White Oak Manor-kings Mountain

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

clothes, under pad and sheets. She (NA #7) and NA #6 apologized and told her we were unsure of what had happened as Resident #139 was not on either of our assignments and they both had just started our shifts. NA #6 told the daughter she would go get some clean linens and bathe Resident #139. NA #7 explained while NA #6 was gone she removed the pillow from under Resident #139's knees and found a soiled brief. NA #6 notified the Unit Manager of the situation, and she came in to assess the Resident. The

interview further revealed they all worked together to get Resident #139 cleaned up and in dry clothes and linens. Resident #139 has never refused care when she was on my assignment. Three attempts were made to contact NA #5 and there was no ability to leave a voicemail, and no return call or text was received. An

interview with the Nurse/Unit Manager #7 was conducted on 08/08/25 at 3:00 PM. Nurse #7 stated Resident #139 was always incontinent of bowel and bladder. Nurse #7 reported, that several weeks ago around 3:00 PM, NA #6 told her, Resident #139 was laying in urine. She reported she went to the room and Resident #139's daughter was quite angry because her mother was soaking wet with urine. Nurse #7 reported that upon entering the room, she noticed a strong urine smell and observed Resident #139 lying

in bed with wet clothes, under pad and sheets and a soiled brief lying at the foot of her bed. There were rings around her body on the sheets and under pad where the urine had begun to dry. Nurse #7 recalled Resident #139's daughter asked her had Resident #139 been changed at all today. Nurse #7 reported she told Resident #139's daughter she had to assume Resident #139 had not from the looks of her bed. Nurse #7 stated no one had reported to her that Resident #139 had refused care during the shift. Nurse #7 reported that Resident #139 would refuse care sometimes. An interview with the Director of Nursing (DON) was conducted on 08/08/25 at 3:45 PM. The DON stated Resident #139 was incontinent of bowel and bladder. The DON indicated Resident #139's daughter made her aware of the incident the day it happened.

A grievance was filed and an investigation done which resulted in the termination of NA #5. DON reported that NA #5 reported to her during the investigation that Resident #139 had refused care all day. NA #5 did not report this to any unit manager or supervisor. An interview with the Administrator was conducted on 08/08/25 at 4:00 PM. The Administrator stated she expected staff to provide care to all residents and if care was being refused then to report that to the Unit Manager or the DON. The Administrator stated she was made aware of the situation during the investigation process and was in agreement with the decision to terminate NA #5 due to her not making anyone aware of Resident #139 refusing care and allowing her to remain wet all day.

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If continuation sheet

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

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

White Oak Manor - Kings Mountain

716 Sipes Street Kings Mountain, NC 28086

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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

neurology office. A telephone interview was attempted with Nurse #4 on 08/07/25 at 11:42 AM. Nurse #4 was not available for interview. An interview with the Administrator was conducted on 08/08/25 at 12:10 PM.

The Administrator stated the day of Resident #43's appointment, Resident #153's health information was inadvertently sent to the appointment. The health information sent incorrectly included a diagnosis list and physician orders for Resident #153, and a list of all facility residents' names, medical record numbers, room numbers, and the residents' allergies. The Administrator stated that a breach report was filed with the Department of Health and Human Services. The Administrator stated that all facility resident representatives were notified of the information breach. Resident #153's representative was notified of the specific breach of health information. The Administrator stated that Resident #43's Representative retained

the medical records. The Administrator reported that the Resident Representative was contacted repeatedly by the Administrator and by Corporate to return the medical records but refused and stated he wanted to prove a point and had not been returned.

Event ID:

Facility ID:

If continuation sheet

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

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

White Oak Manor - Kings Mountain

716 Sipes Street Kings Mountain, NC 28086

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)

Federal health inspectors cited White Oak Manor - Kings Mountain in Kings Mountain, NC for a deficiency under regulatory tag F-F0600 during a standard health inspection conducted on 2025-08-12.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Scope/Severity Level J: isolated, immediate jeopardy to resident health or safety.

This represents an immediate jeopardy situation, the most serious level of deficiency.

This was one of 9 deficiencies cited during this inspection of White Oak Manor - Kings Mountain.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-10.

Federal health inspectors cited White Oak Manor - Kings Mountain in Kings Mountain, NC for a deficiency under regulatory tag F-F0609 during a standard health inspection conducted on 2025-08-12.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of White Oak Manor - Kings Mountain.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-10.

Federal health inspectors cited White Oak Manor - Kings Mountain in Kings Mountain, NC for a deficiency under regulatory tag F-F0610 during a standard health inspection conducted on 2025-08-12.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Respond appropriately to all alleged violations.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of White Oak Manor - Kings Mountain.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-10.

Federal health inspectors cited White Oak Manor - Kings Mountain in Kings Mountain, NC for a deficiency under regulatory tag F-F0627 during a standard health inspection conducted on 2025-08-12.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of White Oak Manor - Kings Mountain.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-10.

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

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

dated [DATE REDACTED] done after the incident, revealed redness to bilateral buttocks. An interview with the Nurse/Unit Manager #7 was conducted on 08/08/25 at 3:00 PM. Nurse #7 stated Resident #139 was always incontinent of bowel and bladder. Nurse #7 reported, that several weeks ago around 3:00 PM, NA #6 told her, Resident #139 was laying in urine. She reported she went to the room and Resident #139's daughter was quite angry because her mother was soaking wet with urine. Nurse #7 reported that upon entering the room, she noticed a strong urine smell and observed Resident #139 lying in bed with wet clothes, under pad and sheets and a soiled brief lying at the foot of her bed. There were rings around her body on the sheets and under pad where the urine had begun to dry. Nurse #7 recalled Resident #139's daughter asked her had Resident #139 been changed at all today. Nurse #7 reported she told Resident #139's daughter she had to assume Resident #139 had not from the looks of her bed. Nurse #7 stated no one had reported to her that Resident #139 had refused care during the shift. Nurse #7 reported that Resident #139 would refuse care sometimes. An interview with the Director of Nursing (DON) was conducted on 08/08/25 at 3:45 PM. The DON stated Resident #139 was incontinent with bowel and bladder. The DON indicated Resident #139's daughter made her aware of the incident the day it happened.

A grievance was filed and an investigation done which resulted in the termination of NA#5. DON reported that NA #5 reported to her during the investigation that Resident #139 had refused care all day. NA #5 did not report this to any unit manager or supervisor. An interview with the Administrator was conducted on 08/08/25 at 4:00 PM. The Administrator stated she expected staff to provide care to all residents and if care is being refused then to report that to the Unit Manager or the DON. The Administrator stated she was made aware of the situation during the investigation process and was in agreement with the decision to terminate NA #5 due to her not making anyone aware of Resident #139 refusing care and allowing her to remain wet all day.

Event ID:

Facility ID:

If continuation sheet

Federal health inspectors cited White Oak Manor - Kings Mountain in Kings Mountain, NC for a deficiency under regulatory tag F-F0700 during a standard health inspection conducted on 2025-08-12.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of White Oak Manor - Kings Mountain.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-10.

Federal health inspectors cited White Oak Manor - Kings Mountain in Kings Mountain, NC for a deficiency under regulatory tag F-F0757 during a standard health inspection conducted on 2025-08-12.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure each resident’s drug regimen must be free from unnecessary drugs.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of White Oak Manor - Kings Mountain.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-10.