Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 The Greens At Gastonia during CMS and state inspections, most recent first.
Failure to Implement Abdominal Wound Care Orders: A resident admitted after abdominal surgery with DM had wound care orders in the hospital discharge summary and later from the Wound Care NP, but the orders were not entered into the TAR right away and wound care was not documented for several days. The resident reported that after soiling the dressings, a nurse refused to change them, and she cleaned the incisions herself and left them open to air before wound care was finally started.
Hand hygiene was not followed during sacral wound care for a resident with a sacral pressure ulcer on EBP. After cleaning the wound, a Wound Care Nurse kept the same gloves on and applied calcium alginate and a bordered gauze dressing without doffing gloves, sanitizing hands, or donning new gloves. The Wound Care Nurse later acknowledged the missed step, and the DON stated the nurse was expected to follow the facility hand hygiene policy.
A resident with severe cognitive impairment and hemiparesis was allowed to smoke unsupervised after an assessment determined she could do so safely, despite no improvement in her condition. While unsupervised, she caught her hair on fire, resulting in burns. Later, the same resident exited the building in her wheelchair without staff knowledge and was found in the parking lot heading toward a main road, stating she wanted to smoke. The facility had not identified her as a wander or elopement risk, and no interventions were in place to prevent her from leaving unsupervised.
A resident who was cognitively intact entrusted a hospitality aide with a debit card to purchase cigarettes, but the aide used the card without authorization for personal purchases and cash withdrawals totaling over $600. The unauthorized transactions were discovered when the resident's card was declined, and the aide later admitted to the misuse. Facility staff confirmed the resident did not authorize these charges, and there was no reimbursement plan in place at the time of the investigation.
A resident with chronic conditions was readmitted with a new order for PRN Tramadol 50 mg, but the prescription was not sent to the pharmacy, resulting in the continued administration of a discontinued 75 mg dose by multiple nurses over several weeks. Staff interviews revealed confusion about procedures for sending new narcotic prescriptions and returning discontinued medications, and the pharmacy confirmed they never received the new order.
A resident with severe cognitive impairment and high ADL needs was left without a functioning call light due to tampering, leaving her unable to call staff for assistance and feeling helpless. Staff and family discovered the unplugged call light with a temperature probe inserted, but could not determine who was responsible or how long the issue persisted.
A resident assessed as clinically unsafe to self-administer medications was found with both a prescribed and a non-prescribed inhaler in their room, which staff were unaware of. The resident reported using both inhalers, despite no physician order allowing self-administration or storage of these medications in the room. Staff interviews confirmed that medications should not have been accessible to the resident under these circumstances.
A dependent resident with severe cognitive impairment and multiple medical conditions was found without a working call light after it was discovered unplugged and tampered with, preventing the resident from calling for assistance. Staff were unable to determine how long the call light had been nonfunctional or who was responsible for the tampering, resulting in the resident being left without a means to request help.
Two residents had discrepancies between their documented code status in care plans and their current DNR orders, with care plans listing them as full code despite signed DNR forms and physician orders indicating otherwise. Staff interviews revealed confusion and lack of clarity regarding responsibility for updating advance directives, with both Social Services and MDS staff unsure of their roles, leading to outdated and inconsistent documentation.
Two residents with multiple medical conditions had their Care Area Assessments (CAAs) incompletely documented, with the MDS Coordinator failing to provide required analysis for most of the triggered care areas in their admission MDS assessments. This resulted in missing information on the nature, causes, and contributing factors for several important care areas, as confirmed by staff interviews.
Surveyors found that three residents' MDS assessments were inaccurately coded: one resident's nightly CPAP use was not documented, another was incorrectly marked as receiving antibiotics despite not receiving any during the assessment period, and a third with a PASRR level II determination was not properly coded due to staff unfamiliarity with PASRR expiration. These errors were confirmed through record review and staff interviews.
A resident with schizoaffective disorder remained in the facility after their initial 30-day PASRR level II expired, but no updated PASRR level II was obtained. The Social Services Director, responsible for monitoring PASRRs, acknowledged that the need for a new screening was overlooked.
A resident with multiple chronic conditions did not receive scheduled doses of pregabalin as ordered, despite staff documenting administration on the MAR, and was also given incorrect doses of tramadol HCL due to staff administering the available 75mg tablets instead of the prescribed 50mg. Staff interviews and record reviews confirmed these medication administration and documentation errors.
A resident with chronic pain did not receive multiple scheduled doses of long-acting morphine due to the medication not being available at the facility. Nursing staff did not consistently reorder the medication in advance, resulting in missed doses and reliance on PRN pain medication instead. The resident, pharmacy consultant, and medical director all confirmed the medication was not available as ordered, and facility leadership was unaware of the issue until after the fact.
Two residents were found with prescription and over-the-counter medicated creams and treatments at their bedsides without physician orders or assessments for self-administration. Staff, including nurses and medication aides, were unaware of the presence or use of these medications, and there was no documentation supporting resident possession or self-administration. Facility leadership confirmed that medications should not be accessible to residents without proper authorization and assessment.
Staff documented the administration of a controlled medication for a resident on the MAR, but failed to record it on the controlled medication declining sheets and did not actually administer the medication. Interviews with nursing staff and a medication aide confirmed the medication was not given, despite being signed for, resulting in incomplete and inaccurate medical records.
A unit manager did not perform hand hygiene after removing gloves and before donning new gloves while providing suprapubic catheter care to a resident, contrary to facility policy. The lapse was observed during care of a resident with a reddened catheter site, and the staff member later acknowledged the oversight.
The facility failed to complete and document weekly skin assessments for a resident with stage IV and stage III pressure ulcers, despite physician orders. Multiple instances of missing documentation were found, and attempts to interview responsible nurses were largely unsuccessful. The interim DON and MD were unaware of the issue.
A resident with multiple diagnoses, including dysphagia and a gastrostomy tube, was fed by a nurse aide who was unaware of the resident's NPO status. The error was discovered by a nurse administering medications, and the resident was sent to the hospital for evaluation. Staff interviews revealed that the aide did not check the meal ticket and was unaware of the resident's diet order.
A resident who had all her teeth extracted remained on a regular diet, causing difficulty in eating. The facility staff, including the RD, DM, and nursing staff, were unaware of the need for a diet change, leading to the resident frequently requesting soft foods and her family having to provide alternative food.
The facility failed to follow hand hygiene protocols during wound care and gastrostomy tube site care for a resident. Both the Treatment Nurse and Unit Manager did not sanitize their hands after removing gloves and before donning new gloves, despite knowing the correct procedures.
The facility failed to maintain accurate TAR for skin assessments for a resident. The TAR showed incomplete documentation and missing diagram sheets for specified dates, with the nurse unable to recall why the forms were not completed. The interim DON expected proper documentation, but attempts to contact the previous DON were unsuccessful.
Failure to Implement Abdominal Wound Care Orders
Penalty
Summary
The facility failed to clarify and implement wound care orders for a resident who was admitted after laparoscopic incarcerated ventral hernia repair and had diabetes mellitus. The hospital discharge summary included an order to wash the surgical incisions daily with soap and water using a fresh washcloth each time. On admission, the resident was documented as having three abdominal surgical incisions, and the physician’s admission note the next day described intact dressings to the right upper abdomen, lower mid-abdomen, and right lower abdomen. The resident was seen by the Wound Care NP four days after admission, and new orders were written to clean the abdominal surgical incisions with wound cleanser and apply a bordered dressing daily. However, the Treatment Administration Record did not show those wound care orders entered until two days later. The record review showed that no wound care was documented on the TAR until that later date, and the wound care treatment then continued daily until it was discontinued by the Wound Care NP weeks later. The resident stated that her abdominal dressing changes were not done for about a week after admission. She reported that after an incontinent episode the day after admission, she asked a nurse to change the dressings and the nurse refused, after which she removed the dressings herself, cleaned the incisions with soap and water, and left them open to air for several days before receiving wound care. The DON confirmed that the discharge summary wound care orders and the Wound Care NP’s orders were not entered into the computer system when written and stated that nursing staff would not know to complete the wound care unless the orders were entered.
Hand Hygiene Not Followed During Wound Care
Penalty
Summary
The facility failed to follow its Infection Control policies and procedures for hand hygiene during sacral wound care for a resident with a sacral pressure ulcer who was on Enhanced Barrier Precautions. During the observation, the Wound Care Nurse cleaned the overbed table, prepared wound care supplies, washed her hands, and donned clean gloves and a gown. She removed the old dressing, used wound cleanser to loosen the dressing edges, discarded the dressing, then doffed her gloves, washed her hands with soap and water, and donned clean gloves again. After the Wound Care NP measured the wound and debrided it with the resident's permission, the Wound Care Nurse cleaned the wound with wound cleanser and gauze. After cleaning the wound, she did not doff her gloves, sanitize her hands, or don new gloves before cutting calcium alginate and placing it on the wound, then covering it with a bordered gauze dressing. In interview, the Wound Care Nurse stated she should have doffed her gloves, sanitized her hands, and donned clean gloves before applying the treatment. The DON stated it was her expectation that the Wound Care Nurse follow the Hand Hygiene policy and procedure and doff gloves, sanitize hands, and don clean gloves after cleaning the wound and before applying treatment.
Failure to Supervise Cognitively Impaired Smoker Leads to Burns and Unsupervised Exit
Penalty
Summary
A deficiency occurred when a facility failed to provide effective supervision and accident prevention for a resident with severe cognitive impairment, hemiparesis, and a history of smoking. The resident had previously been assessed as requiring supervision while smoking due to limited range of motion, weak grasp, and unclear speech, but a subsequent assessment determined the resident could smoke unsupervised. This change was made despite no improvements in the resident's cognition or functional abilities. As a result, the resident was allowed to smoke unsupervised in the designated area. While smoking unsupervised, the resident caught her hair on fire, resulting in singed hair, a blistered eyelid, and mild burns to her hand and behind her ear. The incident was observed by staff after the fact, and the resident required topical treatment for her injuries. The assessment following the incident determined the resident was unable to safely light or hold smoking materials and could not call for emergency assistance, leading to a change back to supervised smoking. Additionally, the resident exited the facility unsupervised in her wheelchair, traveling through the parking lot toward a main road without staff knowledge. She was found by staff after a visitor alerted them, and she stated she was attempting to go smoke. The resident did not have smoking materials in her possession and denied trying to leave the facility, indicating she was seeking staff attention to be taken to smoke. The facility had not identified her as a wander or elopement risk, and there were no interventions in place to prevent her from leaving the building unsupervised.
Removal Plan
- The facility initiated a therapy referral for positioning while in wheelchair for Resident #3.
- Therapy followed resident with plan of treatment.
- The Responsible Person was notified of the incident, follow up treatment plan, and change in supervision with smoking with resident's consent.
- Resident's smoking assessment was re-evaluated by charge nurse and resident was notified that she was now a supervised smoker; resident verbalized understanding and agreement.
- Staff notified of change in supervision with smoking and residents' apparatus by the Director of Nursing.
- Director of Nursing updated smoking binder that is in nurse's stations, front office, and therapy department.
- The facility ordered resident #3 a smoking adaptive apparatus to hold her cigarette.
- Being a supervised smoker, staff will light Resident #3's cigarettes.
- Resident's care plan/kardex updated to reflect that her hair is pulled back per resident acceptance.
- Smoking apron available per resident's acceptance.
- Facility will honor resident's rights and preferences while providing supervision to promote safety.
- The Unit Manager assessed resident for wandering tendencies and determined resident did not present as a risk; resident was provided with a cigarette in designated smoking area.
- Residents' preference for smoking times to be honored per request with staff supervision.
- Facility made aware that resident did not prefer the smoking apparatus and discontinued the apparatus; resident can safely hold a cigarette with supervision.
- Skin assessments were completed on all residents who smoke to ensure no burns identified from smoking; assessments completed by licensed nurses.
- The Director of Nursing and licensed nurses re-assessed all residents who wish to smoke for need of supervision and/or adaptive equipment; no additional residents were noted.
- The Director of Nursing and licensed nurses reviewed care plans and Kardex's for all supervised and unsupervised smokers to ensure up to date and accurate with no additional concerns noted.
- The charge nurse completed a resident headcount to ensure that all residents were accounted for.
Failure to Protect Resident from Misappropriation of Property
Penalty
Summary
A resident who was cognitively intact and had been admitted to the facility entrusted a hospitality aide with his debit card to purchase cigarettes, a practice that had occurred regularly for several months. On one occasion, the aide used the resident's debit card without authorization to make multiple purchases at various stores and to withdraw cash from an ATM, resulting in approximately $628.75 in unauthorized transactions. The resident was unaware of these additional charges and only discovered the missing funds when attempting to make a payment on his account, at which point the card was declined. Upon investigation, it was revealed that the hospitality aide admitted to using the resident's debit card for personal purchases and cash withdrawal without the resident's permission. The incident was reported to law enforcement, and the aide was subsequently terminated. The resident expressed sadness and disappointment, stating that he had trusted the aide due to her previous kindness and care. Interviews with facility staff, including the former business office manager and former administrator, confirmed that the resident did not authorize the additional transactions and that there was no plan in place to reimburse the resident for the stolen funds at the time of their departure from the facility. The resident had not been reimbursed for the stolen money and did not understand the delay in repayment. The facility failed to protect the resident from misappropriation of property, as required by regulation.
Failure to Provide Correct Dosage of PRN Pain Medication Due to Pharmacy Communication Breakdown
Penalty
Summary
A deficiency occurred when a resident with multiple chronic conditions, including congestive heart failure and diabetes with neuropathy, was readmitted from the hospital with a new physician order for as-needed Tramadol HCL 50 mg for pain. Despite the new order being entered into the electronic medical record, the prescription for the new dosage was not sent to the pharmacy, resulting in the pharmacy not dispensing the correct medication. As a result, the facility continued to have the discontinued 75 mg dose available in the medication cart, and the resident received the incorrect dosage on multiple occasions over two months. Multiple nursing staff, including agency nurses, administered the discontinued 75 mg dose instead of the newly ordered 50 mg dose, as documented on the controlled medication declining sheet and confirmed in staff interviews. Several nurses were unaware of the need to send a new prescription to the pharmacy when a narcotic dosage changed, and some had not received education on returning discontinued narcotics. The medication cart was observed to contain only the 75 mg blister packs, and staff relied on what was available in the cart, assuming it matched the current order. Interviews with the pharmacist, medical director, and facility leadership confirmed that the pharmacy had not received a prescription for the new dose and that the expectation was for discontinued medications to be returned and new prescriptions to be sent for dose changes. The failure to communicate the new order to the pharmacy and to remove the discontinued medication from the cart led to the resident receiving the wrong dose of pain medication on several occasions.
Failure to Ensure Functioning Call Light for Dependent Resident
Penalty
Summary
A dependent resident with severe cognitive impairment, who required substantial to maximal assistance for all activities of daily living except eating, was found to have a non-functioning call light. The resident was unable to call staff for assistance due to the call light being unplugged and a temperature probe inserted into the plug, preventing it from alarming. This issue was discovered by the resident's family member during a visit, who observed the unplugged call light and reported the incident to facility administration. The resident expressed feelings of helplessness due to being unable to call for assistance when needed. Staff interviews confirmed that the call light was not working when checked during morning rounds, and a nurse aide provided a replacement call light from an adjacent empty bed after noticing the issue. Multiple staff members, including nurse aides and a unit manager, acknowledged the tampering of the call light but were unable to determine when or by whom it had been done. The facility's expectation, as stated by the Director of Nursing and Administrator, was that all residents should have functioning call lights to request assistance.
Failure to Prevent Unsafe Self-Administration of Medication
Penalty
Summary
A resident with chronic obstructive pulmonary disease (COPD) and acute respiratory failure was assessed by the interdisciplinary team and determined to be clinically unsafe to self-administer medications. Despite this assessment, the resident was found to have both a Symbicort inhaler and an albuterol inhaler stored in the drawer of his bedside table. The resident reported that some nursing staff were aware of the Symbicort inhaler being kept in his room, but none of the staff were aware of the albuterol inhaler. The resident also stated he had used both inhalers while in the facility, although he could not recall the specific dates of use. Review of the resident's physician orders confirmed that only the Symbicort inhaler was prescribed, with no order for albuterol or for any medications to be kept in the resident's room for self-administration. Nursing staff interviewed were unaware of the presence of the inhalers and stated that medications should not be kept in a resident's room unless the resident was assessed as safe to self-medicate and had a physician's order. Facility leadership confirmed that medications should be removed if found in the room of a resident not approved for self-administration.
Failure to Ensure Functioning Call Light for Dependent Resident
Penalty
Summary
A deficiency occurred when a dependent resident with severe cognitive impairment and multiple medical conditions, including diabetes, hypertension, and dementia, was found without a functioning call light. The resident required substantial assistance with activities of daily living and was always incontinent of bowel and bladder. On the day of the incident, a family member discovered the call light unplugged, with a temperature probe cover placed in the plug to prevent it from alarming, rendering the resident unable to call for assistance. Staff interviews confirmed that the call light had been tampered with and was not operational when discovered. The nurse aide assigned to the resident noticed the call light was unplugged during morning rounds and, believing maintenance was working on it, provided a call light from an adjacent empty bed after confirming it worked. However, it was not clear how long the original call light had been nonfunctional prior to discovery. Other staff members recalled the resident was generally able to use her call light, but on this occasion, the tampering prevented its use. The issue was reported by the family member to the facility's former Administrator, who initiated a grievance. Despite efforts, the facility was unable to determine who was responsible for tampering with the call light. Interviews with staff and management confirmed the expectation that all residents should have access to functioning call lights, but this expectation was not met in this instance, resulting in the resident being unable to summon assistance as needed.
Failure to Maintain Accurate Advance Directives in Medical Records
Penalty
Summary
The facility failed to maintain accurate and up-to-date advance directives in the medical records for two residents. For one resident, the care plan indicated a full code status, while a physician's order and a signed DNR form in the advance directive binder reflected a Do Not Resuscitate (DNR) status. Staff interviews revealed confusion regarding the resident's current code status, with the nurse relying on the care plan, which was outdated, and the Social Services Director unaware of the change due to being on leave. The responsibility for updating the care plan was unclear among staff, with the Social Worker, MDS Coordinator, and Unit Manager each providing different accounts of who should update the documentation. For another resident, the care plan also indicated a full code status, despite a recent physician's order and signed DNR form indicating a change to DNR. The Social Services Director acknowledged that the code status must have changed after a hospital stay and was not updated in the care plan. The Social Services Assistant, who attended the care plan meeting where the change was discussed, did not update the care plan and was unsure of her responsibilities, as she was still in training. The Administrator confirmed that both Social Workers and the MDS Coordinator were responsible for updating care plans to reflect changes in advance directives.
Incomplete Care Area Assessments for Two Residents
Penalty
Summary
The facility failed to complete Care Area Assessments (CAAs) comprehensively for two residents upon admission. For one resident with diagnoses including heart failure, diabetes mellitus, and atrial fibrillation, the admission Minimum Data Set (MDS) assessment triggered seven care areas, but analysis of findings was only provided for nutritional status. The remaining six triggered areas—communication, functional abilities, urinary incontinence and indwelling catheter, falls, dehydration/fluid maintenance, and pressure ulcer/injury—lacked documentation describing the nature of the problems, root causes, contributing factors, risk factors, and reasons for care planning. Similarly, another resident with non-Alzheimer's dementia, anxiety disorder, and depression had nine care areas triggered, but only the nutritional status area was analyzed, leaving eight areas without comprehensive assessment. Interviews with the MDS Coordinator confirmed that the required analyses for the triggered care areas were not completed before submission of the MDS assessments for both residents. The MDS Coordinator acknowledged responsibility for the oversight and could not explain how the error occurred. The DON and Administrator both stated their expectations that all CAAs be individualized and completed comprehensively prior to submission, which was not done in these cases.
Inaccurate MDS Coding for Respiratory Care, Antibiotic Use, and PASRR Status
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for three residents in the areas of respiratory care, antibiotic use, and PASRR status. For one resident with a diagnosis of sleep apnea and a physician order for nightly CPAP use, the MDS assessment did not reflect the use of a CPAP device, despite documentation in the Medication Administration Record (MAR) and confirmation from nursing staff that the device was applied nightly. The MDS nurse responsible for coding acknowledged that the information was missed during the assessment process. Another resident was incorrectly coded as receiving antibiotics on the MDS assessment, even though the MAR showed no antibiotics were administered during the assessment period following the resident's return from the hospital. The MDS coordinator confirmed the error after reviewing the records. Additionally, a third resident with schizoaffective disorder and a PASRR level II determination was not coded appropriately on the admission MDS. The MDS nurse responsible was unfamiliar with the expiration of the PASRR level II and mistakenly coded it as a level I, resulting in inaccurate documentation.
Failure to Obtain Updated PASRR Level II for Resident with Expired Screening
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) level II was obtained for a resident with schizoaffective disorder after the initial 30-day PASRR level II expired. Record review showed that the resident was admitted with a 30-day PASRR level II, which expired, but no subsequent level II PASRR was completed while the resident remained in the facility. Interviews with the Social Services Director and the Administrator confirmed that the responsibility for monitoring and obtaining PASRR level II screenings was assigned to the Social Services Director, who acknowledged that the need for a new PASRR was overlooked after the initial one expired.
Failure to Administer and Document Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for one resident. The resident, who had diagnoses including chronic diastolic congestive heart failure, Type 2 diabetes mellitus with diabetic polyneuropathy, and intervertebral disc degeneration, was cognitively intact and had physician orders for pregabalin 200mg twice daily for neuropathy and tramadol HCL 50mg every six hours as needed for pain. Review of medication administration records and controlled medication declining sheets revealed multiple instances where pregabalin was not administered as scheduled, despite being documented as given on the Medication Administration Record (MAR). Staff interviews confirmed that the medication was not actually administered on those occasions, and the Director of Nursing (DON) and other staff acknowledged that discrepancies between the MAR and controlled medication sheets, along with correct narcotic counts, indicated the medication had not been given. Additionally, the resident received incorrect doses of tramadol HCL on several occasions. Although the physician's order specified 50mg, the controlled medication declining sheets and staff interviews confirmed that 75mg doses were administered multiple times. Several nurses and medication aides stated that they administered the 75mg dose because that was what was available in the blister pack, and they did not verify the correct dose against the physician's order. The DON confirmed that the blister packs contained 75mg tablets, not the ordered 50mg dose. Both the Medical Director and the facility Administrator stated that they expected medications to be administered as ordered and for documentation to be accurate and honest. The Medical Director specifically noted that missing doses of pregabalin could cause increased pain or discomfort for the resident. The deficiency was identified through review of records, interviews with staff, and direct confirmation of medication administration errors and documentation inaccuracies.
Failure to Prevent Significant Medication Error Due to Unavailable Scheduled Pain Medication
Penalty
Summary
A significant medication error occurred when a resident with chronic pancreatitis, severe chronic kidney disease, and chronic pain did not receive seven scheduled doses of a long-acting pain medication (MS Contin ER 30 mg) as ordered by the physician. The medication was prescribed to be administered three times daily for pain management. The missed doses were due to the medication not being available at the facility on multiple occasions across March and April, as documented in the Medication Administration Record and nursing notes. Nursing staff and medication aides reported that the medication was not available to administer at the scheduled times, and in several instances, the pharmacy had not yet delivered the medication. Staff interviews revealed that the process for reordering medications was not consistently followed, with some staff not contacting the pharmacy or physician promptly when the medication supply was low or depleted. Instead, staff often relied on administering the resident's as-needed (PRN) pain medication in place of the scheduled long-acting medication, which was not equivalent in duration or frequency. The resident was aware of the missed doses and expressed confusion and concern about the facility's inability to maintain an adequate supply of his prescribed pain medication, especially given his ongoing need for pain control. The pharmacy consultant and medical director both confirmed that medications should be reordered before the last dose is given, and the medical director considered the missed doses a significant medication error. The DON and administrator were not aware of the missed doses until after the fact and acknowledged that medications should be available as ordered.
Failure to Secure and Monitor Resident Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure proper storage and labeling of drugs and biologicals for two residents who had medicated creams and over-the-counter treatments at their bedsides. One resident with dementia, gout, and peripheral vascular disease was observed with a lidded pump container of prescription topical medicated cream for foot pain on his bedside table. The resident stated he brought the cream from home and applied it as needed, but there was no physician order for the medication, and staff were unaware of its presence. The resident was not assessed as able to self-administer medications, and the cream had an expired date. Multiple staff members, including a medication aide and a nurse, reported not noticing the cream in the resident's room during their medication administration duties. Another resident, who was cognitively intact but required extensive assistance with activities of daily living, was found with several over-the-counter medicated products on her bedside tray, including rubbing alcohol, medicated gels, cortisone cream, vapor rub, and oral pain relief gel. The resident reported using these products for various ailments and stated she obtained them from family and friends. There was no documentation of a physician order or an assessment for self-administration of medications or treatments in her medical record. Staff members, including nurses and medication aides, were unaware that the resident possessed or self-administered these products and had not paid close attention to the items on her bedside tray. Interviews with the Medical Director, Director of Nursing, and Administrator confirmed that residents should not have medications or treatments in their possession or self-administer without a physician order and proper assessment. The staff's lack of awareness and failure to observe and remove unauthorized medications from residents' rooms contributed to the deficiency in ensuring drugs and biologicals were properly labeled and securely stored according to professional standards.
Failure to Accurately Document and Administer Controlled Medication
Penalty
Summary
Staff failed to maintain a complete and accurate medical record for a resident prescribed pregabalin, a controlled substance, for neuropathy and pain. On multiple occasions, the Medication Administration Record (MAR) indicated that the medication was administered, with signatures from various nurses and a medication aide. However, corresponding entries were missing from the controlled medication declining sheets, and staff interviews confirmed that the medication was not actually given on those dates, despite being signed as administered on the MAR. The controlled medication count was also correct, further indicating that the doses were not dispensed. Interviews with the involved staff, including nurses and a medication aide, revealed that they did not administer the medication even though they had signed for it on the MAR. The Director of Nursing and Medical Director both stated that accurate and honest documentation is expected on both the MAR and the narcotic record. The administrator also confirmed the expectation that medications are administered as ordered and documented accurately. The failure to document and administer the medication as ordered resulted in incomplete and inaccurate medical records for the resident.
Failure to Perform Hand Hygiene Between Glove Changes During Catheter Care
Penalty
Summary
Unit Manager #2 failed to follow the facility's Handwashing/Hand Hygiene policy while providing suprapubic catheter care to Resident #83. During the procedure, after cleaning the catheter site and removing her gloves, Unit Manager #2 did not perform hand hygiene before donning a new pair of gloves to apply a dressing. This action was observed directly by surveyors, and the facility's policy specifically requires hand hygiene after glove removal and before donning clean gloves for aseptic tasks. Resident #83 had a suprapubic catheter with a slightly reddened area at the insertion site, which was being cleaned and dressed by Unit Manager #2. The failure to perform hand hygiene occurred after the initial cleaning and before the application of a new dressing. Both the Infection Preventionist and the Director of Nursing confirmed in interviews that the expected procedure was not followed, and Unit Manager #2 acknowledged the oversight during her interview.
Failure to Document Weekly Skin Assessments for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to complete and document weekly skin assessments as ordered by the physician for a resident with a known stage IV pressure ulcer to the sacrum and a known stage III pressure ulcer to the right heel. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, had physician orders for weekly skin checks every Thursday. However, reviews of the resident's Medication Administration Record (MAR) and electronic medical record (EMR) revealed multiple instances where these assessments were not documented, specifically on 02/18/24, 03/07/24, 03/14/24, 04/04/24, and 04/19/24. Attempts to interview the nurses responsible for these shifts were largely unsuccessful, with some nurses unable to recall why the assessments were not completed and documented. The interim Director of Nursing (DON) and the oncoming DON confirmed that their expectation was for weekly skin assessments to be completed and documented in the EMR. The interim DON was unsure if the system failed to flag the assessments or if the nurses omitted them. The Medical Director (MD) was also unaware that the weekly skin assessments were not being completed as ordered. Despite efforts to promote wound healing through nutritional supplements and therapy, the lack of documented skin assessments indicated a failure to follow physician orders and ensure proper monitoring of the resident's condition.
Resident Fed Despite NPO Order
Penalty
Summary
The facility failed to prevent a resident from being fed despite having a diet order of nothing by mouth (NPO) with continuous enteral tube feeding. Resident #3, who was admitted with multiple diagnoses including cerebrovascular accident, hemiplegia, aphasia, dysphagia, and gastrostomy tube for feedings, was fed by a nurse aide who was unaware of the resident's NPO status. The resident received two spoonsful of grits, one spoonful of eggs, and approximately two ounces of orange juice before the error was discovered by a nurse administering morning medications. The nurse aide, who was assigned to Resident #3 for the first time, did not check the name on the meal ticket and was unaware of the resident's NPO status. The error was identified when Nurse #4 entered the room to provide medications and found the aide feeding the resident. The tray, which belonged to another resident, was subsequently removed by the Medical Records/Central Supply representative during her rounds. Despite the incident, the resident did not exhibit any immediate adverse effects and was sent to the hospital for evaluation at the request of the family. Interviews with staff revealed that the facility had protocols in place to prevent such incidents, including documentation in the care tracker and regular rounds by administrative staff. However, the nurse aide's lack of awareness and failure to check the meal ticket led to the resident being fed. The incident was reported to the interim Director of Nursing, and the facility conducted education sessions with staff to reinforce the importance of adhering to diet orders and checking meal tickets before feeding residents.
Failure to Provide Appropriate Diet for Resident with Dental Extractions
Penalty
Summary
The facility failed to provide food in a form designed to meet the individual needs of a resident who had all her teeth extracted. Despite the dental extraction report and the resident's expressed difficulty in adjusting to her new diet, the resident remained on a regular diet. The Registered Dietitian (RD) and Dietary Manager (DM) were unaware of the need for a diet change, and the nursing staff did not communicate the necessary dietary adjustments. The resident's family member observed the resident struggling to eat a fried pork chop and had to provide alternative food from home. The resident frequently requested soft foods like pudding and applesauce, indicating her difficulty with the regular diet. Interviews with staff revealed a lack of communication and documentation regarding the resident's dietary needs after her teeth were extracted. The previous RD was unaware of the diet change, and the current RD, who started after the resident's discharge, confirmed that no dietary documentation was found about the teeth removal. The DM and nursing staff also did not receive or act on any information about the necessary diet change. The interim Director of Nursing (DON) stated that her expectation would have been to assess the resident's tolerance to the regular diet and follow recommendations, but this did not occur. Attempts to contact the previous DON were unsuccessful.
Failure to Follow Hand Hygiene Protocol During Wound and Gastrostomy Tube Care
Penalty
Summary
The facility failed to implement their Infection Control Policy for hand hygiene/handwashing during wound care and gastrostomy tube site care for Resident #3. The Treatment Nurse did not sanitize her hands after removing gloves and before donning new gloves while providing wound care to Resident #3's right heel and sacral wound. Despite knowing the proper procedure, the Treatment Nurse admitted to forgetting to sanitize her hands at the appropriate times. The Infection Preventionist and the interim Director of Nursing confirmed that the Treatment Nurse was aware of the correct hand hygiene protocol but did not follow it during the observed care session. Similarly, Unit Manager #1 did not sanitize her hands after doffing gloves and before donning new gloves while providing gastrostomy tube site care for Resident #3. Unit Manager #1 also acknowledged that she knew the correct procedure but forgot to perform hand hygiene as required. The Infection Preventionist and the interim Director of Nursing confirmed that Unit Manager #1 was knowledgeable about the proper hand hygiene practices but failed to adhere to them during the observed care session.
Failure to Maintain Accurate Skin Assessment Records
Penalty
Summary
The facility failed to maintain an accurate Treatment Assessment Record (TAR) for skin assessments for one resident. Resident #2, who was cognitively intact and required assistance with various activities, had a physician's order for weekly skin assessments to be completed every Wednesday on the day shift. However, the TAR for February 2024 showed that the skin assessment on 2/7/24 was completed, but the nurse who initialed/signed the TAR could not be identified. Additionally, Nurse #3 signed off on the skin assessments for 2/14/24 and 2/21/24, but there were no corresponding documentation diagram sheets for these dates, indicating a lack of record for potential skin concerns discovered during the assessments. During interviews, Nurse #3 confirmed working with Resident #2 on the specified dates and usually completing the documentation diagram forms during the assessments but could not recall why the forms were not completed on those days. The interim Director of Nursing (DON) stated that her expectation was for skin assessment documentation to be completed and documented in the medical record. Attempts to contact the previous DON were unsuccessful, leaving the issue unresolved at the time of the report.
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What surveyors actually found near you
We read the 208 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gastonia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Peak Resources - Gastonia | 0.3 mi | ★★★★★ | 2 | 0 |
| Courtland Terrace | 0.6 mi | ★★★★★ | 4 | 0 |
| Gastonia Health & Rehab Center | 1.5 mi | ★★★★★ | 4 | 0 |
| Juniper Gardens Center For Nursing And Rehabilitat | 2.3 mi | ★★★★★ | 4 | 0 |
| Accordius Health At Gastonia | 3.4 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.