Lenoir Health and Rehab: 11 Deficiencies Found - NC
Resident #126 was admitted to Lenoir Health and Rehabilitation Center from the hospital with pneumonia. Unit Manager #2 completed the admission process, but no oxygen order appeared in the resident's physician orders despite her arrival on continuous oxygen therapy.
Federal inspectors observed the resident using an oxygen concentrator via nasal cannula at 2 liters per minute on three separate occasions between November 16 and November 18. Each time, no cautionary signage indicated oxygen was in use outside her room.
The resident's care plan, updated November 14, included interventions to "administer oxygen as ordered" and monitor for respiratory distress. But no such order existed.
Medication Aide #1 told inspectors the resident received oxygen continuously. The aide said she didn't see an oxygen order on the medication administration record and didn't know who was responsible for posting oxygen warning signs. She hadn't noticed the missing sign on the resident's door.
Unit Manager #2 couldn't recall completing admission orders for the resident when interviewed November 20. She said orders typically came from hospital discharge paperwork and were entered into the facility's electronic medical record. There were many admissions that day, she said, and she couldn't remember if she initiated the resident's oxygen.
Whoever started the oxygen should have posted the cautionary signage, Unit Manager #2 said.
The facility's Nurse Practitioner assessed the resident November 17 and found her using oxygen via nasal cannula. The resident showed no respiratory difficulty or shortness of breath during the assessment. Any discharge orders from the hospital would normally be entered by the admitting nurse, the Nurse Practitioner explained.
She didn't know how the oxygen order got overlooked.
Director of Nursing confirmed that oxygen orders should have been in place before initiating oxygen therapy for any resident. All residents using continuous oxygen should have cautionary signage posted outside their rooms, she said.
The resident's admission Minimum Data Set, dated the day of admission, remained incomplete at the time of inspection. No oxygen or respiratory information had been entered.
Federal regulations require nursing homes to provide safe and appropriate respiratory care. Oxygen therapy represents a medical treatment that requires physician authorization before initiation. Safety signage alerts staff and visitors to fire hazards associated with oxygen use.
The violation carried a determination of minimal harm or potential for actual harm. Inspectors found the facility failed in two critical areas: obtaining proper medical authorization for ongoing treatment and implementing basic safety protocols.
Hospital discharge paperwork typically includes oxygen orders when patients require continued therapy. The facility's admission process should have captured and transcribed these orders into the resident's medical record before continuing treatment.
Multiple staff members interviewed couldn't identify who held responsibility for posting oxygen warning signs. This gap in accountability left safety protocols unmonitored across multiple shifts.
The resident continued receiving oxygen therapy throughout the inspection period. Her care plan acknowledged the need for respiratory monitoring and oxygen administration "as ordered," creating a documentation loop that referenced non-existent physician authorization.
Staff interviews revealed confusion about admission procedures when multiple patients arrived the same day. Unit Manager #2's inability to recall specific admission details suggested potential systemic issues with patient intake processes.
The Nurse Practitioner's assessment found the resident clinically stable on oxygen therapy. However, the medical appropriateness of treatment doesn't substitute for proper physician authorization and safety compliance.
Oxygen concentrators pose fire risks that require specific safety measures. Missing door signage could endanger the resident and others during emergencies or routine maintenance when oxygen presence might not be immediately apparent.
The facility's own policies required both physician orders for oxygen therapy and cautionary signage for rooms with oxygen use. Staff failed to implement either requirement for Resident #126.
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 20, 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 was admitted to Lenoir Health and Rehabilitation Center from the hospital with pneumonia.
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.