The Greens at Lincolnton

Inspectors wroteBased on record review and staff interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for residents with new mental health diagnoses for 4 of 5 residents (Resident #9, Resident #14, Resident #15, and Resident #68) reviewed for PASRR.

Inspectors wroteBased on observations, record review, and staff, Nurse Practitioner (NP), Physician, COVID test manufacturer customer service representative, and Health Department (HD) Nurse interviews, the facility failed to follow their infection control policy and procedures during a COVID outbreak. The facility's COVID outbreak began on [DATE] when a Resident (Resident #12) tested positive for COVID. The facility had a total of 25 residents and 12 staff members who tested positive from [DATE] to [DATE]. During the facility's ongoing COVID-19 outbreak, staff failed to wear all personal protection equipment (PPE) required according to Centers for Disease Control and Prevention (CDC) guidance when 1 of 1 Nurse Aide (NA) (NA #2) entered a resident room under transmission-based precautions (TBP) for COVID without wearing eye protection. [...]

Inspectors wroteBased on record review, resident and staff, and Regional Nurse Consultant interviews the facility failed to include documentation in the medical record of education regarding the benefits and potential side effects of the COVID-19 immunization and failed to offer COVID-19 vaccines to 5 of 5 residents reviewed for COVID-19 immunizations (Resident #3, #16, #99, #117 and #127).

Inspectors wroteBased on observations, record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to use a catheter tubing stabilization device to reduce the risk of pulling and tugging of indwelling urinary catheter tubing. This deficient practice occurred for 1 of 3 residents reviewed with a urinary catheter (Resident #2).

Inspectors wroteBased on record review, and resident, staff, and pulmonology office staff interviews, the facility failed to schedule a sleep study per the Pulmonologists recommendations for 1 of 3 residents reviewed for respiratory care (Resident #64).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide Centers for Medicare and Medicaid Services (CMS)-10055 Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) prior to discharge from Medicare Part A skilled services for 2 of 3 residents reviewed for beneficiary protection notification (Residents #60 and Resident # 253).

Inspectors wroteBased on observations, record review, and Nurse Practitioner (NP), Medical Director, family, and staff interviews, the facility failed to prevent an accident when a resident (Resident #1) who received Eliquis (anticoagulant medication) sustained an injury from a bed rail assist bar on 8/30/24. Resident #1's injury from the bed rail assist bar resulted in the formation of a large hematoma, swelling, and diffuse black/purple bruising to her left arm from her left elbow down to her fingertips. The hematoma ruptured resulting in a large open wound to the left upper forearm with fat tissue exposure and uncontrolled bleeding. Resident #1 was transferred to the hospital emergency room on 8/30/24 for treatment of her injury and returned to the facility that evening with a pressure dressing in place to her left arm. [...]

Inspectors wroteBased on observations, record review, Nurse Practitioner (NP), family, and staff interviews, the facility failed to accurately assess a resident (Resident #1) for bed rail assist bars, failed to assess a resident (Resident #1) prior to implementation of bed rail assist bars, and failed to review the risks associated with the use of bed rail assist bars with Resident #1's Resident Representative. Resident #1 sustained a hematoma to her left arm from the bed rail assist bar and was transferred to the hospital emergency room on 8/30/24 and 8/31/24 for treatment. Resident #1 was admitted to the hospital related to her hematoma injury on 8/31/24 and required a blood transfusion during her hospitalization. This deficient practice occurred for 1 of 5 residents reviewed for bed rails.

Inspectors wroteBased on record review, resident, staff, and Nurse Practitioner (NP) interview the facility failed to prevent a significant medication error by administering (Resident #1) a medication without following set parameters for 1 of 3 residents reviewed for assuring facility was free from significant medication errors. Resident #1 was administered a blood pressure medication with set parameters to only administer if blood pressure was greater or equal to 170. Prior to the medication being administered, Resident #1 blood pressure was 139/64, after being administered the medication Resident #1 blood pressure dropped to 70/40 and she was sent out to the hospital for low blood pressure and altered mental status. [...]

Inspectors wroteBased on observations, record reviews, staff, Pharmacist, Medical Director and family member interviews, the facility failed to administer scheduled narcotic pain medication causing the resident (Resident #12) to experience increased pain for 1 of 3 residents reviewed for pain management.

Inspectors wroteBased on record reviews, staff, Pharmacist and Medical Director interviews the facility failed to obtain a narcotic pain medication from the pharmacy which caused a resident to miss 4 doses of the pain medication for 1 of 3 residents (Resident #12) reviewed for pain.

Inspectors wroteBased on record review, observations, Family Member and staff interviews, the facility failed to maintain a resident's dignity by not answering their call light when toileting assistance was requested for 1 of 4 sampled residents (Resident #13). The reasonable person concept was applied to this deficiency as an individual would not want to feel like they were being ignored when assistance with care was requested.

Inspectors wroteBased on observations, record review and resident, family and staff interviews, the facility failed to provide assistance with shaving and dentures for 2 of 4 residents reviewed for activities of daily living (Resident #11 and Resident #12).

Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility failed to ensure a resident's toenails were trimmed for 1 of 4 sampled residents (Resident #11).

Inspectors wroteBased on staff interview, local police interview, and record review, the facility failed to report a suspicious white powder in a little zip bag found in the room of Resident #1 to local law enforcement. The facility also failed to preserve potential evidence when they destroyed the white powder. Resident #1 experienced a potential drug overdose on 1/21/24 which responded with Naloxone (medication designed to rapidly reverse opioid overdose) given by the Emergency Medical Services (EMS) and was sent to the hospital for treatment. This deficient practice occurred for 1 of 1 resident reviewed for accidents (Resident #1).

Inspectors wroteBased on observations, record review, resident and staff interviews the facility failed to secure medications stored at the bedside for 3 of 3 residents reviewed for medication storage (Resident #5, Resident #1, and Resident #3).

Inspectors wroteBased on observation, record review, resident and staff interviews the facility failed to develop a comprehensive, individualized care plan in the areas of oxygen use, Diabetes Mellitus (DM) type 2, and daily anticoagulation use for 1 of 4 residents (Resident #4) reviewed for care plans.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to implement their infection control policy when the Treatment Nurse did not perform hand hygiene after removing a soiled dressing with drainage on it and before cleansing the wound with wound cleanser-soaked gauze for 1 of 1 resident (Resident #152) reviewed for wound care.