The incident at White Oak Manor came to light when the daughter visited around 3:00 PM and found her mother in wet clothes, lying on soaked sheets and under pads. A soiled brief lay at the foot of the bed. Rings had formed around the resident's body where urine had begun to dry on the bedding.
Nurse Manager #7 recalled the daughter's fury when she arrived at the room after being summoned by another aide. The strong smell of urine hit her immediately upon entering.
"Had [my mother] been changed at all today?" the daughter demanded.
The nurse manager told her she had to assume the resident had not been changed, given the condition of the bed.
Nobody had reported any care refusals to supervisors during the shift. Resident #139 was known to sometimes refuse care, but staff protocol required immediate notification to unit managers when this occurred.
The investigation revealed nursing assistant #5 had been assigned to the resident's care but claimed during questioning that the woman had refused assistance throughout the entire day. The aide never informed the unit manager, supervisor, or Director of Nursing about these alleged refusals.
Director of Nursing officials learned about the incident directly from the daughter on the day it happened. A formal grievance was filed, triggering an internal investigation that led to the aide's termination within days.
The resident required extensive cleaning and fresh bedding. A skin assessment conducted after the incident documented redness to both sides of her buttocks, indicating prolonged exposure to moisture.
White Oak Manor's administrator emphasized that staff were expected to provide care to all residents regardless of circumstances. When residents refuse care, the protocol demanded immediate reporting to unit managers or the Director of Nursing so alternative approaches could be implemented.
The administrator supported the termination decision, stating the aide's failure to communicate care refusals while allowing a vulnerable resident to remain in unsanitary conditions all day violated fundamental care standards.
Resident #139 was described by nursing staff as consistently incontinent of bowel and bladder, requiring regular monitoring and assistance throughout each shift. The facility's own policies required documentation and supervisor notification whenever residents declined necessary care.
The daughter's unexpected afternoon visit exposed what appeared to be hours of neglect. The dried urine rings around her mother's body suggested the resident had been lying in the same position in wet conditions for an extended period.
Nursing assistant #5's claim that the resident refused care all day raised additional questions about why no supervisor was notified. Standard nursing home protocols require immediate escalation when residents consistently decline essential hygiene assistance, particularly for those with incontinence issues.
The unit manager who responded to the daughter's complaint had received no reports of care refusals during her shift. She stated that while Resident #139 occasionally refused care, staff typically found ways to provide necessary assistance or promptly involved supervisors in developing alternative approaches.
The investigation concluded that the aide's actions constituted a serious breach of care standards. Allowing any resident to remain in soiled conditions for hours without attempting alternative interventions or notifying supervisors violated both facility policies and basic dignity standards.
The termination occurred after the facility determined the aide had multiple opportunities to either provide care using different approaches or seek supervisory assistance. Instead, the resident was left in increasingly unsanitary conditions that resulted in skin irritation and family distress.
Federal inspection records show the incident represented a violation of regulations requiring nursing homes to provide necessary care and services to maintain residents' highest practicable physical well-being. The facility's own investigation and swift termination of the responsible employee demonstrated recognition of the serious nature of the neglect.
The case highlighted ongoing challenges nursing homes face in ensuring consistent care delivery, particularly for residents with complex needs who may sometimes resist assistance. However, regulations and facility policies clearly established that communication with supervisors remained mandatory when care challenges arose.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for White Oak Manor-kings Mountain from 2025-08-12 including all violations, facility responses, and corrective action plans.
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