Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pineville Rehabilitation And Living Center during CMS and state inspections, most recent first.
A resident with multiple complex medical needs and her representative were not given the opportunity to participate in the person-centered care planning process. Although a care plan was developed, staff failed to hold or document a care plan conference, and there was no clear process for ensuring proper documentation or communication with the resident and representative.
Two residents were affected by inaccurate MDS coding: one was not coded for oxygen therapy despite documented need, and another was incorrectly coded for discharge status, omitting the involvement of home health services. Staff interviews confirmed awareness of the need for accurate coding but revealed errors in assessment completion.
An open multi-use vial of Tuberculin PPD was found in a medication storage room without an open date label. A nurse confirmed that such vials should be labeled with the date of opening, as they are only valid for 30 days after being opened. The ADON also acknowledged the requirement for labeling and stated that frequent use may have contributed to the oversight.
A resident with cognitive impairment and multiple medical conditions was left with a medication cup containing lactulose at her bedside after a nurse failed to ensure all medications were ingested. The resident was unaware of the medication, and there was no assessment for self-administration documented. Facility leadership confirmed that medications should not have been left unattended and that staff should observe residents taking their medications.
A resident with a history of seizure disorder, anxiety, and depression was allowed to keep a lighter and cigarettes in his possession, despite facility policy and care plan interventions requiring smoking supplies to be stored by nursing staff. Multiple staff interviews confirmed inconsistent practices and a lack of awareness regarding the resident's access to smoking materials, resulting in a deficiency related to accident prevention and supervision.
A nurse did not change gloves or perform hand hygiene between treating two separate wounds on a resident, using the same gloves for both wound dressings. This action was observed by the infection preventionist, and the nurse later acknowledged the lapse, which was not in accordance with the facility's infection control policy.
A resident with multiple sclerosis and cognitive impairment was found with wrists restrained using a pillowcase, violating their right to be free from physical restraints. The incident occurred during staff rounding and was reported to authorities. Staff interviews revealed the restraint was applied to manage combative behavior, contrary to facility policy.
Failure to Involve Resident and Representative in Care Plan Conference
Penalty
Summary
The facility failed to conduct a care plan conference and offer a resident and her representative the opportunity to participate in the person-centered care planning process. The resident, who was cognitively intact and had multiple complex medical conditions including deep vein thrombosis, atrial fibrillation, a recent hip fracture, pressure wounds, and dietary restrictions, was admitted and later discharged without documentation of a care plan conference. Although a care plan was created, there was no evidence that the resident or her representative were involved in its development or implementation. Interviews revealed that the resident and her representative were told a care plan conference would occur, but staff did not attend the scheduled meeting, and the conference was not rescheduled. The resident representative made several inquiries but did not receive updates or progress reports. Staff interviews indicated confusion and lack of clarity regarding responsibility for documenting care plan conferences, with no clear process in place to ensure documentation in the electronic medical record. As a result, there was no record that the resident or her representative participated in the care planning process.
Inaccurate MDS Coding for Oxygen Therapy and Discharge Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in the areas of respiratory treatment and discharge location. One resident, admitted with chronic obstructive pulmonary disease (COPD) and requiring continuous supplemental oxygen as documented in both the hospital referral form and nursing progress notes, was not coded for oxygen therapy on the admission MDS. The MDS Coordinator acknowledged reviewing the relevant documentation but stated that the omission was a mistake during the assessment process. Both the Director of Nursing (DON) and the Administrator confirmed that the MDS should be coded accurately but were unable to explain the cause of the error. Another resident, who had a planned discharge to home with home health services, was incorrectly coded on the discharge MDS as discharged to home/community rather than under the care of an organized home health service organization. The MDS Coordinator reported routinely coding discharges to home as home/community and was unaware of the correct coding for discharges involving home health services, despite documentation in the social service progress note. The DON and Administrator both stated that the MDS should be coded accurately but could not provide reasons for the incorrect coding.
Unlabeled Open Tuberculin Vial Found in Medication Storage
Penalty
Summary
Surveyors observed that an open multi-use vial of Tuberculin Purified Protein Derivative (PPD), specifically Diluted Aplisol with an expiration date of 2026/8, was stored in the medication storage room without being labeled with the date it was opened. During interviews, a nurse confirmed that the vial should have been labeled with the open date, as Tuberculin vials are only considered good for 30 days after opening. The nurse was unsure why the vial was not dated and stated she had not used it. The Assistant Director of Nursing (ADON) also confirmed that the vial should have been labeled with the open date and discarded after 30 days, noting that frequent use may have led to staff forgetting to label it. The ADON indicated that medication checks are performed by herself and the unit manager, but the check for that day had not yet been completed at the time of the observation.
Failure to Ensure Medication Ingestion and Secure Medication Administration
Penalty
Summary
A resident with vascular dementia, cirrhosis of the liver, and end stage renal disease was observed with a medication cup containing a green liquid left at her bedside while she was eating breakfast. The resident was moderately cognitively impaired and did not know what the liquid was or where it had come from. There was no documented assessment for medication self-administration in her medical record. The medication was later identified as lactulose, which had been ordered to be given twice daily by mouth. Nurse #1, who had administered the medications, initially believed the resident had taken all her medications while the nurse was present. However, it was discovered during an interview that the nurse had left the medication at the bedside and had not ensured the resident had ingested it. Subsequent interviews with the ADON, DON, and Administrator confirmed that medications should not have been left at the bedside and that the nurse should have observed the resident taking all medications before leaving the room.
Failure to Secure Smoking Supplies and Supervise Resident Smoking Practices
Penalty
Summary
The facility failed to provide adequate supervision and safe storage of smoking supplies for a resident who was assessed as a safe, unsupervised smoker. According to the facility's smoking policy, all smoking materials for residents deemed safe to smoke independently were to be secured by the facility, with supplies such as lighters and cigarettes stored by nursing staff. However, repeated observations showed that the resident kept a lighter and cigarettes in his backpack, accessible at all times, contrary to the policy and his care plan interventions, which specified that his smoking supplies should be stored with the nurse. Interviews with nursing and nurse aide staff revealed inconsistent practices and a lack of awareness regarding the storage of the resident's smoking materials. Staff members stated that the resident had always kept his own supplies and was the only resident allowed to do so, despite the policy requiring all supplies to be stored by the nurse. The Director of Nursing and the Administrator were unaware that the resident had his smoking materials on his person and confirmed that this was not in accordance with facility policy or the resident's signed smoking agreement. The resident in question had a history of seizure disorder, anxiety, and depression, and was cognitively intact and independent in most activities of daily living, using a wheelchair for mobility. Despite the absence of prior incidents related to his possession of smoking materials, the facility's failure to enforce its own policy and care plan interventions resulted in a deficiency related to accident prevention and supervision.
Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
Nurse #2 failed to follow the facility's Hand Hygiene policy during a wound care procedure for a resident with multiple wounds. After removing the old dressings from two wounds on the resident's lower back and sacrum, Nurse #2 doffed her gloves, sanitized her hands, and donned clean gloves before cleaning and dressing the first wound. However, she did not change gloves or sanitize her hands before proceeding to clean and dress the second wound on the sacrum, instead using the same gloves for both wounds. This action was observed by the Infection Preventionist, who was assisting during the procedure. The facility's policy requires hand hygiene and glove changes before moving from a soiled to a clean body site and between different wounds on the same resident. Nurse #2 acknowledged during an interview that she was aware of the missed hand hygiene and glove change between the two wounds, attributing the lapse to nervousness during the procedure. The Infection Preventionist and Director of Nursing both confirmed that the expectation is for staff to perform hand hygiene and change gloves between wound sites, as outlined in the facility's infection control policy.
Resident Found Restrained with Pillowcase
Penalty
Summary
The facility failed to protect a resident's right to be free from physical restraints, as evidenced by an incident involving a resident who was found with his wrists restrained using a pillowcase wrapped in a figure-eight manner and covered with a top sheet. This incident was discovered during staff rounding when a nurse aide noticed the resident's upper extremity range of motion was restricted by linen. Upon further investigation, it was revealed that the resident's wrists were bound together, which restricted his movement and ability to use the call bell for assistance. The resident involved had a medical history that included multiple sclerosis, left-side hemiplegia, left-side hemiparesis, and cerebral infarction. The resident required total assistance with all activities of daily living and had moderate cognitive impairment. Despite these conditions, the resident's care plan did not include the use of physical restraints, and the resident was noted to have no behaviors during the assessment period. However, the care plan did address the resident's resistance to care and behavioral problems, including hitting and kicking staff. Interviews with staff members revealed that one nurse aide had applied the restraining technique to manage the resident's combative behavior, claiming to have learned this method from another aide. The facility's policies clearly stated that physical restraints should only be used for the safety and well-being of residents and never for staff convenience or discipline. The incident was reported to local law enforcement and the Department of Social Services, and the involved staff members were suspended pending investigation.
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What surveyors actually found near you
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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 Pineville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mecklenburg Heath And Rehabilitation | 4.7 mi | ★★★★★ | 3 | 0 |
| Pavilion Health Center At Brightmore | 4.7 mi | ★★★★★ | 1 | 1 |
| The Stewart Health Center | 4.8 mi | ★★★★★ | 1 | 1 |
| The Sharon At Southpark | 5.7 mi | ★★★★★ | 0 | 0 |
| The Lodge At Wellmore- Tega Cay | 5.7 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.