Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Gastonia Health & Rehab Center during CMS and state inspections, most recent first.
The facility did not submit required Level II PASRR evaluation requests for multiple residents who developed new mental health diagnoses or experienced significant changes in condition. Despite prior PASRR Level I screenings recommending further evaluation if new diagnoses arose, staff interviews and record reviews confirmed that no Level II PASRR requests were made for residents diagnosed with conditions such as anxiety disorder, bipolar disorder, major depressive disorder, psychotic disorder, or schizoaffective disorder.
A nursing assistant worked with an expired Nurse Aide Certification after the facility failed to monitor and verify certification status. The HR Director relied on verbal communication to notify the scheduler of expiring certifications, but there was no documented follow-up or verification, resulting in the NA continuing to work without an active certification.
A resident with significant mobility and cognitive impairments experienced multiple falls and injuries due to staff failing to provide required supervision during bathing and transfers, including leaving the resident unattended in an unsuitable shower chair and performing a mechanical lift transfer without the mandated two-person assistance. The resident suffered fractures after falling from the lift, and staff were also observed using incompatible lift slings and not consistently following manufacturer guidelines.
A resident who was dependent on staff for incontinence care was left in a saturated brief and wet bedding for several hours due to missed care during the night and lack of timely assistance during the day. The resident, who required two-person assistance and had multiple medical conditions, was not changed from 1:30 AM until 10:30 AM, despite her care plan and usual routine. Staff interviews revealed communication lapses and staffing challenges contributed to the delay, and the resident reported discomfort from being left wet for an extended period.
A resident with non-Alzheimer's dementia did not have denture care included in their care plan, leading to inadequate oral hygiene. The MDS Nurse and DON acknowledged the oversight, and the Administrator expected comprehensive care plans.
The facility failed to manage medication storage properly, as observed in two medication carts. Medication cart #2 contained a resident's unidentified medication container and 21 loose pills, while cart #1 had four loose pills. Both carts had debris, and nurses acknowledged the need for proper identification and disposal of unidentifiable medications. The DON confirmed that nurses are responsible for maintaining cart cleanliness.
A resident with moderately impaired cognition and non-Alzheimer's dementia did not receive adequate oral care due to staff unawareness and lack of specific denture care instructions in the care plan. The resident's dentures were found unclean, and interviews revealed that nursing staff were not informed or educated about the resident's denture care needs.
Failure to Submit Level II PASRR Evaluations for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit requests for Level II Preadmission Screening and Resident Review (PASRR) evaluations for residents who developed new mental health diagnoses or experienced significant changes in condition. Record reviews for six residents revealed that although PASRR Level I screenings were completed prior to admission, each included recommendations to resubmit paperwork for Level II PASRR if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. Despite this, there was no evidence in the medical records that requests for Level II PASRR evaluations were submitted after residents were diagnosed with conditions such as anxiety disorder, bipolar disorder, major depressive disorder, psychotic disorder, or schizoaffective disorder. Interviews with facility staff indicated a lack of follow-through on PASRR requirements. The Social Worker, who began employment in August 2025, acknowledged responsibility for completing PASRR paperwork and was aware that Level II PASRR should be completed for residents with new mental health diagnoses or significant changes. However, she admitted she had not reviewed residents admitted prior to her start date or those readmitted, and could not provide a reason why the sampled residents did not have Level II PASRR evaluations completed. She confirmed that, based on their diagnoses, Level II PASRR evaluations should have been performed. The Administrator, who started in October 2025, was not aware of who was previously responsible for PASRR Level II requests and was unaware that the sampled residents lacked the required evaluations. He stated his understanding that Level II PASRR should be completed in a timely manner upon admission, readmission, or when a resident receives a new mental health diagnosis or experiences a significant change in condition. The absence of Level II PASRR evaluations for these residents was confirmed through both record review and staff interviews.
Failure to Monitor and Verify Nurse Aide Certification Status
Penalty
Summary
A nursing assistant (NA) was employed and worked at the facility with an expired Nurse Aide Certification. Review of the personnel file and staffing schedules confirmed that the NA's certification had expired, yet the NA continued to work scheduled shifts after the expiration date. The Human Resources (HR) Director stated she had verbally informed the scheduler about the impending expiration but could not recall the specific date of notification. The scheduler did not recall receiving this notification and indicated that, per usual practice, the NA would be removed from the schedule if the certification was not renewed. However, there was no documented communication or verification that the certification had been renewed. Interviews with the Director of Nursing (DON) and the Administrator revealed that both expected NAs to have active certifications and to be removed from the schedule if their certification expired. The responsibility for monitoring certification status and notifying the scheduler was assigned to the HR Director, but the process relied on verbal communication without documentation. As a result, the NA continued to work without an active certification, and no one verified the renewal status before allowing the NA to remain on the schedule.
Failure to Provide Adequate Supervision and Safe Transfers Resulting in Resident Falls and Injury
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and ensure a safe environment for a resident with multiple risk factors, including morbid obesity, dementia, decreased mobility, and a history of falls. The resident was dependent on staff for transfers, bathing, and mobility, and required the use of a mechanical lift and two-person assistance for safe care. Despite these needs, there were multiple incidents where staff did not follow established protocols or manufacturer's recommendations, resulting in accidents. In one incident, a nurse aide left the resident unsupervised in a shower chair that was not the resident's preferred type, as it did not allow her feet to touch the floor, compromising her sense of balance. The aide turned away twice to gather supplies, and during the second instance, the chair tipped forward, causing the resident to fall onto the shower floor. Although no injury was noted from this fall, the event highlighted a lack of supervision and disregard for the resident's expressed concerns about the equipment being used. In a separate event, the same resident was transferred from bed to wheelchair using a mechanical lift by a single nurse aide, despite facility policy and training that required two staff members for such transfers. During the transfer, the lift tilted and the resident fell to the floor while still in the sling, and the lift itself fell on top of her, resulting in a left calcaneal fracture and a left anterior talus fracture. Additionally, there were observations of staff using slings that did not match the brand of the mechanical lift, contrary to manufacturer instructions, and staff were responsible for determining sling size without clear oversight. These failures in supervision, adherence to protocols, and equipment compatibility directly led to resident harm.
Failure to Provide Timely Incontinence Care Resulting in Prolonged Resident Exposure to Wet Bedding
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for all activities of daily living, including incontinence care, was not provided timely assistance, resulting in her remaining in a saturated brief and wet bedding for an extended period. The resident, who had diagnoses including atrial fibrillation, diabetes mellitus, decreased mobility, osteoarthritis, and non-Alzheimer's dementia, was cognitively intact and required two-person assistance for toileting. Her care plan specified that she should be kept clean, dry, and comfortable, with incontinence care provided as needed and regular monitoring for skin issues. On the day in question, the resident was last changed at 1:30 AM and did not receive further incontinence care until 10:30 AM, despite her usual care pattern of being changed two to three times during the night. During the 7:00 PM to 7:00 AM shift, the assigned nurse aide was unable to return to change the resident as planned due to a busy workload and lack of available assistance, and did not request help from the nurse. The aide reported off to the incoming shift that the resident needed to be changed, but the information was not clearly communicated or acted upon. The resident remained in a wet brief and bedding, as confirmed by observation at 10:30 AM, when two other nurse aides, not assigned to her care, found her saturated and provided the necessary care while preparing her for transfer to her wheelchair. Interviews with staff revealed that the resident's care was delayed due to staffing challenges and lack of communication between shifts. The unit manager was unaware of the lapse in care and stated that residents are expected to be checked and changed every 2 to 3 hours. The assigned day shift aide had not yet reached the resident before others intervened, and no one had reported the overnight lapse to her. The resident herself reported feeling wet and cold for several hours and had eaten breakfast in bed while still in a wet brief.
Deficiency in Comprehensive Care Planning for Resident's Denture Care
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident with non-Alzheimer's dementia, specifically in the area of activities of daily living (ADL) related to oral hygiene and denture care. The resident's care plan did not include denture care, despite the resident requiring partial assistance with oral hygiene as indicated in the Minimum Data Set (MDS). During an observation, it was found that the resident's dentures were not being properly cleaned, as evidenced by food debris and black areas between the teeth on the upper plate. Nurse #1 was unaware of the resident's need for denture care, which was not documented in the care plan, leading to inadequate oral hygiene. Interviews with the MDS Nurse and the Director of Nursing revealed that the omission of denture care in the resident's care plan was due to human error. The MDS Nurse acknowledged overlooking the inclusion of denture care, while the Director of Nursing confirmed that the resident required assistance with cleaning and soaking dentures. The Administrator expressed the expectation that care plans should be comprehensive and accurate, highlighting the deficiency in the facility's care planning process.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to properly manage and store medications in accordance with accepted professional principles, as observed in two medication carts. On medication cart #2, a resident's personal weekly medication container was found in the narcotic drawer without any identifying information, containing multiple pills in various slots. Additionally, 21 loose and unidentifiable pills were found at the bottom of the drawers, along with debris such as paper shavings and rubber bands. Nurse #1, who was responsible for the cart at the time, stated that the medication container was already present when she took over the cart and that she was unaware of the owner of the medications. She acknowledged the need to dispose of the unidentifiable medications and admitted that she had not had the opportunity to clean the cart. Similarly, medication cart #1 was found to contain four loose and unidentifiable pills, as well as debris of paper shavings and rubber bands. Nurse #2, who was observed with this cart, indicated that the night shift was responsible for maintaining the cleanliness and order of the medication carts. She also stated that the loose pills should be discarded due to the lack of identification. The Director of Nursing confirmed that both carts had been cleaned and organized about a month prior and emphasized that each nurse was responsible for keeping their assigned medication carts clean and orderly.
Failure to Provide Adequate Oral Care for Resident
Penalty
Summary
The facility failed to provide adequate oral care for a resident with moderately impaired cognition and non-Alzheimer's dementia. The resident was admitted with a care plan that required partial staff assistance with oral hygiene, but the plan did not specifically address denture care. During observations and interviews, it was revealed that the nursing staff, including a nurse and two nursing assistants, were unaware of the resident's need for denture care. The resident's dentures were found to be coated with debris and had black areas between the teeth, indicating a lack of proper cleaning. Interviews with the nursing staff revealed a lack of awareness and education regarding the resident's denture care needs. The nursing assistants assigned to the resident on different shifts admitted to not providing oral care or checking for dentures. The Director of Nursing and the Administrator acknowledged the oversight and attributed it to a lack of staff education and the absence of specific denture care instructions in the resident's care plan. The deficiency was identified as a failure to ensure the resident received necessary oral and denture care as per the facility's expectations.
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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 Gastonia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Peak Resources - Gastonia | 1.2 mi | ★★★★★ | 2 | 0 |
| The Greens At Gastonia | 1.5 mi | ★★★★★ | 2 | 0 |
| Courtland Terrace | 1.7 mi | ★★★★★ | 4 | 0 |
| Accordius Health At Gastonia | 2.4 mi | ★★★★★ | 2 | 0 |
| Juniper Gardens Center For Nursing And Rehabilitat | 3.8 mi | ★★★★★ | 4 | 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.