Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Shaire Nursing Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment who used a wheelchair as her primary mobility device was observed with a damaged left armrest, which caused skin irritation. Despite the issue being visible and reported by a nurse aide to rehabilitation staff, the repair was not communicated to the maintenance department, and the problem persisted. Staff interviews revealed a lack of awareness and communication regarding the repair process, resulting in the resident continuing to use the wheelchair in disrepair.
A resident with anxiety disorder and severely impaired cognition had an active PRN lorazepam order without the required 14-day stop date, despite staff awareness of CMS guidelines. The order remained in effect for over a month, even after the resident was started on scheduled lorazepam, due to an oversight by the Medical Director and Consultant Pharmacist.
Two residents had inaccuracies in their MDS assessments: one was incorrectly coded as having an indwelling catheter and frequent urinary incontinence after the catheter had been discontinued, and another was coded as receiving anticoagulants despite not receiving them during the required look-back period. The MDS Coordinator and DON confirmed the coding errors.
A Consultant Pharmacist did not identify or report a drug regimen irregularity for a resident with anxiety disorder and severely impaired cognition, who had both a PRN and scheduled lorazepam order without a stop date for the PRN medication. The PRN order remained active but unused after the scheduled dose began, and the omission was attributed to pharmacist oversight despite facility expectations and CMS guidelines.
Three staff members failed to wear gowns as required by Enhanced Barrier Precautions (EBP) while performing or assisting with wound care for two residents with open wounds. Despite EBP policies, signage, and prior education, staff either misunderstood the requirements or neglected to use gowns during high-contact care activities, resulting in noncompliance with infection control protocols.
Staff failed to immediately report a resident's allegation of being hit, resulting in delayed notification to the DON and Administrator, and subsequent delays in reporting to authorities and initiating an investigation, contrary to facility policy.
A resident with heart failure and diabetes was discharged from hospice care, but the facility failed to complete a Significant Change in Status Assessment. The MDS Coordinator was not informed of the discharge, and assessments continued to be coded for hospice care. The Administrator and DON were unaware of the discharge, leading to inaccurate MDS coding.
A facility failed to accurately code MDS assessments for three residents, leading to deficiencies in hospice care, falls, and discharge documentation. One resident was incorrectly coded as receiving hospice care after discharge, another's fall history was not reflected in their MDS, and a planned discharge was inaccurately marked as unplanned. These errors were attributed to communication gaps and human oversight by the MDS Coordinator.
Failure to Maintain Wheelchair in Good Repair for Resident
Penalty
Summary
The facility failed to maintain a resident's wheelchair in good repair, resulting in a torn, ripped, and cracked vinyl cover on the left armrest. The resident, who had moderate cognitive impairment and relied on a wheelchair as her primary mobility device, was observed on multiple occasions with her left arm in contact with the damaged armrest. The resident reported that the damaged armrest irritated her skin at times and expressed a desire for it to be fixed. Weekly skin assessments indicated her skin was intact during the review period, and staff confirmed there was no redness or open areas at the time of observation. Despite the visible damage, nursing and aide staff either did not notice the issue or, when it was noticed, did not ensure the repair was reported and addressed. The nurse aide stated she had reported the issue to rehabilitation staff weeks prior, but the rehabilitation director denied receiving any such report. The maintenance department, responsible for repairs, was not made aware of the problem and did not conduct routine checks for wheelchair repair needs, instead relying on staff to submit work orders. Facility leadership, including the DON and Administrator, expected staff to be attentive to residents' mobility devices and to report repair needs promptly, but this did not occur in this instance.
PRN Psychotropic Medication Order Lacked Required 14-Day Stop Date
Penalty
Summary
The facility failed to ensure that a PRN (as needed) psychotropic medication, lorazepam, prescribed for a resident with anxiety disorder, included a required 14-day stop date as per CMS guidelines. The resident, who had severely impaired cognition and a history of anxiety, was admitted with both scheduled and PRN orders for lorazepam, both entered by the Medical Director without a stop date for the PRN order. Review of the medication administration records showed that the PRN lorazepam order remained active for over a month without being administered, even after the resident was started on a scheduled lorazepam regimen. Staff interviews revealed that nursing staff were aware of the ongoing PRN lorazepam order and the requirement for a 14-day stop date for PRN psychotropic medications. However, the nurse involved believed the rules may have changed when she noticed the missing stop date. The DON and Administrator both confirmed that the PRN lorazepam order should have included a 14-day stop date and attributed the oversight to the Medical Director and Consultant Pharmacist, rather than a systemic failure.
Inaccurate MDS Coding for Bladder, Bowel, and Medication Status
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for two residents in the areas of bladder and bowel status, and medication administration. For one resident, the nursing progress note indicated that a urinary catheter was discontinued per order without difficulty or complaint, yet the admission MDS assessment incorrectly coded the resident as having an indwelling catheter and being frequently incontinent of urine. The MDS Coordinator acknowledged that the assessment should have reflected the absence of a catheter and that the incontinence status was auto-populated based on nurse aide responses. For another resident, the quarterly MDS assessment was coded to indicate the use of anticoagulant medication. However, a review of the Medication Administration Record showed that the resident only received an anticoagulant for three days, and not during the required 7-day look-back period for the assessment. The MDS Coordinator confirmed that the resident should not have been coded as receiving anticoagulants, as the medication had been discontinued prior to the look-back period. The Director of Nursing also confirmed that both assessments should have been coded accurately.
Consultant Pharmacist Failed to Identify and Report PRN Lorazepam Order Irregularity
Penalty
Summary
A Consultant Pharmacist failed to identify and report a drug regimen irregularity for one of five residents reviewed for unnecessary medications. The resident in question was admitted with an anxiety disorder and had severely impaired cognition. Physician orders included both a PRN (as needed) lorazepam 0.5 mg every 4 hours for anxiety and a scheduled lorazepam 0.5 mg four times daily, both initiated on the same date. The PRN lorazepam order did not have a stop date and remained active in the electronic health record, although it had not been administered since the scheduled lorazepam was started. During the monthly Medication Regimen Review, the Consultant Pharmacist did not make any recommendations regarding the lack of a stop date for the PRN lorazepam order, despite being aware of CMS guidelines requiring such a stop date. Interviews with facility staff, including the DON and Administrator, confirmed their expectation that the Consultant Pharmacist would identify and report such irregularities. The Consultant Pharmacist acknowledged the oversight and could not explain why a recommendation was not made.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow its infection control policies and procedures for Enhanced Barrier Precautions (EBP) during wound care for residents who met the criteria for these precautions. Specifically, three out of six staff members observed and reviewed for infection control practices did not wear a gown while performing or assisting with wound care, as required by the facility's EBP policy. The policy mandates the use of gloves and gowns for high-contact resident care activities, including wound care for residents with open wounds or indwelling medical devices, even if the resident is not known to be infected or colonized with a multidrug-resistant organism (MDRO). During wound care for a resident with a stage 2 pressure ulcer, a nurse was observed performing hand hygiene and using gloves but did not don a gown at any point during the procedure. The nurse later stated she believed a gown was unnecessary because the wound was not open, although she acknowledged the resident should have been on EBP. Another nurse who regularly performed wound care for the same resident was unaware that EBP was required for residents with open wounds and had not been informed by the Infection Preventionist. The Infection Preventionist was also unaware that the resident's pressure ulcer was open and confirmed that EBP should have been initiated when the wound was identified. In a separate incident, another nurse and a nurse aide performed wound care on a different resident without wearing gowns, despite EBP signage and PPE being available outside the resident's room. The nurse aide believed gowns were only necessary for incontinence care, and the nurse admitted he forgot to wear a gown due to being in a hurry, though he knew it was required. Both staff members had previously received education on EBP, but failed to comply with the policy during the observed wound care procedure.
Failure to Immediately Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to ensure that staff implemented the abuse policy and procedure regarding immediate reporting, investigation, and protection following an allegation of abuse. Specifically, when a resident was found with a bruise on her right shoulder and reported being hit by a woman, nurse aides promptly informed a nurse, who then informed the Nurse Supervisor. However, the Nurse Supervisor delayed reporting the allegation to the Director of Nursing (DON) and the Administrator, as required by facility policy, which defines 'immediately' as within two hours for abuse allegations. The DON and Administrator were not made aware of the incident until informed by the surveyor, resulting in a delay in notifying the State Agency, local law enforcement, and Adult Protective Services (APS), as well as a delay in initiating an investigation. Interviews with staff revealed that the resident gave inconsistent accounts of the incident, but staff acknowledged that the policy required immediate reporting regardless of the resident's changing statements. The DON stated that she would have suspended any suspected staff and begun an investigation had she been notified in a timely manner. The Administrator confirmed that he would have reported the allegation to the appropriate authorities within the required timeframe if he had been informed. The failure to follow the established abuse reporting protocol led to a delay in protective actions and regulatory notifications for the resident involved.
Failure to Complete Significant Change in Status Assessment After Hospice Discharge
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment for a resident who was discharged from hospice care. Resident #3, who had diagnoses including heart failure and diabetes, was admitted to hospice services with a life expectancy of less than six months. The resident was discharged from hospice services and switched to hospice palliative care, which was later discontinued. However, there was no facility documentation indicating that hospice palliative care services had been ordered or discontinued. The MDS Coordinator was not informed about the discharge from hospice and palliative care services, and the most recent assessments continued to be coded for receiving hospice care. The MDS Coordinator stated that a significant change in status assessment should have been completed when hospice services ended. The Administrator and DON were also unaware of the resident's discharge from hospice services and expected the MDS assessments to be coded accurately. This lack of communication and documentation led to the failure to complete the necessary assessment.
Inaccurate MDS Coding for Hospice, Falls, and Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the documentation of hospice care, falls, and discharge status. Resident #3 was incorrectly coded as receiving hospice care on quarterly MDS assessments, despite being discharged from hospice and palliative care services. This error was due to a lack of communication to the MDS Coordinator, who relied on nurses and resident charts for information. The Administrator and Director of Nursing were unaware of the discharge, highlighting a gap in communication and documentation. Resident #40's MDS assessment failed to reflect a history of falls with major injury, despite being readmitted to the facility after a fall resulting in a neck fracture. The MDS Coordinator admitted to oversight and human error in not checking the correct boxes. Similarly, Resident #50's discharge was inaccurately coded as unplanned, although it was a planned discharge with home health referrals and follow-up appointments arranged. The MDS Coordinator acknowledged this as another oversight, and the Director of Nursing confirmed the discharge should have been coded as planned.
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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 Lenoir
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hibriten Mountain Nursing And Rehabilitation | 3.5 mi | ★★★★★ | 14 | 0 |
| Lenoir Health And Rehabilitation Center | 6.1 mi | ★★★★★ | 14 | 0 |
| Hickory Falls Health And Rehabilitation | 6.2 mi | ★★★★★ | 0 | 0 |
| Autumn Care Of Drexel | 7.6 mi | ★★★★★ | 3 | 0 |
| College Pines Health And Rehabilitation | 7.7 mi | ★★★★★ | 2 | 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.