The Greens at Weaverville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff, Primary Care Physician (PCP), facility Physician, Nurse Practitioner (NP), assisted living Director of Nursing, and Consultant Pharmacist interviews, the facility failed to provide an accurate medication list on an FL-2 to an assisted living facility for a resident who was discharged home from the facility while waiting on assisted living placement. The allergies listed were also incorrect. This deficient practice occurred for 1 of 3 residents reviewed for discharge (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included an encounter for orthopedic aftercare following surgical amputation of right second toe, Alzheimer's dementia, essential hypertension, and hyperlipidemia. Resident #1's discharge instructions dated 3/18/26 revealed he was discharged home on 3/18/26 with his correct current medication summary list. This list of medications was signed by the Responsible Party (RP), dated 3/18/26 and included the following…

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 interviews with staff, the facility failed to remove expired food with signs of spoilage stored for use in 1 of 3 refrigerators (the walk-in refrigerator). This had the potential to affect food served to the residents in the facility.Findings includedOn 7/28/25 at 10:15 AM an observation with the Dietary Manager (DM) in the walk-in refrigerator found a box of yellow squash with a written date of 7/9. The box of yellow squash was located underneath an additional box of yellow squash with a written date of 7/14 stored on the second shelf. The yellow squash dated 7/9 were observed to contain dark, splotchy and sunken in areas and the squash was not firm to touch. Furthermore, 1 squash located in the bottom of the box was broken into two pieces and was mushy when touched. The DM stated during the observation the yellow squash needed to be thrown out. The DM immediately removed and threw away the yellow squash. A follow-up interview with the DM was conducted on 7/31/25 at 12:56 PM. He stated it was his responsibility to check all food storage areas in 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 and interviews, the facility failed to care plan a resident who had a physician's order for an antipsychotic medication. This was for 1 of 5 residents reviewed for unnecessary medication (Resident #86).Findings includedResident #86 was admitted on [DATE] with diagnoses that included adjustment disorder.Resident #86's admission Minimum Data Set (MDS) assessment dated [DATE] coded her cognitively intact and indicated she had received an antipsychotic during the 7-day look back period. Resident #86 had a physician's order dated 6/23/25 for quetiapine fumarate oral tablet 50 milligram (antipsychotic). With instructions to give 1 tablet by mouth at bedtime for adjustment disorder with other symptoms. A review of Resident #86's care plan that was dated last reviewed on 6/30/25 found no care plan for antipsychotic medication use. On 7/31/25 at 10:22 AM, MDS Nurse #1 stated Resident #86's care plan had not included a care plan for an antipsychotic medication. MDS Nurse #1 added the physician's…

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 a clean and sanitary kitchen floor, date an opened nutritional supplement and food in 1 of 3 nourishment rooms (300 hall), clean and sanitize an ice scoop and holder for 1 of 3 ice chests, and date opened cheese in the walk-in refrigerator. This practice had the potential to affect food served to all residents. The findings included: a. An observation of the kitchen on 6/9/24 at 9:44 AM found the kitchen floor tiles to be covered with a black substance and sticky when walked on as evidenced by the sound that was made when the floor was walked on, and the surveyor's shoes stuck to the floor. The black substance and sticky floor were not contained to one area of the kitchen floor and was spread throughout the kitchen. An observation of the kitchen floor on 6/11/24 at 12:18 PM found the kitchen floor unchanged. The floor areas underneath and directly around 3 food prep tables were found to contain food and other debris. b. An observation of the 300-nourishment room refrigerator was conducted on 6/11/24 at 10:54…

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 reviews and staff interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level II was completed for 2 of 2 residents (Resident #80 and Resident #86) reviewed for PASRR. The findings included: 1. Resident #80 was originally admitted to the facility on [DATE] and was re-admitted on [DATE]. A review of Resident #80's medical record indicated bipolar disorder was added to her diagnoses list effective 6/5/23. There was no information in Resident #80's medical record regarding PASRR. An interview with the Social Services Director (SSD) on 6/12/24 at 9:13 AM revealed she started working at the facility in November 2023, and she was responsible for PASRR. The SSD stated she knew Resident #80 had been at the facility for a while even before she started working at the facility. During the interview, the SSD searched for PASRR information in Resident #80's medical record and agreed that she could not find any. She looked up Resident #80's PASRR from the North Carolina…

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, and interviews with resident, staff, Registered Dietitian and the Medical Director, the facility failed to provide a nutritional supplement and double protein as ordered by the Registered Dietitian for 1 of 4 residents (Resident #90) reviewed for nutrition. The findings included: Resident #90 was admitted to the facility on [DATE] with the diagnoses of diabetes and a pressure ulcer on left buttocks. On 2/1/24 Resident #90 was weighed using a sit-down scale and his weight was 253.0 pounds. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #90 was alert and cognitively intact. He had no weight loss. Resident #90's care plan dated 5/15/24 stated he was to have dysphagia (difficulty swallowing) advanced meats and mechanically altered diet for all food categories. The interventions included to provide and serve supplements as ordered and provide and serve diet as ordered. On 4/24/24 Resident #90 was weighed using a total mechanical lift and his weight was…

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 interviews the facility failed to assess the ability of residents to self-administer medications for 3 of 3 residents reviewed for self-administration of medication (Resident #35, Resident #39, and Resident #7). Findings included: 1. Resident #35 was admitted to the facility 06/17/22 with multiple diagnoses including spinal stenosis (when the spaces in the spine narrow and cause pressure on the spinal cord and nerve roots). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #35 was cognitively intact. Review of the medical record revealed no documentation that Resident #35 had been assessed for self-administration of medication. An observation of Resident #35's room on 04/03/23 at 11:32 AM revealed the following: a. a 15 milliliter (ml) bottle of carboxymethylcellulose sodium 0.5% eye drops (eye drops that help with dry eyes) sitting on the overbed table b. a 1.76 ounce (oz) tube of diclofenac sodium topical gel 1% (a topical anti-inflammatory…

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 remove expired food, and to date and label opened food in 1 of 3 kitchen refrigerators. The facility failed to remove expired resident food in 1 of 2 nourishment refrigerators (nourishment room [ROOM NUMBER]). Additionally, the facility failed to maintain a clean wall behind the dish machine free of black matter and maintain and repair a leaking dish machine pipe. This practice had the potential to affect food served to residents. The findings included 1. On 4/03/23 at 8:15 AM an observation of the walk-in refrigerator in the kitchen revealed multiple stored food items that were expired or stored without a use by date. The Dietary Manager was not present at the time of the observation. The second shelf of the walk-in refrigerator contained as followed: 1 opened bag of French toast not dated. 2-quart plastic container of lettuce dated 3-27 and use by 3-30. 2-quart container of chicken broth dated 3-26 and use by 4-2. 1 plastic bag with Swiss…

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 and staff interviews, the facility failed to treat a resident in a dignified and respectful manner when Nurse Aide #1 spoke and acted in a manner that made a resident feel uncomfortable for 1 of 7 residents reviewed for dignity (Resident #21). Findings included: Resident #21 was admitted to the facility on [DATE] with diagnoses that included left tibia (larger bone in the lower leg) and fibula (smaller bone in the lower leg) fractures. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #21 with intact cognition. Resident #21 required physical assistance of one to two staff members with transfers, bed mobility and toileting. During an interview on 04/03/23 at 10:43 AM, Resident #21 revealed on Saturday 04/01/23, NA #1 had just finished cleaning her up after an incontinence episode when within minutes she had another incontinent episode where urine leaked out from her brief onto the bed. Resident #21 stated that while NA #1 was cleaning her up the second time,…

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 request a Preadmission Screening and Resident Review (PASRR) for a resident with a new mental health diagnosis for 1 of 1 resident reviewed for PASRR (Resident #44). Findings included: Resident #44 was admitted to the facility on [DATE]. Her diagnoses included panic disorder, major depressive disorder, and psychotic disorder with delusions due to a known physiological condition. The North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry dated 04/06/23 revealed Resident #44 had a Level I PASRR effective 10/11/22. A Psychiatrist progress note dated 01/26/23 revealed in part, Resident #44 had been having some delusions that her water was poisoned and hearing people talking to her. It was further noted Resident #44 reported feeling restless, anxious, and realized people were not in the room with her but still worried about the voices. The assessment and plan noted a new diagnosis of psychotic disorder with delusions due to known…

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 and resident interviews the facility failed to correctly enter an order to obtain a speech therapy (ST) evaluation as ordered by a Nurse Practitioner (NP) for 1 of 4 residents (Resident #76) reviewed for therapy services. Findings included: Resident #76 was admitted to the facility 02/08/23 with multiple diagnoses including dysphagia (difficulty swallowing). Resident #76 had a Physician order dated 02/10/23 to receive a mechanical soft diet (a diet consisting of foods that could be swallowed safely). The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #76 was cognitively intact and received a mechanically altered diet. The nutrition care plan initiated 02/15/23 revealed Resident #76 had a nutritional problem related in part to a diagnosis of dysphagia and interventions included providing her diet as ordered and monitoring her meal intakes. NP #1's progress note revealed Resident #76 was seen for diet/swallowing on 03/07/23. The note further stated Resident #76…

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, staff and resident interviews, and record review the facility failed to secure medication for 1 of 1 resident (Resident #10) observed with medication at bedside. The findings included: Resident #10 was admitted to the facility on [DATE] with diagnoses including a stage 3 pressure ulcer. A review of Resident #10's physician's orders revealed an order dated 12/16/22 to clean wound with wound cleaner and apply zinc with collagen every shift and as needed. The annual Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact. On 11/25/22 Resident #10's self-administration of medication assessment documented Resident #10 was not able to self-administer medications. An observation of Resident #10's room and interview were conducted on 4/3/23 at 10:09 AM. The Resident was alert and lying in bed. A container labeled zinc oxide with collagen paste was on the overbed table. The Resident stated the zinc oxide with collagen paste was left on her overbed table a lot of the time. Nurse # 1…

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.