Lenoir Health and Rehab: 11 Care Deficiencies - NC
Resident #126 arrived at the facility with pneumonia and immediately began receiving oxygen through a nasal cannula at 2 liters per minute. Federal inspectors found her using the oxygen concentrator during observations on November 16, 17, and 18, but no physician's order existed for the treatment.
Unit Manager #2, who completed the admission, told inspectors she "could not recall" whether she initiated the oxygen therapy. "There were many admissions that day, and she could not remember if she initiated Resident #126's oxygen or not," according to the inspection report.
The facility also violated safety protocols by failing to post required cautionary signage outside the resident's room indicating oxygen was in use. Inspectors noted the missing signs during all three observation visits.
Medication Aide #1 confirmed the resident "received oxygen continuously" but said she "did not see an order for oxygen on the medication administration record." The aide also said she "did not know who was responsible for applying the oxygen in use cautionary signs to resident rooms" and hadn't noticed the missing door sign.
The resident's care plan, updated on November 14, included interventions to "administer oxygen as ordered" and "monitor for signs of respiratory distress." However, no actual physician's order existed to authorize the treatment.
Nurse Practitioner assessed Resident #126 on November 17 and found her using oxygen via nasal cannula. The practitioner noted the resident "had no respiratory difficulty or shortness of breath" during the assessment but acknowledged she "did not know how the order for oxygen got overlooked."
The practitioner explained that "any orders on discharge paperwork would be entered by the nurse admitting the resident." Hospital discharge orders should have been transferred to the facility's electronic medical record system during admission.
Director of Nursing confirmed that "oxygen orders should have been in place for oxygen use for Resident #126 prior to initiating oxygen." The administrator also stated that "oxygen-in-use cautionary signage should be posted outside the doors of all residents' rooms who used continuous oxygen."
The missing signage created potential fire hazards, as oxygen increases combustion risk and requires special safety precautions. Federal regulations require facilities to clearly mark rooms where oxygen is in use to alert staff and visitors.
Unit Manager #2 said "orders were received from the hospital via discharge paperwork and entered into facility electronic medical record," but couldn't explain why the oxygen order was missing. The manager stated that "whoever initiated the oxygen should have placed the cautionary signage on Resident #126's door."
Resident #126's admission Minimum Data Set, the standardized assessment tool, remained incomplete at the time of inspection. "No oxygen or respiratory information was complete," inspectors noted.
The facility's care plan identified the resident as having "risk of respiratory complications" with a goal that she "would be free from respiratory complications." Staff were instructed to check vital signs as needed and monitor for respiratory distress.
Despite the missing physician's order, the resident appeared stable during the inspection period. The Nurse Practitioner's assessment found no signs of respiratory difficulty, suggesting the oxygen therapy was appropriate even though improperly authorized.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm." The finding affected few residents, indicating the oxygen order oversight was isolated to this case.
The inspection revealed gaps in the facility's admission process, particularly during busy periods with multiple new residents. Staff confusion about responsibilities for oxygen initiation and safety signage suggested inadequate protocols for respiratory care coordination.
Resident #126 continued receiving the unauthorized oxygen treatment throughout the inspection period while staff worked to resolve the documentation issues.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lenoir Health and Rehabilitation Center from 2025-11-24 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 21, 2026 · Our methodology
Lenoir Health and Rehabilitation Center in Lenoir, NC was cited for violations during a health inspection on November 24, 2025.
Resident #126 arrived at the facility with pneumonia and immediately began receiving oxygen through a nasal cannula at 2 liters per minute.
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.