The Greens at Spruce Pines

Based on observations and staff interviews, the facility failed to maintain a clean floor and walls in of 1 of 1 kitchen dry food storage room.The findings included:On 5/11/26 at 9:56 AM an observation was made of the kitchen's dry food storage room with the Dietary Manager. The dry food storage room floor had vinyl tiles, painted walls and vinyl wall base molding. The front wall to the left of the door was 10 feet wide and backed up to the walk-in freezer on the other side of the wall. There were three, 6-foot-tall shelves the full length of front wall from left to right including a 2-foot-wide wire rack shelf on wheels, a 2-foot-wide stationary solid metal can shelf, and a 4-foot- wide wire rack shelf on wheels. The left wall was 10 feet wide, had wire rack shelving on wheels covering the wall's full length, and backed up to the building's exterior on the other side of the wall. Scattered dark floor and wall stains were partly visible through the lower wire rack shelves on the front and left walls. The Dietary Manager pulled the wire rack shelving on wheels away from the front and…

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 and staff interviews, the facility failed to clean and maintain the reach-in refrigerator, walk-in refrigerator and the steam table knobs in the kitchen. The facility also failed to remove expired tube feeding containers from 1 of 2 nourishment rooms. This practice had the potential to affect residents in the facility. Findings included a. An observation of the kitchen's reach-in refrigerator was made with the Dietary Manager (DM) on [DATE] at 10:38 AM. The observation found the inside floor of the refrigerator and the bottom of the inside side of the door contained splattered, sticky to touch red substance. The reach-in refrigerator's circulatory fan cover was observed covered with thick brown/gray debris that was crumbly to touch. b. On [DATE] at 10:46 AM the walk-in refrigerator ceiling was found to contain gray in color, loosely hanging debris. The debris was crumbly to touch and was in the back of the walk-refrigerator near the cooling fan. c. On [DATE] at 10:49 AM each of the six the…

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 observations and staff interviews, the facility failed to maintain and repair 1 of 1 leaking steam cooker for 1 of 1 steam cooker observed. Findings included On 1/23/25 at 12:11 PM an observation of the kitchen's steam cooker found hot water dripping from the bottom of the steam cooker door while in use. The steam cooker was observed spewing steam out from each side of the closed steam cooker door when it was being used to heat food. The Dietary Manager (DM) stated the steamer had been leaking water and steam since he had become the DM in August 2024. The DM said he had not informed the Maintenance Director the steamer needed repair since he became the DM, and he thought the door seal needed to be replaced to keep the steam and water from leaking out when in use. The DM stated when something needed to be repaired in the kitchen, he verbally communicated it to the Maintenance Director who would complete the repairs or outsource to complete the repairs. The Maintenance Director was interviewed on 1/24/25 at 11:26 AM. He stated the steam cooker seal had been repaired once…

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, observation, and staff interviews, the facility failed to develop an accurate baseline care plan for a resident (Resident #70) when the care plan did not include the type of thickened liquids ordered for Resident #70. This deficient practice occurred for 1 of 1 resident reviewed for baseline care plans. Findings included: Resident #70 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #70 was cognitively intact. He was coded on the MDS as having a mechanically altered diet. A diet order dated 12/17/24 read, regular diet, mechanical soft texture, nectar thick liquids. The order was discontinued on 12/19/24. A baseline care plan dated 12/17/24 read under dietary: Diet order, regular mechanical soft thickened liquids. A diet order dated 12/19/24 read, regular diet, puree texture, nectar thick liquids. The order was discontinued on 1/13/25. A hospital discharge summary for Resident #70 dated 1/13/25 revealed he was admitted to the…

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, observation, staff and Physician Assistant (PA) interviews, the facility failed to provide thickened liquids as ordered to a resident (Resident #70) when Nurse Aide (NA) #1 gave Resident #70 nectar thick liquids to drink instead of honey thick liquids. Resident #70 required honey thick liquids due to his risk of aspiration and history of aspiration pneumonia. This deficient practice occurred for 1 of 3 residents reviewed for accident hazards. The findings included: Resident #70 was admitted to the facility on [DATE]. He was re-admitted to the facility on [DATE] following hospitalization. The admission minimum data set (MDS) dated [DATE] revealed Resident #70 was cognitively intact. The MDS documented he had no behavior or rejection of care. The MDS indicated Resident #70 required substantial/ maximal assistance from staff with eating. He was coded on the MDS as having a mechanically altered diet. The hospital discharge summary for Resident #70 dated 1/13/25 revealed he was admitted to the…

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, staff, Physician Assistant (PA), and Pharmacist interviews the facility failed to maintain a medication error rate of less than 5% by having 3 errors out of 35 opportunities which resulted in an 8.57% medication error rate. This affected 1 of 4 residents observed for medication administration (Resident #19). Findings included: Resident #19 was admitted to the facility on [DATE]. Her medical diagnoses included: hypertension (high blood pressure), angina (chest pain), chronic obstructive pulmonary disease (COPD) (chronic respiratory disease), and gastro-esophageal reflux disease (GERD). A Physician's order dated 9/26/24 read, may crush medications unless contraindicated. A physician's order dated 9/27/24 read Isosorbide Mononitrate (cardiac medication) extended release (ER) 24-hour 30 milligram (mg) oral tablet, give one tablet by mouth one time a day for angina. The manufacturer's package insert instructions for the administration of Isosorbide Mononitrate dated 2/2025…

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 observations and staff interviews, the facility failed to ensure the 400-hall medication cart was secured while unattended. This was for 1 of 5 medication carts observed (400 hall). Findings included An observation on 1/22/25 at 1:52 PM revealed the 400-hall medication cart was unattended and unlocked with the lock in the outward position. The medication cart was located directly outside the nurses' station and across the hall from a resident activity room. A continuous observation of the medication cart occurred on 1/22/25 from 1:52 PM to 2:03 PM in which 16 facility staff passed the unlocked cart. A resident was observed sitting in their wheelchair approximately 10 feet from the cart while unlocked. Nurse #1 who was assigned to the 400 hall nurses cart arrived back to the medication cart on 1/22/25 at 2:03 PM, locked the cart and was interviewed. Nurse #1 stated she had placed the medication cart by the nurses' station and did not double check that the cart was locked. She stated she normally locked the cart and should have locked the cart before leaving it unattended.…

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, and staff interviews, the facility failed to provide drinks consistent with the resident's needs for 1 of 1 sampled resident (Resident #70) reviewed for drinks available to meet resident needs. The findings included: Resident #70 was re-admitted to the facility on [DATE]. A diagnosis of dysphagia (difficulty swallowing) was listed on Resident #70's 1/13/25 hospital discharge summary. A diet order dated 1/13/25 read, regular diet, puree texture, honey thick liquids. Resident #70 had a care plan revised on 1/14/25 that read: Resident #70 has a nutritional problem or potential nutritional problem and is reliant on thickened liquids and puree food at this time. The care plan intervention said to provide and serve diet as ordered. An observation was completed on 1/21/25 at 1:10 PM of the hydration cooler in Resident #70's room. The cooler contained a carton labeled nectar thick lemon water. The carton was dated with an open date of 1/21/25. An interview was conducted with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to provide a hazard-free environment by leaving a pair of blunt tipped scissors unsecured in the dining room of the locked memory care unit, resulting in a resident obtaining the scissors and making multiple superficial cuts to his penis. This deficient practice occurred for 1 of 3 residents reviewed for accidents (Resident #1). Findings included: Resident #1 was admitted to the facility 08/15/24 with a diagnosis including non-Alzheimer's dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was moderately cognitively impaired and did not have behaviors during the look back period. An interview with Nurse Aide (NA) #1 on 10/22/24 at 11:00 AM revealed she was caring for Resident #1 on 09/02/24 on the 7:00 AM to 3:00 PM shift. She stated she and NA #2 went into Resident #1's room the morning of 09/02/24 to assist him out of bed when she noticed blood on his bed sheet. NA #1 stated she thought Resident #1 had…

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 observations and staff interviews, the facility failed to remove expired food items stored for use in the walk-in freezer, cooler, and dry goods storage room in the kitchen and failed to remove and/or label and date food items available for use in 1 of 2 nourishment rooms (100 Hall nourishment room). These practices had the potential to affect food served to residents. Findings included: 1. An observation and interview conducted on 09/26/23 at 9:35 AM with the Dietary District Manager revealed during the initial kitchen tour a bag of 11 frozen Salisbury steaks were observed to be undated in the walk-in freezer. The observation further revealed in the dry goods storage room was three cereals with the discard date 09/21/23, 09/24/23, and 09/14/23. Also included were flour tortillas with discard date 06/16/23, and 14 46 fl. ounce cartons of emergency orange juice with discard date 07/05/23. The dietary District Manager stated the items observed should have been discarded. 2. An observation and interview conducted on 09/26/23 at 10:00 AM with Nurse #1 revealed the nourishment…

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 resident interviews the facility failed to label a tube feeding formula bag for 1 of 2 residents (Resident # 204). The findings included: Resident #204 was admitted to the facility on [DATE] with diagnoses which included hemiplegia to the left dominant side, and gastrostomy status (surgical procedure for inserting a tube through the abdomen wall and into the stomach. The tube is used for feeding or drainage). Review of Resident #204's nursing admission assessment revealed the resident was cognitively intact and was independent with eating (oral intake) but was dependent for continuous tube feedings. Review of Resident #204's baseline care plan dated 09/23/23 revealed the resident received tube feedings. The goal for Resident #204 was to maintain weight. Review of a physician order dated 09/24/23 revealed an order for Resident #204 to receive Two Cal HN 120 millimeters (ml) per hour (hr) administered over a 2-hour period and to equal 240 ml three times a day via…

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.