Lenoir Health & Rehab: Feeding Tube Care Failures - NC
Federal inspectors found the facility administered oxygen to Resident #126 at 2 liters per minute through a nasal cannula continuously from her admission through at least November 18, despite having no physician's order authorizing the treatment.
The resident was admitted from a hospital with pneumonia diagnoses. Unit Manager #2 completed her admission, but inspection of the physician orders revealed no authorization for oxygen use.
Inspectors observed the resident using an oxygen concentrator in her room on three separate occasions: November 16 at 12:41 PM, November 17 at 7:54 AM, and November 18 at 7:42 AM. Each time, the machine delivered 2 liters per minute through nasal cannula.
The facility's own 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 during a November 18 interview that the resident "received oxygen continuously." When asked about authorization, the aide said she "did not see an order for oxygen on the medication administration record."
The aide also said she didn't know who was responsible for posting oxygen warning signs and "had not noticed that Resident #126 did not have an oxygen in use sign on door."
Federal regulations require facilities to post cautionary signage outside rooms where oxygen is in use. Inspectors found no such signs during any of their three observations of the resident's room.
Unit Manager #2, when interviewed November 20, said she "could not recall if she completed the admission orders" for the resident. She explained that "orders were received from the hospital via discharge paperwork and entered into facility electronic medical record."
The unit manager said there were "many admissions that day" and she "could not remember if she initiated Resident #126's oxygen or not." She added that "whoever initiated the oxygen should have placed the cautionary signage" on the door.
The facility's Nurse Practitioner assessed the resident on November 17 and found her using "oxygen via nasal cannula." The NP said the resident "had no respiratory difficulty or shortness of breath on assessment" but admitted she "did not know how the order for oxygen got overlooked."
The NP explained that when residents are "admitted from the hospital, any orders on discharge paperwork would be entered by the nurse admitting the resident."
Director of Nursing confirmed during her November 20 interview that "oxygen orders should have been in place for oxygen use for Resident #126 prior to initiating oxygen." She also stated that "oxygen-in-use cautionary signage should be posted outside the doors of all residents' rooms who used continuous oxygen."
The resident's admission Minimum Data Set, the comprehensive assessment tool used by nursing homes, showed no completed oxygen or respiratory information at the time of the inspection.
The violation occurred despite the facility having established protocols. The resident's care plan specifically listed goals to keep her "free from respiratory complications" and included monitoring for signs of respiratory distress.
Oxygen therapy requires physician authorization because it's considered a medical treatment with potential risks and complications. The missing safety signage created additional hazards, as oxygen supports combustion and requires special fire safety precautions.
The inspection was conducted in response to a complaint. Federal inspectors classified the violation as causing minimal harm or potential for actual harm to residents.
Unit Manager #2's inability to remember whether she initiated the oxygen therapy highlighted gaps in the facility's admission process, particularly during busy periods with multiple new residents arriving simultaneously.
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.
The resident was admitted from a hospital with pneumonia diagnoses.
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.