Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cardinal Healthcare And Rehabilitation during CMS and state inspections, most recent first.
Failure to Complete Significant Change MDS After Hospice Election: A resident with diagnoses including a femur fracture, disorientation, and atrial fibrillation was admitted to hospice with a primary diagnosis of senile degeneration of the brain. The facility did not complete the required significant change in status MDS within 14 days of hospice admission, and a later quarterly MDS instead coded hospice. The MDS nurse said the omission was due to confusion about the payment source, and the DON stated hospice admission required a significant change MDS within 14 days.
A resident with a history of stroke and dementia was incorrectly coded on the MDS as receiving dialysis and hospice care, despite only receiving palliative care for pain management and having no history of dialysis. Interviews confirmed the errors, and facility leadership acknowledged the expectation for accurate coding.
A resident with a history of femur fracture and dementia was prescribed Enoxaparin Sodium for DVT prophylaxis, but the comprehensive care plan did not include any interventions or focus area related to anticoagulant use. The omission was confirmed through record review and staff interviews, despite ongoing administration of the medication and its high-risk status.
A nurse did not remove gloves, perform hand hygiene, and don clean gloves after cleansing a resident's coccyx wound and before applying a clean dressing, contrary to facility policy. The nurse acknowledged the oversight, and leadership confirmed that proper hand hygiene is expected during wound care transitions from dirty to clean procedures.
The facility failed to honor the dining preferences of three cognitively intact residents, who were not allowed to eat dinner in the dining room for several months. Staff cited time constraints and lack of assistance as reasons, despite no staffing issues being reported. The administration was unaware of the issue until the survey.
The facility's QAPI committee failed to maintain procedures and monitor interventions following surveys, leading to repeated deficiencies in honoring resident preferences and providing scheduled showers. Despite having Process Improvement Plans (PIPs) in place, the facility showed a pattern of inability to sustain an effective QAPI program.
The facility failed to include two residents and their representatives in the care plan process. One resident, who was severely cognitively impaired, and another who was cognitively intact, both had no documentation of care plan meetings being completed. The Social Worker admitted to not conducting these meetings due to a lack of training, and the Administrator was unaware of these deficiencies.
The facility failed to complete PASRR Level II for two residents with mental health diagnoses. One resident was admitted with paranoid schizophrenia, and another was later diagnosed with bipolar disorder and major depressive disorder. The Social Worker, still in training, did not complete the necessary paperwork, and the Administrator confirmed the oversight.
Failure to Complete Significant Change MDS After Hospice Election
Penalty
Summary
The facility failed to complete a significant change in status MDS assessment within the required 14-day period after Resident #11 was admitted to hospice services. Resident #11 was admitted to the facility with diagnoses including fracture of the left femur with routine healing, disorientation, and atrial fibrillation, and was later admitted to hospice with a primary hospice diagnosis of senile degeneration of the brain. A review of the MDS assessments showed that no significant change in status assessment was completed after the hospice election, and instead a quarterly MDS completed later coded hospice. During interview, the MDS Nurse stated that a significant change in status MDS should be completed within 14 days of hospice admission and reported that it was not completed for Resident #11 because of confusion about the payment source. The DON stated that hospice admission was considered a significant change in status and required a significant change MDS assessment within 14 days of the hospice admission date.
Inaccurate MDS Coding for Dialysis and Hospice Care
Penalty
Summary
The facility failed to accurately code a significant change Minimum Data Set (MDS) assessment for a resident with a history of cerebral vascular accident and dementia. The MDS assessment incorrectly indicated that the resident was receiving dialysis treatments and was on hospice care, despite the resident not having a history of dialysis and not currently being on hospice. The resident was, in fact, receiving palliative care for pain management, and her previous hospice care had been discontinued in 2022. The assessment also failed to indicate that the resident did not have a condition or chronic disease likely to result in a life expectancy of less than six months. Interviews with the resident confirmed she had never received dialysis and was not on hospice care at the time of the assessment. The MDS Coordinator, who was not employed at the facility when the assessment was completed, acknowledged that the resident should not have been coded for hospice or dialysis and attributed the errors to a keying mistake. Both the Director of Nursing and the Administrator stated their expectations that MDS assessments be coded accurately to reflect each resident's actual condition.
Failure to Address Anticoagulant Use in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop an individualized comprehensive care plan addressing the use of anticoagulant medication for a resident who was admitted with a left femur fracture, dementia, and was prescribed Enoxaparin Sodium for deep vein thrombosis prophylaxis. Despite the resident's severe cognitive impairment and ongoing administration of the anticoagulant, the care plan dated several weeks after admission did not include any focus area or interventions related to anticoagulant use. Record review confirmed that the resident received the anticoagulant medication nightly over a period of nearly a month, yet this was not reflected in the care plan. Interviews with the MDS Coordinator and the DON confirmed that the care plan should have addressed the use of anticoagulant medication, especially given its high-risk nature and potential side effects. The Administrator also stated an expectation that all care plans should reflect residents' clinical conditions, including anticoagulant use.
Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
Nurse #1 failed to follow the facility's Handwashing/Hand Hygiene policy during wound care for Resident #2. After cleansing the resident's coccyx wound with normal saline-soaked gauze and patting it dry, Nurse #1 did not remove her gloves, perform hand hygiene, and don clean gloves before proceeding to pack the wound and apply a clean dressing. This action was observed during a wound care procedure, where the nurse transitioned from a dirty to a clean procedure without the required change of gloves and hand hygiene, as outlined in the facility's policy. The facility's policy specifically requires hand hygiene before handling clean dressings and after removing gloves, which was not followed in this instance. Nurse #1 later acknowledged the oversight, attributing it to nervousness during observation. Interviews with the Infection Preventionist, DON, and Administrator confirmed that the expectation was for staff to adhere strictly to the hand hygiene protocol, especially during wound care procedures involving a transition from dirty to clean tasks.
Failure to Honor Resident Dining Preferences
Penalty
Summary
The facility failed to honor the preferences of three cognitively intact residents who wished to eat their dinner in the dining room. Resident #46, who was independent in eating, expressed that she had not been allowed to eat dinner in the dining room for at least four months, despite her preference and the presence of multiple staff members on the hall. This made her feel isolated and aggravated. Similarly, Resident #47, who required set-up and clean-up assistance for eating, reported that she had been served dinner in her room for the past few months, which made her feel stuck and deprived her of socialization opportunities. Resident #39, who required supervision for eating, also shared that he had not been allowed to eat dinner in the dining room for several months, which made him feel left out and bothered him as it deprived him of a change of setting and social interaction with other residents. Staff interviews corroborated the residents' accounts. Dietary Aide #1 observed that residents were no longer being brought to the dining room for dinner and noted that she never received an explanation from the staff. Nursing Assistant (NA) #1, who had been employed at the facility for six years, confirmed that residents were being served dinner in their rooms because staff did not have the time to assist them to the dining room. Nurse #1, who had been with the facility for several years, also observed that residents were being served dinner in their rooms and was unaware of any staffing issues that would prevent residents from being taken to the dining room. The facility's administration, including the Administrator, Director of Nursing (DON), and Vice-President of Clinical Services, stated that they were unaware of the issue until it was brought to their attention during the survey. They confirmed that there had been no staffing issues that would prevent residents from being taken to the dining room and emphasized that staff should always honor residents' mealtime preferences. The lack of communication and awareness among the staff and administration contributed to the failure to honor the residents' preferences for dining room meals.
Failure to Maintain Effective QAPI Program
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions following the recertification and complaint investigation surveys conducted on 10/28/21. This failure was evident in the area of Self Determination, where the facility did not honor resident preferences and requests to eat dinner in the dining room for three residents reviewed for choices. Additionally, during the 10/28/21 survey, the facility failed to provide showers for one resident at least two times per week as scheduled. These deficiencies were cited again during the recertification and complaint investigation survey completed on 3/14/24, indicating a pattern of the facility's inability to sustain an effective QAPI program. During an interview with the Administrator, it was revealed that the QAPI committee meets monthly with department heads and administrative staff, and at least quarterly with the Medical Director, Pharmacist, and Registered Dietician. The Administrator reported that they had Process Improvement Plans (PIPs) addressing issues identified at the facility, including grievances and care plan meetings. However, the recurrence of deficiencies suggests that the interventions and monitoring by the QAPI committee were not effectively maintained or implemented to ensure ongoing compliance.
Failure to Include Residents and Representatives in Care Plan Meetings
Penalty
Summary
The facility failed to afford residents and/or their representatives the right to participate in the care plan process for two residents. Resident #7, who was severely cognitively impaired, had no documentation of a care plan meeting being completed with the resident or their representative. The resident's representative confirmed they had not been invited to any care plan meetings in several months and expressed a desire to be included in these meetings. The Social Worker, who was hired in November 2023 and had only recently received training for conducting care plan meetings, acknowledged that Resident #7 did not have a care plan meeting this past quarter and that the representative was not notified of this omission. Similarly, Resident #22, who was cognitively intact, also had no documentation of a care plan meeting being completed. The resident confirmed they had not been invited to care plan meetings in several months and wanted to attend these meetings to discuss their care. The Social Worker admitted that due to a lack of training, Resident #22's care plan meeting was not completed, and the resident was not notified. The Administrator was unaware of these deficiencies and expected care plan meetings to be completed and the resident representatives to be notified of any changes.
Failure to Complete PASRR Level II for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level II was completed for two residents with mental health diagnoses. Resident #9 was admitted with a diagnosis of paranoid schizophrenia, but only had a PASRR Level I completed prior to admission. The Social Worker (SW) was unaware of the need for a PASRR Level II and had not completed the necessary paperwork. The Administrator confirmed that a PASRR Level II should have been completed upon admission for Resident #9 due to the mental health diagnosis. Similarly, Resident #15 was admitted with a PASRR Level I and later diagnosed with bipolar disorder and major depressive disorder. The SW, who was still in training, did not complete the PASRR Level II paperwork for Resident #15's new mental health diagnoses. The Administrator acknowledged that a PASRR Level II should have been completed in a timely manner for Resident #15 following the new diagnoses. Both instances indicate a failure in the facility's process for coordinating assessments with the PASRR program and ensuring timely completion of necessary reviews for residents with mental health conditions.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lincolnton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lincolnton Rehabilitation Center | 1.4 mi | ★★★★★ | 0 | 0 |
| The Greens At Lincolnton | 1.9 mi | ★★★★★ | 8 | 0 |
| Peak Resources-cherryville | 8.3 mi | ★★★★★ | 0 | 0 |
| Carolina Care Health And Rehabilitation | 9.7 mi | ★★★★★ | 0 | 0 |
| Abernathy Laurels | 12 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.