Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Matthews Health & Rehab Center during CMS and state inspections, most recent first.
A resident admitted with a MOST form, physician order, and advance directive all indicating DNR had this status omitted from the EHR banner, eMAR, and care plan. During a medication pass, the resident, who had severe cognitive impairment, was found unresponsive, and because the code status was not visible in the electronic systems used by staff, an RN initiated CPR and EMS was called. Another nurse located a code status binder showing DNR, at which point CPR was stopped and EMS was canceled. Interviews with the POA, physician, DON, unit manager, and social worker showed that although several staff were responsible for ensuring code status was entered and updated, the DNR status was never entered into the EHR banner, and the POA was not informed that CPR had been initiated.
A resident with diabetes and failure to thrive had physician-ordered labs that could not be collected as scheduled. Nursing staff did not notify the NP or physician of the missed lab draw, following facility protocol to reschedule for the next day. The NP was not informed of the delay and stated that immediate notification was necessary to determine if further interventions were needed. This lack of timely provider notification when labs were not obtained led to the deficiency.
The facility failed to implement infection control measures during a COVID-19 outbreak, leading to additional cases among staff and residents. The facility did not initiate contact tracing or broad-based testing until surveyor intervention and did not adhere to CDC guidelines for staff returning to work after testing positive. Observations revealed staff not consistently following PPE protocols, increasing the risk of transmission.
The facility failed to resolve grievances from Resident Council Meetings regarding unresponsive call lights and lack of evening snacks. Despite repeated documentation of these issues, no resolution was demonstrated. Residents felt ignored, and the Activity Director and Administrator were unaware of any improvements or resolutions, highlighting a lack of communication and follow-up.
A resident with a stage 4 sacral pressure ulcer did not receive the prescribed wound vac therapy over a weekend, as the facility staff used a wet-to-dry dressing instead. Despite the wound vac being functional, it was not utilized, and the physician was not informed of this deviation from the treatment plan. The facility's DON and Administrator acknowledged the failure to follow the treatment orders.
A resident with neuromuscular dysfunction of the bladder had an unsecured indwelling urinary catheter, despite the facility having a supply of securing devices. Observations showed the catheter tubing was not secured, and the resident was unaware of securing devices. Nursing staff were aware of securing devices for other residents but not for this resident. A nurse incorrectly stated there was no supply, although a device was found in a medication cart. The physician confirmed the necessity of securing devices, and the DON and Administrator acknowledged their availability.
The facility failed to provide evening snacks to residents in two halls, as nursing staff were unable to access the kitchen and snacks were not delivered. Residents reported not receiving snacks, and staff interviews confirmed the issue. The Dietary Manager was recently informed, but the Director of Nursing and Administrator were unaware.
The facility failed to ensure RN coverage for 8 consecutive hours on two specific days, as required. A review of staffing data revealed missing RN coverage on these days. The Administrator and DON claimed coverage was present and provided timecards for other dates, but failed to produce evidence for the days in question.
A facility failed to notify a resident and their family in writing about a hospital transfer and did not consistently inform the Ombudsman of resident transfers and discharges over several months. Interviews revealed confusion among staff about responsibilities for issuing transfer letters and communicating with the Ombudsman, following changes in administration.
A resident with lung disease was hospitalized for an upper respiratory infection and did not receive a required bed hold notice from the facility. Interviews with staff revealed confusion about who was responsible for issuing the notice, with the Administrator indicating that the social work department should handle it. This lack of clarity led to the deficiency.
A resident with cognitive impairments was physically assaulted by another resident who was cognitively intact, resulting in the victim being hospitalized. The incident occurred when the aggressor perceived the victim was going through his belongings. Despite staff intervention, the victim sustained a head injury and was transferred to another facility for further care.
A facility failed to report a resident-to-resident abuse incident to APS in a timely manner. The incident involved one resident punching another, causing injury and requiring hospital evaluation. Although the Facility Administrator was informed shortly after the event, APS was not notified immediately due to a misunderstanding of the screening criteria.
Failure to Accurately Reflect DNR Status in Electronic Record Leading to Initiation of CPR
Penalty
Summary
The facility failed to ensure that a resident’s advance directive and DNR status were consistently and accurately entered and displayed throughout the electronic medical record. The resident was admitted with a Medical Orders for Scope of Treatment (MOST) form and a physician’s order indicating a Do Not Resuscitate (DNR) status, and the advance directive documentation also reflected DNR. However, the electronic health record (EHR) face sheet banner, which is used to display key resident information including code status, did not show either Full Code or DNR for this resident. The resident’s care plan contained no documentation of an advance directive, and the code status was not available in the electronic Medication Administration Record (eMAR), which staff use to review treatment information. The resident had severe cognitive impairment per the 5‑day MDS assessment and was therefore not able to communicate wishes at the time of the incident. During a medication pass at approximately 10:00 AM, a nurse found the resident unresponsive. Because the code status was not visible in the EHR banner or eMAR, the nurse initiated CPR and called for assistance. Another nurse went to the nurse’s station to locate the code status binder and identified that the resident had a DNR order. CPR, which had been performed for less than one minute with approximately 25 chest compressions, was then discontinued, and EMS, which had been contacted, was later canceled once the DNR status was confirmed. Interviews revealed that multiple staff members had roles related to ensuring accurate code status documentation but that the resident’s DNR status had not been entered into the EHR banner or reflected in the care plan. The unit manager stated that nursing staff were responsible for entering admission orders and updating the banner to show Full Code or DNR, and indicated that a former ADON who worked with the family at admission may have missed updating the banner. The DON stated that all nursing staff were responsible for updating and entering code status in the banner and that each resident should have an advance directive status ordered upon admission. The physician confirmed the resident had a DNR order upon admission initiated by another provider per the POA. The POA reported that the resident’s wishes were for DNR and that he was not informed that CPR had been initiated.
Failure to Notify Provider of Unsuccessful Lab Collection
Penalty
Summary
The facility failed to notify the physician or Nurse Practitioner (NP) when ordered laboratory services could not be obtained for a resident. The resident was admitted with diagnoses including diabetes mellitus type II and adult failure to thrive. A physician's order was placed for a comprehensive metabolic panel (CMP) and a complete blood count (CBC) to be collected the following morning. However, when the phlebotomist attempted to collect the blood sample, they were unsuccessful in obtaining a specimen. Nurse #1 stated that it was standard practice for the laboratory to reschedule the collection for the next day and did not notify the NP or Medical Director about the missed lab collection, as the labs were ordered on a routine basis rather than as a stat order. The NP, upon interview, indicated that he was not informed that the labs were not obtained and emphasized that nursing staff should have notified him so he could determine if further interventions were necessary. The Medical Director also stated that the decision to notify would rest with the NP who ordered the labs. The Director of Nursing (DON) and the Administrator both stated that facility protocol was to reschedule lab work if collection was unsuccessful and believed staff followed this protocol. However, the NP clarified to the DON that immediate notification to providers is necessary if labs are delayed or not drawn, especially to ensure proper follow-up. The lack of timely notification to the provider when the labs were not obtained constituted the deficiency identified during the survey.
Failure to Implement Infection Control Measures During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement its infection control policy and procedures in accordance with current CDC guidance during a COVID-19 outbreak. The outbreak began when two staff members tested positive for COVID-19, but the facility did not initiate contact tracing or broad-based testing for staff and residents until surveyor intervention. This delay in testing led to additional cases among staff and residents, with a total of nine staff members and seven residents testing positive before broad-based testing was implemented. The facility also failed to implement staff source control measures and did not ensure that staff wore the required personal protective equipment (PPE) when entering rooms under transmission-based precautions. The facility did not adhere to CDC guidelines for staff returning to work after testing positive for COVID-19. Several staff members returned to work without obtaining a negative COVID-19 test, contrary to CDC recommendations. The Infection Preventionist (IP) was unaware of the correct return-to-work criteria, leading to staff returning to work prematurely, potentially increasing the risk of further transmission within the facility. The facility's failure to follow these guidelines contributed to the continued spread of COVID-19 among residents and staff. Observations during the survey revealed that staff did not consistently follow PPE protocols. Nursing assistants were observed entering rooms of COVID-positive residents without wearing the appropriate PPE, such as gowns, gloves, and eye protection. Additionally, a nurse was observed not wearing a mask for source control while administering medications. These lapses in infection control practices further increased the likelihood of COVID-19 transmission within the facility.
Unresolved Resident Council Grievances
Penalty
Summary
The facility failed to address and resolve grievances raised during Resident Council Meetings over a period of several months. Specifically, the Resident Council repeatedly expressed concerns about nursing staff not responding to call lights in a timely manner and the lack of snacks being provided in the evening. These issues were documented in the meeting minutes from August to December, yet the facility did not demonstrate any response or resolution to these grievances. Interviews with residents confirmed that these concerns remained unaddressed, and they felt that the staff did not care about their ongoing issues. The Activity Director acknowledged that concerns were raised during stand-up meetings and with department heads, but there was no documentation to show that these issues were resolved. The Administrator was unaware that grievances from the Resident Council meetings were not being completed and resolved, despite expecting that concerns would be addressed and documented. This lack of communication and follow-up led to the ongoing dissatisfaction and unresolved grievances among the residents.
Failure to Maintain Wound Vac Therapy for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to maintain proper wound care for a resident with a stage 4 sacral pressure ulcer, as ordered by the physician. The resident, who was admitted with a chronic sacral decubitus, type 2 diabetes, and peripheral artery disease, had a wound vac therapy order to be changed on Monday, Wednesday, and Friday. However, the wound vac was not used over the weekend, and instead, a wet-to-dry dressing was applied, which was not in accordance with the physician's orders. Observations and interviews revealed that the wound vac machine was not in use from Saturday to Monday, despite being in proper working order. Nurse #1 applied a wet-to-dry dressing on Saturday and reinforced it on Sunday, following instructions from her supervisor, even though the wound vac was not broken. The Treatment Nurse confirmed that the wound vac was functional and that the wet-to-dry dressing was not an acceptable treatment for the resident's condition. The physician was not informed of the deviation from the prescribed treatment and stated that the wet-to-dry dressing was inappropriate due to the high risk of infection. The Director of Nursing and the Administrator acknowledged that the treatment orders were not followed as written, indicating a lapse in communication and adherence to medical directives within the facility.
Failure to Secure Indwelling Urinary Catheter
Penalty
Summary
The facility failed to secure the indwelling urinary catheter for a resident with neuromuscular dysfunction of the bladder, which was necessary to reduce tension and prevent injury. The resident was admitted with a physician's order for an indwelling urinary catheter but lacked an order for a securing device. Observations over several days revealed that the catheter tubing was not secured, and the resident was unaware of what a securing device looked like. The care plan for the resident included goals to reduce the risk of urinary tract infections but did not address the need for securing the catheter tubing. Interviews with nursing staff indicated that they were aware of securing devices for other residents but had not seen any for this particular resident. A nurse stated that the facility did not have a supply of securing devices, although one was found in a medication cart. The physician confirmed that securing devices should be used for all residents with indwelling catheters as a standard recommendation. The Director of Nursing and the Administrator acknowledged that the facility had a supply of securing devices and that nursing staff should utilize them.
Failure to Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to have systems in place for providing evening snacks to residents in two of its halls, which affected residents who requested snacks outside of scheduled meal times. During a Resident Council Meeting, several residents reported that they had not been offered evening snacks by nursing staff, and when they requested snacks, they were informed that the staff could not access the kitchen or that no snacks were available. This issue had been reported to the Dietary Manager, but it persisted. Interviews with staff revealed that nursing staff were often unable to access the kitchen at night to retrieve snacks, and there were multiple occasions when snacks were not provided for distribution. A nurse aide working the second shift confirmed that residents had not received bedtime snacks on multiple days due to the kitchen staff's failure to deliver them and the nursing staff's inability to access the kitchen. The Dietary Manager acknowledged being recently informed of the issue and stated that snack bins were checked and stocked daily, suggesting that nursing staff were not offering snacks as needed. The Director of Nursing and the Administrator were unaware of the issue, although they expected snacks to always be available for residents.
Failure to Provide RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours on two specific days, 4/20/24 and 4/21/24, as required. This deficiency was identified through a review of the Payroll Based Journal (PBJ) staffing data report from the Certification and Survey Provider Enhanced Report (CASPER) database, which showed missing RN coverage on these dates. During an interview, the Administrator and Director of Nursing claimed that RN coverage was present and attempted to provide timecard evidence. However, they could only produce timecards for 5/05/24 and 6/02/24, confirming RN coverage on those days, but failed to provide any documentation for 4/20/24 and 4/21/24. Despite further attempts to locate the necessary evidence, the Administrator was unable to provide additional timecard information to support RN coverage on the missing dates.
Failure to Notify Resident and Ombudsman of Transfers
Penalty
Summary
The facility failed to provide timely written notification to a resident and their family member regarding a transfer to the hospital. Specifically, a resident who was cognitively intact was transferred to the hospital for an upper respiratory infection and later readmitted to the facility. However, there was no documentation of a transfer letter being provided to the resident or their representative. Interviews with the social workers and the business office manager revealed uncertainty about who was responsible for issuing these letters, indicating a lack of clarity in the facility's procedures. Additionally, the facility did not consistently notify the Ombudsman of transfers and discharges over a three-month period. While discharge reports for August, September, and October were eventually sent in November, there was no record of reports being sent for January. The social worker indicated that the responsibility for communicating with the Ombudsman had shifted following changes in administration, but the process was not consistently followed. The Ombudsman confirmed the lack of timely communication, highlighting a breakdown in the facility's protocol for notifying relevant parties of resident transfers and discharges.
Failure to Provide Bed Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide a bed hold notice for a resident who was hospitalized, which is a requirement when a resident is transferred to a hospital or takes therapeutic leave. The resident, who was cognitively intact and had a diagnosis of lung disease, was transferred to the hospital for an upper respiratory infection and later readmitted to the facility. Upon review of the resident's electronic medical record, it was found that no bed hold notice was provided, and the resident confirmed that he did not receive such a notice during his hospitalization. Interviews with facility staff, including two social workers and the Business Office Manager, revealed uncertainty about who was responsible for issuing bed hold notices. The Administrator acknowledged a change in the social work department and indicated that the social work team should be responsible for providing the written bed hold notice. This lack of clarity and communication among staff members contributed to the failure to issue the required notice to the resident or their representative.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident, who was cognitively intact, physically assaulted him. The incident occurred when the aggressor resident became upset after perceiving that the victim, who was severely cognitively impaired, was going through his belongings. The aggressor resident hit the victim three times on the back of the head and neck, resulting in the victim being transported to the emergency department for evaluation. A CT scan revealed a 4-millimeter hyperdense focus in the right frontal region of the victim's brain, which was questionable for focal hemorrhage, subarachnoid bleeding, or contusion. The victim, who was diagnosed with dementia and other cognitive impairments, was admitted to the facility with fluctuating inattention and disorganized thinking. Despite these impairments, the victim had clear speech and adequate vision and hearing. The aggressor resident, on the other hand, was cognitively intact and independent in self-care, using a manual wheelchair for mobility. The incident was reported by a nursing assistant who heard yelling and observed the aggressor resident hitting the victim. The nurse on duty intervened by restraining the aggressor and calling for emergency services. Interviews with staff and residents revealed that the aggressor resident had expressed concerns about the victim going through his clothes but had not filed any formal complaints. The facility's investigation found no prior indications that the aggressor resident would abuse others. The incident was reported to the police, who declined to cite the aggressor due to his physical condition and reliance on medical staff. The facility's failure to prevent this incident resulted in the victim being hospitalized and later transferred to another skilled nursing facility.
Failure to Report Resident-to-Resident Abuse to APS
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to Adult Protective Services (APS) in a timely manner. The incident involved two residents, where one resident was observed punching another resident, resulting in the injured resident being sent to the hospital for evaluation due to bleeding from the face. The altercation was witnessed by two nursing assistants and a nurse, who intervened to separate the residents and notified the Facility Administrator and local law enforcement. The Facility Administrator was informed of the incident shortly after it occurred but did not contact APS immediately, as he believed the screening criteria were not met. The initial report of the incident was submitted to the North Carolina Health Care Personnel Registry, but it did not include notification to APS. The Administrator later reported the incident to APS after realizing the potential for the injured resident not returning to the facility. The deficiency was identified during a review of facility-reported incidents, where it was found that APS was not notified as required. The failure to report the incident to APS promptly was a significant oversight in the facility's handling of the situation, as it involved a serious altercation between residents that resulted in injury and required hospital evaluation.
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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 Matthews
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Royal Park Rehabilitation & Health Center | 2.1 mi | ★★★★★ | 8 | 0 |
| Willowbrooke Court Sc Ctr At Matthews Glen | 2.1 mi | ★★★★★ | 4 | 0 |
| Brookdale Carriage Club Providence | 3.3 mi | ★★★★★ | 1 | 0 |
| Sardis Oaks | 4.5 mi | ★★★★★ | 4 | 0 |
| Pelican Health Randolph Llc | 5.5 mi | ★★★★★ | 15 | 0 |
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