Lenoir Health and Rehab: Food Safety Violations - NC
Resident #126 arrived at Lenoir Health and Rehabilitation Center from the hospital with pneumonia. Hospital discharge paperwork should have included oxygen orders that nurses would transfer to the facility's system during admission.
It didn't happen.
Inspectors found the resident breathing oxygen through a nasal cannula at 2 liters per minute when they observed her room on November 16 at 12:41 PM. She was still on oxygen the next morning at 7:54 AM. And again the following morning at 7:42 AM.
No physician's order existed for any of it.
Unit Manager #2, who handled the admission, told inspectors she "could not recall" if she completed Resident #126's admission orders. 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, and she could not remember if she initiated Resident #126's oxygen or not," according to the inspection report.
The facility's own care plan, updated November 14, included interventions to "administer oxygen as ordered" and monitor for respiratory distress. But no order existed to administer.
Medication Aide #1 told inspectors she knew Resident #126 received oxygen continuously. When asked about the medication administration record, she said she "did not see an order for oxygen" and didn't know who was responsible for posting oxygen safety signs.
She also hadn't noticed the missing safety signage outside Resident #126's door.
Federal regulations require facilities to post cautionary signs outside rooms where oxygen is in use. The signs warn staff and visitors about fire hazards and smoking restrictions around oxygen equipment.
Inspectors found no such signage during any of their three observations of Resident #126's room over three consecutive days.
The Nurse Practitioner assessed Resident #126 on Monday, November 17, and found her using oxygen via nasal cannula. The resident showed no respiratory difficulty or shortness of breath during the assessment.
"She did not know how the order for oxygen got overlooked," the Nurse Practitioner told inspectors.
The breakdown occurred during what should have been a routine admission process. Hospital patients on oxygen typically arrive with discharge orders specifying flow rates and duration of treatment. Admitting nurses are responsible for reviewing these orders and entering them into the facility's system.
Unit Manager #2 acknowledged that "orders were received from the hospital via discharge paperwork and entered into facility electronic medical record." But somewhere between the hospital's discharge and the facility's admission, the oxygen order disappeared from the documentation.
The Director of Nursing confirmed 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 all rooms where residents use continuous oxygen.
Both requirements existed in facility policy. Neither happened in practice.
The missing physician's order meant nursing staff administered a medical treatment without proper authorization for multiple days. The missing safety signs created potential fire hazards, since oxygen makes materials more flammable and requires special precautions around heat sources and smoking.
Resident #126's care plan identified her as at risk for respiratory complications and included a goal that she "would be free from respiratory complications." The plan specified interventions including administering oxygen as ordered and monitoring for signs of respiratory distress.
Staff followed some parts of the plan. They monitored her condition and continued the oxygen therapy. The Nurse Practitioner found no respiratory distress during her assessment.
But they failed to ensure the most basic requirement was met: a doctor's order authorizing the treatment they were providing around the clock.
The resident continued receiving oxygen throughout the inspection period. Her condition remained stable. But the facility's admission process had failed to transfer critical medical orders from hospital to nursing home, leaving staff to provide unauthorized respiratory care for days before anyone noticed the missing documentation.
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 arrived at 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.