Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Wesley Pines Retirement Community during CMS and state inspections, most recent first.
A resident with chronic constipation and gastroparesis had a provider order for Linzess 290 mcg, one capsule PO daily, but nurses and medication aides instead honored the resident’s request to take three capsules twice weekly. Staff routinely placed the daily capsule into a bedside bottle and, on designated days, removed three accumulated capsules and left them in a med cup for the resident to self-administer, while continuing to document the drug as given daily per order. Multiple nurses and med aides acknowledged they knew this practice did not match the written order yet did not notify the MD, NP, or DON of the resident’s ongoing refusal of the ordered regimen or the altered dosing schedule, and leadership and the NP reported they were unaware of the deviation until it was discovered during survey.
A resident with chronic constipation, paraplegia, and significant contractures, who was assessed as unable to self-administer medications, was ordered Linzess 290 mcg PO daily along with Magnesium Citrate twice weekly and PRN Simethicone. Instead of administering Linzess once daily and observing ingestion, multiple nurses and medication aides routinely placed each day’s Linzess capsule into an empty Simethicone bottle kept at the bedside, then removed three capsules on certain days and left them in a medication cup for the resident to take later according to her personal bowel regimen. The resident reported and demonstrated how she self-administered the three capsules using her mouth, and surveyors observed a cup with three capsules on her bed and found a Linzess capsule stored in the Simethicone-labeled bottle. Staff interviews confirmed this practice had been ongoing for an extended period, that the MAR was signed as if Linzess had been given daily as ordered, and that there was no provider order authorizing the altered dosing schedule or self-administration.
A resident had multiple medications, including Linzess, Biotin, Simethicone, and Clobetasol spray, stored on a bedside table, with some products expired and a Linzess capsule placed in a bottle labeled for Simethicone. Several nurses and medication aides acknowledged routinely placing the Linzess capsule into the bedside bottle at the resident’s request, despite knowing medications should not be stored in resident rooms. On a medication cart, an opened Novolog insulin pen lacked an open date, and an opened Lantus insulin pen remained available for use beyond the manufacturer’s 28-day discard period, even though staff reported they were responsible for checking carts daily and dating and discarding insulin pens appropriately.
Surveyors found that the outside cleaning area near the kitchen exit was unusable due to scattered debris, leaves, and multiple pieces of broken equipment, including a sauna tub, recliner, and metal racks, along with discarded items from maintenance, housekeeping, and dietary. The drain in this enclosed brick area was blocked by leaves and debris, preventing proper drainage when pressure hoses are used to clean kitchen items, wheelchairs, and beds. The DM and Maintenance Director acknowledged that Dietary, Housekeeping, and Maintenance were responsible for keeping this area clean and functional, but it remained cluttered and open to the elements, creating conditions available to pests and rodents.
A nurse failed to follow the facility’s nephrostomy tube care policy during a dressing change for a resident with a nephrostomy tube. After removing the old dressing, discarding soiled items, and removing her gloves, the nurse did not perform hand hygiene before donning sterile gloves and applying a new sterile dressing. Facility policy required handwashing after glove removal and before putting on sterile gloves. In subsequent interviews, the nurse acknowledged forgetting this step, and the IP, NP, and DON all confirmed that hand hygiene should have occurred between removal of the old dressing and application of the new dressing, with the NP noting this lapse put the resident at risk for bacterial introduction to the ostomy site.
A resident with advanced dementia, Parkinson’s disease, severe cognitive impairment, bowel incontinence, and a history of combative behavior during ADLs and prior falls was receiving incontinence care from a NA around mealtime. After an initial brief change during which the resident remained calm, the resident had another bowel movement. When the NA resumed care, the resident began hitting and pinching, prompting the NA to call for assistance via radio. While other staff were occupied, the NA was able to calm the resident and chose to resume incontinence care alone, despite the resident’s known behavioral history. During this care, with the resident turned away from the caregiver, the resident grabbed the metal bed frame, pulled himself off the bed, and fell, striking his head on a dresser and sustaining a forehead laceration that required treatment in the ED. Interviews and documentation confirmed the resident’s established pattern of aggression during care and that only one staff member was present at the time of the fall.
Staff failed to accurately document the administration and refusals of a constipation medication (Linzess) for a resident. Although the physician ordered a daily oral dose on specific days of the week, multiple nurses and medication aides admitted they charted the drug as given on days when it was not administered and was instead left or stored in the resident’s room. One nurse reported the resident had actually been taking three capsules only on two days per week for an extended period, contrary to the daily order. The NP and consulting pharmacist stated they rely on accurate MAR documentation, including refusals, for clinical decision-making, and the DON confirmed the MAR must be accurate at all times.
A staff member at a facility misappropriated a Duragesic pain patch from a resident with chronic back pain. The staff member, who was not scheduled to work, entered the resident's room and took the patch, leading to his own medical distress. The incident was reported to authorities, and the staff member was terminated. The resident did not report any pain or missing doses, and no adverse reactions were noted.
A dependent resident with cognitive impairment and hemiplegia did not receive a breakfast tray due to a nursing assistant forgetting to provide it. The resident required feeding assistance, and the tray was found in the kitchen warmer later in the morning. The DON confirmed the oversight, and the nursing assistant admitted to forgetting without asking for help.
Failure to Notify Provider of Resident’s Long-Term Deviation From Ordered Linzess Regimen
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician when nursing staff were not following a physician’s order for the administration of Linzess for a resident with chronic idiopathic constipation, gastroparesis, and rectal paralysis. The resident was cognitively intact and had a physician’s order for Linzess 290 mcg, one capsule by mouth daily. Review of the Medication Administration Record showed the medication was documented as given daily between 7:00 AM and 11:00 AM. However, during an observation of the resident’s room, three capsules were seen in a medication cup on the bed, and the resident reported these were her Linzess capsules, which she took to help move her bowels. Further interviews revealed that the resident did not take Linzess daily as ordered. Instead, nursing staff and medication aides placed the daily capsule into an empty medication bottle kept at the bedside. On specific days of the week, staff removed accumulated capsules from the bottle and placed three capsules into a medication cup for the resident to take together, in accordance with the resident’s request to take three capsules twice weekly rather than one capsule daily. Multiple staff members, including nurses and medication aides, acknowledged they had been following this practice for an extended period, knew it did not match the written physician order, and did not question or clarify the order. Staff interviews also showed that nurses and medication aides did not notify the physician, nurse practitioner, or DON that the resident was refusing the ordered daily dose and instead taking three capsules twice weekly. Nurses stated they understood they should have notified the provider about the resident’s refusal to take the medication as ordered but instead honored the resident’s request. Medication aides stated they believed it was the nurses’ responsibility to notify the provider and did not escalate the issue, despite recognizing that the administration method did not match the order. The DON and nurse practitioner both reported they had no prior knowledge of this altered dosing regimen and that they first became aware only after the DON was informed during the survey.
Failure to Follow Physician’s Order and Improper Medication Storage for Linzess
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for administration of Linzess for a resident with chronic idiopathic constipation, gastroparesis, paraplegia, and bilateral upper and lower extremity contractures. The resident had been assessed and determined not to be able to self-administer medications, and her care plan noted a history of refusing medications and care at times based on her personal routine. Despite this, nursing staff and medication aides routinely deviated from the written order for Linzess 290 mcg by mouth daily and instead accommodated the resident’s preferred regimen of taking three capsules twice weekly. The resident reported that staff left three Linzess capsules in a medication cup at her bedside on specific days for her to take later, and she demonstrated how she self-administered them using her mouth due to her hand contractures. Surveyor observations confirmed that a medication cup with three capsules was left on the resident’s bed while she sat in her wheelchair, and that she had significant bilateral hand and wrist contractures. The resident explained that staff placed her daily Linzess capsules into an empty medication bottle labeled for Simethicone kept on her bedside table, and on certain days staff removed three capsules from that bottle, placed them in a medication cup, and left them for her to take at a specific time. The DON later opened the bedside bottle labeled Simethicone and found a Linzess capsule inside. Review of the medical record showed no order from the resident’s gastroenterologist authorizing three Linzess capsules twice weekly, and the current physician’s orders specified a single 290 mcg capsule daily, including Saturdays, as well as Magnesium Citrate twice weekly and Simethicone as needed. Multiple staff interviews revealed that several nurses and medication aides had long been placing the Linzess capsules into the Simethicone bottle at the bedside and allowing the resident to take three capsules on designated days, rather than administering one capsule daily as ordered and observing ingestion. Nurse #1 admitted she had been placing the daily Linzess capsule into the bedside bottle for some time and acknowledged she should not have done so, especially given the resident did not have an order to self-administer medications. Medication Aides #1 and #2 stated they had been trained or told by other nurses to store the Linzess in the bedside bottle and to set out three capsules on the resident’s preferred days, and they acknowledged they did not question the discrepancy with the physician’s order. Another nurse confirmed that the resident had been taking three capsules on two days per week “for as long as she could remember” and that she knew this practice did not follow the written order. In contrast, one night-shift nurse reported she always stayed with the resident until she took the ordered Linzess and refused to leave capsules in the bedside bottle. The Nurse Practitioner and Consulting Pharmacist later confirmed that the dose the resident was actually taking exceeded the recommended maximum daily dose and that the medication should have been administered as prescribed, but there was no documentation in the record authorizing the altered regimen. The facility’s own documentation showed that the Medication Administration Record was being signed to indicate that Linzess was administered daily as ordered, even though staff interviews and resident statements showed that the medication was being stored in a mislabeled bottle at the bedside and taken in a different dose and schedule than prescribed. The resident’s self-administer medication assessment, updated shortly before the survey, continued to show she was not approved to self-administer medications, yet staff left medications in her room and did not consistently remain present to verify ingestion. The DON stated she had no knowledge that staff were leaving Linzess capsules in the Simethicone bottle or that the resident was taking three capsules twice weekly instead of one capsule daily, and she stated she expected staff to follow the five rights of medication administration and the physician’s orders as written.
Improper Medication Storage in Resident Room and Undated/Expired Insulin Pens on Medication Cart
Penalty
Summary
The deficiency involves failure to properly secure, label, and manage medications, including allowing medications to be stored in a resident’s room and maintaining expired medications. One cognitively intact resident had multiple medications stored on her bedside table, including a Simethicone bottle containing a Linzess capsule, two opened Biotin bottles (one with 1,000 mcg tablets and one with 5,000 mcg tablets expired in 04/2024), an opened Simethicone bottle expired in 01/24/2024, and a Clobetasol Propionate 0.05% spray. The Linzess capsule was being placed into an empty Simethicone bottle and left at the bedside, and the resident reported that nursing staff routinely left the daily Linzess capsule in that bottle on her bedside table. Multiple staff interviews confirmed that nurses and medication aides had been placing Linzess capsules into the empty Simethicone bottle and leaving it in the resident’s room at her request, despite knowing medications should not be stored in resident rooms. One nurse acknowledged she had left the Linzess capsule in the Simethicone bottle without realizing the bottle was labeled for a different medication. Two medication aides reported that, over their respective periods of employment, they had routinely placed Linzess capsules into the bottle with the pink cap kept at the bedside. Another nurse stated she was aware that Linzess capsules were being stored in the labeled Simethicone bottle in the resident’s room until administration on specific days and admitted she had placed the capsules there even though she knew residents were not to have medications at the bedside. A separate deficiency was identified on a medication cart, where an opened Novolog insulin pen had no documented open date and an opened Lantus insulin pen remained on the cart past its 11/24/25 expiration date, despite manufacturer instructions to discard 28 days after opening. Observation of the Lantana hall medication cart with a nurse revealed these issues, and the nurse stated that nurses and medication aides were responsible for checking carts daily for expired medications and ensuring insulin pens were dated when opened and discarded when expired. The DON stated her expectation that opened insulin pens be dated so staff could determine if they were still appropriate for use and that expired medications be removed from the cart.
Improper Disposal and Accumulation of Debris in Kitchen Outside Cleaning Area
Penalty
Summary
Surveyors identified a deficiency related to improper disposal and accumulation of garbage, refuse, and broken equipment in the outside cleaning area adjacent to the kitchen exit. During an observation of the kitchen’s outside cleaning area, located approximately four feet from the kitchen exit door, surveyors noted scattered debris and leaves, a broken sauna bathtub, a broken recliner, broken metal racks, and additional discarded items from maintenance, housekeeping, and kitchen departments. The amount of debris and discarded equipment rendered the enclosed brick cleaning area unusable, and leaves and debris were observed blocking the drain that is intended to allow water to drain when pressure hoses are used to clean kitchen items, wheelchairs, and beds. In interviews, the DM stated that Maintenance, Housekeeping, and Dietary were jointly responsible for keeping the outside cleaning area clean and functional, with trash removed so the drain could operate properly during cleaning activities. The DM acknowledged that the area could not currently be used because it was full of discarded broken equipment and debris, and the drain was blocked. A subsequent tour with the Maintenance Director and Administrator confirmed the presence of scattered debris, leaves, broken equipment, and discarded items from multiple departments around the sides and back of the enclosure, which was open to the elements and available to pests and rodents. The Administrator stated an expectation that Maintenance ensure the cleaning area was usable and free of debris and broken facility equipment.
Failure to Perform Hand Hygiene During Nephrostomy Tube Dressing Change
Penalty
Summary
The deficiency involves a failure to follow the facility’s infection prevention and control procedures during nephrostomy tube care for one resident. The facility’s policy for nephrostomy tube dressing changes specifies that after removing the soiled dressing and discarding it, staff must remove gloves, perform hand hygiene, and then don sterile gloves. During an observed nephrostomy tube dressing change for Resident #15, Nurse #3 donned a gown and gloves, removed the old dressing, discarded it, and cleansed the tubing and connection port with alcohol pads. After discarding the soiled items and removing her gloves, Nurse #3 immediately donned sterile gloves without washing her hands, and then applied a new sterile dressing to the nephrostomy tube insertion site. In interviews following the observation, Nurse #3 acknowledged that she should have washed her hands after removing the gloves used to change the old dressing and before putting on sterile gloves, stating she forgot but understood the importance of proper handwashing in infection control. The Infection Preventionist confirmed that hand hygiene should have been performed after removal of the old dressing and prior to donning sterile gloves and described hand hygiene as one of the most important steps in preventing infections. The NP caring for Resident #15 stated that the nurse should have washed her hands between handling the old dressing and applying the new dressing and explained that failure to follow this protocol put the resident at risk for introduction of bacteria to the ostomy site, which could cause infection. The DON stated that nurses changing any dressing should wash their hands before beginning, after removing the old dressing, before applying the new dressing, and after completing the dressing change, and confirmed that Nurse #3 did not follow this process.
Failure to Provide Safe Incontinence Care to Combative Resident Resulting in Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision was provided during incontinence care. The resident involved had multiple significant diagnoses, including Alzheimer’s disease, Parkinson’s disease, history of transient ischemic attack, chronic pain syndrome, essential hypertension, major depressive disorder, orthostatic hypotension, and non‑traumatic brain dysfunction. A quarterly MDS showed he had severely impaired cognitive skills, no recall ability, dependence on staff for all care, bowel incontinence, and an indwelling urinary catheter. He had a history of falls with minor injury and was receiving hospice care, as well as antibiotic, opioid, and antipsychotic medications. The resident’s care plan identified him as at risk for falls related to use of a mechanical lift and documented a history of recurrent falls. A separate behavior care plan identified him as at risk for behavior problems related to dementia and refusal of care or medications, with a history of anxiety, refusal of care, choking a staff member, restlessness, wandering, suicidal ideation, and combative behavior. Specific documented behaviors in the days prior to the incident included swinging his hands with balled fists, grabbing and squeezing staff hands, being combative during incontinence care, grabbing and digging his nails into staff skin, clenching arms and legs to prevent bathing, throwing offered items such as stuffed animals or washcloths to the floor, and hitting a nurse during a pain patch change. Interventions included assisting with self‑care needs, determining triggers for behaviors, intervening to ensure safety, monitoring hand placement during care, and gently holding the resident’s hands during care as able. On the day of the incident, a nurse aide decided to provide incontinence care around suppertime after the resident had a bowel movement, before meal trays arrived. During the first brief change, the resident remained calm while the aide talked to him. After the brief was applied, the resident had a second bowel movement, and the aide began incontinence care again. At that point, the resident started to hit and pinch the aide, who then stopped care and used her radio to summon a second staff member. She reported that all other staff were occupied providing care in other rooms. While waiting, she was able to calm the resident and, without a second staff member present, resumed incontinence care. The resident, who was facing away from her while she was wiping his rectal area, grabbed the metal bed frame, pulled himself off the bed, and fell, striking his head on a nearby dresser. The aide stated it was normal for him to hold onto the bed frame during care and believed it was a comfort measure. She also stated that the resident was not care planned for a two‑person assist during ADL care and acknowledged that the accident might have been avoided if she had waited for assistance. When the nurse responded to the aide’s call after the fall, the resident was found lying on the floor between the bed and the dresser, bleeding from a forehead laceration. The nurse documented that the aide reported the resident had pulled himself off the bed while she was cleansing him after a large soft bowel movement. The resident’s vital signs were recorded, and he was sent to the emergency department, where he was treated for a soft tissue skin tear to the forehead that required cleansing and steri‑strips. Imaging, including a head CT and pelvic x‑ray, showed no acute injury. Interviews with the nurse, DON, and Administrator confirmed that the resident was known to become combative during ADL care, that the aide had attempted to obtain help but resumed care alone once the resident calmed, and that the resident pulled himself off the bed while holding the bed frame during incontinence care, resulting in the fall and injury.
Inaccurate MAR Documentation for Constipation Medication
Penalty
Summary
The deficiency involves the facility’s failure to accurately document the administration and refusals of Linzess, a medication for chronic constipation, for one resident. A physician’s order dated 04/16/25 directed that Linzess 290 mcg be given orally once daily on Sunday through Friday. Review of the Medication Administration Records (MARs) for November, December, and January showed multiple entries by several nurses and medication aides indicating that the resident received single capsules of Linzess on numerous dates. However, during interviews, Nurse #1, Medication Aide #1, Medication Aide #2, and Nurse #4 each admitted they had documented that the medication was administered on Sundays, Mondays, Wednesdays, and Thursdays when it was not actually given and was instead left or stored in the resident’s room. Nurse #4 further stated that, for as long as she could remember, the resident had actually been taking three capsules of Linzess only on Tuesdays and Fridays, not daily as ordered. The Nurse Practitioner reported that she relied on the MAR documentation to determine whether medication changes were needed and expected accurate documentation at all times. The Consulting Pharmacist stated she would have expected staff to accurately document refusals of the daily Linzess dose and emphasized that the MAR is used to make clinical decisions and that accurate refusal documentation could have supported earlier intervention, such as a medication change. The DON also stated that nursing staff should have accurately documented refusals of Linzess and that the MAR is an important clinical tool that must be accurate at all times.
Misappropriation of Resident's Pain Patch by Staff Member
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property when a staff member, Nurse #2, took a Duragesic pain patch that was ordered for a resident. The incident involved Resident #29, who was admitted with a diagnosis of chronic back pain and was cognitively intact according to the Minimum Data Set. On the morning of the incident, Nurse #2, who was not scheduled to work, entered the facility and went into Resident #29's room, allegedly to replace a Duragesic patch. However, the patch was not replaced, and Nurse #2 was later found to be hypotensive and exhibiting signs of low oxygenation. The Director of Nursing (DON) was notified of the situation, and an investigation was conducted. It was revealed that Nurse #2 had taken the patch from Resident #29, which was confirmed by Nurse #2 himself. The investigation included interviews with various staff members, including Nurse #3, who had worked with Nurse #2 that morning. Nurse #3 reported that she had given Nurse #2 a new patch to apply to Resident #29, but later discovered that the patch was not on the resident. The Assistant Director of Nursing (ADON) and the Nurse Practitioner (NP) were also involved in assessing the situation and ensuring that Resident #29 received a replacement patch. The incident was reported to the local police department, the North Carolina Board of Nursing, and the North Carolina Department of Health and Human Services. Nurse #2 was terminated from his position, and the facility conducted an in-service for staff on communication, reporting, medication administration, and protecting their licenses. Despite the incident, Resident #29 did not report any pain or recall missing any doses of the pain patch, and there were no adverse reactions noted.
Neglect in Providing Meal to Dependent Resident
Penalty
Summary
The facility neglected to provide a breakfast tray for a dependent resident, identified as Resident #212, who was admitted with diagnoses including hemiplegia following a stroke and aphasia. The resident was assessed as cognitively impaired and dependent on staff for personal hygiene, toileting, oral hygiene, and eating. Her care plan indicated she was at nutritional risk and required staff assistance with feeding at mealtimes. On the morning of the incident, the Director of Nursing (DON) was informed by a Dining Assistant that Resident #212's breakfast tray was still in the kitchen warmer, indicating that the resident had not been fed. Nursing Assistant #1, who was responsible for Resident #212 during the shift, admitted to forgetting to provide the breakfast tray. Interviews with the Dining Assistant and Nurse #1 confirmed that the nursing assistants were responsible for obtaining meal trays for residents who ate in their rooms and required feeding assistance. Despite being aware of the resident's dependency, NA #1 did not retrieve the tray or seek help from other staff members. The DON confirmed that breakfast was typically served between 7:30 AM and 9:00 AM, and NA #1 acknowledged forgetting the task without requesting assistance.
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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 Lumberton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodhaven Nursing Center | 0.3 mi | ★★★★★ | 7 | 0 |
| The Carrolton Of Lumberton | 1 mi | ★★★★★ | 9 | 0 |
| Harborview Lumberton | 1.9 mi | ★★★★★ | 0 | 0 |
| Glenflora | 2.5 mi | ★★★★★ | 2 | 0 |
| Pembroke Center | 10.9 mi | ★★★★★ | 23 | 0 |
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