Gates Health and Rehab: Wound Care Failures Cited - NC
The inspection, completed August 15, 2025, was triggered by a complaint. It centered on the wound care provided to Resident 56, a man with at least two open wounds, one on his heel and one on his left buttock.
A wound care nurse practitioner had been visiting the facility weekly and had given explicit instructions: betadine was to be applied liberally to Resident 56's heel. A barrier was to be placed under his buttocks before wound care began. The wound surface was to be cleaned starting at the center and moving outward in continuous circular motion.
Nurse 2 did the wound care instead. She did not apply the betadine. She did not re-clean the buttock wound after repositioning the resident onto his brief. The Wound Care Nurse, who was present, knew Nurse 2 had skipped the betadine treatment. She said nothing at the time. She stated to inspectors that Nurse 2 "did not provide this treatment" but had claimed she did.
The administrator acknowledged to inspectors that Nurse 2 was nervous. She said Nurse 2 was knowledgeable about wound care but was rattled by having the Wound Care Nurse and surveyors in the room watching. The administrator confirmed she had been told about the wound care problems on August 14, the day before inspectors arrived.
The Director of Nursing told inspectors she did not believe the wound needed to be re-cleaned after Resident 56 was placed back on his brief. She said she was unaware the wound NP had ordered betadine to be used liberally. She also said she did not think wounds had to be cleaned from center outward, which was the technique the NP had been teaching staff during her weekly visits.
Then she said that betadine was difficult to see on Resident 56 because he was a person of color.
The comment appears in the inspection record without elaboration or correction from anyone present. The inspection report classifies the violation as causing minimal harm or potential for actual harm, affecting a few residents.
The Wound Care Nurse told inspectors she had been providing education on correct technique to the nursing staff during those weekly visits. Whether that education reached Nurse 2 in any meaningful way, or whether the DON had absorbed it at all, is not resolved in the record.
What the record does show: a nurse performed wound care incorrectly on an open heel wound, told a colleague it had been done right, and the facility's top nursing official responded to the investigation by questioning both the wound care protocol and whether the color of a resident's skin made a treatment hard to assess.
Resident 56's wounds, and his condition following the inspection, are not described further in the report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gates Health and Rehabilitation Center from 2025-08-15 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Gates Health and Rehabilitation Center in Gatesville, NC was cited for violations during a health inspection on August 15, 2025.
The inspection, completed August 15, 2025, was triggered by a complaint.
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.