The Greens At Cabarrus
The Greens at Cabarrus in Concord, NC — inspection on November 14, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
protocol to increase his dose to 12 mg.
Unit Manager #1 explained she believed she wrote a physician order to increase his dose to 12 mg, but upon reviewing the physician orders, reported she had not written the order.
Unit Manager #1 explained Resident #1 should have received 12 mg of warfarin on 11/11/25, 11/12/25, and 11/13/25.
The Unit Manager #1 reported the lab was unable to obtain the blood sample for the PT/INR on 11/13/25 and she had written an order to have an immediate PT/INR lab drawn 11/14/25. A follow-up interview was conducted with Unit Manager #1 on 11/14/25 at 1:00 PM and she reported Resident #1's PT/INR results was 2.8 and he would resume warfarin 12 mg at 8:00 PM on 11/14/25.
The NP was interviewed on 11/14/25 at 12:48 PM and she reported Resident #1 had been difficult to get to a therapeutic PT/INR level which would be 2.0-3.0, and he required frequent warfarin dosage adjustments.
The NP reported the lab results were sent to the facility, and the Unit Managers used the physician approved warfarin protocol to adjust the warfarin dose.
The NP explained that missing the 3 doses of warfarin did not harm Resident #1.
The NP reported when she was notified of the missed warfarin, she checked on Resident #1 and he was fine.
The NP concluded that she expected the staff to follow the warfarin protocol for all residents receiving warfarin.
The Director of Nursing (DON) was interviewed on 11/14/25 at 2:48 PM.
The DON reported on 11/14/25 Unit Manager #1 was reviewing the PT/INR results from 11/13/25 and noticed that the PT/INR for Resident #1 was not obtained.
The DON explained the facility ordered for an immediate PT/INR lab draw and notified the NP of the missed medication.
The DON reported Unit Manager #1 reported she thought she put in the new warfarin order, but it was not in the system.
The DON reported she expected the changed warfarin orders to be entered into the system according to the warfarin protocol.
The Administrator was interviewed on 11/14/25 at 3:45 PM and she reported she expected the policy and procedures to be followed to prevent medication errors.
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