Average — CMS composite of the measures below.
The next survey window likely opens around October 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 Juniper Gardens Center For Nursing And Rehabilitat during CMS and state inspections, most recent first.
Three residents experienced failures in dignity and prompt care, including repeated delays in incontinence care, being told to wait for scheduled rounds, and an incident of aggressive behavior by a nurse aide. Residents reported feeling neglected, and in one case, care was provided without proper hygiene. Staff were largely unaware of these issues, and communication interventions for a resident with hearing impairment were not followed.
A resident's advance directive information was inconsistent across the EHR, care plan, and Advance Directives binder, with conflicting documentation of DNR and Full Code status. Staff interviews and observations confirmed the presence of outdated and contradictory forms, and the resident reported being a DNR, while documentation and staff understanding varied.
Surveyors found that the facility did not post required contact information for state agencies and advocacy groups, including the State Survey Agency, Department of Social Services, and the Ombudsman. Residents reported not knowing how to contact these resources, and staff confirmed the postings were missing and should have been the Administrator's responsibility.
Survey results were not accessible to residents, their representatives, or visitors, as the binder containing the results could not be located in the designated area or elsewhere in the facility. Staff and residents were unaware of the binder's location, and signage referencing the binder did not correspond to its actual presence.
A transport driver failed to secure a resident in her wheelchair during transport, resulting in a fall and subsequent injury. The driver did not notify medical personnel or the facility after the incident, and the resident later reported the fall upon returning to the facility. Medical assessments revealed a fracture in the resident's femur, highlighting the driver's failure to follow proper safety protocols.
A transport driver failed to secure a resident with multiple sclerosis properly during transport, leading to a fall and a fracture. The resident was not secured with a lap belt, and a sudden stop caused her to fall from her wheelchair. The incident was confirmed by video footage, and the driver was subsequently dismissed.
The facility failed to post cautionary and safety signage outside resident rooms and at the main entrance to indicate oxygen use for residents receiving respiratory care. Observations showed residents using oxygen via nasal cannula without appropriate signage. Interviews with the Administrator and DON revealed a lack of awareness about the requirement for such signage.
During a COVID-19 outbreak, a facility failed to implement proper infection control measures. A resident's room was entered by staff without the required PPE, and another resident received insulin without the nurse wearing gloves or performing hand hygiene. Additionally, a unit manager did not perform hand hygiene between glove changes during wound care for a resident.
Two residents in an LTC facility experienced significant medication errors. One resident with leukemia did not receive Bosulif as prescribed, resulting in a surplus of medication, while another resident with schizophrenia received an incorrect dose of Olanzapine for 11 days. Despite these errors, neither resident suffered harm. The errors were attributed to discrepancies in medication administration and ordering processes.
A resident's responsible person was not informed of a scheduled cystoscopy procedure following a urology appointment. The resident, who was moderately cognitively impaired, underwent the procedure without the RP's knowledge. The Director of Nursing assumed the urology office had notified the RP, leading to the oversight.
The facility failed to accurately code MDS assessments for several residents, resulting in deficiencies in documenting oxygen use and hospice services. A resident with chronic respiratory failure and COPD was not coded for continuous oxygen and hospice services. Two other residents with orders for oxygen as needed were not documented in their MDS assessments. Additionally, a resident receiving hospice services was not coded in the significant change MDS assessment. These inaccuracies were identified as oversights by the MDS Coordinator.
Failure to Ensure Resident Dignity and Prompt Care
Penalty
Summary
Surveyors identified that the facility failed to ensure residents' rights to dignity and prompt care for three residents. One resident, who was cognitively intact and required substantial assistance with toileting due to frequent incontinence, reported that a night shift nurse aide repeatedly made her wait for incontinence care, telling her that regulations required care only every two hours and that the previous shift should have addressed her needs. The resident described feeling forgotten and tracked the aide's response times on her phone. The nurse aide confirmed informing the resident about the two-hour schedule and deferring care, while nursing staff were unaware of the resident's concerns. Another resident, also cognitively intact and dependent on staff for toileting due to paraplegia, reported frequent delays in care during the night shift, with wait times of up to 1.5 hours. This resident stated that the same nurse aide told him that state law only required changes every two hours and would defer care requests until scheduled rounds. The resident described an incident where his call light was turned off without care being provided, and when care was eventually given, it was incomplete, as the aide only changed his brief without cleaning him. Nursing staff were again unaware of these concerns, and another aide reported no knowledge of care being withheld. A third resident, who was moderately cognitively impaired and required assistance with activities of daily living, alleged that a nurse aide was aggressive during care, including pushing him onto the bed, throwing a brief at him, and telling him to change himself. A former roommate corroborated the account, stating that the aide yelled at and pushed the resident. The aide denied physical aggression but admitted to raising her voice due to the resident's hearing impairment. The resident's care plan included specific communication interventions due to his hearing loss, but these were not followed during the incident.
Inconsistent Advance Directive Documentation for a Resident
Penalty
Summary
The facility failed to ensure that advance directive information was accurate and consistent throughout the medical record for a resident. The resident's electronic health record (EHR) contained conflicting physician orders regarding code status, with one order indicating Do Not Resuscitate (DNR) and another indicating Full Code. The resident's care plan also listed the code status as Full Code, while the Advance Directives binder at the nursing station contained both a signed DNR form and a Medical Orders for Scope of Treatment (MOST) form indicating Full Code. The DNR form was signed by a physician and had no expiration date, while the MOST form was signed by both the resident and the physician. Staff interviews and observations revealed further inconsistencies and confusion regarding the resident's code status. The Social Worker and a nurse both identified the presence of the outdated DNR form in the Advance Directives binder but did not remove it, instead placing it back in the binder after review. The nurse stated she would check the EHR and MOST form to confirm code status, while the resident himself stated he was a DNR. The Director of Nursing acknowledged that the code status information in the Advance Directive binder and the EHR should match, but this was not the case for this resident.
Failure to Post Required State Agency and Advocacy Group Contact Information
Penalty
Summary
The facility failed to post a list of names, addresses (mailing and email), and telephone numbers of all required state agencies and advocacy groups, including the State Survey Agency, Department of Social Services, State Long Term Care Ombudsman Program, and the resident advocacy network. This deficiency was observed on three out of four days during the onsite recertification survey, with surveyors noting the absence of these postings in all hallways and common areas of the facility. Multiple observations confirmed that the required information was not displayed anywhere accessible to residents or their representatives. During a Resident Council meeting, several residents reported not knowing who the local Ombudsman was, how to contact them, or how to contact the State Agency to file a complaint. Interviews with the Activities Director and the DON confirmed the lack of postings and indicated that it was the Administrator's responsibility to ensure this information was available. The Administrator acknowledged that the information should be posted in a visible and accessible location but believed that the existing federal posting related to Medicare/Medicaid was sufficient.
Survey Results Not Accessible to Residents and Public
Penalty
Summary
The facility failed to display survey results in a location accessible to residents and the public for the entire duration of the survey. Observations over four days revealed that the survey result signage was placed in a picture frame on a table behind the receptionist in the main lobby, with a statement indicating that the survey results were in a binder under the sign. However, no binder was observed under the signage or in any other area of the facility during multiple checks. Further observations confirmed the continued absence of the survey results binder at the designated location and elsewhere in the facility. During a Resident Council meeting, attendees, including the Resident Council President, reported not knowing where the survey results were located, despite some having been at the facility for several years. Interviews with the Activities Director and the DON confirmed their belief that the binder should be behind the receptionist desk, but they were unable to locate it during a walking tour. The Administrator later stated that the binder should be behind the receptionist desk, but suggested it may have been moved to a bookshelf in the main dining room, possibly by a resident. Throughout the survey, the survey results were not accessible to residents, their representatives, or visitors as required.
Transport Driver's Failure to Secure Resident Leads to Injury
Penalty
Summary
The facility's contracted transport driver failed to leave a resident in place for a clinical assessment of injury after a fall that occurred during transport. The resident, who was being transported back from a medical appointment in a contract transport van, was unsecured in her wheelchair. The driver made a sudden stop, causing the resident to fall forward out of her wheelchair onto the van floor. The driver then pulled the van off to the side of the road, transferred the resident back into her wheelchair, and continued back to the facility without notifying facility staff of the incident. Upon arrival at the facility, the resident informed staff of the fall, and a subsequent assessment by nursing staff revealed swelling and a skin tear to her left knee. A hospital CT scan later confirmed that the resident had suffered a distal left fracture to the femur due to the fall. The resident had a history of multiple sclerosis, muscle weakness, and contractures, which may have contributed to her vulnerability to injury. Interviews with the Director of Nursing and the physician revealed that the driver did not have the resident assessed by medical personnel prior to moving her after the fall. The physician indicated that moving a resident before an assessment could cause further injury or trauma. The facility's administrator confirmed that the driver had not secured the resident into her wheelchair and had not contacted medical personnel after the fall, as corroborated by video footage from the van.
Removal Plan
- The facility initiated immediate investigation. Resident #12 medical director and responsible person made aware of incident. Order obtained for x-ray to the left ankle, left foot, left knee, left tibia and left fibula. Resident complained of pain, MD notified, and new orders obtained for Ibuprofen and Tylenol for acute pain post fall. Pain medication effective with a pain scale of 0 noted. Resident transported via ambulance and MD was notified of the transport. Resident returned back to the facility via stretcher accompanied by two emergency management technicians attendants. Resident complained of pain and discomfort to the left femur upon assessment pain meds were administered and effective. New orders from emergency department for Naproxen. Ortho follow up appointment with Orthopedic surgery as soon as possible. Facility made Resident an Ortho appointment. RP and MD made aware of the appointment. Resident was taken to Ortho via facility transport. Ortho plan state Resident is not a strong surgical candidate given knee contracture, would not recommend a long leg cast. Instead recommended a knee immobilizer and limit range of motion of including weight-bearing.
- The Director of Nursing reviewed the accidents for the last three months and there were no other situations where licensed nurses did not assess the resident before the resident was moved.
- The van drivers were re-educated by the Administrator on the proper procedures if a resident was to have a fall/injury or abnormal event in the facility van, that 911 is to be called prior to moving the resident. The education was already a component of the Transportation Driver orientation given by Administrator/Designee. The Administrator notified the contract transportation company via phone, and stated that until proof of driver training to include wheelchair procedures and calling 911, then contracted transportation will not be utilized. Any transportation from contract services was required to provide the driver's PASS training to the Administrator/Designee prior to transporting the facilities residents. These competencies are maintained by the Administrator/Designee. The contracted transportation supervisor who is PASS Certified completed education for contracted drivers and ongoing; prior to transporting facility residents. This education included both wheelchair patent procedures and to contact 911 immediately should any emergencies with patients occur during transport.
- Director of Nursing/Designee audited incident/accident logs to ensure no resident had a fall during transportation and 911 wasn't called. Director of Nursing/Designee reviewed incident/accident logs 5 days a week for 4 weeks, 3 days a week for 4 weeks and weekly for 4 weeks. Administrator made the decision to take audits to the monthly Quality Assurance meeting for tracking, trending, and recommendations from the IDT team. Interviews with facility transporters revealed they had received education on proper procedures if a resident was to have a fall, injury, or accident in the facility van, that 911 was to be called immediately, do not move resident until assessed by a medical professional, and call facility to notify of incident. The education was included as a component of the transportation orientation. Contract transport company re-education verified staff were educated on passenger safety and sensitivity training, wheelchair procedures, and calling 911 immediately for any emergencies during transport. Review of the audit tool for the review of the incident/ accident logs was completed with no issues noted. Interviews were also conducted with alert and oriented residents who had been transported with no concerns, incidents, or accidents identified. Interview with the Administrator revealed she had educated facility transport drivers on proper procedures if a fall, injury, or accident occurred while transporting to include calling 911 immediately and not moving resident until assessed by medical personnel and notifying facility of the incident. The Administrator also verified the contract transport company had educated their drivers on the proper wheelchair procedures, calling 911 for any emergencies during transport, and safety and sensitivity training.
Transport Driver Fails to Secure Resident, Resulting in Injury
Penalty
Summary
The deficiency involved a contracted transport driver failing to secure a resident properly during transportation. The resident, who had multiple sclerosis and was dependent on a wheelchair for mobility, was being transported back from a medical appointment. The driver secured the wheelchair but neglected to apply the resident's lap belt, leaving her unsecured. During the journey, the driver made a sudden stop, causing the resident to fall forward out of her wheelchair onto the van floor, resulting in a fracture to her left femur. The resident, who was cognitively intact, reported the incident upon returning to the facility. She experienced swelling and a skin tear on her left knee, and a subsequent CT scan confirmed a distal femur fracture. The resident's medical history included muscle weakness and contractures, which may have contributed to the severity of the injury. The driver did not contact emergency services or the facility before moving the resident back into her wheelchair and continuing the transport. Interviews with facility staff and the transport company confirmed the driver's failure to secure the resident properly. The transport company reviewed video footage that corroborated the resident's account of the incident. The driver was no longer employed with the company following the incident. The facility was notified of the immediate jeopardy posed by this deficiency, highlighting the need for proper training and adherence to safety protocols during resident transport.
Removal Plan
- Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.
- Address how the facility will identify other residents having the potential to be affected by the same deficient practice.
- Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.
- Address how the facility plans to monitor its performance to make sure that solutions are sustained.
Failure to Post Oxygen Use Signage
Penalty
Summary
The facility failed to post cautionary and safety signage outside of resident rooms to indicate the use of oxygen for four residents who were receiving respiratory care. Observations revealed that these residents were using oxygen via nasal cannula at specified liters per minute, yet there was no signage at the entrance to their rooms to alert staff and visitors of the oxygen use. This deficiency was noted for residents who had physician orders for continuous or as-needed oxygen therapy, but their rooms lacked the necessary safety signage. Additionally, the facility did not have cautionary signage at the main entrance to notify those entering the building that oxygen was in use. Interviews with the Administrator and the Director of Nursing revealed a lack of awareness regarding the requirement for such signage. The Administrator acknowledged the absence of signage at the facility's main entrance and outside resident rooms, while the Director of Nursing confirmed that they were unaware of the requirement for posting safety signage for oxygen use.
Infection Control Lapses During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement Special Droplet Contact Precautions during a COVID-19 outbreak, as observed in the case of Resident #4. Nurse Aide #1 entered the resident's room wearing only a surgical mask, without donning the required PPE as instructed by the signage. Similarly, Nurse #1 entered the same room without the necessary PPE, mistakenly believing the signage indicated Enhanced Barrier Precautions. Both staff members acknowledged their oversight in not adhering to the posted instructions. In another instance, Nurse #2 did not follow the facility's infection control policy for hand hygiene while administering insulin to Resident #28. She failed to wear gloves during the procedure and did not perform hand hygiene afterward. Nurse #2 admitted to being in a hurry, which led to her neglecting these critical infection control practices. Additionally, Unit Manager #1 did not perform hand hygiene after removing dirty gloves and before donning clean gloves during wound care for Resident #12. This oversight occurred despite the facility's policy requiring hand hygiene between glove changes. Unit Manager #1 acknowledged the lapse, attributing it to an oversight during the procedure.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered by the Physician for two residents, leading to significant medication errors. Resident #9, diagnosed with chronic myelocytic leukemia, was supposed to receive Bosulif 100 mg daily. However, a surplus of Bosulif was discovered on the medication cart, indicating that the resident did not receive the medication as prescribed from January 2024 through March 2024. Despite the medication administration records showing that the medication was given, the presence of extra tablets suggested otherwise. Interviews with the Assistant Director of Nursing, Director of Nursing, and the Physician revealed that the surplus was unexpected, and the Physician confirmed that the resident had not been hospitalized, implying missed doses during that period. Resident #13, diagnosed with schizophrenia, was ordered to receive Olanzapine 10 mg daily. However, the resident received Olanzapine 20 mg daily from February 5, 2024, to February 16, 2024, due to an error in medication ordering and administration. The Director of Nursing was unable to recall how the error was discovered but confirmed that the incorrect dose was administered for 11 days. The Consultant Pharmacist noted that there were active orders for both 10 mg and 20 mg doses in the system, leading to the wrong dose being refilled and administered. Both residents were found to have not suffered harm from these medication errors, as confirmed by their respective healthcare providers. Resident #9's laboratory tests remained unchanged, and Resident #13 had previously taken the higher dose without adverse effects. However, these incidents were considered significant medication errors due to the deviation from the prescribed medication regimen.
Failure to Notify Responsible Person of Scheduled Procedure
Penalty
Summary
The facility failed to notify the responsible person (RP) of a follow-up urologist appointment for a scheduled procedure for a resident. The resident, who was moderately cognitively impaired and had an indwelling catheter, was seen by a urologist for urinary retention. During the appointment, a cystoscopy procedure was recommended and scheduled. However, the RP was not informed of this recommendation or the scheduled procedure. The resident's RP, who is the legal guardian, was responsible for reviewing all medical recommendations. She was not made aware of the cystoscopy procedure until after it was completed. The Director of Nursing (DON) assumed that the urology office had notified the RP, which led to the oversight. The RP expressed that the facility should have contacted her directly about the recommendations and scheduled procedure. The DON acknowledged the oversight, stating it was a human error. The DON and nursing staff are typically responsible for notifying RPs of follow-up recommendations and scheduled procedures. The Administrator also recognized the incident as an oversight, noting that medical offices usually notify RPs as well. However, in this case, the assumption that the urology office had contacted the RP led to the deficiency.
Inaccurate MDS Coding for Oxygen and Hospice Services
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for several residents, leading to deficiencies in the documentation of oxygen use and hospice services. Resident #1, who was admitted with chronic respiratory failure and COPD, had physician orders for continuous oxygen and was admitted to hospice services. However, the quarterly MDS assessment did not reflect these services. Similarly, Resident #6, with diagnoses including COPD and emphysema, had orders for oxygen as needed, but this was not coded in the MDS assessment. Resident #8, diagnosed with a nontraumatic intracranial hemorrhage and obstructive sleep apnea, also had orders for oxygen as needed, which were not documented in the admission MDS. Additionally, Resident #4, admitted with non-Alzheimer's dementia, was receiving hospice services, but this was not coded in the significant change in condition MDS assessment. Interviews with the MDS Coordinator revealed that these coding inaccuracies were oversights. The Administrator and the Director of Nursing both expressed expectations for accurate MDS coding, indicating a lapse in the facility's adherence to proper documentation protocols.
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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) |
|---|---|---|---|---|
| Courtland Terrace | 2.2 mi | ★★★★★ | 4 | 0 |
| The Greens At Gastonia | 2.3 mi | ★★★★★ | 2 | 0 |
| Peak Resources - Gastonia | 2.6 mi | ★★★★★ | 2 | 0 |
| Gastonia Health & Rehab Center | 3.8 mi | ★★★★★ | 4 | 0 |
| Accordius Health At Gastonia | 5.2 mi | ★★★★★ | 2 | 0 |
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