Greensboro Nursing Home

Inspectors wroteBased on observation, interview, and policy review, it was determined that the facility failed to store food in accordance with professional standards for food service safety. This has the potential to impact all residents. This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey dated 6/11/25.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's medical record clearly communicated the resident's code status for 1 of 17 sampled residents (Resident #4).

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident [Resident #28] of 17 sampled residents remained free from physical abuse regarding a resident-to-resident altercation. This is a repeat deficiency for this facility, with the violation cited during a previous partial survey dated 12/22/25.

Inspectors wroteBased on interview and record review the facility failed to ensure that their policies related to screening for abuse via background checks had been implemented for 2 of 5 employees (LNAs #1 and #2).

Inspectors wroteBased on interview and record review the facility failed to ensure documentation was accurate and true for one of three sample residents (Resident #1).

Inspectors wroteBased on interview and record review the facility failed to ensure three of three residents sampled (Resident#1, #2, and #3) were able to be informed to make treatment decisions by failing to have the resident or resident representative sign consent for prescribed psychotropic medication.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' right to be free from verbal abuse by a visitor for 2 of 3 sampled residents (Resident #1 and Resident #3).

Inspectors wroteBased on interview and record review, the facility failed to report incidences of abuse for 2 of 3 sampled residents (Resident #1 and Resident #3). This is a repeat deficiency for this facility, with violations cited during the previous recertification surveys dated 6/11/25.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of verbal abuse, send a summary of the investigation to the State Survey Agency, and take appropriate corrective action for 2 of 3 sampled residents (Resident #1 and Resident #3).

Inspectors wroteBased on observations and interview, the facility failed to ensure medications were removed from the medication storage room when expiration dates were reached.

Inspectors wroteBased on observation and interview, the facility failed to store food in accordance with professional standards for food service safety and failed to maintain a sanitary kitchen.

Inspectors wroteBased on interview and record review, the facility failed to implement an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections related to Legionella prevention.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents are free from chemical restraints for one of three sampled residents (Resident #4) as evidenced by administration of medications without proper indication for use and no discontinued date.

Inspectors wroteBased on interview and record review the facility failed to ensure that an allegation of abuse was reported to facility administration, Adult Protective Services, and the State Licensing Agency.

Inspectors wroteBased on interview and record review, the facility failed to provide one of two residents sampled (Resident #77) or the resident's representative with a bed-hold notice after discharge to the hospital.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to review, revise, and implement resident care plans for 1 of 5 residents in the applicable sample related to falls (Residents #4).

Inspectors wroteBased on interview and record review, the facility failed to coordinate and implement hospice care measures for 1 of 1 sampled resident (Resident #20).

Inspectors wroteBased on interview and record review, the facility failed to act on a pharmacist's Medication Regimen Review (MMR) that was then ordered by a physician for 1 of 5 Residents in the sample (Resident #20). The facility also failed to ensure that monthly MMRs were completed for 1 of 5 Residents in the sample (Resident #9). 1. Per record review there was no evidence that Monthly Medication Regimen Reviews were completed for Resident #9 for the month of March of 2025. Per interview on 6/11/2025 at 10:30 AM the Director of Nursing (DON) stated that the pharmacist sends the MMRs to her and she reviews them then follows up with the physician. The DON confirmed that there was no documented evidence in the record and that she could not produce the MMRs for March of 2025. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain laboratory services when ordered by a physician for 1 of 5 residents in the sample (Resident #20). The facility also failed to obtain laboratory results and promptly notify the ordering physician of laboratory results for 1 of 5 residents in the sample (Resident #9).

Inspectors wroteBased on interview, staff education record review, and the facility assessment, the facility failed to ensure that licensed nurses and licensed nursing assistants were assessed for competency and skill sets to provide care and respond to each resident's individualized needs. This has the potential to affect all residents.

Inspectors wroteBased on staff interviews and record review, the facility failed to employ either a full-time dietitian and/or a part-time dietitian; and a certified Director of Nutrition Services.

Inspectors wroteBased on interview, the facility failed to establish and maintain a water management program to minimize the risk of Legionella ( a bacteria that causes inflammatory conditions of the lungs) and other opportunistic pathogens in building water systems that would include an assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas Acinetobacter) could grow and spread; and measures to prevent the growth of opportunistic waterborne pathogens (also known as control measures), and how to monitor them.

Inspectors wroteBased on observation, interview, and record review, for 1 applicable resident (Resident #13), the facility failed to protect the resident's privacy and treat the resident with respect and dignity. The facility also failed to ensure each resident has a right to self-determination and access to persons and services outside of the facility, by locking all doors to the facility 24 hours a day, 7 days a week. By creating a locked facility, there is a failure to ensure the right of each resident to exercise their rights as a citizen (or resident) of the United States or make personal choices about going outside without interference. This can potentially affect all residents of the facility and all visitors, including family, legal representatives, and advocates. Findings Include: 1. Per record review, Resident #13 has resided at this facility since [DATE]. [...]