The Greens At Lincolnton

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $12,542

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $12,542

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.