White Oak Manor-Kings Mountain: Neglect Complaint - NC
The unit manager, Nurse #7, walked in and took in the same scene. The daughter asked whether her mother had been changed at all that day. Nurse #7 told her she had to assume the answer was no, based on what she was looking at.
That exchange is documented in a federal inspection report completed August 12, 2025, following a complaint investigation at White Oak Manor-Kings Mountain, a nursing facility at 716 Sipes Street. The resident at the center of the report, identified as Resident #139, was always incontinent of bowel and bladder, according to both the unit manager and the Director of Nursing. She required regular care throughout every shift.
The nursing assistant assigned to her that day was NA #5.
According to the inspection report, NA #6 was the one who eventually discovered the situation, finding a soiled brief from under Resident #139's knees and notifying the unit manager. The unit manager came to assess the resident. Staff worked together to get her cleaned up, into dry clothes, and onto fresh linens.
By that point, the damage was visible in the sheets themselves.
The facility launched an internal investigation. During that process, NA #5 told the Director of Nursing that Resident #139 had refused care all day. It was the first time anyone had heard this explanation. NA #5 had not reported a care refusal to the unit manager. She had not reported it to any supervisor. She had not documented it or flagged it at any point during the shift while the resident lay wet in her bed.
The Director of Nursing confirmed to inspectors that Resident #139's daughter had brought the incident to her attention the same day it happened. A grievance was filed. The investigation concluded with the termination of NA #5.
NA #6, who found the resident and reported it, told inspectors that Resident #139 had never refused care on any shift when she was the assigned aide. Nurse #7, the unit manager, told inspectors that no one had reported a care refusal to her during the shift in question. She acknowledged that Resident #139 would sometimes refuse care, but said nothing had been communicated to her that day.
Inspectors attempted to reach NA #5 three times. There was no ability to leave a voicemail. No call or text was returned.
The administrator told inspectors she expected staff to report care refusals to a unit manager or the Director of Nursing rather than simply allowing a resident to remain in a soiled condition. She said she was made aware of the situation during the investigation and agreed with the decision to terminate NA #5.
The inspection report classified the level of harm as minimal harm or potential for actual harm, with few residents affected.
What the classification does not capture is the specific texture of what the unit manager walked into that afternoon: the strong smell of urine, the wet clothes, the soiled brief discarded at the foot of the bed, the dried rings left on the sheets and under pad where the urine had settled and begun to dry over the course of a full shift. Nor does it capture what it meant for a daughter to walk into her mother's room and have to ask a nurse whether anyone had cared for her mother at all that day, and to receive an answer that amounted to: probably not.
Resident #139's daughter filed the grievance. Her mother had been lying there long enough for the sheets to show it.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
White Oak Manor-Kings Mountain in Kings Mountain, NC was cited for neglect violations during a health inspection on August 12, 2025.
The unit manager, Nurse #7, walked in and took in the same scene.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.