Below 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 White Oak Manor-shelby during CMS and state inspections, most recent first.
A resident with right‑sided hemiplegia, vascular dementia, and dependence for all ADLs was being provided incontinent care in bed by a NA. The bed was raised to waist height with bilateral half side rails in place, and the NA rolled the resident away from her to adjust a bed pad, assuming the resident would grasp the side rail as usual. The NA did not verify that the resident’s hand was securely on the rail before turning, and the resident’s hand slipped, her legs continued over the side of the bed, and she rolled off the bed onto the floor. Nurses initially noted a right knee abrasion and pain, with later swelling and pain in the right wrist, and hospital imaging confirmed fractures of the right wrist and right knee. Multiple staff and the resident consistently reported that the fall occurred when the resident’s hand slipped from the side rail during the turn, and leadership acknowledged staff were expected to ensure secure hand placement on the rail before repositioning in bed.
Three residents had inaccurate MDS assessments, including one resident incorrectly coded for daily restraint use despite not using bedrails, another resident coded for active TB when only latent TB was present, and a third resident whose fall with a major injury was not documented in the MDS. These errors were attributed to mistakes and oversights by the new MDS Coordinator, as confirmed by staff interviews and record reviews.
A resident with type 2 diabetes and constipation did not have an individualized care plan addressing their wounds and constipation, despite multiple physician orders for wound care and laxatives. The care plan was not updated to reflect these needs, and staff interviews confirmed this was due to oversight.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment contained risks that were not properly managed, and supervision was insufficient to ensure resident safety.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter. Despite EBP signage, a nurse aide did not wear a gown during catheter care, indicating a lack of understanding of EBP protocols. Interviews revealed that while staff were educated on EBP, there were no formal policies, and the facility relied on CDC guidelines without specific procedures, leading to the deficiency.
The facility failed to appoint a qualified Infection Preventionist (IP) with specialized training in infection prevention and control, affecting all residents. The ADON assumed the IP role without completing necessary training, and the oversight was only addressed after surveyor inquiry. The DON had prior SPICE training but lacked certification documentation.
A resident with cognitive impairment and muscle weakness did not receive proper nail care, resulting in long, jagged fingernails with a brown substance underneath. Staff interviews revealed a lack of training and clarity regarding nail care responsibilities, and the DON was unaware of the resident's condition.
A resident with moderate cognitive impairment and dependent on two-person assistance for transfers was injured during a transfer when Nurse Aides failed to use a required gait belt. The resident suffered a right horizontal fracture involving the superior patella and was discharged back to the facility with an immobilizer.
The facility failed to provide evening and weekend group activities, leaving residents feeling bored and lonely. The activity calendar showed no scheduled activities during these times, confirmed by residents and staff. Four cognitively intact residents expressed dissatisfaction, noting the absence of activities for at least six months. The Activities Director acknowledged the issue, citing staffing challenges, and the facility was attempting to hire new staff to address the deficiency.
A resident missed 28 doses of Atorvastatin due to a failure in processing the medication order. The ADON did not send the order to the pharmacy, and despite being informed, staff did not follow up effectively. The pharmacy confirmed they never received the order, and the DON acknowledged the oversight. The resident did not experience side effects from missing the medication.
The facility failed to consistently provide evening snacks to residents who requested them. Despite the nourishment room being well-stocked, residents were not informed about the availability of snacks, and nursing staff were not instructed to offer them. This affected residents with conditions like diabetes and heart failure, who expressed a desire for evening snacks due to hunger after dinner.
A resident requiring assistance with toileting was left unattended on a commode for 40-45 minutes, resulting in a bowel movement and feces on his clothes and wheelchair. The nursing assistant involved admitted to forgetting the resident after being sidetracked and going on a lunch break. The incident was reported to the DON after a grievance was filed by the resident's family.
Two residents prescribed anticoagulant medications did not have their care plans updated to include management of these high-risk medications. Despite receiving apixaban as prescribed, their care plans lacked focus areas or interventions related to anticoagulant use, as confirmed by interviews with facility staff. This oversight failed to ensure staff awareness of potential risks such as bleeding or bruising.
A resident with hypertension was readmitted to a facility with specific orders to monitor blood pressure and pulse for Carvedilol administration. The facility monitored the resident's pulse twice daily but only checked blood pressure weekly, contrary to discharge instructions. Interviews revealed a lack of communication and adherence to the hospital's orders, with staff following an undocumented standard protocol instead.
Failure to Ensure Safe In‑Bed Turning During Incontinent Care Resulting in Fall With Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe in‑bed care and adequate supervision during incontinent care for a resident with right‑sided hemiplegia and vascular dementia, resulting in a fall with fractures. The resident had a history of stroke with hemiplegia and hemiparesis affecting the right dominant side, vascular dementia, vitamin deficiencies, and demineralization, and was assessed as dependent on staff for all ADLs, mobility, and transfers, and frequently incontinent of bowel and bladder. A bed rail assessment and care plan documented the use of bilateral half side rails as an enabler to assist with positioning, mobility, and support in bed, and interventions included giving verbal cues and using bilateral half side rails to enhance mobility and safety. Therapy and the NP confirmed the resident was capable of using the half side rails for bed mobility but still required staff assistance to ensure her hand was securely placed on the rail before turning or repositioning. On the morning of the fall, a nurse aide on night shift entered the resident’s room around the end of the shift to provide incontinent care and fix the bed pad. The aide reported that the bed was raised to about waist height, both half side rails were up, and she stood on the side of the bed closest to the door. While attempting to fix the bed pad, she rolled the resident away from her toward the window, assuming the resident would grab and hold the half side rail as she normally did. The aide did not instruct or ensure that the resident had reached for and secured her hand on the side rail before initiating the turn. During the roll, the resident’s left leg crossed over the right, her hand slipped off the side rail, and her legs continued over the side of the bed, causing her to roll off the bed and onto the floor. The aide attempted to stop the fall but was unable to do so. Nursing staff responding to the incident found the resident on the floor on her right side or partially on her right abdomen, facing the window, with her right arm under her torso. Initial assessments by nurses noted a small abrasion and pain to the right knee, no immediate swelling, and no obvious deformities or leg length discrepancies; the resident was able to move extremities within her normal limits and follow commands. Later observations by another aide and nurses identified mild swelling and pain in the right wrist and continued pain in the right knee, and the resident reported significant pain despite scheduled and PRN pain medications. The resident and multiple staff consistently reported that the fall occurred when the aide rolled the resident during care, the resident’s hand slipped from the side rail, and her legs kept going over the side of the bed. Hospital imaging subsequently revealed fractures of the right wrist and right knee, and the resident stated she believed this was the worst fall she had suffered. Interviews with the DON, Director of Therapy, and NP confirmed that staff were expected to ensure the resident’s hand was securely on the side rail before turning or repositioning her in bed and that the aide did not do so at the time of the incident. The DON stated that NA #1 should have assured the resident’s safety by making sure her hand was secured onto the side rail before beginning care or fixing the bed pad. The NP and Director of Therapy reiterated that, although the resident could use the side rails to assist with mobility, staff were responsible for assisting and confirming proper hand placement on the rail prior to turning. The failure to ensure secure use of the side rail and to provide safe in‑bed assistance during incontinent care directly preceded the resident’s fall from the raised bed and the resulting fractures to her right wrist and right knee.
Inaccurate MDS Coding for Restraints, Infections, and Falls
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents in the areas of restraints, infections, and falls with major injury. For one resident with epilepsy, the quarterly MDS assessment indicated daily use of bedrails as restraints, but direct observation and interviews revealed that no side rails were in use and the resident was unable to use them for positioning or support. The Nurse Assessment Coordinator admitted to incorrectly coding the MDS due to inexperience in the role. Another resident with chronic obstructive pulmonary disease, diabetes mellitus, and latent tuberculosis was incorrectly coded on the MDS as having active tuberculosis. Review of the medical record showed no treatment for TB, and both the resident and the Nurse Practitioner confirmed that the resident only had latent TB and no active disease. The Nurse Assessment Coordinator acknowledged the error, attributing it to a mistake made while learning the MDS process. A third resident, diagnosed with dementia and muscle weakness, experienced a fall resulting in a fractured finger. Despite documentation of the injury and subsequent treatment orders, the quarterly MDS assessment failed to indicate a fall with major injury. The MDS Coordinator confirmed the omission was an oversight. In all cases, facility leadership, including the DON and Administrator, stated that MDS assessments are expected to accurately reflect residents' clinical status and care needs.
Failure to Develop Comprehensive Care Plan for Resident with Wounds and Constipation
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered comprehensive care plan for one resident with multiple medical needs. The resident was admitted with diagnoses including type 2 diabetes and constipation. Despite having physician orders for several laxatives and wound treatments for the left foot, the comprehensive care plan did not include interventions for either constipation or the wounds. The omission was identified through record review, observation, and interviews with staff and the resident. Interviews with the MDS Coordinator, DON, and Administrator confirmed that the care plan should have been updated to reflect the resident's current clinical conditions, including the development of two wounds and ongoing constipation. The MDS Coordinator acknowledged that the lack of care plan initiation was an oversight, and both the DON and Administrator stated that care plans are expected to accurately reflect residents' needs and be updated with any changes in condition.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment posed risks that were not properly addressed, and supervision was insufficient to prevent potential incidents. No further details about the specific hazards, the nature of the supervision, or the residents involved are provided in the report.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and implement policies and procedures for Enhanced Barrier Precautions (EBP) in their infection prevention and control program. During an observation, Nurse Aide #1 was seen providing urinary catheter care to a resident with an indwelling catheter without wearing a gown, despite the presence of EBP signage indicating the need for gloves and a gown. Nurse Aide #1 was unaware that EBP was required for residents with an indwelling urinary catheter, indicating a gap in understanding and implementation of EBP protocols. Interviews with staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), revealed that while staff were educated on EBP, there were no formal policies or procedures in place. The ADON, who also served as the Infection Preventionist, acknowledged the lack of audits on PPE usage and the need for additional training. The DON confirmed that EBP was new to the facility and that staff were instructed to follow CDC guidelines, but no specific facility policies had been developed. This lack of formalized procedures contributed to the failure in implementing EBP during urinary catheter care.
Facility Lacks Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) who had completed specialized training in infection prevention and control to oversee the Infection Control Program. This deficiency potentially affected all 105 residents at the facility. During an entrance conference, the Administrator revealed that the Assistant Director of Nursing (ADON) had assumed the role of IP after the previous IP left in July. However, the ADON had not received any formal training in infection prevention and control, nor had she completed the Statewide Program for Infection Control and Epidemiology (SPICE) training, which is necessary for the role. Interviews with the facility's staff, including the Administrator, ADON, and Director of Nursing (DON), confirmed that the ADON had been in the IP role without the required training since July. The Administrator acknowledged the oversight and mentioned that the ADON was only signed up for the SPICE training after the surveyor's inquiry. The DON, who had completed SPICE training over five years ago, did not have a copy of her certification. This lack of a qualified IP was identified as a deficiency during the survey.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate nail care for a dependent resident, identified as Resident #2, who was moderately cognitively impaired and required maximum assistance for bathing and supervision for personal hygiene. Observations revealed that the resident had 1/4 inch long jagged fingernails with a brown substance underneath, indicating a lack of proper nail care. The resident reported that her nails were only trimmed or cleaned during activities, suggesting a gap in routine personal hygiene care. Interviews with staff members, including Nurse Aides #2 and #3, revealed that there was a lack of clarity and training regarding the responsibility for performing nail care. NA #3, who was assigned to Resident #2, stated she had not been instructed to perform fingernail care since starting at the facility. The Director of Nursing acknowledged that Nurse Aides were responsible for nail care on an as-needed basis but was unaware of the resident's condition, indicating a communication breakdown and oversight in ensuring the resident's personal hygiene needs were met.
Failure to Safely Transfer Resident Resulting in Injury
Penalty
Summary
The facility failed to safely transfer a resident, resulting in a significant injury. Resident #240, who was moderately cognitively impaired and dependent on two-person assistance for transfers, was transferred from the bed to a wheelchair by Nurse Aides #3 and #4 without using a gait belt, as required by the resident's care plan. During the transfer, the resident reported pain and a popping sensation in her knee. An x-ray at the emergency room revealed a right horizontal fracture involving the superior patella with large knee joint effusion. The resident was discharged back to the facility with an immobilizer and a follow-up appointment with an orthopedic provider. The incident occurred when NA #3 and NA #4 entered Resident #240's room to assist with a transfer. Despite the resident's care plan indicating the need for a two-person assist with a gait belt, the aides did not use the gait belt because they were in a hurry. As they attempted to transfer the resident, she lost her balance and fell back into the wheelchair, causing her right leg to bend behind the chair. The resident immediately complained of severe pain and stated that her knee had popped. Nurse #4 assessed the resident and instructed the aides to weigh her despite her complaints of pain. Interviews with the staff revealed that the aides were aware of the requirement to use a gait belt but failed to do so. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were not present at the time of the incident and were not immediately aware of the details. The DON confirmed that the transfer was not conducted correctly and that a gait belt should have been used. The incident was not reported immediately, and no in-service or education was conducted with the staff following the incident.
Lack of Evening and Weekend Activities for Residents
Penalty
Summary
The facility failed to provide evening and weekend group activities for residents, which was important to them for socialization and engagement. A review of the activity calendar for May 2024 showed that activities were only scheduled during weekday mornings and afternoons, with the exception of a Saturday morning church service. This lack of scheduled activities during evenings and weekends was confirmed through interviews with residents and staff, who noted that this had been the case for at least the past six months. Four residents, all cognitively intact, expressed their dissatisfaction with the absence of evening and weekend activities. They reported feelings of boredom, loneliness, and sometimes depression due to the lack of engagement opportunities outside of watching television. These residents had not directly communicated their concerns to the Activities Director, although they had discussed them in resident council meetings. Nursing assistants also confirmed the absence of scheduled activities during these times, noting that residents were left to find their own activities. The Activities Director acknowledged the deficiency, explaining that the facility had struggled to retain activity assistants for evening and weekend shifts, with the last assistant leaving in December 2023. The director and the administrator were aware of the issue and were in the process of trying to hire new staff to cover these shifts. In the meantime, they were considering adjusting the schedules of current staff to provide some evening and weekend activities.
Failure to Administer Prescribed Medication Due to Order Processing Error
Penalty
Summary
The facility failed to obtain a routine medication, Atorvastatin 40 mg, for a resident, resulting in the resident missing 28 doses over a period of nearly two months. The resident, who was cognitively intact, was readmitted to the facility with a hospital discharge order for Atorvastatin to manage high cholesterol. However, due to an oversight during the medication reconciliation process, the order was not sent to the pharmacy. This error was compounded by the failure of staff members to follow up adequately after being informed that the medication was not available. The Assistant Director of Nursing (ADON) did not check the necessary box in the computer system to send the order to the pharmacy. Despite being informed by the Medication Aide and the Staff Development Coordinator, the issue was not resolved, and the medication was not obtained. The pharmacy confirmed that they never received the order, and the Director of Nursing acknowledged the oversight. Interviews with the Nurse Practitioner and Pharmacist indicated that the resident would not have experienced side effects from missing the medication, but the facility did not ensure the resident received the prescribed medication as ordered.
Failure to Provide Consistent Evening Snacks to Residents
Penalty
Summary
The facility failed to consistently provide evening snacks to residents who requested them, as observed in the cases of four residents. These residents, who were cognitively intact and had various medical conditions such as type 2 diabetes, heart failure, anemia, and hypertension, reported not receiving evening snacks consistently. They expressed a desire for evening snacks due to hunger after dinner and were unaware of the availability of snacks in the nourishment room. Some residents relied on family members to provide snacks, indicating a lack of consistent snack offerings by the facility. Interviews with nursing assistants revealed that evening snacks were not routinely offered to residents. The nursing staff were not informed or instructed to offer evening snacks, and there was a lack of awareness among staff about the availability of snacks in the nourishment room. Although the nourishment room was well-stocked with various snacks and drinks, the staff did not consistently offer these to residents, and residents were not informed about their ability to request snacks or access the nourishment room. The Dietary Manager confirmed that the nourishment room was regularly stocked with snacks and drinks, and there were no complaints about shortages. However, the staff did not offer evening snacks, and there was a communication gap regarding the expectation to provide snacks to residents. The facility administrator expected snacks to be available and offered, but this expectation was not communicated effectively to the nursing staff, leading to the deficiency in snack provision.
Resident Left Unattended on Commode
Penalty
Summary
The facility failed to treat a resident in a dignified manner when a nursing assistant (NA) left a resident on the commode for an extended period. The resident, who required substantial one-person assistance with toileting and transfers, was left unattended in the shower room for approximately 40-45 minutes. During this time, the resident had a bowel movement and was unable to clean himself or pull his pants up fully, leading him to transfer himself back to his wheelchair, resulting in feces on his clothes and wheelchair. The resident, who was cognitively intact and required a wheelchair for mobility, expressed feeling upset and mad about the incident. The resident's family discovered him in this state when they arrived to take him out for a visit. The nursing assistant involved admitted to leaving the resident on the commode, stating she had been sidetracked by another resident's family and then went on her lunch break, forgetting about the resident. The Director of Nursing (DON) was not initially aware of the incident until informed by the Social Work Director following a grievance filed by the resident's responsible person. The DON's investigation revealed that the nursing assistant was remorseful and acknowledged the mistake as human error. The facility's administrator emphasized that residents should not be left on a commode without supervision, especially those requiring assistance.
Failure to Include Anticoagulant Management in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents who were prescribed anticoagulant medications. Resident #4, diagnosed with congestive heart failure and atrial fibrillation, had a physician's order for apixaban, an anticoagulant medication, but her care plan did not include any focus area or interventions related to this medication. Despite receiving the medication as prescribed, the care plan was not updated to reflect the use of anticoagulants, which are considered high-risk medications. Interviews with the MDS Nurse, Regional MDS Coordinator, and Director of Nursing confirmed that the care plan should have addressed the anticoagulant medication to ensure all staff were aware of the potential risks, such as bleeding or bruising. Similarly, Resident #31, with diagnoses of deep vein thrombosis and embolism, was also prescribed apixaban. Her care plan, however, did not include any focus area or interventions related to the anticoagulant medication. The quarterly MDS assessment confirmed the resident received the medication, but the care plan failed to capture this aspect of her clinical condition. Interviews with facility staff, including the MDS Nurse, Regional MDS Coordinator, and Director of Nursing, reiterated the importance of including anticoagulant management in the care plan to provide an accurate clinical picture and ensure staff awareness of the associated risks.
Failure to Clarify and Follow Blood Pressure Monitoring Orders
Penalty
Summary
The facility failed to clarify and adhere to the hospital discharge orders for monitoring blood pressure and pulse for a resident receiving Carvedilol, an antihypertensive medication. The resident, who was cognitively intact and had a diagnosis of hypertension, was readmitted to the facility with specific instructions to monitor heart rate and blood pressure, avoiding the medication if the heart rate was below 70 and blood pressure was below 120/80. However, the facility's Medication Administration Record (MAR) for April and May 2024 showed that the resident's pulse was monitored twice daily, but blood pressure was only monitored weekly, contrary to the discharge instructions. Interviews with facility staff revealed a lack of communication and clarification regarding the monitoring parameters. The Assistant Director of Nursing (ADON) admitted to following a standard protocol that was not documented and did not align with the hospital's discharge orders. The Nurse Practitioner indicated that blood pressure should have been monitored twice daily, and the Pharmacist confirmed that the order included parameters for holding the medication based on specific blood pressure and heart rate thresholds. The Director of Nursing (DON) acknowledged a computer issue that prevented the parameters from being transferred to the MAR, and stated that the nursing staff should have clarified the orders with the Nurse Practitioner or Medical Director.
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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 Shelby
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cleveland Pines | 1.5 mi | ★★★★★ | 7 | 0 |
| Peak Resources- Shelby | 10.5 mi | ★★★★★ | 7 | 0 |
| Carolina Care Health And Rehabilitation | 10.8 mi | ★★★★★ | 0 | 0 |
| White Oak Manor-kings Mountain | 11.1 mi | ★★★★★ | 13 | 1 |
| Peak Resources-cherryville | 12.5 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 July 2026) and official state health department websites.