Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Greens At Spruce Pines during CMS and state inspections, most recent first.
A resident with a history of aspiration pneumonitis and acute hypoxic respiratory failure was admitted to a facility and placed on a modified diet. Despite a downgrade in diet and high risk for aspiration, speech therapy was not consulted. The resident experienced a choking incident, leading to hospitalization where esophageal dysphagia and aspiration pneumonia were diagnosed. The facility staff assumed the resident was under hospice care, contributing to the oversight in providing necessary therapy services.
The facility failed to maintain cleanliness in the kitchen and manage expired tube feeding containers. Observations revealed a sticky red substance and debris in the reach-in refrigerator, debris in the walk-in refrigerator, and sticky build-up on steam table knobs. Additionally, 21 expired tube feeding cartons were found in the nourishment room. The Dietary Manager and Central Supply Manager admitted to lapses in cleaning schedules and inventory checks.
The facility failed to repair a leaking steam cooker in the kitchen, with hot water and steam escaping during use. The DM knew of the issue since August 2024 but did not inform the Maintenance Director, who was unaware of the problem. The Maintenance Director confirmed the door seal needed replacement.
A facility failed to include the specific type of thickened liquids in a resident's baseline care plan upon admission, leading to potential confusion among staff. The resident, who was cognitively intact, had dietary orders that changed from nectar thick to honey thick liquids following a hospital discharge. Interviews with staff revealed that the omission was due to oversight and a lack of detailed documentation, highlighting a gap in the facility's care planning process.
A resident with a history of aspiration pneumonia was given nectar thick liquids instead of the prescribed honey thick liquids, leading to a potential risk of aspiration. Staff were unaware of the resident's specific dietary needs, resulting in the incorrect liquid being provided. The Speech Therapist confirmed signs of aspiration with the incorrect liquid, highlighting the need for honey thick liquids.
A facility failed to maintain a medication error rate below 5%, resulting in an 8.57% error rate. A resident with multiple medical conditions was affected when Nurse #5 improperly crushed extended-release (ER) medications, contrary to manufacturer's instructions. The nurse was unsure about the orders and did not consult the Unit Manager or pharmacy. Interviews with staff confirmed that ER medications should not be crushed, as it alters their effectiveness and release time.
A medication cart on the 400 hall was found unattended and unlocked outside the nurses' station, with 16 staff members passing by and a resident nearby. Nurse #1, responsible for the cart, admitted to not ensuring it was locked before leaving. The DON and Administrator confirmed that medication carts should be locked when unattended.
A resident with dysphagia was given nectar thick liquids instead of the prescribed honey thick liquids due to a shortage and miscommunication among staff. The resident expressed thirst, and staff provided the incorrect consistency, which was found in the resident's hydration cooler. The facility had run out of the required honey thick liquids, leading to the error.
A resident in a memory care unit obtained unsecured blunt-tipped scissors and caused self-harm, resulting in superficial lacerations. The facility failed to maintain a hazard-free environment, as the origin of the scissors was unknown, and staff did not secure them despite noticing them in the day room. The resident, with non-Alzheimer's dementia, had no prior self-harm behaviors, and the incident highlighted a lapse in supervision and security.
Failure to Provide Speech Therapy Evaluation and Services
Penalty
Summary
The facility failed to provide necessary speech therapy evaluation and services to a resident who was admitted with a history of aspiration pneumonitis and acute hypoxic respiratory failure. Upon admission, the resident was placed on a mechanical soft diet with nectar thickened liquids, but after being diagnosed with pneumonia, the diet was downgraded to puree with nectar thick liquids. Despite these changes and the resident's high risk for aspiration, speech therapy was not consulted to evaluate the resident's swallowing capabilities. The resident experienced a choking and aspiration incident, leading to hospitalization where it was confirmed that the resident had esophageal dysphagia and aspiration pneumonia. The hospital discharge summary recommended speech therapy, but upon readmission to the facility, speech therapy was still not initiated. The facility's staff, including the Speech Therapist, were not aware of the resident's need for speech therapy, and there was a lack of communication and follow-up regarding the resident's dietary needs and therapy requirements. Interviews with facility staff revealed that there was an assumption that the resident was under hospice care, which contributed to the oversight in providing speech therapy. The facility's standard admission orders included a provision for speech therapy evaluation, but this was not acted upon. The Director of Nursing and other staff members acknowledged the communication breakdown and the failure to ensure the resident received the necessary therapy services, which led to the resident's hospitalization due to aspiration.
Deficiencies in Kitchen Cleanliness and Expired Tube Feeding Management
Penalty
Summary
The facility failed to maintain cleanliness and proper storage practices in the kitchen and nourishment room, as observed during a survey. The reach-in refrigerator was found with a sticky red substance and a circulatory fan cover covered with thick brown/gray debris. The walk-in refrigerator had gray, crumbly debris hanging from the ceiling near the cooling fan. Additionally, the steam table knobs were observed with a sticky build-up. These areas were not cleaned or maintained according to a regular schedule, as confirmed by the Dietary Manager (DM), who admitted that the reach-in refrigerator was not cleaned the previous week, and the debris in the walk-in cooler and steam table knobs were overlooked. In the nourishment room, 21 expired tube feeding cartons were found, which were supposed to be managed by the Central Supply staff. The Central Supply Manager acknowledged that the tube feeding containers were checked monthly for expiration, but the expired items were overlooked. The Administrator confirmed that the kitchen should have been clean and tidy and on a regular cleaning schedule, indicating a lapse in the facility's adherence to professional standards for food storage and cleanliness.
Failure to Repair Leaking Steam Cooker
Penalty
Summary
The facility failed to maintain and repair a leaking steam cooker in the kitchen. During an observation, hot water was seen dripping from the bottom of the steam cooker door, and steam was spewing from the sides while in use. The Dietary Manager (DM) admitted that the steamer had been leaking since he assumed his role in August 2024 but had not informed the Maintenance Director about the need for repairs. The DM believed the door seal needed replacement to prevent leaks. The Maintenance Director, unaware of the issue, confirmed the seal was not fully attached and required replacement. The Administrator acknowledged that the Maintenance Director should have been notified about the repair needs.
Failure to Include Specific Thickened Liquids in Baseline Care Plan
Penalty
Summary
The facility failed to develop an accurate baseline care plan for a resident upon admission, specifically omitting the type of thickened liquids ordered. The resident, who was cognitively intact, was initially placed on a mechanically altered diet with nectar thick liquids, which was later changed to a puree diet with honey thick liquids following a hospital discharge. The baseline care plan did not specify the type of thickened liquids, leading to potential confusion among staff regarding the resident's dietary needs. Interviews with facility staff, including the MDS nurse, Nurse #4, the Director of Nursing, and the Administrator, revealed that the omission was due to oversight and a lack of detailed documentation in the care plan. Staff members indicated that the care plan should have included the specific type of thickened liquids to ensure consistency with physician orders and dietary tickets. The deficiency was identified during a review of the resident's records and staff interviews, highlighting a gap in the facility's process for developing and reviewing baseline care plans.
Failure to Provide Correct Thickened Liquids
Penalty
Summary
The facility failed to provide the correct thickened liquids as ordered for a resident, leading to a potential risk of aspiration. The resident, who was cognitively intact and required substantial assistance with eating, was on a puree diet with honey thick liquids due to a history of esophageal dysphagia and aspiration pneumonia. Despite this, a nurse aide provided the resident with nectar thick liquids instead of the prescribed honey thick liquids, which were not thick enough to prevent aspiration. The incident occurred when a nurse aide, unfamiliar with the resident's specific dietary needs, assumed the nectar thick liquids found in the resident's hydration cooler were correct. The resident attempted to drink the nectar thick liquid through a straw and subsequently coughed, indicating possible aspiration. The nurse aide did not verify the type of thickened liquid before serving it, and another nurse aide later confirmed that the resident could not drink honey thick liquids through a straw due to their thickness. Further interviews revealed that the staff, including nurses and nurse aides, were not fully aware of the resident's dietary orders. A nurse had provided nectar thick liquids from the kitchen without confirming the resident's specific needs. The Speech Therapist confirmed that the resident showed signs of aspiration with nectar thick liquids and required honey thick liquids. The Director of Nursing and the Administrator acknowledged the error, noting that the resident should have received honey thick liquids as ordered.
Medication Error Rate Exceeds 5% Due to Improper Crushing of ER Medications
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an 8.57% error rate due to three errors out of 35 opportunities. This deficiency affected one resident who was observed for medication administration. The resident had multiple medical diagnoses, including hypertension, angina, COPD, and GERD, and was prescribed several medications, including Isosorbide Mononitrate ER, Mucinex ER, and Pantoprazole Sodium. During an observation, Nurse #5 was seen preparing the resident's medications by crushing them, including the ER tablets, which should not be crushed according to the manufacturer's instructions. Nurse #5 mistakenly believed it was acceptable to crush the ER tablets because they were not capsules and was unsure about the pantoprazole order. She admitted that if uncertain, she would typically consult the Unit Manager or pharmacy. The Unit Manager confirmed that ER medications should not be crushed as it would release the medication all at once. Interviews with the Director of Nursing, Physician Assistant, and Pharmacist further confirmed that ER medications should not be crushed, as it alters the release time and effectiveness of the medication. The Pharmacist explained the potential impacts of crushing these medications, including decreased effectiveness and altered symptom management. The Administrator emphasized the importance of following physician orders and consulting with the pharmacy or physician regarding medication administration.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure the 400-hall medication cart was secured while unattended. On 1/22/25 at 1:52 PM, the medication cart was observed to be unlocked and unattended outside the nurses' station and across from a resident activity room. During a continuous observation from 1:52 PM to 2:03 PM, 16 facility staff passed by the unlocked cart, and a resident was noted to be sitting approximately 10 feet away. Nurse #1, responsible for the cart, returned at 2:03 PM, locked the cart, and admitted to not double-checking that it was locked before leaving it unattended. The Director of Nursing confirmed that medication carts should be locked if not attended by a nurse or within a nurse's line of sight. The Administrator also stated that the cart should have been locked when unattended.
Failure to Provide Correct Thickened Liquids for Resident with Dysphagia
Penalty
Summary
The facility failed to provide drinks consistent with a resident's needs, specifically for a resident with dysphagia who required honey thick liquids. The resident was readmitted with a diagnosis of dysphagia and had a diet order for honey thick liquids. However, during an observation, a carton of nectar thick lemon water was found in the resident's hydration cooler, which was inconsistent with the prescribed diet. Interviews with staff revealed that the resident had expressed thirst, and due to a lack of available honey thick liquids, nectar thick liquids were mistakenly provided. The Dietary Manager confirmed that the facility had run out of pre-thickened honey thick liquids and had to source them from a sister facility. Staff interviews indicated that there was confusion and a lack of communication regarding the availability of thickened liquids, leading to the resident receiving the incorrect consistency. The Director of Nursing and the Administrator acknowledged the error, confirming that the resident should have received honey thick liquids to prevent aspiration.
Resident Self-Harm Due to Unsecured Scissors in Memory Care Unit
Penalty
Summary
The facility failed to maintain a hazard-free environment in the locked memory care unit, resulting in a resident obtaining a pair of unsecured blunt-tipped scissors and causing self-harm. The incident involved a resident with non-Alzheimer's dementia, who was moderately cognitively impaired and had no prior behaviors indicating self-harm. On the morning of the incident, nurse aides discovered blood on the resident's bed sheets and multiple superficial lacerations on his penis, which were presumed to have been caused by the scissors. Interviews with staff revealed that the scissors were found in the resident's room, although their origin was unknown. A nurse aide had noticed the scissors in the day room/dining room the previous night but did not secure them, assuming residents were always supervised in that area. The activities director confirmed that blunt-tipped scissors were not allowed on the memory care unit, and the facility's staff were unable to determine how the resident obtained them. The Director of Nursing and the Administrator were unable to identify the source of the scissors or how they ended up in the resident's possession. The facility's staff, including the nurse practitioner and physician, assessed the resident's injuries, which were superficial and did not show signs of infection. Despite the facility's efforts, the origin of the scissors remained unknown, and the incident highlighted a lapse in maintaining a secure environment for residents in the memory care unit.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Spruce Pine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Smoky Ridge Health And Rehabilitation | 11.4 mi | ★★★★★ | 0 | 0 |
| Autumn Care Of Marion | 14.7 mi | ★★★★★ | 10 | 1 |
| The Waters Of Roan Highlands,llc | 19.7 mi | ★★★★★ | 1 | 0 |
| Life Care Center Of Banner Elk | 20.6 mi | ★★★★★ | 5 | 0 |
| Deer Park Health And Rehabilitation | 20.9 mi | ★★★★★ | 3 | 3 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.