White Oak Manor: Resident Left in Urine All Day - NC
The incident at White Oak Manor-Kings Mountain came to light when the resident's daughter arrived for a visit and found her mother soaking wet. Federal inspectors documented the violation during an August complaint investigation.
Resident 139 was discovered lying in bed with wet clothes, under pad and sheets when her daughter visited around 3:00 PM. A soiled brief lay at the foot of her bed. Rings had formed around her body on the sheets and under pad where the urine had begun to dry, indicating she had been wet for hours.
The daughter confronted two nursing assistants who had just started their shifts. Both apologized and said they were unsure what had happened since Resident 139 wasn't on either of their assignments. One assistant told the daughter she would get clean linens and bathe the resident.
When the assistant removed a pillow from under Resident 139's knees, she found another soiled brief underneath.
The unit manager came to assess the situation after being notified. All three staff members worked together to get Resident 139 cleaned up and into dry clothes and linens.
Nurse 7, the unit manager, told inspectors she noticed a strong urine smell when she entered the room. The resident's daughter was "quite angry because her mother was soaking wet with urine," according to the nurse's account.
The daughter asked whether Resident 139 had been changed at all that day. The unit manager responded that "she had to assume" the resident hadn't been changed "from the looks of her bed."
Nobody had reported that Resident 139 refused care during the shift, the unit manager said. She noted that while the resident would sometimes refuse care, no staff member had informed her of any refusal that day.
The facility's investigation revealed that nursing assistant NA 5 was responsible for Resident 139's care during the shift when the incident occurred. During questioning, NA 5 claimed the resident had refused care all day but admitted she never reported this to any unit manager or supervisor.
The Director of Nursing said Resident 139's daughter filed a grievance the day the incident happened. The subsequent investigation resulted in NA 5's termination.
Federal regulations require nursing homes to provide necessary care and services to help residents maintain their highest level of physical well-being. When residents refuse care, staff must document the refusal and notify supervisors to develop alternative approaches.
The facility administrator told inspectors she expected staff to provide care to all residents. If care was refused, staff should report that immediately to the unit manager or Director of Nursing. She supported the decision to terminate NA 5 for failing to notify anyone about the alleged care refusal and allowing the resident to remain wet all day.
Inspectors made three attempts to contact NA 5 for her account of events but received no response. The facility provided no voicemail system, and the assistant didn't return calls or texts.
The violation was classified as causing minimal harm with few residents affected. However, the incident highlighted gaps in the facility's oversight of direct care staff and communication protocols for reporting care refusals.
Resident 139 was described as always being incontinent of bowel and bladder, requiring regular assistance with personal care. Staff familiar with her care said she had never refused assistance when they were assigned to her.
The case demonstrates how quickly neglect can escalate when staff fail to follow proper reporting procedures. What began as an alleged care refusal became hours of a vulnerable resident lying in her own waste, discovered only when family arrived for a visit.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
White Oak Manor-Kings Mountain in Kings Mountain, NC was cited for violations during a health inspection on August 12, 2025.
The incident at White Oak Manor-Kings Mountain came to light when the resident's daughter arrived for a visit and found her mother soaking wet.
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.