Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Wilora Lake Healthcare during CMS and state inspections, most recent first.
A resident who was cognitively intact and managed her own finances had her debit card information accessed by a former Business Office Manager while receiving assistance with a Medicaid application. Over several months, the former Business Office Manager used the resident’s debit card to make multiple unauthorized payments for personal credit cards, utilities, and internet service, totaling nearly $5,000. The misuse was not detected until after the employee resigned, when a Travel Business Office Manager reviewed historical bank statements for the Medicaid process and identified the suspicious transactions. The resident confirmed she had not authorized any of these charges and stated she would not have known about the missing funds without this review.
Staff failed to follow infection control policies for hand hygiene and Enhanced Barrier Precautions during high-contact care for a resident on EBP with a suprapubic urinary catheter. One NA performed suprapubic catheter and incontinence care, repeatedly changing gloves without performing required hand hygiene between glove changes. During separate incontinence and transfer-related care, two NAs donned gloves but did not wear gowns while cleaning the resident, assisting the resident to stand with a walker, repositioning the resident, and pulling the resident up in bed, despite posted EBP signage and available PPE. Both NAs later reported they were unaware that gowns were required for these high-contact activities, while nursing leadership stated they expected compliance with the facility’s hand hygiene and EBP policies.
A resident with multiple comorbidities, including type II DM, neurogenic bladder with suprapubic catheter, muscle weakness, and lymphedema, required substantial to maximal assistance with toileting hygiene and was frequently bowel incontinent. During observed suprapubic catheter care, a NA removed a visibly and odiferously soiled pull-up and, without cleansing the resident after the bowel movement, completed catheter care and applied a clean pull-up before covering the resident. The resident later reported she would have wanted to be cleaned, the NA admitted he had seen and smelled the stool but forgot to clean the resident due to nervousness about being observed, and the ADON acknowledged smelling the soiled pull-up and not intervening, while the DON stated she expected residents to be cleaned after bowel movements before clean briefs are applied.
A cognitively intact resident with an established goal of community discharge was sent home after active discharge planning and education on medication administration, but no written transfer or discharge notice was documented or provided, and no copy was sent to the Regional Ombudsman. The Ombudsman reported not receiving any transfer or discharge notices since the prior SW left, and interviews with former and current administrative, social services, and medical records staff showed that responsibilities for preparing and sending discharge notices were unclear and that no one recalled issuing or transmitting a notice for this resident.
A nurse aide failed to maintain privacy for a resident during incontinent care by leaving the room with the door open, exposing the unclothed resident to the hallway. The resident, who was dependent on assistance for daily living, expressed discomfort with being left exposed. Interviews confirmed that the facility's procedures require staff to ensure privacy by covering residents and closing doors during care.
A resident with cognitive impairment and a history of potential aggression struck another resident with a cane in their shared room, resulting in a raised red area on the victim's neck. The incident occurred after the victim re-entered the room to retrieve a personal item, despite the aggressor's known discomfort with others near his belongings. The facility failed to prevent this altercation, which led to harm.
The facility failed to document a thorough investigation into medication misappropriation involving two residents. A resident with hypertension and dementia was identified as affected when narcotics were found missing. Another resident with diabetes also had missing narcotics, but was not documented in the investigation report. Interviews revealed missing documentation, including narcotic count sheets and staff interviews, leading to the deficiency.
The facility inaccurately coded MDS assessments for two residents, leading to deficiencies in prognosis and discharge location. One resident under Hospice care was not coded for a prognosis of six months or less, while another resident's discharge to home was incorrectly recorded as a discharge to an acute hospital. Staff interviews revealed a lack of accurate documentation and communication regarding these assessments.
The facility failed to follow fall prevention and safe transfer protocols for three residents. Two residents, identified as fall risks, did not have fall mats in their rooms as required by their care plans. Another resident was improperly transferred using a mechanical lift by a single nurse aide, contrary to the care plan requiring two-person assistance. No injuries were reported, but the incidents highlighted a lack of adherence to safety protocols.
A nurse failed to disinfect a resident's glucometer according to guidelines, using an alcohol pad instead of EPA-approved wipes. Despite training, the nurse admitted to this practice, leading to a deficiency in infection control.
Two residents, both assessed as cognitively intact, were not given the opportunity to participate in the development or revision of their person-centered care plans. There was no evidence that these residents or their representatives were invited to care plan conferences or provided input following recent MDS assessments, and both the residents and their representatives did not recall being involved in such meetings. Documentation of invitations and attendance was missing for the relevant periods.
A resident with ESRD requiring dialysis did not have consistent documentation of post-dialysis access site assessments, including monitoring for infection, bleeding, and pain. Facility staff failed to complete required sections in both the dialysis communication form and EHR on multiple occasions, and communication with the dialysis center was not reliably maintained. Interviews with staff and leadership confirmed lapses in documentation and communication processes.
Misappropriation of Resident Funds by Former Business Office Manager
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident’s personal funds from misappropriation by a former Business Office Manager. The resident, who was her own responsible party and handled her own finances, was admitted on an unspecified date and later required assistance from the facility with an ongoing Medicaid application. During the period in question, the former Business Office Manager had access to the resident’s financial information, including her debit card, in connection with this assistance. Record review of the resident’s bank statements showed that, between late September and late December, the former Business Office Manager used the resident’s debit card to make multiple unauthorized payments for the former Business Office Manager’s personal expenses. These included several credit card payments, a natural gas payment, and an internet service fee, totaling $4,945.62. The resident confirmed in interview that she had not given permission for the former Business Office Manager to use her debit card and stated that the charges were not authorized. She also reported that she would not have known any money was missing from her account if the Travel Business Office Manager had not reviewed her past bank statements for the Medicaid application. The misappropriation was discovered only after the former Business Office Manager had resigned from employment. When the Travel Business Office Manager assumed the former Business Office Manager’s duties related to the resident’s Medicaid application and reviewed several years of bank statements, she identified transactions made in the name of the former Business Office Manager over a defined three‑month period. This discovery led to notification of facility leadership and external agencies, and subsequent interviews with the resident and multiple staff confirmed that the resident’s funds had been wrongfully used for the former Business Office Manager’s personal bills. No other residents were identified as having unauthorized charges during the time the former Business Office Manager was employed, but the facility’s failure to prevent or detect the misuse of this resident’s debit card resulted in misappropriation of the resident’s personal funds.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control program, specifically related to hand hygiene and adherence to Enhanced Barrier Precautions (EBP). During an observation of suprapubic urinary catheter care for Resident #24, who was on EBP and had a suprapubic urinary catheter, NA #1 initially washed his hands with soap and water and donned a gown, face shield, and gloves. He prepared two basins of water and began care by removing the resident’s soiled brief and discarding it. After removing his gloves, NA #1 did not sanitize his hands before donning a clean pair of gloves to clean the suprapubic catheter with soaped washcloths. He again removed his gloves and, without performing hand hygiene, donned another clean pair of gloves to rinse the catheter and apply a new pull-up, only washing his hands with soap and water after all care and PPE removal were completed. The facility’s Hand Hygiene policy, last revised on 11/13/25, required staff to perform hand hygiene when indicated, including before applying and after removing PPE such as gloves, and specified alcohol-based hand rub as the preferred method in most clinical situations. NA #1 later acknowledged in interview that he had not followed appropriate hand hygiene practices, stating he forgot to sanitize his hands between glove changes despite carrying hand sanitizer in his pocket. The Assistant DON, serving as the Infection Preventionist, and the DON both stated they would have expected NA #1 to sanitize his hands each time he removed gloves before putting on clean gloves, consistent with the facility’s policy. A separate deficiency was identified regarding noncompliance with the facility’s EBP policy, also last revised on 11/13/25, which required gowns and gloves for high-contact resident care activities such as transferring and changing briefs. During an observation of incontinence care for Resident #24, NA #1 entered the room, donned gloves only, and performed incontinence care and assisted the resident to stand with a walker to complete cleaning and adjust the pull-up, without wearing a gown. After briefly leaving to obtain assistance, NA #1 and NA #2 returned, donned gloves but no gowns, and together repositioned the resident side to side to place a turn sheet and then pulled the resident up in bed using the turn sheet. Both NAs later stated they were not aware they were supposed to wear a gown for incontinence care, transferring, or adjusting a resident up in bed, despite the EBP sign and PPE caddie on the door. The Infection Preventionist and DON both indicated they would have expected gowns to be worn during these high-contact care activities for a resident on EBP.
Failure to Provide Toileting Hygiene Before Applying Clean Incontinence Brief
Penalty
Summary
The facility failed to provide toileting hygiene after a bowel movement before applying a clean pull-up for a resident who was dependent on staff for ADL assistance. The resident had type II diabetes mellitus, a neurogenic bladder with a suprapubic catheter, muscle weakness, and lymphedema, and her care plan included interventions related to impaired physical mobility and evaluation of her ability to perform ADLs. An admission MDS showed she was cognitively intact but required substantial to maximal assistance of one staff member for toileting hygiene, bed mobility, and transfers, and that she was occasionally incontinent of bladder and frequently incontinent of bowel. During an observed episode of suprapubic catheter care, a nurse aide removed the resident’s pull-up, which had visible brown substance and an odor of stool, and proceeded directly to perform catheter care without cleaning the resident. After completing catheter care, the aide placed a new pull-up on the resident and covered her without providing any toileting hygiene. The resident later stated she could not always tell when she had a bowel movement but would have wanted to be cleaned and preferred to be clean and free of stool odor. The aide acknowledged seeing and smelling the brown liquid substance on the pull-up and admitted he did not know why he had not cleaned the resident, stating he was nervous about being observed and had forgotten. The ADON, who was observing the procedure, reported she smelled the soiled pull-up and did not know why the aide had not cleaned the resident before putting on a clean pull-up, and the DON stated she expected staff to clean all residents after a bowel movement before applying clean pull-ups or briefs.
Failure to Provide Written Discharge Notice and Notify Regional Ombudsman
Penalty
Summary
The deficiency involves the facility’s failure to provide a written discharge notice to a resident being discharged home and to send a copy of that notice to the Regional Ombudsman. The resident was cognitively intact, had an overall goal of discharge to the community, and active discharge planning was underway with referrals made to a local contact agency. Nursing documentation showed that the resident was discharged home, was alert and oriented, and had medication administration explained, which she was able to repeat back, but there was no corresponding written transfer or discharge notice in the electronic medical record. Interviews with the Regional Ombudsman and multiple facility staff confirmed that no written transfer or discharge notice for this resident was issued or sent. The Regional Ombudsman reported not receiving any transfer or discharge notices, including for this resident, since the former social worker left several months earlier. The former administrator did not recall the resident or whether a written notice was given and stated that the former social worker, and later the former medical records coordinator, were responsible for sending notices to the Ombudsman. The former medical records coordinator stated that after the former social worker left, the former administrator handled social work tasks, that she did not recall this resident, and that she did not have access to any transfer or discharge notices to send. The current social worker and current administrator both started after the resident’s discharge and were not familiar with the case, with the administrator stating she expected a designated staff member would have provided the discharge notice and sent copies to the Regional Ombudsman.
Failure to Maintain Resident Privacy During Incontinent Care
Penalty
Summary
The facility failed to maintain personal privacy for a resident during incontinent care. A nurse aide left the room with the door open while the resident was unclothed and uncovered, making the resident visible from the hallway. This incident involved a resident who was cognitively intact but frequently incontinent and dependent on assistance for activities of daily living. The nurse aide did not cover the resident or close the door when she exited the room to retrieve gloves, leaving the resident exposed. Interviews with the resident, the nurse aide, a nurse, and the Director of Nursing confirmed the deficiency. The resident expressed discomfort and frustration with being left exposed, while the nurse aide acknowledged the oversight. The facility's standard procedure, as described by the nurse and the Director of Nursing, requires staff to ensure privacy by covering residents and closing doors when leaving the room during care. The administrator also emphasized the importance of maintaining privacy during incontinence care.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when a resident-to-resident incident occurred. Resident #20, who was moderately cognitively impaired and had a history of potential physical aggression, struck Resident #7 on the back of the head and neck with a metal cane. This incident happened after Resident #7 re-entered their shared room to retrieve a personal item, despite Resident #20's known discomfort with others near his belongings. Resident #7 sustained a raised red area on the back of his neck as a result of the attack. Resident #7 was admitted to the facility with diagnoses including type 2 diabetes and essential primary hypertension and was noted to be cognitively intact with no behavioral issues. In contrast, Resident #20 had diagnoses including end-stage renal disease and unspecified intellectual disabilities, with a care plan indicating a potential for physical aggression when parting with possessions. Despite these known risks, the facility did not adequately prevent the incident from occurring. The incident was reported immediately, and the residents were separated. Staff interviews revealed that Resident #20 had not previously exhibited this level of aggression, although he was known to become upset when others were near his belongings. The facility's social worker and Director of Nursing confirmed that Resident #7 was moved to a different room following the incident, and Resident #20 was sent to the hospital for evaluation. However, the report highlights a failure in preventing the initial altercation, which resulted in harm to Resident #7.
Incomplete Investigation of Medication Misappropriation
Penalty
Summary
The facility failed to maintain documented evidence of a thorough investigation into an allegation of misappropriation of medication for two residents. Resident #278, who was admitted with hypertension and non-Alzheimer's dementia, was identified as an affected resident when the facility became aware of a drug diversion allegation. The investigation report noted that a narcotic medication for Resident #278 was missing from the narcotic lock box. Nurse #6 was interviewed and suspended pending further investigation, while Nurse #7, who was also involved, did not report to work as scheduled and was unreachable. Despite these actions, the investigation documentation was incomplete, lacking narcotic count sheets, substance inventory count sheets, staff interviews, and audit sheets. Additionally, Resident #279, who had been diagnosed with Diabetes Mellitus, was also affected by the misappropriation, as noted by Nurse #8 during a narcotic medication count. However, there was no documentation related to Resident #279 in the facility's investigation report, and the state agency was not notified about this resident. Interviews with the former Administrator and the President of Clinical Operations revealed that they were unable to locate any further documentation related to the investigation, and the former DON claimed that all investigation information was left in the office. The lack of documentation and incomplete investigation led to the deficiency noted in the report.
Inaccurate MDS Coding for Prognosis and Discharge Location
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the areas of prognosis and discharge location. Resident #9, who was admitted with chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and adult failure to thrive, was under Hospice care with a certified prognosis of six months or less. However, the MDS assessment did not reflect this prognosis accurately, as it was coded 'no' for a prognosis of six months or less. The previous MDS Coordinator stated that she did not have the certification of the prognosis at the time of coding, despite being aware that Hospice services had been initiated. Resident #73, admitted for short-term rehabilitation with a plan to discharge home, was inaccurately coded in the MDS as having been discharged to an acute hospital. The resident's electronic medical record indicated a discharge to home with family, and the Social Worker confirmed the discharge plan and execution. The traveling MDS Nurse, involved in discharge planning, was uncertain why the discharge location was inaccurately coded. The Administrator acknowledged that the MDS should accurately reflect the resident's discharge location.
Failure to Implement Fall Prevention and Safe Transfer Protocols
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans for Resident #5 and Resident #6, and did not provide a safe transfer for Resident #36 using a mechanical lift. Resident #6, who was admitted with diagnoses including cerebral infarction and dementia, experienced two falls within the facility. Despite being identified as a fall risk, observations revealed that a fall mat, which was part of the care plan, was not present in Resident #6's room. Interviews with staff and family confirmed the absence of the fall mat, indicating a lack of adherence to the care plan interventions. Resident #5, admitted with cerebrovascular accident and diabetes, also had a care plan that included the use of a fall mat due to a history of falls. However, multiple observations confirmed the absence of the fall mat in Resident #5's room. Interviews with staff revealed a lack of awareness regarding the requirement for a fall mat, and the Administrator acknowledged the oversight, suggesting it may have been removed during cleaning and not returned. Resident #36, with a chronic neurologic disorder, was involved in an incident where a mechanical lift was improperly used by a single nurse aide, contrary to the care plan that required two-person assistance. During the transfer, the lift tilted, causing the resident to slide off the bed. Although no injuries were reported, the incident highlighted a failure to follow established safety protocols. The Director of Maintenance later found a mechanical lift with a malfunctioning manual lever, but it was unclear if this was the lift used during the incident.
Improper Disinfection of Glucometer
Penalty
Summary
The facility failed to properly disinfect a resident's dedicated glucometer according to the manufacturer's guidelines, as observed during a medication pass. Nurse #3 was seen using an alcohol pad to clean the glucometer after monitoring Resident #69's blood sugar, instead of using the EPA-approved wipes as required. The nurse admitted to using alcohol pads for cleaning throughout the day, despite having completed the facility's online glucometer training upon hire. The Director of Nursing confirmed that the correct procedure involved using white top wipes with bleach and allowing a 3-minute dry time, which was not followed. The Administrator stated that all staff received training on the proper cleaning of glucometers, and the necessary supplies were available. However, the nurse's deviation from the protocol led to the deficiency in infection control practices.
Failure to Involve Residents in Care Plan Development and Revision
Penalty
Summary
The facility failed to ensure that residents were given the opportunity to participate in the development and revision of their person-centered care plans for two residents. For one resident with diagnoses including rheumatoid arthritis, frequent falls, depression, and chronic joint pain, there was no evidence in the electronic medical record that she was invited to attend care plan meetings or provide input regarding her care plan following two quarterly MDS assessments, despite being cognitively intact. The resident did not recall being invited to a care plan conference or having her goals discussed, and her representative also did not recall participating in any care plan conference. The last documented care plan conference for this resident was several months prior to the most recent MDS assessments, with no documentation of invitations or attendance for subsequent conferences. For another resident with peripheral vascular disease, atrial fibrillation, hypertensive heart disease, chronic kidney disease, moderate dementia, and depression, the care plan indicated impaired cognitive function but the most recent MDS assessment showed the resident was cognitively intact. The resident did not recall being invited to or attending a care plan conference, and the guardian reported not receiving invitations for recent conferences. The last documented care plan conference was several months prior, with no documentation of invitations or attendance for care plan conferences following more recent MDS assessments. The Social Services Director stated that the process involved notifying residents and representatives, but documentation was lacking for the relevant periods.
Failure to Document and Communicate Dialysis Care and Access Site Assessments
Penalty
Summary
The facility failed to maintain ongoing communication with the dialysis center and did not consistently document assessments of the dialysis access site post-dialysis for a resident with end stage renal disease who was dependent on dialysis. Despite physician orders and care plan interventions requiring regular assessment and documentation of the dialysis access site for signs of infection, bleeding, pain, and skin condition, multiple instances were found where the hemodialysis communication form and the electronic health record (EHR) were incomplete or missing required documentation for several dates. Staff interviews confirmed that while assessments were expected, documentation was not consistently completed in both the communication book and the EHR, particularly regarding the appearance of the access site and signs of infection. Further, the dialysis nurse reported that the communication book was not always received by the dialysis center, and that the facility staff did not always remove the bandage to assess the access site as required. The physician stated he relied on nursing staff to communicate any changes or new orders and did not review the dialysis communication forms. The Director of Nursing and Administrator confirmed the process for documentation and communication but acknowledged gaps in completion. These failures resulted in a lack of proper monitoring and communication regarding the resident's dialysis care.
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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 Charlotte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Redwood Health & Rehab | 0.7 mi | ★★★★★ | 4 | 0 |
| Asbury Health And Rehabilitation Center | 2 mi | ★★★★★ | 5 | 0 |
| Peak Resources - Charlotte | 2.5 mi | ★★★★★ | 0 | 0 |
| White Oak Manor - Charlotte | 2.7 mi | ★★★★★ | 10 | 2 |
| Shamrock Nursing Center | 2.7 mi | ★★★★★ | 0 | 0 |
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