The Greens at Lincolnton

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for residents with new mental health diagnoses for 4 of 5 residents (Resident #9, Resident #14, Resident #15, and Resident #68) reviewed for PASRR. The findings include:a. Review of Resident #9's medical record revealed PASRR level I was completed 8/23/24 prior to admission to the facility with a recommendation to resubmit paperwork for a PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. Resident #9 was admitted to the facility on [DATE] and readmission on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #9's current active diagnoses included psychotic disorder (diagnosed on [DATE]) and major depressive disorder (diagnosed on [DATE]). There was no evidence in the medical record that a request was submitted for a Level II PASRR evaluation. b. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff, Nurse Practitioner (NP), Physician, COVID test manufacturer customer service representative, and Health Department (HD) Nurse interviews, the facility failed to follow their infection control policy and procedures during a COVID outbreak. The facility's COVID outbreak began on [DATE] when a Resident (Resident #12) tested positive for COVID. The facility had a total of 25 residents and 12 staff members who tested positive from [DATE] to [DATE]. During the facility's ongoing COVID-19 outbreak, staff failed to wear all personal protection equipment (PPE) required according to Centers for Disease Control and Prevention (CDC) guidance when 1 of 1 Nurse Aide (NA) (NA #2) entered a resident room under transmission-based precautions (TBP) for COVID without wearing eye protection. Additionally, 1 of 1 Unit Manager (UM) (UM#1) failed to wear all PPE required according to CDC guidance while performing resident COVID testing. The facility also failed to restrict 9 of 9 staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff, and Regional Nurse Consultant interviews the facility failed to include documentation in the medical record of education regarding the benefits and potential side effects of the COVID-19 immunization and failed to offer COVID-19 vaccines to 5 of 5 residents reviewed for COVID-19 immunizations (Resident #3, #16, #99, #117 and #127).The findings included:Resident #3 was admitted to the facility on [DATE].The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact and was coded No for Covid-19 immunization being up to date.Review of Resident #3's medical record revealed no history of a Covid-19 vaccination. There was no documentation in the medical record that indicated the COVID-19 vaccine had been offered to Resident #3 or education had been provided to Resident #3 regarding the benefits and potential side effects of the COVID-19 vaccine.An interview was conducted on 2/12/26 at 10:40 AM with Resident #3. He stated he does not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to use a catheter tubing stabilization device to reduce the risk of pulling and tugging of indwelling urinary catheter tubing. This deficient practice occurred for 1 of 3 residents reviewed with a urinary catheter (Resident #2).Findings included:Resident #2 was admitted to the facility on [DATE] with diagnoses that included bladder neck obstruction (urinary disorder).The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #2 had an indwelling urinary catheter.An indwelling catheter care plan dated 11/17/25 was in place. The care plan goal was to remain free from catheter related trauma. The care plan interventions included, to secure catheter to prevent excess tension.An order dated 12/5/25 read, change [indwelling] catheter as needed for infection, dislodgement, or obstruction. Insert coude catheter (specialized curved urinary catheter) indwelling due to urinary retention with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident, staff, and pulmonology office staff interviews, the facility failed to schedule a sleep study per the Pulmonologists recommendations for 1 of 3 residents reviewed for respiratory care (Resident #64). The findings included: Resident #64 was admitted to the facility on [DATE] with diagnoses that included chronic pain and atrial fibrillation. A quarterly Minimum Data Set for Resident #64 dated 8/23/24 revealed the resident was cognitively intact with no respiratory issues noted. Review of pulmonologist note dated 7/03/24 revealed Resident #64 had been seen for scheduled office visit on 7/03/24 for the following issues: acute respiratory infection, shortness of breath, chronic rhinitis and morbid obesity. Order referrals were made for Resident #64 to have scheduled a pulmonary function test and split sleep study test by a sleep provider only. A telephone interview was conducted on 11/06/24 at 1:43 PM with the Pulmonology Office Manager. The Office Manager revealed Resident #64…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, Family Member and staff interviews, the facility failed to maintain a resident's dignity by not answering their call light when toileting assistance was requested for 1 of 4 sampled residents (Resident #13). The reasonable person concept was applied to this deficiency as an individual would not want to feel like they were being ignored when assistance with care was requested. Findings included: Resident #13 was admitted to the facility on [DATE] with diagnoses that included dementia. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #13 with severe cognitive impairment. Resident #13 required substantial/maximal assistance with toileting hygiene and displayed no rejection of care during the MDS assessment period. An Activities of Daily Living (ADL) care plan, last revised on 03/15/23, revealed Resident #13 had an ADL self-care performance deficit related to weakness and confusion. Interventions included: requires extensive assistance of one staff member for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and resident, family and staff interviews, the facility failed to provide assistance with shaving and dentures for 2 of 4 residents reviewed for activities of daily living (Resident #11 and Resident #12). Findings included: 1. Resident #11 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (trouble breathing), shortness of breath, and anxiety disorder. The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #11 with severe cognitive impairment and requiring partial to moderate staff assistance with personal hygiene. Resident #11 displayed verbal behaviors toward others 1 to 3 days and did not reject care during the MDS assessment period. A review of Resident #11's comprehensive care plans last revised 02/12/24 revealed no plan that addressed Activities of Daily Living (ADL). During an observation and interview on 03/13/24 at 12:23 PM, Resident #11 was lying in bed with the head of bed slightly elevated.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, resident and staff interviews, the facility failed to ensure a resident's toenails were trimmed for 1 of 4 sampled residents (Resident #11). Findings included: Resident #11 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (trouble breathing), shortness of breath, and anxiety disorder. A physician's order dated 01/31/24 for Resident #11 read, may be seen and treated by a Podiatrist. The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #11 with severe cognitive impairment and requiring partial to moderate staff assistance with personal hygiene. Resident #11 displayed verbal behaviors toward others 1 to 3 days and did not reject care during the MDS assessment period. A review of Resident #11's medical record revealed no documentation she was seen by a Podiatrist since her admission to the facility. During an observation and interview on 03/13/24 at 12:23 PM, Resident #11 was lying in bed with her feet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, local police interview, and record review, the facility failed to report a suspicious white powder in a little zip bag found in the room of Resident #1 to local law enforcement. The facility also failed to preserve potential evidence when they destroyed the white powder. Resident #1 experienced a potential drug overdose on 1/21/24 which responded with Naloxone (medication designed to rapidly reverse opioid overdose) given by the Emergency Medical Services (EMS) and was sent to the hospital for treatment. This deficient practice occurred for 1 of 1 resident reviewed for accidents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] and she was readmitted on [DATE]. Interview with the Nursing Assistant (NA #1) on 1/30/24 at 11:15 AM stated that she worked several days with Resident #1, and she found the Resident #1 slumped in her wheelchair after her breakfast around 10 AM on 1/21/24. NA #1 stated that she was going around taking Vital Signs (VS) for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews the facility failed to secure medications stored at the bedside for 3 of 3 residents reviewed for medication storage (Resident #5, Resident #1, and Resident #3). Findings included: 1. Resident #5 was admitted to the facility 11/01/23 with a diagnosis of gastroesophageal reflux disease (acid reflux). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact. Review of Resident #5's physician orders dated 12/01/23 revealed an order for calcium carbonate 1,250 milligrams (mg) one tablet twice a day. An observation of Resident #5's overbed table on 01/17/24 at 1:00 PM revealed one round yellow pill in a medication cup sitting on top of the table. Resident #5 was not in her room. An interview with Nurse #1 on 01/17/24 at 1:02 PM revealed the yellow pill on Resident #5's overbed table was calcium carbonate (an antacid). She stated she was training a Medication Aide (MA) #1 on how to perform a medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interviews the facility failed to develop a comprehensive, individualized care plan in the areas of oxygen use, Diabetes Mellitus (DM) type 2, and daily anticoagulation use for 1 of 4 residents (Resident #4) reviewed for care plans. The findings include: 1. Resident #4 was admitted to the facility on [DATE] with the following diagnosis: history of Covid-19, Chronic Obstructive Pulmonary Disease (COPD), deep vein thrombosis (DVT), and insulin dependent DM type 2. Review of physician orders for Resident #4 revealed: - 3/6/23 for anticoagulation to be administered daily and dosage to change according to lab results for a history of deep vein thrombosis (DVT). - 3/13/23 for Insulin 14 units at bedtime and changed on 6/18/23 to 10 units at bedtime for DM type 2 -5/22/23 for Oxygen at 2 Liters per minute via nasal cannula for COPD Review of admission minimum data set (MDS) assessment dated [DATE] revealed Resident #4 had moderate cognitive impairment. She…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and staff interviews, the facility failed to implement their infection control policy when the Treatment Nurse did not perform hand hygiene after removing a soiled dressing with drainage on it and before cleansing the wound with wound cleanser-soaked gauze for 1 of 1 resident (Resident #152) reviewed for wound care. The findings included: The facility's policy entitled Infection Control Guidelines for All Nursing Procedures last revised on 12/29/20, under General Guidelines read in part: 4. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: a. Before and after direct contact with residents, b. Before donning gloves, e. Before handling clean or soiled dressings, gauze pads, etc. h. After handling used dressings, contaminated equipment, etc. j. After removing gloves. An observation of wound care by the Treatment Nurse was made on 06/21/23 at 1:26 PM. The Treatment Nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.