Average — CMS composite of the measures below.
A standard survey is most likely before 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 Lincolnton Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not provide group activities outside the facility for residents who expressed a desire for such outings, citing the lack of a van and high transportation costs. Several residents, including those who were cognitively intact, reported feeling sad or depressed due to being unable to participate in community activities like shopping or dining out. Staff confirmed that no off-site activities had been scheduled since before 2020, and only in-house activities were offered.
Two dependent, cognitively intact residents were unable to access the overhead light switch cords in their rooms due to broken or inaccessible cords. Both residents had to rely on staff to control the lighting, which was inconvenient for their daily activities. Staff had not reported the issue to maintenance, and facility leadership was unaware of the problem until it was identified during the survey.
A resident who was cognitively intact and required significant assistance with daily living was not invited to participate in the review and revision of their care plan. Staff interviews and record reviews confirmed that no care plan meeting had been scheduled or conducted for this resident since the last documented meeting, and the breakdown in scheduling was attributed to miscommunication among the MDS nurse, Social Worker, and Social Services Assistant.
A resident with hemiplegia and muscle weakness, who required two-person assistance for bed mobility and incontinent care, was assisted by only one nurse aide during care. While being turned in bed, the resident slid off the side and was lowered to the floor, resulting in multiple bruises and abrasions. Staff and leadership confirmed that the care provided did not follow the resident's documented needs for two-person assistance.
A resident with diabetes and hypertension, who was cognitively intact and required extensive assistance with toileting, was left in a soiled brief for over an hour despite requesting care. The resident informed a Nurse Aide, who did not provide immediate assistance, leading to the resident feeling upset and undignified. The Unit Manager and ADON later provided the necessary care, confirming that such delays should not occur.
A resident was sent to a medical appointment with their belongings without proper discharge paperwork or instructions. The facility did not verify the discharge location, order home health services, or follow up to ensure the resident's needs were met. The resident felt abandoned and had to contact a family member to take them home.
A resident with a tracheostomy was not allowed to return to the facility after a therapeutic leave for an infusion appointment. The facility lacked the necessary supplies and staff training to care for the resident's tracheostomy, leading to the resident being sent to the ED without proper orders. The resident was left at the infusion center with his belongings and had to contact a family member to pick him up. The incident revealed a lack of communication and coordination among the facility staff.
The facility failed to provide timely incontinence care for two residents, leading to adverse outcomes. One resident reported sitting in a soiled brief for over an hour, resulting in redness and soreness on her buttocks. Another resident experienced a similar delay, leading to feces on the bed sheets, thighs, and urinary catheter. The staff's failure to provide timely care was acknowledged by the facility's management.
A facility failed to notify the physician of a facility-initiated discharge for a resident with multiple diagnoses, including cancer and respiratory failure. The resident was sent to an infusion appointment with all his belongings and was later informed he would be going to the ED without further information. The DON decided on the transfer without notifying the NP or MD, and the Admissions Director informed the infusion center that the resident could not return to the facility.
The facility failed to complete a PASRR level II for two residents with mental health diagnoses. One resident was diagnosed with anxiety disorder, major depressive disorder, PTSD, and mood disorder after admission, while another was diagnosed with major depressive disorder and unspecified mood disorder upon admission. The Social Worker was not made aware of the new diagnoses, leading to the oversight.
The facility's QAA Committee failed to maintain procedures and monitor interventions in dignity and respect, notification of change, and safe discharges. One resident was left in a soiled brief, another felt unsafe during a transfer, and a third was discharged without proper paperwork or instructions. Despite frequent discussions at QAA meetings, these issues persisted, indicating a failure to sustain effective interventions.
Failure to Provide Off-Site Group Activities for Residents
Penalty
Summary
The facility failed to provide group activities outside of the facility for residents who expressed a desire and need for such activities. Record review, activity calendar review, and interviews with residents and staff revealed that no off-site group activities were scheduled or provided from July 2024 to July 2025. Residents consistently reported that they had not participated in any activities outside the facility since admission, primarily due to the lack of a facility van for transportation. The activity calendar only included in-house activities, and the facility was located within a short driving distance to various community amenities, yet these were not utilized for resident outings. Multiple residents, including those who were cognitively intact and those with moderate cognitive impairment, expressed feelings of sadness, frustration, and depression due to the inability to leave the facility for group activities such as shopping or dining out. Residents stated that they missed engaging in activities they previously enjoyed and felt confined to the facility. Some residents indicated that they did not participate in in-house activities because they were not interested, but would have participated in off-site activities if available. Interviews with the Activity Director, DON, Administrator, and Director of Clinical Services confirmed that no off-site activities had been provided since before 2020, citing the lack of a facility van and the high cost of third-party transportation as barriers. Staff were not aware of residents' requests for off-site activities, and the only outings arranged were for medical appointments or when family members provided transportation. The facility's practice was to shop for residents' requested items rather than facilitate group outings, and there was no evidence of recent efforts to arrange or schedule off-site group activities.
Failure to Provide Accessible Light Switches for Dependent Residents
Penalty
Summary
The facility failed to ensure that two dependent residents had access to the light switch cords for the overhead lights in their rooms. Both residents were cognitively intact but unable to ambulate or stand, and had resided in their respective rooms for an extended period. Observations revealed that the light switch cords were either too short or broken, making them inaccessible from the residents' beds. Despite repeated observations over several days, the cords remained unrepaired and out of reach for both residents. Interviews with the residents confirmed that they had never been able to reach the light cords and had to rely on nursing staff to control the overhead lights. This lack of access was inconvenient for the residents, as one needed the light to use her computer and the other to read and do word puzzles. Both expressed a desire for the cords to be fixed so they could independently control their room lighting. Staff interviews indicated a lack of awareness and reporting regarding the broken or inaccessible cords. Nurse aides acknowledged the issue when it was pointed out but had not previously reported it to maintenance. The maintenance supervisor stated he depended on staff to submit work orders for repairs and was unaware of the problem. Facility leadership, including the DON and Administrator, stated they expected staff to report such issues promptly to ensure residents' needs were accommodated, but were not aware of the specific deficiencies until the time of the survey.
Resident Not Invited to Care Plan Meeting
Penalty
Summary
A cognitively intact resident who required maximum assistance or was dependent on staff for most activities of daily living did not have the opportunity to participate in the review and revision of his care plan. The resident had not been invited to a care plan meeting since his last documented meeting, despite having a significant change in status assessment. The electronic health record showed no care plan meeting had been conducted since early January, and the resident confirmed he had not been invited to any recent meetings, though he had attended in the past and expected to be included. Interviews with facility staff revealed a breakdown in the scheduling process for care plan meetings. The Social Worker and Social Services Assistant both relied on schedules provided by the MDS nurse, but neither had a record of the resident being scheduled or invited to a care plan meeting. The MDS nurse confirmed that the resident had not had a care plan meeting as required and could not explain why the meeting was missed. The Administrator, who was new to the facility, was unaware of the care plan schedules but acknowledged that residents should be invited to these meetings.
Failure to Provide Required Two-Person Assistance During Bed Mobility
Penalty
Summary
A deficiency occurred when a resident with hemiplegia and muscle weakness, who was assessed as cognitively intact but required substantial to maximal assistance with toileting hygiene and bed mobility, was not provided care according to her documented needs. The resident's care plan specified a two-person assist for incontinent care and bed mobility. However, on the morning of the incident, a single nurse aide provided care without a second staff member present. During the process of turning the resident in bed, the resident slid off the side of the bed and was lowered to the floor by the aide. Following the incident, the resident was initially assessed and found to have no complaints of pain or visible injuries. However, a subsequent skin assessment revealed multiple areas of discoloration and abrasions on the resident's arms, abdomen, thigh, heel, toes, and back. The resident later began to complain of lower extremity pain, prompting a transfer to the emergency department for further evaluation. X-rays were negative for fractures or acute injury, and the resident was returned to the facility with no new orders. Interviews with facility staff, including nurses, the nurse practitioner, the DON, and the administrator, confirmed that the resident required two-person assistance for bed mobility and incontinent care. It was acknowledged by staff and leadership that providing care with only one aide was not in accordance with the resident's care plan and was unsafe. The nurse aide involved did not have a second person assisting at the time of the incident, which directly led to the resident sliding off the bed.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to treat a resident in a dignified manner by not providing incontinent care when requested. Resident #80, who was admitted with diagnoses of diabetes mellitus and hypertension, was cognitively intact and required extensive assistance with toileting. On the day of the incident, Resident #80 had been sitting in a soiled brief since 9:30 AM and had informed Nurse Aide (NA) #1 about her condition. However, NA #1 did not provide immediate care as she was preoccupied with another task. This led to Resident #80 feeling upset and undignified, as she had to sit in a soiled brief for an extended period. The situation was brought to the attention of the Unit Manager and Assistant Director of Nursing (ADON), who then provided the necessary incontinence care. During the care, it was observed that Resident #80's top sheet, bed pad, and fitted sheet were soiled with feces, and she had feces extending down onto her thighs and covering her urinary catheter. Interviews with the Unit Manager, ADON, and Director of Nursing (DON) confirmed that the care should have been provided immediately upon the resident's request, and no resident should feel like a third-class citizen or have to sit in a soiled brief for an extended period.
Failure to Provide Safe and Orderly Discharge
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a resident who had a scheduled medical appointment. The resident's belongings were packed by staff and sent with him to the appointment without providing discharge paperwork or instructions. The discharge location was not verified, home health services were not ordered, and there was no follow-up to ensure the resident's needs were met. This resulted in the resident feeling abandoned and mad. The resident was admitted to the facility with multiple diagnoses, including cancer, malnutrition, respiratory failure, and muscle weakness. The resident had a tracheostomy, and the facility staff were not familiar with caring for a resident with a cuffed tracheostomy. The Respiratory Therapist recommended changing the tracheostomy type, but the facility did not have the necessary supplies. The Director of Nursing decided to send the resident to the Emergency Department after the infusion appointment for the tracheostomy change, but no orders were obtained for this. The resident was sent to the infusion appointment with his belongings and was informed by the infusion staff that he could not be sent to the Emergency Department without orders. The resident contacted a family member to pick him up and take him home. The facility did not contact the resident's representative until two days later, and the resident did not receive any discharge information, services, medicines, or supplies. The facility staff, including the Assistant Director of Nursing, Social Worker, and Director of Nursing, were unaware of the resident's whereabouts and did not follow up appropriately.
Failure to Permit Resident Return After Therapeutic Leave
Penalty
Summary
The facility failed to permit a resident to return after a therapeutic leave, resulting in the resident feeling abandoned and mad. The resident, who had a tracheostomy and was diagnosed with cancer, malnutrition, respiratory failure, and muscle weakness, was sent to an infusion appointment. Prior to the appointment, the resident's belongings were packed by staff, and he was informed he would be sent to the Emergency Department (ED) after the appointment. However, the resident was not allowed to return to the facility following the appointment, leading to significant distress for the resident. The Respiratory Therapist (RT) assessed the resident and recommended changing the tracheostomy from a cuffed to an uncuffed type. The facility did not have the necessary supplies, and the nursing staff was not familiar with caring for a cuffed tracheostomy. The Director of Nursing (DON) decided to send the resident to the ED after the infusion appointment for the trach change, but no physician orders were obtained. The resident was not in distress and could have waited for the supplies to be obtained. The resident was left at the infusion center with his belongings and was informed by the infusion staff that they could not send him to the ED without orders. The resident contacted a family member to pick him up as he had no other place to go. Interviews with various staff members, including the Assistant Director of Nursing (ADON), DON, Nurse Practitioner (NP), and Medical Director (MD), revealed a lack of communication and coordination regarding the resident's care. The DON admitted to not notifying the NP or MD to obtain the necessary orders for the trach change. The facility staff failed to follow up on the resident's whereabouts, and it was only discovered two days later that the resident had gone home from the infusion appointment. The prior Admissions Director could not recall the details of the incident, and the Administrator was unaware that the RT could not write orders and that the physicians had not been notified about the resident's situation.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, leading to adverse outcomes. Resident #53, who was cognitively intact and required extensive assistance with toileting, reported sitting in a soiled brief for over an hour. Despite notifying Nurse Aide (NA) #1, the resident did not receive care promptly, resulting in redness and soreness on her buttocks. The delay in care was attributed to NA #1 prioritizing other tasks and forgetting to return to the resident's room. The Unit Manager and Director of Nursing confirmed that staff were not instructed to delay incontinence care due to meal tray duties, and the resident developed a new open area on her right buttocks, which was later treated with zinc oxide by the wound nurse and assessed by the wound physician. Similarly, Resident #80, who also required extensive assistance with toileting, experienced a delay in incontinence care. The resident reported sitting in a soiled brief for over an hour and informed NA #1, who acknowledged the request but did not provide immediate care. The resident's condition was later observed by the surveyor, revealing feces on the bed sheets, thighs, and urinary catheter. The Unit Manager and Assistant Director of Nursing had to perform a complete bed change and provide incontinence care. NA #1 admitted to prioritizing another resident's bed bath over changing Resident #80, leading to the delay. Interviews with the Unit Manager, Assistant Director of Nursing, and Director of Nursing revealed that the facility's policy did not support delaying incontinence care for other tasks. Both residents experienced significant discomfort and potential health risks due to the delays in care. The staff's failure to provide timely incontinence care was acknowledged by the facility's management, who emphasized that such delays were not acceptable practice.
Failure to Notify Physician of Facility-Initiated Discharge
Penalty
Summary
The facility failed to notify the physician of a facility-initiated discharge for a resident who was scheduled for a medical appointment. The resident, who had diagnoses including cancer, malnutrition, respiratory failure, and muscle weakness, was sent to an infusion appointment with all his belongings packed by the staff. The resident was informed by a staff member that he would be going to the Emergency Department (ED) after his appointment without any further information. The resident contacted a family member to pick him up from the infusion center as he had nowhere else to go. The Infusion Center Nurse confirmed that the facility had instructed them to send the resident to the ED because they could not care for him, and the resident had a bag packed with his belongings. The Admissions Director could not recall the details of the conversation with the infusion center staff or the discharge of the resident. The Director of Nursing (DON) revealed that the Respiratory Therapist had recommended changing the resident's tracheostomy from a cuffed to an uncuffed one, but the facility lacked the necessary supplies. The DON decided to have the tracheostomy changed at the ED after the resident's infusion appointment but did not notify the Nurse Practitioner (NP) or the Medical Director (MD) to obtain orders for the ED transfer. The DON was unaware that the resident had taken his belongings and did not know that the Admissions Director had informed the infusion center that the resident could not return to the facility. Both the NP and MD confirmed that they were not notified about the resident's transfer to the ED or the tracheostomy change, and they had not assessed the resident during his stay at the facility.
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) was completed for residents with mental health diagnoses upon admission and for residents with new mental health diagnoses. Specifically, Resident #67 had a PASRR level I completed prior to admission but was later diagnosed with anxiety disorder, major depressive disorder, PTSD, and mood (affective) disorder without a subsequent PASRR level II being completed. The Social Worker (SW) responsible for PASRR assessments was not made aware of these new diagnoses, which led to the oversight. The Administrator confirmed that a PASRR level II should have been completed based on the new diagnoses. Similarly, Resident #90 had a PASRR level I completed prior to admission and was diagnosed with major depressive disorder and unspecified mood disorder upon admission. However, no PASRR level II was completed for this resident either. The SW admitted that the admission diagnosis and PASRR level for Resident #90 had been overlooked. The Administrator also confirmed that a PASRR level II should have been completed in a timely manner based on the resident's admission diagnoses.
Failure to Maintain Dignity, Notify Physicians, and Ensure Safe Discharges
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions in the areas of dignity and respect (F550) and notification of change (F580). Specifically, the facility did not provide incontinent care when requested for one resident, making her feel undignified and upset. Additionally, during a previous complaint investigation survey, a Nurse Aide was rough during a transfer, making a resident feel unsafe, and another resident was not assisted at eye level during a meal. Despite frequent discussions at quarterly QAA meetings, these issues persisted, indicating a failure to sustain effective interventions. The facility also failed to notify the physician of a facility-initiated discharge and did not provide a safe and orderly discharge for a resident. The resident's belongings were packed and sent with him to a medical appointment without discharge paperwork or instructions, leaving him feeling abandoned and mad. During a previous survey, the facility failed to notify the physician about a resident's deteriorating wound and did not ensure the necessary medical equipment was delivered upon discharge. Despite discussions at QAA meetings, these deficiencies were not addressed effectively, showing a pattern of non-compliance.
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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) |
|---|---|---|---|---|
| The Greens At Lincolnton | 1.2 mi | ★★★★★ | 8 | 0 |
| Cardinal Healthcare And Rehabilitation | 1.4 mi | ★★★★★ | 1 | 0 |
| Peak Resources-cherryville | 8.8 mi | ★★★★★ | 0 | 0 |
| Carolina Care Health And Rehabilitation | 10.4 mi | ★★★★★ | 0 | 0 |
| Stanley Total Living Center | 11.7 mi | ★★★★★ | 9 | 0 |
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