the staff were unaware of the need to issue the SNF ABN, resulting in the residents not receiving the necessary documentation about their financial responsibilities after Medicare coverage ended.
A resident on Eliquis sustained a severe injury from a bed rail assist bar, resulting in a large hematoma and open wound. The resident, with severe cognitive impairment and requiring assistance with bed mobility, was found with swelling and bruising on her arm. The facility's investigation determined the bed rail assist bar was the likely cause, as the resident's arm was often pressed against it during care. The resident's condition was worsened by her anticoagulant medication, which increased her bleeding risk.
A resident with severe cognitive impairment and impaired vision was not properly assessed for bed rail use, leading to a significant injury. The facility failed to account for the resident's cognitive deficits and anticoagulant medication use in their assessment. Additionally, informed consent was not obtained from the resident's representative, as the risks associated with bed rail use were not discussed. This oversight resulted in the resident sustaining a hematoma from the bed rail, requiring hospitalization.
A resident was administered a blood pressure medication without following set parameters, leading to hospitalization for low blood pressure. Additionally, the same resident was given a medication they were allergic to, as documented in their medical record. The facility's previous Medical Director was aware of the allergy but prescribed the medication regardless.
Failure to Request Level II PASRR Evaluations for Residents With New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit required Level II Preadmission Screening and Resident Review (PASRR) evaluations for multiple residents who developed new mental health diagnoses after admission. Record review showed that four residents each had a PASRR Level I completed prior to admission, with explicit recommendations to resubmit paperwork for a Level II PASRR if a new mental health diagnosis was suspected or if there was a significant change in condition. For one resident, the quarterly MDS documented active diagnoses of psychotic disorder and major depressive disorder that were established after admission, yet there was no evidence of a Level II PASRR request. Another resident’s quarterly MDS reflected active diagnoses of anxiety disorder, major depressive disorder, and schizoaffective disorder, bipolar type, all diagnosed after admission, with no corresponding Level II PASRR request in the record. A third resident’s annual MDS documented active diagnoses of psychotic disorder, anxiety disorder, and major depressive disorder, all diagnosed after admission, without any evidence that a Level II PASRR evaluation had been requested. A fourth resident’s quarterly MDS showed active diagnoses of autism, psychotic disorder, and anxiety disorder, again with no documentation of a Level II PASRR request despite the pre-admission Level I instruction to resubmit if new mental health diagnoses occurred or there was a significant change. In interviews, the Social Worker stated she believed she was responsible for PASRR Level II paperwork but had not received training on when and how to complete and submit it, and she was unaware that Level II PASRR paperwork was required for new mental health diagnoses, significant changes, or expiring temporary Level II determinations. The Administrator confirmed that the Social Worker was responsible for PASRR paperwork, acknowledged the Social Worker had not received full PASRR training, and stated his understanding that Level II PASRR evaluations should be completed upon admission or readmission with a mental health diagnosis and with any new mental health diagnosis or change in condition, which had not occurred for the sampled residents.
Failure to Follow COVID-19 PPE, Isolation, Testing, and Test-Expiration Requirements During Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policies and current CDC guidance during an ongoing COVID-19 outbreak. The facility policy required staff entering rooms of residents with suspected or confirmed COVID-19 to use an N95 or higher-level respirator, gown, gloves, and eye protection. One resident who tested positive for COVID-19 was placed on transmission-based precautions (TBP) with a door sign specifying gown, gloves, N95, and eye protection. A nurse aide entered this resident’s room wearing a gown, gloves, and mask but without eye protection, and there was no eye protection available on the PPE caddy outside the room. The nurse aide stated she believed her eyeglasses counted as eye protection. The infection prevention (IP) nurse, ADON, Administrator, and Regional Nurse all confirmed that full PPE, including eye protection, was required and that staff had been educated, but they could not explain why the nurse aide did not comply. The facility also failed to ensure appropriate PPE use during COVID-19 specimen collection. CDC interim guidelines for collecting and handling clinical specimens for COVID-19 require an N95 or higher-level respirator, eye protection, gloves, and gown for healthcare providers collecting specimens or working within 6 feet of patients suspected to be infected. The facility did not have a policy addressing PPE for COVID-19 specimen collection. During observation of resident COVID testing, one unit manager collecting nasal swabs wore an N95, gown, and gloves but did not wear eye protection, while another unit manager handling the specimens in the hallway wore an N95 and gloves. The IP nurse and ADON stated that full PPE, including eye protection, should be worn for COVID testing and that the facility had an adequate supply of face shields. The unit manager who collected the specimen reported she was unsure if eye protection was required and only obtained face shields after consulting someone from corporate. The facility failed to follow CDC return-to-work criteria for staff with COVID-19 and did not maintain adequate records of staff testing. The facility’s policy referenced CDC interim guidance for managing healthcare personnel with COVID-19 infection, which requires at least 7 days since symptom onset with a negative viral test within 48 hours prior to return (or 10 days if testing is not performed or if the day 5–7 test is positive), and, if using antigen tests, negative tests on day 5 and again 48 hours later. Review of the facility’s COVID-positive staff log showed 12 staff had tested positive, and 9 returned to work before 10 days from symptom onset without documentation of negative tests on both day 5 and day 7. The IP nurse stated staff were tested with antigen tests on day 5 and allowed to return to work on day 7 if that test was negative, and that she did not perform or document a second test on day 7. She also stated staff performed self-testing, that tests were placed in the break room or taken home, and that there was no process to track when staff tested, whether they tested as required, or whether tests were performed according to manufacturer instructions. The facility Physician and Administrator stated the facility should follow its infection control policies and CDC guidance, and the Administrator acknowledged there was no oversight or logging of staff COVID test results. The facility also failed to maintain TBP for COVID-positive residents in accordance with its policy and CDC guidance. The facility’s policy required residents with mild to moderate illness who were not moderately to severely immunocompromised to remain on TBP for at least 10 days after symptom onset, with additional criteria for severe illness and for test-based strategies requiring two negative tests 48 hours apart. Review of the COVID-positive resident log showed that multiple residents were removed from TBP after 7–9 days from symptom onset, rather than after the full 10 days. The IP nurse stated residents were tested with antigen tests on day 5 and, if negative, were removed from TBP after 7 days; if positive on day 5, TBP continued for 10 days. She reported she did not perform a second test on day 7 before discontinuing TBP and was unaware that two negative tests 48 hours apart were required when using a testing strategy. She also stated that TBP orders were entered for 10 days in the electronic system but were not discontinued when residents were taken off precautions earlier. Additionally, the facility used expired COVID-19 test kits for resident and staff testing during the outbreak and did not follow manufacturer expiration dates. Observations in the staff break room showed boxes of two different brands of COVID tests with expiration dates already passed. The IP nurse stated three brands of COVID tests, all with listed expiration dates that had passed, were used for staff and resident testing during the outbreak and that she believed the tests could be used for six months beyond the printed expiration date. Customer service representatives for each test manufacturer confirmed that the lot numbers in question did not have extended expiration dates, that the printed expiration dates were final, and that tests used after those dates would not be considered accurate or valid, with potential for false negative or false positive results. The Health Department nurse stated the facility had recently contacted them about using expired tests and that the department was working on guidance. The facility Physician stated that using expired COVID tests could affect test efficacy, that the protein in the test solution breaks down over time, and that expired tests could produce false negative results.
Failure to Educate, Offer, and Document COVID-19 Vaccination for Residents
Penalty
Summary
The deficiency involves the facility’s failure to educate residents on the benefits and potential side effects of the COVID-19 vaccine, to offer the vaccine, and to document vaccination status and related education in the medical record. Five cognitively intact residents were identified whose Minimum Data Set (MDS) assessments showed they were not up to date with COVID-19 immunization and whose records contained no history of COVID-19 vaccination. For each of these residents, there was no documentation that the COVID-19 vaccine had been offered or that education regarding the benefits and potential side effects of the vaccine had been provided. Resident #3, Resident #16, Resident #99, Resident #117, and Resident #127 were all cognitively intact per their respective MDS assessments and were coded as not up to date for COVID-19 immunization. Record review for each resident revealed no COVID-19 vaccination history and no documentation of an offer of the vaccine or provision of education on its benefits and potential side effects. In interviews, each resident reported not remembering any discussion, offer, or education from the facility regarding the COVID-19 vaccine. Some residents stated they would not want the vaccine, some were unsure, and one resident indicated he would probably take it if it were offered, but these preferences were not documented in the medical record. Interviews with facility staff revealed systemic process gaps related to COVID-19 vaccination. The Infection Preventionist (IP) nurse stated she offered the COVID-19 vaccine annually and tracked resident interest using a personal list marked with "Y" or "N" but did not maintain formal documentation of consent or declination in the medical record. She reported that the Admissions Coordinator obtained electronic consent forms for influenza and pneumonia vaccines, which were uploaded into the medical record and reviewed by nursing staff, but this process did not include COVID-19 vaccination. The IP nurse acknowledged she did not have a defined process for offering COVID-19 vaccination to new admissions, was unsure if it was consistently offered, and did not provide risk-versus-benefit education, only side-effect education. The ADON reported relying on the IP nurse to manage COVID-19 vaccination, and the Administrator stated he expected all consents, declinations, and vaccinations to be recorded in the residents’ medical records, which was not occurring for COVID-19 vaccines.
Failure to Use Catheter Stabilization Device for Resident With Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to use a catheter tubing stabilization device for a resident with an indwelling urinary catheter, despite care plan interventions to secure the catheter and prevent excess tension. The resident was admitted with bladder neck obstruction and had an indwelling catheter documented on the quarterly MDS, with orders for catheter changes as needed and routine flushing due to increased sediment. During an observation, the resident’s indwelling catheter was connected to a bedside drainage bag with visible yellow urine and sediment, and no catheter stabilization device was in place. The Assistant Director of Nursing (ADON), upon assessing the resident, confirmed that there was no device securing the catheter tubing and acknowledged that the resident should have had one in place to keep the catheter from being pulled. A nurse aide reported that on the morning of the same day, when she put the resident back to bed, she noticed the absence of a catheter stabilization device and informed the assigned nurse. The nurse aide stated the resident usually had such a device and that nurse aides were not permitted to change or replace it. The assigned nurse confirmed she had been told about the missing device, assessed the catheter, and delayed applying a new stabilization device while waiting to speak with the Nurse Practitioner (NP) in case a catheter change was needed. By the time she returned after speaking with the NP, the ADON was already in the process of changing the catheter. The NP stated she believed it was protocol for the resident to have a catheter stabilization device to prevent pulling of the catheter tubing and noted that pulling or tugging could cause trauma or pain. The Administrator also stated that if something was recommended to prevent the catheter tubing from being pulled, it should have been in place.
Failure to Schedule Sleep Study for Resident
Penalty
Summary
The facility failed to schedule a sleep study for a resident as recommended by the pulmonologist. The resident, who was admitted with diagnoses including chronic pain and atrial fibrillation, was seen by a pulmonologist for issues such as acute respiratory infection, shortness of breath, chronic rhinitis, and morbid obesity. The pulmonologist recommended a pulmonary function test and a sleep study. While the pulmonary function test was completed, the sleep study was repeatedly scheduled and then canceled by the facility, with no further appointments made. Interviews with the pulmonology office manager revealed that the sleep study was initially scheduled for the resident but was canceled and rescheduled multiple times by the facility, ultimately resulting in no sleep study being conducted. The resident expressed awareness of the pulmonologist's recommendation for a sleep study and indicated a desire to have it rescheduled, despite not currently experiencing respiratory issues. The facility's transportation logs confirmed the absence of any scheduled sleep study appointments. Interviews with facility staff, including the Unit Manager, Social Work Director, and Director of Nursing, indicated a lack of awareness regarding the sleep study orders and the cancellations. The previous scheduler, who was responsible for managing appointments, had left the facility, and the current staff were unaware of the need for the sleep study. The facility's failure to follow through with the pulmonologist's orders and ensure the resident received the recommended sleep study constitutes a deficiency in providing medically-related social services to help the resident achieve the highest possible quality of life.
Failure to Issue SNF ABN Prior to Medicare Part A Discharge
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to two residents prior to their discharge from Medicare Part A skilled services. Resident #60 was admitted to the facility and was issued a Notice of Medicare Non-Coverage (NOMNC) form, indicating the termination of Medicare Part A services. However, the SNF ABN form was not provided to Resident #60 or her Responsible Party (RP) before the discharge, despite the resident continuing to stay in the facility. The Social Worker and Business Manager, during an interview, admitted to issuing the NOMNC but were unaware of the requirement to issue the SNF ABN. They had informed the resident and RP verbally about the change in payment responsibility but did not provide the necessary documentation. Similarly, Resident #253 was also not issued the SNF ABN form before the termination of Medicare Part A services, although the NOMNC was provided. The Social Worker and Business Manager confirmed their lack of awareness regarding the SNF ABN requirement. The Administrator, during an interview, acknowledged the oversight and stated that the SNF ABN should have been issued. The Administrator was new to the facility and was not aware that the forms had not been completed and issued as required.
Resident Injury from Bed Rail Assist Bar
Penalty
Summary
The facility failed to prevent an accident involving a resident who was on anticoagulant medication, Eliquis, and sustained a severe injury from a bed rail assist bar. The resident, who had severe cognitive impairment, impaired vision, and required substantial assistance with bed mobility, was found with a large hematoma and bruising on her left arm, which later ruptured, causing an open wound with uncontrolled bleeding. The injury was discovered during routine rounds by a nurse, who noted the resident's arm was swollen and discolored, but the resident did not complain of pain. The nurse did not initially inform the on-call nurse practitioner that the resident was on anticoagulant medication, which could have influenced the severity of the injury. The resident's care plan included the use of a bed rail assist bar to aid with bed mobility due to left-sided weakness from a stroke. However, the resident was unable to reposition herself in bed and required total staff assistance. Interviews with staff revealed that the resident's arm was often seen pressed against the bed rail assist bar during care, and the location of the injury correlated with the position of the bed rail. The facility's investigation determined that the bed rail assist bar was the likely cause of the injury, as there was nothing else in the bed that could have caused such damage. The resident was transferred to the hospital for treatment of the injury, where it was confirmed that the hematoma and subsequent skin tear were likely caused by pressure from the bed rail. The resident's condition was exacerbated by her use of Eliquis, which increased her risk of bleeding. The facility's failure to recognize the risks associated with the resident's use of the bed rail assist bar, given her medical conditions and medication, contributed to the accident.
Removal Plan
- Resident #1 was reassessed for use of bed rails. The Assessment revealed that the resident was not able to utilize the Assist Side Rails without staff prompting, and this put her at further risk for injury as well as her having vision impairment, dementia, diagnosis of muscle weakness and being on a blood thinning medication.
- Assist Side Rail was removed from Resident #1's bed.
- The Director of Nursing, Administrator and clinical team completed a root cause analysis for this event and determined Resident #1 had an assist side rail which contributed to an injury.
- Nursing leadership (which included the Director of Nursing and Unit Managers) in conjunction with the Wound Care Nurse Practitioner completed 100% audit of all current residents with Assist Side Rails in use, for skin integrity to ensure no other injuries related to assist rails. No injuries noted.
- Nursing Staff, including nurses and Certified Nursing Assistants (CNAs), including agency staff were educated by the Director of Nursing and Staff Development Coordinator (SDC) regarding bed mobility and ensuring resident's safety with bed rails.
- Education also included an assessment of bed rails for residents to ensure residents safety with use, to include review of vision status, bed mobility, cognitive status and medications which put resident at risk.
- Nurses Aides were educated on bed mobility and observing for changes and any concerns related to residents' use of side rails, ie: leaning on them, limbs against them/through them, resting head against rails, not being able to grasp independently). If they note any concerns with safety to report to the charge nurse immediately.
- This education is ongoing with no staff working until education is completed.
- Director of Nursing and/or Designee will ensure new hires or agency staff receive the education.
- The Director of Nursing is responsible for tracking and educating staff who were not educated. This education was completed in person.
- The Administrator and Director of Nursing made the decision to implement a weekly audit. Audits of residents with Assist Side Rails X 4 weeks, then quarterly.
Failure to Assess and Obtain Consent for Bed Rail Use Leads to Resident Injury
Penalty
Summary
The facility failed to accurately assess a resident for the use of bed rail assist bars, leading to a significant injury. The resident, who had severe cognitive impairment, impaired vision, and required substantial assistance with mobility, was not properly evaluated for the risks associated with bed rail use. The assessment conducted by the Director of Nursing was inaccurate, as it did not account for the resident's cognitive deficits, visual impairments, or the use of anticoagulant medication, which required safety precautions. Furthermore, the facility did not obtain informed consent from the resident's representative before implementing the bed rail assist bars. The consent form was incomplete, with unchecked boxes indicating that the risks of using bed rails, such as entrapment or injury, were not reviewed with the family. Interviews with family members confirmed that the risks were not discussed, and the consent form was presented as a routine admission requirement without proper explanation. As a result of these oversights, the resident sustained a hematoma on her left arm from the bed rail, which led to significant bleeding and required hospitalization. The resident's condition was exacerbated by her use of Eliquis, an anticoagulant medication, which contributed to the severity of the bleeding. The facility's failure to conduct a thorough assessment and obtain informed consent directly contributed to the resident's injury and subsequent hospitalization.
Removal Plan
- Resident #1 was reassessed for use of bed rails and the Assist Side Rail was removed from Resident #1's bed.
- Director of Nursing, Administrator and clinical team completed a root cause analysis of the event.
- Regional Director of Clinical Services educated the DON regarding completing the assessment accurately and consents with review of risks with RP and/or Resident.
- Director of Nursing completed a new Bed Rail Assessment on all current residents with Side Rail Assist Bars in place.
- Nursing Staff, including nurses and Certified Nurse Aides (CNAs), were educated by the Staff Development Coordinator (SDC) and Director of Nursing (DON) on how to accurately complete the Bed Rail Assessment, and completion of the consent for rail use and educating the Resident or Responsible Party (RP) on risk of use.
- Agency and contracted staff were educated by SDC and DON on how to accurately complete Bed Rail Assessment, completion of the consent for rail use and educating the Resident or RP on risk of use.
- Regional Director of Operations met with the Maintenance Director and reinforced education with him on ensuring that he follows manufacturers' recommendations for installation of assist side rails.
- When a resident that has had Assist Side Rails on their bed discharges, the Maintenance Director removes the rails from the bed.
- Director of Nursing/ Designee will assess any newly installed Assist Side Rails for any gaps head of bed elevated, size of rails, to ensure no gaps or risk for entrapment.
- A weekly audit of all residents with Assist Side Rails will be conducted to ensure that the resident remains appropriate for use of Assist Side Rails and that there are no signs of injury from Assist Side Rail use.
- Results of ongoing audits will be taken to the monthly QAPI meeting.
Significant Medication Errors Due to Non-Adherence to Parameters and Allergy Documentation
Penalty
Summary
The facility failed to prevent a significant medication error by administering a blood pressure medication to a resident without following the set parameters. The resident was given Clonidine, which was only to be administered if the systolic blood pressure was greater than or equal to 170. At the time of administration, the resident's blood pressure was 139/64. Following the administration, the resident's blood pressure dropped to 70/40, leading to hospitalization for low blood pressure and altered mental status. The nurse involved did not complete an incident report or notify the Director of Nursing (DON) or the administrator immediately, and the incident was only discovered later through staff discussions and record reviews. Additionally, the facility failed to prevent another significant medication error by administering a medication to the same resident that was listed as an allergy in the electronic medical record and admission paperwork. The resident was prescribed and administered Reglan for reflux disease, despite having an allergy to it documented. The allergy was noted on the admission paperwork, but the origin and reaction were unknown. The medication was administered daily from December 2023 until March 2024, and the error was only identified when the resident was hospitalized for a separate issue. Interviews with staff and the resident's responsible party revealed that the facility's previous Medical Director was aware of the allergy but chose to prescribe the medication regardless. The DON and the administrator took steps to address the issue with the Medical Director's supervisor, leading to the discontinuation of the medication order. The resident did not suffer any documented adverse reactions from the medication, but the failure to adhere to allergy documentation protocols posed a significant risk to the resident's health and safety.
Latest citations in North Carolina
A resident with hemiplegia after a cerebral infarction and chronic atrial fibrillation was receiving rivaroxaban 20 mg daily as an anticoagulant, as documented in active medication orders, the MDS, and the MAR over several months. However, the comprehensive care plan, from admission through a later update, did not include any problem, goal, or intervention related to anticoagulant use. The MDS Coordinator stated she reviews and updates care plans after MDS completion and acknowledged she had overlooked adding anticoagulant use to the care plan, while the Administrator reported an expectation that all high-risk medications, including anticoagulants, be reflected in resident care plans.
A resident with a chronic heel wound with drainage, classified as high risk under the facility’s Enhanced Barrier Precautions (EBP) policy, received wound care from a Wound Nurse and a NA who wore masks and gloves but did not don gowns during multiple high-contact wound care activities on both lower extremities. The facility’s EBP policy requires both gloves and gowns for high-contact care, including wound care, for residents with chronic wounds. At the time of care, there was no EBP sign on the door and no PPE caddie or supplies outside the room. In subsequent interviews, the Wound Nurse and NA reported they did not wear gowns because there was no sign on the door and the nurse was not wearing one, while the IP and DON stated they would have expected gown use and confirmed that wound care is considered a high-contact activity under the policy.
Over more than a year, residents repeatedly reported during Resident Council meetings that call lights were not answered timely, staff sometimes turned off call lights without meeting needs, ice and water were not passed consistently on all shifts, water pitchers were not washed as expected, and care was not always provided during meal times. Residents also described staff using poor attitudes, including cursing and aggressive tones, and noted that coffee on hall carts was often empty or cold at breakfast. Despite these concerns being raised month after month, residents stated they felt the facility only responded by saying staff were being educated, while the same problems continued. The Social Worker and DON acknowledged that these issues had been discussed numerous times without true resolution, and residents expressed a desire for their needs to be met and for clear feedback from administration about efforts to address their ongoing concerns.
A resident was admitted with documented PTSD and COPD, and hospital records showed PTSD as a chronic condition monitored during hospitalization. Although the care plan and MDS admission assessment identified PTSD as an active psychiatric/mood disorder and the resident received an antidepressant, the PASRR Determination Notification reflected only a Level I PASRR, and the FL2 form from the hospital did not list PTSD. The SW, who was responsible for PASRR submissions, relied on quarterly audits of admission paperwork and the MDS to identify cases needing Level II PASRR, resulting in no timely Level II request being submitted for this resident’s PTSD diagnosis.
Surveyors found multiple opened nutritional supplement containers in unit nourishment refrigerators that were either undated or stored beyond the manufacturer’s specified use-by timeframe. A one-quart shake in one unit refrigerator lacked an opening date despite a label requiring use within four days of opening, while two dated one-quart shakes and an opened, undated diabetic shake in another unit refrigerator were not managed according to their labeled time limits. The DM reported that nursing staff, not dietary, were responsible for dating and discarding resident nutritional shakes, while dietary staff only checked and restocked kitchen-provided items. A nurse and the Administrator both confirmed that the person opening the shake was responsible for dating it and ensuring it was used or discarded within the manufacturer’s guidelines.
A resident with ESRD, peripheral vascular disease, and an AV fistula returned from dialysis with a gauze dressing applied by the dialysis nurse, which remained in place into the following day. A physician order and care plan required nursing staff to remove the AV fistula dressing on the night of dialysis and assess the site for complications and signs of infection. The assigned nurse acknowledged she knew she was required to remove the dressing and assess the site but forgot because she was busy with another resident. The physician emphasized the importance of post-dialysis AV fistula assessment due to the resident’s vascular disease and prior complications, and the DON stated she expected staff to follow the order and routinely assess the fistula site.
A resident admitted with bipolar disorder, generalized anxiety disorder, vascular dementia with severe behavioral disturbance, and active BPSD was maintained on multiple psychotropic medications, including an antipsychotic with a documented contraindication to gradual dose reduction, but only had a Level I PASRR on file. At admission, the SW verified that a PASRR existed in NC MUST but did not confirm that the resident’s mental health diagnoses were captured, and no Level II PASRR request was submitted. The SW reported she relied on prior guidance that a Level I PASRR was sufficient unless there was a change in condition, and the Administrator confirmed the SW was responsible for Level II PASRR submissions, resulting in the failure to obtain a required Level II determination.
A resident with dementia, stroke, dysphagia, and severe cognitive impairment, who was edentulous and dependent for ADLs, was care planned and listed on the NA Kardex to receive assisted oral care at least twice daily. Over nearly a month, NA documentation showed denture care was provided only three times, and surveyors observed the resident’s upper and lower dentures with brown stains and debris buildup. One NA, assigned on several day shifts, believed the resident did not have dentures and only offered mouthwash and a basin, while another NA, aware the resident wore dentures, usually did not perform denture care because the resident was already in bed and did not want to remove them. The DON later confirmed the dentures had visible debris and staining and that the care plan required regular oral care and proper denture cleaning.
The facility failed to ensure residents received their mail in a timely manner, particularly mail delivered on Saturdays. During a council meeting, several residents reported that Saturday mail was not brought to them until Monday. The new Activity Director did not work weekends and was unfamiliar with the weekend mail process. The weekday receptionist stated that the weekend receptionist had no key to the outdoor mailbox, so mail was not retrieved on Saturdays unless the Business Office Manager was present. The Business Office Manager confirmed that when she was absent on weekends, no one else could access or deliver residents’ mail, and that after the prior Activity Director left, there was no designated staff to deliver weekend mail, resulting in periods when residents did not receive their mail on the day it arrived.
The facility failed to maintain and implement its antibiotic stewardship and infection surveillance program, as required by its own policy. For most months reviewed, there were no infection control records, including antibiotic order listings, documentation confirming infections, surveillance logs, or trend analyses, and the only available data for one month was an unstructured list of residents who received antibiotics without formal tracking of infection rates or antibiotic use. The DON, who was also expected to serve as the Infection Preventionist, reported being unable to locate infection control reports or surveillance data for an extended period, and the Administrator confirmed that, during a time of multiple interim DONs, infection control tracking and analysis of infection and antibiotic use trends had not been completed.
Failure to Care Plan for High-Risk Anticoagulant Therapy
Penalty
Summary
The facility failed to develop an individualized comprehensive care plan addressing anticoagulant medication use for a resident who had been prescribed rivaroxaban 20 mg daily with the evening meal for a history of cerebral infarction. The resident was admitted with hemiplegia following a cerebral infarction and chronic atrial fibrillation, and the active medication orders showed continuous administration of rivaroxaban from its start date through the survey review period. The quarterly MDS assessment documented that the resident was receiving an anticoagulant, and the Medication Administration Record confirmed daily administration of rivaroxaban over several months. Despite this ongoing anticoagulant therapy and the resident’s relevant diagnoses, the comprehensive care plan dated at admission and updated later did not include any focus area, goals, or interventions related to anticoagulant use. During an interview, the MDS Coordinator acknowledged that the care plan did not address the anticoagulant medication and stated that she must have overlooked it when updating the care plan after completing the MDS assessment. In a separate interview, the Administrator stated that her expectation was that all resident care plans reflect high-risk medications, including anticoagulants.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Infection Control policies and procedures for Enhanced Barrier Precautions (EBP) during wound care for a resident. The facility’s EBP policy, last revised on 04/15/26, requires staff to don both gloves and a gown for high-contact care activities with high-risk residents, including those with chronic wounds. High-contact activities listed in the policy include wound care, and the policy specifies that residents with chronic wounds should remain on EBP for the duration of their stay or until the wound resolves. Resident #12 was admitted with a chronic heel wound with drainage, placing the resident in the high-risk category under the EBP policy. During an observation of wound care on 05/12/26 at 12:33 PM, the Wound Nurse and Nurse Aide (NA) #1 entered the resident’s room wearing masks and gloves but no gowns. There was no EBP sign on the door and no PPE caddie or supplies outside the room. The resident was seated in a wheelchair beside the bed with the door open. The Wound Nurse performed multiple wound care steps on the resident’s right leg, right heel, left third toe, and left heel, repeatedly donning and doffing gloves and performing hand hygiene, while NA #1 assisted by holding the resident’s legs. At no point during these high-contact wound care activities did either staff member wear a gown. In interviews following the observation, the Wound Nurse stated he did not wear a gown because there was no sign on the door indicating the resident was on EBP and later acknowledged learning that a gown should have been worn. NA #1 similarly reported that she did not wear a gown because there was no sign on the door and the Wound Nurse was not wearing one, and she later learned that both should have worn gowns. The Infection Preventionist (IP) stated that the resident should have had an EBP sign on the door and a PPE caddie available, and explained that the sign and supplies were likely left on the resident’s previous room after a move. The IP and the Director of Nursing both stated they would have expected the Wound Nurse and NA #1 to wear gowns while providing wound care, and the DON identified wound care as a high-contact activity requiring gown use under the facility’s EBP policy.
Ongoing Failure to Resolve Resident Council Concerns About Call Lights and Basic Services
Penalty
Summary
The deficiency involves the facility’s failure over a 13‑month period to effectively resolve and communicate resolution of repeated concerns raised in Resident Council meetings, particularly regarding call light response times, staff turning off call lights without meeting needs, inconsistent ice and water pass, and care during meal times. Resident Council minutes from multiple months document that residents, especially those on the 200 hall, repeatedly reported that call lights were not answered in a timely manner and that staff sometimes turned off call lights and left without providing the requested care. Residents also reported that when they turned their call lights back on, staff questioned why they had done so, despite their needs not having been met. These concerns were documented as new issues in successive meetings, indicating that the same problems persisted over time. The Resident Council minutes further show that residents repeatedly complained that ice was not being passed consistently on second and third shifts and on all halls, and that water pitchers were not being washed weekly as expected. At various meetings, residents stated that ice was not being passed daily on all shifts, that ice was not being passed routinely, and that ice was not being passed on every shift. Additional concerns were raised about staff attitudes, including cursing and using an aggressive tone of voice, and about care not being provided during meal times. Residents also reported that coffee on the hall cart was often empty or cold at breakfast. These issues were brought up under both Old Business and New Business in multiple meetings, demonstrating that residents perceived them as ongoing, unresolved problems. During a Resident Council group interview, several residents who lived on the 200 hall and regularly attended the meetings stated they felt the facility did not truly address their concerns because the typical response they heard was that staff were being educated, yet the same problems continued. Multiple residents agreed that call lights not being answered timely was a continual problem and expressed that they wanted resolution and their needs to be met, as well as feedback from administration about efforts made to address their concerns. The Social Worker confirmed that call light response time, passing ice on all shifts, and providing care during meal times had been discussed numerous times and acknowledged there was still no resolution to these issues. The DON acknowledged that grievances from Resident Council regarding clinical issues were assigned to her and that the 200 hall was considered challenging, with residents there being more alert, oriented, and vocal about their needs, but the ongoing nature of the same complaints showed that the facility did not effectively resolve or communicate resolution of the residents’ repeated concerns. The Administrator, who had recently started in the role, stated that they were hoping to achieve resolution of the call light response concerns and that call lights should be answered as quickly as possible, with staff not turning off call lights and failing to return to meet residents’ needs. Despite these stated expectations, the documented Resident Council minutes and resident interviews demonstrate that residents continued to experience and report the same issues over many months. Overall, the deficiency centers on the facility’s inaction and ineffective response to recurring Resident Council complaints, resulting in residents feeling that their concerns about call light response, ice and water service, staff behavior, and care during meals were not being resolved or adequately addressed.
Failure to Request Level II PASRR for Resident With PTSD Diagnosis
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident admitted with a serious mental health disorder. The resident’s hospital course and treatment note documented chronic post-traumatic stress disorder (PTSD), which was monitored during that hospitalization. A PASRR Determination Notification letter showed the resident only had a Level I PASRR with no expiration date. The North Carolina Medicaid FL2 Level of Care Screening Tool completed by the hospital social worker and sent to the facility did not list PTSD as a diagnosis, even though the resident was admitted with diagnoses including COPD and PTSD. The resident’s care plan, initiated shortly after admission, identified a risk for impairments or complications due to a history of PTSD and included interventions such as approaching the resident calmly, avoiding triggers, building a trusting relationship, obtaining psychiatric referrals as needed, and involving the resident in care decisions. The admission MDS assessment indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, but it did list PTSD as an active psychiatric/mood disorder diagnosis and documented that the resident received an antidepressant during the assessment period. The facility social worker, who was responsible for submitting Level II PASRR requests, acknowledged that the resident had a PTSD diagnosis that was not included on the FL2 and stated she conducted PASRR audits on a quarterly basis by reviewing admission paperwork and the MDS to identify diagnoses requiring Level II submission. She reported she was in the process of completing these audits and preparing to submit requests, including one for this resident. The administrator stated that the social worker should have reviewed the admission diagnoses and MDS triggers and requested a Level II PASRR evaluation for the resident’s PTSD at the time of admission or within a month of admission or new diagnosis, rather than waiting for quarterly audits.
Failure to Date and Discard Opened Nutritional Supplements per Manufacturer Instructions
Penalty
Summary
The deficiency involves the facility’s failure to properly date and discard opened containers of nutritional supplements stored in nourishment room refrigerators on the North and South Units. During observations of these refrigerators with the Dietary Manager, surveyors found a one-quart nutritional shake in the North Unit refrigerator with no date indicating when it was opened, despite the manufacturer’s label stating it must be used within four days after opening if refrigerated. In the South Unit refrigerator, surveyors observed two one-quart nutritional shakes dated 4/24 and 4/28, both beyond the manufacturer’s four-day use-by period, as well as an opened and undated 8-ounce diabetic nutritional shake whose label required use within 48 hours of opening. In interviews, the Dietary Manager stated that dietary staff did not stock the nutritional shakes in the nourishment refrigerators and that nurses were responsible for the nutritional shakes given to residents, including dating them when opened and discarding them when past the use-by date. The Dietary Manager also explained that dietary staff checked the nourishment refrigerators twice daily only for items provided by the kitchen, including restocking and checking expiration dates on those snacks and drinks. A nurse confirmed that a physician’s order was required for a resident to receive a nutritional shake and that nurses were responsible for dating the shakes when opened and ensuring they were used and discarded according to the manufacturer’s instructions. The Administrator stated that the person who opened a nutritional shake was responsible for writing the date opened on the container and noted that historically dietary staff checked dates on food and drinks stored in the nourishment refrigerators.
Failure to Remove Dialysis AV Fistula Dressing and Perform Ordered Assessment
Penalty
Summary
The facility failed to follow a physician’s order to remove a dressing and visually assess a resident’s arteriovenous (AV) fistula after dialysis. The resident, who had diagnoses including AV fistula, end stage renal disease, dialysis, and peripheral vascular disease, was cognitively intact and received dialysis. A physician order dated 2/2/2026 directed staff to remove the dressing to the AV fistula on the night of dialysis every Monday, Wednesday, and Friday to avoid skin breakdown and damage to the AV fistula. The resident’s care plan, updated on 2/27/2026, included interventions to check and change the AV fistula dressing as ordered and to observe the site for signs and symptoms of infection. On observation, the resident was noted to have a gauze dressing with tape on the left upper arm AV fistula the day after dialysis, and the resident reported that the dressing had been applied by the dialysis nurse after treatment. The nurse assigned to the resident on the 3:00 PM to 11:00 PM shift acknowledged that she was supposed to remove the dressing and assess the AV fistula site when the resident returned from dialysis but stated she forgot because she was busy with another resident. The physician stated that it was important for nursing staff to remove the dressing and assess the AV fistula after dialysis due to the resident’s significant vascular disease and history of complications with hypotension and falls after dialysis, and described the AV fistula as the resident’s lifeline. The DON stated that nursing staff usually removed the dressing and assessed the AV fistula site after dialysis and that she expected staff to follow physician orders and assess for signs and symptoms of infection.
Failure to Request Level II PASRR Evaluation for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to submit a request for a Level II PASRR evaluation for a resident admitted with serious mental health disorders. A PASRR Determination Notification letter showed the resident had only a Level I PASRR with no expiration date. The resident was admitted with diagnoses including bipolar disorder, generalized anxiety disorder, and vascular dementia with severe behavioral disturbance. A psychiatric progress note documented a long history of bipolar disorder and recent behavioral and psychological symptoms of dementia, with active diagnoses of bipolar disorder, bipolar depression, and generalized anxiety disorder. The resident was receiving multiple psychotropic medications, including duloxetine, clonazepam, quetiapine (in both morning and bedtime doses), and trazodone. The admission MDS assessment indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, despite active psychiatric/mood disorder diagnoses of anxiety disorder and bipolar disorder and ongoing antipsychotic use with a physician-documented contraindication to gradual dose reduction. An NC MUST inquiry confirmed that only a Level I PASRR, effective more than a year prior, was on file and that no PASRR requests for a Level II determination had been submitted prior to the survey date. The Social Worker reported that she checked NC MUST for a current PASRR at admission but did not verify whether mental health diagnoses were included in the initial screening, and she relied on prior guidance from a PASRR evaluator that a Level I PASRR was sufficient unless there was a change in condition. The Administrator stated the Social Worker was responsible for submitting Level II PASRR requests and acknowledged that, based on this prior guidance, a Level II request for this resident was not completed.
Failure to Provide Ordered Denture and Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide ordered assistance with denture and oral care for a dependent resident with severe cognitive impairment, dementia, stroke, dysphagia, and edentulism. The resident’s admission MDS documented severely impaired cognition, a need for setup or clean-up assistance with oral hygiene, and no refusal of care or behaviors. The care plan and NA Kardex both directed staff to provide or assist with oral care at least twice daily using a soft toothbrush or foam swabs, and identified the resident as at risk for oral and dental health problems and dependent in ADL self-care. However, NA documentation showed denture care was recorded as provided only three times over nearly a month-long period. During observation, the resident reported wearing upper and lower dentures and displayed dentures with brown stains and debris buildup around the teeth and gums, stating he could brush his dentures if he had a toothbrush and toothpaste. One NA, assigned on multiple day shifts, stated she provided only mouthwash and a basin because the resident had difficulty brushing, believed the resident did not have dentures, and confirmed she had not provided denture care. Another NA on night shift acknowledged knowing the resident wore dentures, having seen them on the bed or nightstand, but stated she usually did not perform denture care because the resident was already in bed and did not want to remove them, and described denture care only as soaking them overnight. When the DON later observed the dentures, he confirmed visible debris and brown staining, and acknowledged that the care plan and Kardex required oral care at least twice daily and that dentures should be brushed and soaked overnight.
Failure to Ensure Timely Weekend Mail Delivery to Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ right to receive mail, including mail delivered on Saturdays. During a Resident Council group interview, several residents reported that when mail was delivered to the facility on Saturdays, it was not distributed to them until Monday by the Activity Director. Multiple residents agreed with this account, and no residents present disagreed. The new Activity Director, who had transitioned from working as a Certified Occupational Therapist Assistant on 04/24/26, stated she did not work weekends and was unsure how mail delivery to residents was handled on weekends. Staff interviews further showed that the weekend receptionist did not have a key to the outdoor mailbox and therefore could not retrieve Saturday mail. The weekday Receptionist reported that she collected the mail from the outdoor mailbox on Monday mornings and gave it to the Business Office Manager, after which the Activity Director delivered it to residents. The Business Office Manager confirmed that if she was not at work on weekends, no one else had access to the outdoor mailbox. She stated she worked most Saturdays, checked and sorted the mail, and then gave residents’ mail to activity staff or delivered it herself, but noted that after the previous Activity Director left 6–7 weeks earlier, there was no one designated to deliver mail to residents on weekends when she was not present. The Administrator acknowledged that there were approximately three weeks when weekend mail was not delivered to residents due to turnover in the activity department and the absence of an Activity Director.
Failure to Maintain Facility-Wide Antibiotic Stewardship and Infection Surveillance
Penalty
Summary
The facility failed to implement a facility-wide system to monitor antibiotic use as required by its Antibiotic Stewardship Program policy. The policy, last revised in December 2016, required that all clinical infections treated with antibiotics undergo review by the Infection Preventionist or designee, including review of antibiotic utilization, antibiotic orders, clinical documentation confirming infections, infection surveillance logs, microbiology testing, and trends in infection and antibiotic use data. Surveyors found that for eight of nine months reviewed—July, August, September, October, November, and December 2025, and February and March 2026—the facility was unable to provide any infection control data, including listings of antibiotic orders, clinical documentation confirming infections, surveillance logs, or trending of infections. For January 2026, the facility had only a list of residents who exhibited symptoms and were treated with antibiotics, but did not use a structured tool to track infection rates, antibiotic use, or to monitor, conduct surveillance, or identify trends related to infections or possible infections. During interviews, the DON, who assumed the position on April 13, 2026 and was also expected to function as the Infection Preventionist, reported being unable to locate Infection Control reports, surveillance records, or infection tracking data for July 2025 through April 2026, except for the January list of residents who received antibiotics. The Administrator confirmed that multiple interim DONs had served since July 2025 and acknowledged that tracking of infection control data, including infection trends and antibiotic use, had not been completed, despite the facility’s stated intent for a comprehensive Infection Control Program that included surveillance, tracking, and trend analysis.
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