Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Viewmont during CMS and state inspections, most recent first.
A moderately cognitively impaired, functionally dependent resident with a history of stroke, hemiparesis, and prior heavy smoking obtained a cigarette lighter in a non‑smoking facility and ignited her clothing and bedding while alone in her room. Staff had recently provided peri care and left the resident in bed with the door closed at the roommate’s request; no one reported seeing a lighter at that time. Shortly afterward, the fire alarm activated, and staff found the resident in bed with flames and embers on her upper body and linens, which they extinguished with bedding and wet towels. A lighter matching one owned by a staff member who reported a hole in her scrub pocket was found on the resident’s nightstand, and the resident stated she had stolen it. EMS and hospital records documented 16% TBSA second‑ and third‑degree burns to the abdomen, breast, genital/perineal area, hand, and thigh, requiring ICU care, NG feeding, and surgical excision with allograft placement. The roommate, who was cognitively intact and had an oxygen concentrator in the room (not in use), reported smelling smoke, activating the call bell, and calling for staff before the alarm sounded.
A resident with a history of neurogenic bladder and an indwelling urinary catheter was not accurately coded in the MDS assessment, as the diagnosis of neurogenic bladder was omitted despite being documented in physician orders. Staff interviews revealed reliance on automated systems and incomplete review of all relevant records, resulting in the deficiency.
A nurse left a cup of oral medications at a resident's bedside without confirming ingestion, despite the resident not being assessed for self-administration. The resident, who was cognitively intact and had multiple chronic conditions, reported that some nurses left medications at the bedside while others did not. The DON confirmed that facility policy requires nurses to ensure residents swallow their medications and not leave them unattended.
The facility exceeded the acceptable medication error rate due to improper medication administration by nursing staff. Two residents were involved: one was allowed to self-administer a steroid inhaler and eye drops incorrectly without proper assessment or instruction, and another received insulin via pen without the required priming step. These errors were confirmed through staff interviews and contributed to a medication error rate above 5%.
A Wound Nurse did not perform hand hygiene after removing gloves and before donning new gloves while treating a resident's stage IV sacral pressure ulcer. This action was not in accordance with the facility's hand hygiene policy, as confirmed by both the nurse and the DON during interviews.
Resident Severely Burned After Obtaining Lighter in Non‑Smoking Facility
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accident‑hazard‑free environment and adequate supervision for a moderately cognitively impaired resident who obtained a cigarette lighter and ignited herself and her bedding. The facility had a tobacco‑free campus policy and Resident #1’s admission agreement, MDS assessments, and a smoking safety evaluation all indicated that she did not smoke. Resident #1 had a history of epilepsy, chronic kidney disease, left‑sided hemiplegia/hemiparesis after stroke, major depressive disorder, anxiety disorder, and a left above‑knee amputation. She was care planned as needing one to two staff for turning, repositioning, toileting, and most ADLs, and was documented as moderately cognitively impaired with short‑term memory loss. PACE staff, including the social worker and NP, confirmed moderate cognitive impairment and a past history of heavy smoking at home, but reported that since admission to the facility she had not voiced a desire to smoke. On the day of the incident, nursing assistants provided peri care to Resident #1 around mid‑afternoon, rolling her side to side and noting that she held onto staff during care. Both NAs reported that Resident #1 required assistance for bed mobility and did not see a lighter in her possession, and neither recalled her expressing a desire to smoke. One NA later reported that she owned a lighter similar to the one found with Resident #1 and that her scrub top worn that day had a hole in the pocket; she stated she normally did not bring her lighter into the building but acknowledged the possibility it could have fallen through the pocket. After care, another NA straightened Resident #1’s sheets, asked if she needed anything, then left the room and closed the door at the roommate’s request. The facility allowed staff to smoke at the back of the building despite its non‑smoking status for residents. At approximately 4:39 PM, the fire alarm sounded and the fire panel indicated the source was Resident #1’s room. Staff observed light smoke coming from under the closed door. When Nurse #1 opened the door, he found Resident #1 in bed with flames and smoke on her abdomen and upper torso. Nurse #1 and Nurse #2 used bedding from the foot of the bed to extinguish the flames, and other staff applied wet towels and washcloths to smoldering areas on Resident #1’s torso, breasts, groin, and left hand, and removed burned linens and clothing. Multiple staff observed orange embers on the shirt and sheets, and a pinkish‑purple lighter was found on the nightstand as Resident #1 attempted to reach toward it; when asked how she obtained it, Resident #1 stated she had stolen it and could not identify from whom. The fire department and EMS arrived within minutes. EMS and hospital records documented second‑ and third‑degree burns over 16% of Resident #1’s body, including full‑thickness burns of the abdominal wall and left breast, burns to the genital and perineal areas, left hand and digits, and right thigh, with Resident #1 generally alert but confused and often denying pain. The roommate, who was cognitively intact and had an oxygen concentrator in the room (not in use at the time), reported smelling smoke, activating the call bell, and calling out for staff before the alarm sounded, and stated that the resident sometimes talked about smoking. The fire investigation noted damage to the mattress and bed controller consistent with several minutes of burning and confirmed that a lighter matching staff descriptions was provided by the facility as the ignition source associated with the event. Resident #1 was transported by EMS, then airlifted to a trauma center burn ICU, where she required critical care for 16% TBSA burns, NG tube placement for poor oral intake, and surgical excision of burned tissue with application of an allograft to the abdomen and bilateral lower extremities, with plans for subsequent autografting. Hospital staff documented that Resident #1 was disoriented to place and had dementia, and that she described a scenario in which a staff member’s lighter fell from their scrubs, she picked it up without the staff member noticing, and later played with it, leading to the fire. The facility’s failure to prevent a resident with moderate cognitive impairment and significant physical limitations from obtaining and using a cigarette lighter in a non‑smoking environment, and to adequately supervise her so as to prevent ignition of her clothing and bedding, resulted in severe burn injuries. There was also a high likelihood for serious injury or harm to the roommate, who was present in the room and used oxygen equipment, although it was not running at the time of the incident.
Failure to Accurately Code MDS Assessment for Neurogenic Bladder Diagnosis
Penalty
Summary
The facility failed to accurately code a Minimum Data Set (MDS) assessment for a resident who had a diagnosis of neurogenic bladder and an indwelling urinary catheter. The resident was admitted with multiple diagnoses, including neuromuscular dysfunction of the bladder, and had a physician order for a catheter due to neurogenic bladder. However, the quarterly MDS assessment did not reflect the diagnosis of neurogenic bladder in section I, despite the presence of supporting documentation in the resident's medical record and physician orders. Interviews with facility staff revealed that the MDS nurse typically relies on information pulled from various sources, such as nurse practitioner notes and hospital discharge summaries, and does not routinely review physician orders, assuming the system will automatically import relevant diagnoses. Both the MDS nurse and the DON acknowledged that the diagnosis of neurogenic bladder should have been included in the MDS assessment, and the administrator confirmed the expectation that MDS assessments accurately reflect each resident's diagnoses and care needs.
Failure to Ensure Resident Swallowed Medications During Administration
Penalty
Summary
A deficiency occurred when a nurse failed to ensure that a resident swallowed their prescribed oral medications during medication administration. The resident, who had diagnoses including coronary artery disease, diabetes mellitus, peripheral vascular disease, and Alzheimer's disease, was cognitively intact according to a recent assessment. During a morning medication pass, the nurse left a cup containing six pills on the resident's over-bed table while the resident was eating breakfast, allowing the resident to take the medications at her own discretion. The resident confirmed that some nurses leave her medications at the bedside, while others do not, and stated she would take them when she was ready. The nurse involved explained that she believed it was acceptable to leave the medications with the resident because the resident was alert and oriented, noting that this was the first time she had done so. However, the Director of Nursing later clarified that the resident had not been assessed for self-administration of medications, and facility policy required nurses to ensure residents swallow their medications and not leave them at the bedside. This failure to follow professional standards of medication administration led to the cited deficiency.
Medication Error Rate Exceeds Regulatory Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors out of 26 opportunities, resulting in an 11.54% error rate. For one resident with renal insufficiency, dyspnea, and vascular dementia, a nurse allowed the resident to self-administer a corticosteroid inhaler and artificial tears without proper assessment for self-administration capability. The resident was not instructed to rinse her mouth after using the inhaler, as required by the physician's order and manufacturer’s instructions, and improperly administered the eye drops by dragging the bottle tip across her eyelashes and using more than the prescribed number of drops. The nurse acknowledged these errors during an interview, noting nervousness as a factor for not providing proper instruction. In another instance, a nurse administered Lispro insulin via a prefilled pen to a resident with diabetes mellitus without priming the pen as required by the manufacturer’s instructions and facility policy. The nurse was unaware that priming was necessary each time, not just with new pens. Both the DON and Pharmacy Consultant confirmed that priming is a required step to ensure correct dosing. These actions contributed to the facility’s medication error rate exceeding the regulatory threshold.
Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
A deficiency occurred when the Wound Nurse failed to follow the facility's Handwashing/Hand Hygiene policy during a pressure ulcer treatment for a resident with a stage IV sacral pressure ulcer. The Wound Nurse initially washed her hands, donned a gown and gloves, and set up the work surface. After removing the old dressing and her gloves, she washed her hands before applying new gloves. However, after cleansing the wound and removing her gloves again, she did not wash or sanitize her hands before donning a new pair of gloves to continue the treatment, which included applying a medicated pad and border dressing. The facility's policy, last revised in October 2015, requires staff to perform hand hygiene after removing gloves and before applying new gloves. During an interview, the Wound Nurse acknowledged the lapse, stating she usually washed her hands but was nervous due to being observed. The DON confirmed that the facility's policy mandates hand hygiene after glove removal and before donning new gloves, and that the Wound Nurse did not follow this protocol during the observed wound care procedure.
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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 Hickory
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trinity Village | 1 mi | ★★★★★ | 3 | 0 |
| The Greens At Hickory | 2.8 mi | ★★★★★ | 14 | 0 |
| Trinity Ridge | 4.4 mi | ★★★★★ | 1 | 0 |
| Hickory Falls Health And Rehabilitation | 6.8 mi | ★★★★★ | 0 | 0 |
| Conover Nursing And Rehabilitation Center | 7 mi | ★★★★★ | 1 | 0 |
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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.