The Greens at Lincolnton

In the surveyor’s words

From the most serious findings on record at The Greens at Lincolnton, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 17, 2023

  Based on record review, staff, resident, family, and emergency room (ER) Physician interviews, the facility failed to protect a resident's right to be free from an injury of unknown origin when Resident #1 was found on 03/11/23 at approximately 8:12 AM to have facial swelling and bruising for 1 of 2 residents reviewed with injuries of unknown origin. Resident #1 was transferred to the local ER for evaluation where it was determined that Resident #1 had an acute subdural hematoma (bleeding on the brain), multiple facial fractures, and a large subcutaneous (under the skin) hematoma (blood collected and pooled under skin) over the mandible (jaw) that measured 4.7 centimeters (cm) by 3.1 cm and required an additional transfer to another hospital that had a trauma intensive care unit to care… […]

• Actual harm, isolatedF689Sep 19, 2024

  Based 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. […]

• Actual harm, isolatedF700Sep 19, 2024

  Based 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 roiagnom on [DATE] 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. […]

• Actual harm, isolatedF760May 16, 2024

  Based 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. […]

• Actual harm, isolatedF697Mar 14, 2024

  Based 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. The finding included: Resident #12 was admitted to the facility on [DATE] with diagnoses that included chronic gout, arthritis and chronic pain. Review of Resident #12's revised care plan dated 03/18/23 revealed a risk for developing complications related to the use of opioid pain medication. […]