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
- 22
- 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 cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
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