Lenoir Health & Rehab: Infection Control Failures - NC
Resident 126 arrived at Lenoir Health and Rehabilitation Center in November from a hospital stay for pneumonia. Unit Manager 2 completed her admission paperwork, but no oxygen order appeared anywhere in the resident's medical records.
For at least three consecutive days, inspectors observed the resident using an oxygen concentrator via nasal cannula at 2 liters per minute. On November 16 at 12:41 PM, she was on oxygen. The next morning at 7:54 AM, still on oxygen. November 18 at 7:42 AM, oxygen again.
Each time, inspectors found no cautionary signage outside her door warning that oxygen was in use inside the room.
Medication Aide 1 told inspectors on November 18 that the resident "received oxygen continuously." But when asked about authorization, the aide said she "did not see an order for oxygen on the medication administration record." She also said she "did not know who was responsible for applying the oxygen in use cautionary signs to resident rooms."
The aide admitted she "had not noticed that Resident 126 did not have an oxygen in use sign on door."
Unit Manager 2, who handled the admission, couldn't provide answers when interviewed two days later. She told inspectors she "could not recall if she completed the admission orders for Resident 126."
The manager explained that "orders were received from the hospital via discharge paperwork and entered into facility electronic medical record." But with "many admissions that day," 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 Resident 126's door."
The facility's Nurse Practitioner assessed the resident on November 17. She found the patient "on oxygen via nasal cannula at time of assessment" with "no respiratory difficulty or shortness of breath."
But the practitioner couldn't explain the missing authorization either. She told inspectors she "did not know how the order for oxygen got overlooked."
The resident's care plan, updated November 14, included interventions to "administer oxygen as ordered" and "monitor for signs of respiratory distress." The plan's stated goal was for the resident to "be free from respiratory complications."
However, no actual order existed for the oxygen treatment the plan referenced.
Director of Nursing acknowledged the violations during her November 20 interview. She stated that "oxygen orders should have been in place for oxygen use for Resident 126 prior to initiating oxygen."
She also confirmed 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 required for nursing home residents, remained incomplete at the time of the inspection. No oxygen or respiratory information had been documented.
Federal regulations require nursing homes to provide safe and appropriate respiratory care, including proper physician authorization for oxygen therapy and appropriate safety measures. Oxygen concentrators pose fire hazards that require specific precautions and warning signs.
The inspection classified the violation as causing minimal harm or potential for actual harm. Inspectors found the facility failed to obtain required physician orders and failed to post mandatory safety signage for at least one of five residents reviewed for respiratory care.
Three different staff members interviewed couldn't identify who initiated the oxygen therapy or explain why standard safety protocols weren't followed. The breakdown occurred despite the resident's care plan specifically calling for oxygen administration "as ordered" when no such order existed.
Nobody could explain how a resident continued receiving medical treatment for days without proper authorization or safety measures in place.
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 in November from a hospital stay for 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.