The Greens at Viewmont

Inspectors wroteBased on observations and staff interviews, the facility failed to remove an expired medication stored in 1 of 4 medication carts reviewed for medication storage (300 hall medication cart).

Inspectors wroteBased on observations, record reviews, and staff, Resident Representative, emergency responders, Nurse Practitioner (NP), Medical Director, hospital staff, Program of All-Inclusive Care for the Elderly (PACE) staff interviews, the facility failed to supervise a moderately cognitively impaired resident (Resident #1) who obtained a cigarette lighter and ignited herself and her bedding on fire. On 4/09/26 at 4:39 PM the fire alarm at the facility sounded. Staff responded to Resident #1's room and noted smoke coming from under the closed door. When Nurse #1 opened the door, he found Resident #1 in flames on the top portion of her body. Nurse #1 and Nurse #2 grabbed bedding from the foot of the bed and began patting out the flames. Other staff responded to the room and began wetting washcloths and towels to fully extinguish the existing embers that were on Resident #1 and her bedding. [...]

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to accurately code a Minimum Data Set assessment when they failed to include a resident's diagnosis of neurogenic bladder for 1 of 1 resident reviewed for catheters. (Resident #74)

Inspectors wroteBased on observations, record reviews, staff and resident interviews, the facility failed to ensure Resident #35 swallowed medication during medication administration for 1 of 2 residents reviewed for professional standards.

Inspectors wroteBased on observations, record reviews, manufacturer's instructions, and staff and Pharmacy Consultant interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 26 opportunities, resulting in a medication error rate of 11.54% for 1 of 4 residents observed during the medication administration (Resident #17 and Resident #46).

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to follow their Handwashing/Hand Hygiene policy when the Wound Nurse performed a pressure ulcer treatment on Resident #51 and did not wash or sanitize her hands before donning new gloves. This practice occurred for 1 of 2 staff members (Wound Nurse) observed for infection control.

Inspectors wroteBased on record review, staff, and Health Care Personnel Investigator (HCPI) interviews the facility failed to terminate and allowed Nurse Aide (NA) #1 to continue to work after becoming aware that she had substantiated findings of misappropriation of resident property which occurred while NA #1 was employed in a nursing facility and had a substantiated finding of fraud against a resident which occurred while NA #1 was employed in a nursing facility on the North Carolina Nurse Aide Registry on 08/15/23. NA #1 was terminated on 12/21/23 following an investigation of misappropriation of Resident #27's property that allegedly occurred in the facility on 12/13/23. This deficient practice of allowing NA #1 to continue to work had the high likelihood to affect other residents.

Inspectors wroteBased on record review and staff interviews the facility failed to implement their abuse policy by failing to separate employment of Nurse Aide (NA) #1 on 08/15/23 when the facility became aware that she had substantiated findings of misappropriation of resident property and fraud against a resident that occurred while the individual was employed in a nursing facility. NA #1 continued her employment with the facility until 12/21/23 when she was terminated following an allegation of misappropriation of resident property. This deficient practice affected 1 of 3 residents (Resident #27) reviewed for abuse, neglect, and misappropriation of resident property and had the high likelihood to affect other residents in the facility. The census at the time of the survey was 86 residents.

Inspectors wroteBased on observations, record review, and resident, staff, Police Officer, and Health Care Personnel Investigator interviews the facility failed to protect the resident's right to be free from misappropriation of resident property when Nurse Aide (NA) #1 allegedly stole a wallet and $320.00 from Resident #27. Resident #27 stated he felt like he was taken advantage of, and it really bothered him that she (NA #1) would do something like that. Resident #27 become tearful as he stated that he did not want this to happen to anyone else. This deficient practice affected 1 of 3 residents reviewed abuse, neglect, and misappropriation of resident property.

Inspectors wroteBased on observations and staff interviews, the facility failed to safeguard protected health information (PHI) for 8 of 8 residents (Residents #7, #10, #11, #55, #72, #77, #85 and #91) observed for privacy and confidentiality, by leaving confidential PHI exposed on an unattended medication cart in an area accessible to the public.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to ensure the code status information was accurate throughout the medical record for 3 of 19 residents (Resident #44, Resident #72 and Resident #140) reviewed for advanced directives.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to accurately code the Minimum Data Set assessments in the areas of discharge and lower extremity impairment for 1 of 2 discharged residents and 1 of 1 resident reviewed for choices (Resident #89 and Resident #1).

Inspectors wroteBased on observations, record reviews and staff interviews, the facility failed to implement a care plan intervention for a non slip mat on a resident's wheelchair used to prevent the resident from sliding for 1 of 3 residents (Resident #23) reviewed for accidents.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to keep a dependent resident's fingernails clean and trimmed for 1 of 2 residents reviewed for activities of daily living (Resident #51).

Inspectors wroteBased on observations, record reviews and interviews the facility failed to post cautionary and safety signs that indicated the use of oxygen for 2 of 3 residents (Resident #6 and Resident #58) reviewed for respiratory care.

Inspectors wroteBased on observations, record review, staff, consultant pharmacist, and Medical Director interviews the facility failed to maintain a medication error rate of less than 5% by having 2 errors out of 28 opportunities which resulted in a 7.14% medication error rate. This affected 2 of 6 residents observed on medication pass (Resident #39 and Resident #93).

Inspectors wroteBased on record review, staff and Hospice Nurse interviews the facility failed to obtain a physician order for hospice services for 1 of 1 resident (Resident #44) reviewed for hospice.

Inspectors wroteBased on observations, record reviews, resident, 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 the recertification and complaint survey conducted on 03/25/21 and 11/17/22 and for the complaint investigation conducted on 11/09/21. This failure was for eight deficiencies that were originally cited in the areas of Resident Rights (F578) and (F583), Freedom from Abuse, Neglect, and Exploitation (F607), Quality of Care (F695), Quality of Life (F677), Resident Assessment (F641), and Comprehensive Resident Centered Care plan (F656), and Infection Control (F880) that were subsequently recited on the current recertification and complaint investigation survey of 03/08/24. [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to implement their infection control policy when Nurse Aide #3 did not handle soiled linen in a sanitary manner and did not perform hand hygiene after completing incontinence care for 1 of 2 observations of infection control.