Gastonia Health & Rehab Center

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

another NA to change her but said she never came back before NA #5 and NA #6 came in to get her ready to get up in the wheelchair and they had changed her brief. Resident #1 stated they usually changed her two to three times during the night because she urinated frequently but said they had only changed her once after midnight at 1:30 AM. Resident #1 indicated she knew she was wet because when she woke up sometime between 5:30 AM and 6:00 AM she felt her wet sheet against her leg and it was cold. The resident further indicated she had eaten her breakfast in bed in her wet brief but said she was more concerned with eating because her blood sugar had been low earlier at 6:00 AM. A telephone interview on 10/14/25 at 3:20 PM with NA #8 who was assigned to care for Resident #1 during the night shift on 10/14/25 revealed she had not changed Resident #1 after 1:30 AM. She stated it had been a busy night and she had gone to change the resident around 6:00 AM and the resident was shaking and told NA #8

she thought her blood sugar was low and asked her to get the nurse. NA #8 stated she was going back to change Resident #1 around 6:30 AM to 6:45 AM and said her coworker had left shift early and was not available to assist her so she had reported off to 1st shift (could not recall who she reported off to) that Resident #1 needed to be changed. NA #8 further stated Resident #1 should have been changed one additional time during the night but said it was difficult when there were only 2 NAs working to get both NAs

in one room to change the resident. NA #8 indicated she had not asked the nurse for assistance because

she had been busy with other tasks but said that she probably should have asked her to assist and changed the resident.An interview on 10/14/25 at 11:10 AM with NA #5 and NA #6 revealed they were not assigned to care for Resident #1 but said they had been asked to lift her out of bed into her wheelchair by Unit Manager #1. NA #5 and NA #6 both stated when they went into the room to get her ready for the lift,

they found her wet through her brief and turn sheet and onto her bed sheet, so they had provided her with incontinence care prior to lifting her in the mechanical lift into her wheelchair. Both NAs stated they were not assigned to care for the resident but had been asked to get her up, so they had changed her prior to getting her up in the wheelchair.An interview on 10/14/25 at 2:08 PM with NA #7 who was assigned to care for Resident #1 during the 7:00 AM to 7:00 PM shift revealed she was working her way towards Resident #1 but had not gotten to her before NA #5 and NA #6 had changed her to get her up in her wheelchair. NA #7 stated Resident #1 had told her that she had not been changed since 1:30 AM and said the resident should have been changed twice more during the night shift. NA #7 stated she had to wait until there was another NA available to help her change Resident #1 and said Unit Manager #1 had pulled an NA from the rehabilitation floor to come assist with Resident #1's care and getting her up in the wheelchair. NA #7 further stated no one had reported off to her that the resident had not been changed but once during the night but said the resident had told her and she was waiting for another staff member's assistance to get her changed.An interview with Unit Manager #1 on 10/14/25 at 3:35 PM revealed she was not aware that Resident #1 had gone from 1:30 AM to 10:30 AM on 10/14/25 without being provided incontinence care.

She stated no one had asked her for assistance and said she assisted with care to residents all the time.

Unit Manager #1 stated NA #7 was an agency NA and probably was waiting until one of the other NAs was free to assist. Unit Manager #1 further stated it was their expectation that residents be rounded on every 2 to 3 hours and checked and changed as needed. She said that no resident should go from 1:30 AM to 10:30 AM without being checked and changed several times. The Director of Nursing (DON) was not available for interview.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Gastonia Health & Rehab Center

1770 Oak Hollow Road Gastonia, NC 28054

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident #1 returned to the facility from the hospital on the evening of 09/29/25 and had a follow up appointment at the orthopedic specialist's office on 10/01/25. The DON further stated there had been no other incidents since 09/29/25 with mechanical lifts. The DON indicated the NAs were responsible for determining the sling size a resident required for mechanical lifts. She explained that each sling had a weight capacity on the tag inside the sling and the NAs measured the resident from the base of their spine to the top of their shoulder with a tape measure to determine if the sling was an appropriate fit for the resident. She further explained that a large sling had a maximum weight capacity of 500 pounds and an extra-large sling had a maximum weight capacity of 850 pounds and the extra-large sling was the one used for Resident #1. According to the DON the root cause of Resident #1's fall on 09/29/25 was only one staff member transferring the resident in the mechanical lift. c. Review of the manufacturer's information for the brand of mechanical lift used by the facility revealed it had a lift capacity of 600 pounds. There was also a placard on the mechanical lift that indicated the weight capacity as 600 pounds. In addition, the manufacturer's recommendations stated the following: Slings are made specifically for use with the mechanical patient lifts. For the safety of the patient, DO NOT intermix slings and patient mechanical lifts of different manufacturers. According to the manufacturer's recommendations the slings for the brand of mechanical lift at the facility come in sizes extra-small through extra extra-large and come with their own identification information on the label. The information on the label included model reference number, type of sling, size, date of manufacture, care instructions, weight capacity and an identification picture of the sling. The extra-small through large slings had a weight capacity of 500 pounds. The extra-large sling had a weight capacity of 550

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