The Greens at Gastonia

Inspectors wroteBased on record review, observation, and resident and staff interviews, the facility failed to maintain residents' dignity when staff failed to knock before entering residents' rooms and when staff spoke negatively about a resident in the hall for 3 of 3 residents reviewed for dignity and respect (Resident #47, Resident #48 and Resident #90). The residents stated they felt very frustrated, angry, embarrassed, hurt and not worthy of respect or care.

Inspectors wroteBased on record review, resident, Resident Representative, staff, Consulting Pharmacist, and Medical Director interviews, the facility failed to obtain consent and inform the resident or Resident Representative in advance of the risks and benefits of psychotropic medications prior to the initiation or increase of the medication for 4 of 5 residents reviewed for unnecessary medications (Resident #15, Resident #47, Resident #27, Resident #1).

Inspectors wroteBased on record review, staff, Responsible Party, and Medical Director interviews, the facility failed to maintain accurate advanced directives throughout the medical record for 1 of 1 resident reviewed for advanced directives (Resident #103).

Inspectors wroteBased on observation, record review, resident, staff and Medical Doctor interviews, the facility failed to provide a treatment as ordered by the physician for a moisture associated skin issue for 1 of 3 residents reviewed for non-pressure skin treatments (Resident #48).

Inspectors wroteBased on record review, Medical Doctor and staff interviews, the facility failed to maintain an accurate Treatment Administration Record (TAR) for 1 of 3 residents reviewed for medical record accuracy (Resident #48).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to follow their Hand Hygiene policy when Nurse #1 did not perform hand hygiene before each donning of clean gloves during catheter care and failed to perform hand hygiene between residents during medication pass. This deficient practice affected 3 of 7 residents reviewed for infection control and included 1 of 7 staff observed for infection control. (Resident #112, #121, #135).

Inspectors wroteBased on record reviews, resident, staff, Nurse Practitioner (NP), and physician interviews, the facility failed to clarify and/or implement wound care orders as specified in the hospital discharge summary. In addition, the resident was seen by a Wound Care NP four days after admission and the wound care orders were not implemented until two days later. As a result, the resident was not provided wound care to three abdominal surgical wounds until six days after admission to the facility. The deficient practice occurred for 1 of 2 residents reviewed for wound care (Resident #1).

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to follow their Infection Control policies and procedures for Hand Hygiene when the Wound Care Nurse failed to doff her gloves, sanitize her hands, and don clean gloves after cleaning a sacral wound. With the same gloves on after cleaning the sacral wound with wound cleanser the Wound Care Nurse applied the treatment to the sacral wound for Resident #5 with a sacral pressure ulcer who was on Enhanced Barrier Precautions (EBP). The deficient practice occurred for 1 of 7 staff observed for infection control practices (Wound Care Nurse).

Inspectors wroteBased on observations, record reviews, and Nurse Practitioner, resident, and staff interviews, the facility failed to provide effective supervision for Resident #3 who had dementia with severe cognitive impairment, hemiparesis (mild or moderate weakness) of the dominant right side due to a stroke, and a history of smoking. A smoking assessent completed on 12/20/24 noted Resident #3 had limited range of motion and unclear speech response but was determined as having no issues with her ability to smoke safely and was determined to be safe to smoke unsupervised. On 3/19/25, Resident #3 was smoking unsupervised in the designated smoking area and caught her hair on fire. Resident #3 patted her hair with her right hand to put out the fire. [...]

Inspectors wroteBased on record review, resident, and staff interviews, the facility failed to protect the resident's (Resident #76) right to be free from misappropriation of property when Hospitality Aide #1 used Resident #76's debit card to withdraw cash from an Automatic Teller Machine (ATM) and purchase various items from several stores without Resident #76's permission or knowledge. Hospitality Aide #1 was alleged to have spent approximately $628.75 on November 29, 2024. Resident #76 stated it made me real sad that she took advantage of me. He indicated he trusted Hospitality Aide #1 as she had been kind to him and was upset she stole his money. This deficient practice occurred for 1 of 3 residents (Resident #76) reviewed for abuse, neglect, and misappropriation of resident property.

Inspectors wroteBased on observations, record reviews, staff, Pharmacist, and Medical Director interviews, the facility failed to have an effective system in place to ensure a new physician order for an as needed pain medication was available to administer for 1 of 5 residents (Resident #2) reviewed for pharmacy services. Resident #2 received a new order for her as needed pain medication in January 2025. Resident #2 received seven wrong dosages in March 2025 and two wrong dosages in April 2025 of her as needed pain medication due to the pharmacy not having received the new order from January 2025 and the correct dosages not being sent to the facility.

Inspectors wroteBased on record review, and family member and staff interviews, the facility failed to ensure a dependent resident (Resident #158) had a functioning call light to call staff for assistance with care. Resident #158 told her family member it made her feel helpless not being able to call for assistance. A reasonable person would expect to have their call light function so they could call staff for assistance with care when needed. This deficient practice affected 1 of 3 residents reviewed for dignity and respect (Resident #158).

Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility failed to stop a resident who had been assessed and determined clinically unsafe to self-medicate from self-medicating medications for 1 of 1 resident reviewed for self-administration of medication (Resident # 99).

Inspectors wroteBased on record reviews and staff interviews, the facility failed to ensure a call light was plugged in and in working order for 1 of 5 dependent residents who were reviewed for reasonable accommodation of needs (Resident #158).

Inspectors wroteBased on record review and staff interviews, the facility failed to have advance directives accurate throughout the medical record for 2 of 4 residents (Resident #68 and Resident #48) reviewed for advance directives.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete Care Area Assessments (CAA) comprehensively to address the underlying causes and contributing factors of the triggered areas for 2 of 6 sampled residents reviewed for CAA (Residents #99 and Resident #508).

Inspectors wrote3. Resident #63 was admitted to the facility [DATE] with diagnoses that included schizoaffective disorder. Resident #63's Preadmission Screening and Resident Review (PASRR) level II determination letter dated [DATE] revealed nursing facility placement was appropriate for 30 days and the PASRR level II expired on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had a diagnosis of schizoaffective disorder but was not coded for a PASRR level II. An interview with MDS Nurse #2 on [DATE] at 2:27 PM revealed she was responsible for completing the PASRR level II section of the MDS. MDS Nurse #2 revealed she reviewed Resident #63's PASRR determination letter but was not familiar with a PASRR level II that expired after 30 days and thought it was a PASRR level I. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) level II was obtained for a resident with an expired PASRR level II. This deficient practice occurred for 1 of 4 residents reviewed for PASRR (Resident #63).

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to administer medications as ordered by the physician for 1 of 5 (Resident #2) residents reviewed for medications.

Inspectors wroteBased on record review, and resident, staff, Pharmacist, and Medical Director interviews the facility failed to prevent a significant medication error when scheduled pain medications were not administered as ordered by the physician for 1 of 3 residents (Resident #112) reviewed for assuring facility was free from significant medication errors. Resident #112 was ordered to receive a scheduled pain medication three times a day and failed to receive seven dosages of his scheduled pain medication due to the medication not being available at the facility.

Inspectors wroteBased on observations, record review, and resident, staff and Medical Director interviews, the facility failed to store a lidded container of prescription topical medicated cream to treat foot pain (Resident #110), a lidded container of topical ointment to treat chest congestion, a lidded tube of topical medicated gel to treat arthritis pain, and a lidded tube of topical anti-itch cream (Resident #13) in a secure locked storage area for 2 of 2 residents observed with medicated creams at the bedside (Resident #110 and Resident #13).

Inspectors wroteBased on observation, record review, Physician and staff interviews, the facility failed to maintain a complete and accurate medical record when staff documented on the MAR that a scheduled medication was administered, but it was not signed as administered on the controlled medication declining sheets for 1 of 3 residents reviewed for medications (Resident #2).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to follow their Handwashing/Hand Hygiene policy when Unit Manager #2 did not perform hand hygiene before donning clean gloves while providing suprapubic catheter care to Resident #83. This deficient practice occurred for 1 of 6 staff members observed for infection control practices (Unit Manager #2).

Inspectors wroteBased on record reviews, and staff interviews the facility failed to complete and document weekly skin assessments as ordered by the physician for a resident with a known stage IV pressure ulcer to the sacrum and a known stage III pressure ulcer to the right heel for 1 of 3 residents (Resident #3) reviewed for the treatment and prevention of pressure ulcers.

Inspectors wroteBased on record review, and staff interviews, the facility failed to prevent a resident (Resident #3) from being fed when his diet order was nothing by mouth (NPO) with continuous enteral tube feeding for 1 of 2 residents reviewed for gastrostomy tube care.

Inspectors wroteBased on record review, family and staff interviews the facility failed to provide food in the form to meet individual needs of 1 of 1 resident (Resident # 2) reviewed for nutrition.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to implement their Infection Control Policy for hand hygiene/handwashing when the Treatment Nurse did not perform hand hygiene according to the facility's policy and procedure when providing wound care to 1 of 3 residents (Resident #3) and when Unit Manager #1 did not perform hand hygiene according to the facility's policy and procedure when providing gastrostomy tube site care for 1 of 2 residents (Resident #3) reviewed for infection control practices.

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain an accurate Treatment Assessment Record (TAR) for skin assessments for 1 of 2 residents (Resident #2) sampled for accuracy of resident records (skin assessments).

Inspectors wroteBased on observations, record reviews, resident and staff interviews, and test tray the facility failed to provide palatable food that was appetizing in temperature for 6 of 6 residents reviewed for food palatability (Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #14) . This practice had the potential to affect other residents on all halls.

Inspectors wroteBased on record reviews, observations, resident, and staff interviews, and a test tray, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following a recertification and complaint investigation that occurred on 02/01/24, a complaint investigation that occurred on 06/26/23 and a recertification and complaint investigation survey that occurred on 10/03/22 for a deficiency that was cited in the area of Activities of Daily Living for Dependent Residents (F677), a recertification and complaint investigation survey that occurred on 02/01/24, a recertification and complaint investigation survey that occurred on 04/15/21 for a deficiency cited in the area of Label/Storage of Drugs Biologicals (F761), a recertification and complaint investigation survey that occurred on 02/01/24 in the [...]

Inspectors wroteBased on observations, record review, resident, and staff interviews, the facility failed to provide nail care and trim fingernails for 1 of 3 sampled residents (Resident #1) reviewed for activities of daily living (ADL).

Inspectors wroteBased on observations, record review, resident, and staff interviews, the facility failed to provide podiatry services and/or toenail care for 1 of 3 sampled residents (Resident #1) reviewed for foot care.

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to secure medications stored at the bedside for 1 of 2 residents reviewed for medication storage (Resident #15).

Inspectors wroteBased on record review and staff interviews the facility failed to maintain complete and accurate medical records related to wound treatments for 1 of 3 residents (Resident #5) reviewed for wounds.

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to implement their hand hygiene/handwashing policy as part of their infection control policy, when the Treatment Nurse did not perform hand hygiene according to the facility ' s policy and procedure when providing wound care to 1 of 3 residents (Resident #1) reviewed for wound care.

Inspectors wroteBased on observations, and resident and staff interviews the facility failed to have systems in place for providing evening snacks to residents' in 5 of 5 halls. The deficient practice had the potential to affect all residents requesting a evening snack.

Inspectors wroteBased on observations and staff interviews, the facility failed to date and label fresh vegetables in 1 of 1 kitchen walk-in refrigerators, store a bucket of counter cleaning solution away from food items in kitchen, date and label a resident's food item in 1 of 2 nourishment room refrigerators, and prevent possible cross contamination by storing a dirty meal tray on a cart with trays that had not been served for 1 of 5 tray carts.

Inspectors wroteBased on record reviews, observations, and family and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following a complaint investigation that occurred on 06/26/23 and a recertification and complaint investigation survey that occurred on 10/03/22 for a deficiency that was cited in the area of Activities of Daily Living for Dependent Residents (F677), a recertification and complaint investigation survey that occurred on 10/03/22 for a deficiency that was cited in the area of Free of Accidents/Hazards (F689), a recertification and complaint investigation survey that occurred on 04/15/21 for a deficiency cited in the area of Label/Storage of Drugs Biologicals (F761), a recertification and complaint investigation that occurred on 10/03/22 in the area of Food [...]

Inspectors wroteBased on record reviews, observations and staff interviews, the facility failed to implement their infection control policies for the safe handling of soiled laundry when 1 of 5 staff members (Laundry Staff) failed to follow standard precautions during the infection control observation.

Inspectors wroteBased on record review, staff and nurse practitioner interviews the facility failed to notify the provider when a resident experienced a severely low blood sugar and when a resident experienced a high blood sugar for 2 of 2 residents (Resident #74 and Resident #7) reviewed for notification.

Inspectors wroteBased on record review, observations, resident, family member, and staff interviews, the facility failed to provide showers to a dependent resident for 1 of 6 residents (Resident #83) reviewed for activities of daily living.

Inspectors wroteBased on observation, record review, and resident, staff, and Nurse Practitioner interviews, the facility failed to follow a physician order to recheck a resident's blood sugar for 1 of 5 residents (Resident #7) reviewed for unnecessary medication.

Inspectors wroteBased on record review, responsible party and staff interviews, the facility failed to ensure a resident's toenails were trimmed and podiatry services were arranged for 1 of 1 resident reviewed for foot care (Resident #56).

Inspectors wroteBased on record reviews, and interviews with resident and staff, the facility failed to provide care in a safe manner for 1 of 4 residents (Resident #49) reviewed for supervision to prevent accidents. On 05/10/23, Resident #49's lower half of his body went off the other side of the bed during incontinence care but did not result in an injury.

Inspectors wroteBased on record review, observations, resident, family member and staff interviews, the facility failed to provide sufficient nursing staff to provide showers to a dependent resident for 1 of 6 residents reviewed for staffing (Resident #83). This tag was cross-referenced to: F677 - Based on record review, observations, resident, family member, and staff interviews, the facility failed to provide showers to a dependent resident for 1 of 6 residents (Resident #83) reviewed for activities of daily living. An interview with NA #2 and NA #3 on 01/31/24 at 2:34 PM revealed they typically worked the shower team unless they were pulled to work as a NA on the hall. NA #2 indicated they were sometimes pulled to the hall to work as a NA and on those days, it was up to the NA on the floor to complete the resident's showers or bed baths. [...]

Inspectors wroteBased on observations, staff interviews, and record review the facility failed to date opened multi-dose vials of medications in 1 of 3 medication administration carts (400 Hall).