Lenoir Health And Rehabilitation Center
Inspection Findings
F-Tag F0552
Federal health inspectors cited Lenoir Health and Rehabilitation Center in Lenoir, NC for a deficiency under regulatory tag F-F0552 during a standard health inspection conducted on 2025-11-24.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Ensure that residents are fully informed and understand their health status, care and treatments.
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 11 deficiencies cited during this inspection of Lenoir Health and Rehabilitation Center.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2025-12-19.
F-Tag F0580
F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
familiar with Resident #63. Nurse #1 stated one night in October 2025, she did not recall the specific date,
she was worried about Resident #63 having a high blood sugar over 400, and no orders for sliding scale insulin coverage at that time. Nurse #1 stated she asked another nurse, she could not remember which one, what to do and the nurse told her to turn off the tube feeding. Nurse #1 stated she thought they had been turning off the tube feeding early due to high blood sugars, so Nurse #1 turned off Resident #63's tube feeding and did not notify the provider.
During a telephone interview on 11/18/2025 at 7:05 AM Unit Manager #4 stated sometime around mid-October Nurse #1 reported to Unit Manager #4 that Resident #63's tube feeding had been held due to high blood sugar, that other nurses had done it since Resident #63 had no sliding scale insulin coverage for elevated blood sugars. Unit Manager #4 stated she told Nurse #1 that a tube feeding was not supposed to be turned off for elevated blood sugars, and a provider should have been notified. Unit Manager #4 stated
she reported the information the NP #2 who gave new sliding scale insulin coverage orders, and to the Director of Nursing (DON).
Review of a progress note from the NP #2 dated 10/13/2025 revealed in part, NP #2 had seen Resident #63 on 10/13/2025 regarding weight loss, with an additional note that revealed NP #2 had a telephone encounter 10/15/2025 and spoke with bedside nurse who stated that Resident #63 received before meals and a bedtime blood glucose checks without any sliding scale insulin coverage in place. Per nurse- tube feeding was stopped by night shift nurse due to blood sugar of 446. Per nursing reports tube feeding gets turned off frequently due to elevated blood sugars. Reviewed blood sugars and added sliding scale insulin coverage and would continue to monitor and adjust plan of care as needed.
During a telephone interview on 11/17/2025 at 4:29 PM the Nurse Practitioner (NP) #2 stated she was notified by the facility that Resident #63's had weight loss in early October 2025 and Resident #63's tube feeding rate was reviewed by the RD and the tube feeding rate was increased. The NP #2 stated near the middle of October, Unit Manager #4 reported that when Resident #63 had elevated blood sugars the nurses had turned off Resident #63's tube feeding instead of calling the provider to get orders for insulin. NP #2 stated she expected nurses to administer tube feedings as ordered and should contact a provider to get an order for a tube feeding to be turned off early.
During an interview on 11/19/2025 at 4:50 PM the Medical Director stated he expected tube feedings to be administered as ordered and to be contacted by the nurse to receive orders to turn a tube feeding off early, and for a provider to be notified for blood sugars over 400, if a resident did not have an order for coverage.
During an interview on 11/18/2025 at 8:45 AM the DON stated a physician ordered tube feeding should not be turned off early unless the nurse contacted the provider and received orders to turn the feeding off early.
During an interview on 11/20/2025 at 7:10 AM the Administrator stated she expected nurses to administer tube feedings as ordered, and to contact a provider for an order to turn a tube feeding off early.
FORM CMS-2567 (02/99) Previous Versions Obsolete
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
11/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lenoir Health and Rehabilitation Center
322 Nuway Circle Lenoir, NC 28645
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-Tag F0607
F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
reported to Unit Manager #1 that the night shift NAs were rough with her and dug their hand into her side
during incontinence care. Unit Manager #1 revealed she did not know what NAs had worked with Resident #23 the night before. At that time, a bruise was noted to Resident #23's left lower quadrant of her abdomen.
Unit Manager #1 stated she did not notify the Administrator and assumed Unit Manager #2 had. Unit Manager #1 stated that she was new to the role of Unit Manager and had not been educated in the supervisory reporting process of the Unit Manager role. A review of the initial allegation report revealed an abuse allegation in which NA #1 and NA #2 were allegedly rough with Resident #23 while providing incontinent care at 5:45 AM on 11/15/25. The Administrator was notified of the allegation on 11/16/25 at 1:40 PM. The Administrator notified law enforcement and Adult Protective Services on 11/16/25 at 2:18 PM.
The completed initial allegation report was submitted to the State Agency on 11/16/25 at 2:38 PM. A review of staffing schedules revealed the following: NA #1 and NA #2 worked from 11:00 PM on 11/14/25 to 7:00 AM on 11/15/25. NA #1 was scheduled to work from 3:00 PM on 11/1625 until 7:00 AM on 11/17/25. NA #2 was not scheduled to work after 11/15/25 due to scheduled time off. A joint interview with the Regional Nurse Consultant and Administrator conducted on 11/16/25 at 3:32 PM revealed that the Administrator identified NA #3 (agency staff) as the alleged perpetrator of the staff to resident abuse. The agency had been contacted, and NA #3 had been terminated from the facility. This Surveyor revealed to the Administrator that NA #1 and NA #2 were the alleged perpetrators and worked with Resident #23 on 11/15/25 and not NA #3. The Administrator and Regional Nurse Consultant were notified by this Surveyor that NA #1 was in the building preparing to start her shift at that time. The Administrator stated they were not aware that NA #1 was one of the alleged perpetrators or that she was currently in the facility working and would be sent home immediately pending the investigation. The Administrator stated that NA #2 was not working due to scheduled time off and would remain out until the investigation was completed. A subsequent interview with the Administrator was conducted on 11/20/25 at 10:19 AM. The Administrator stated the staff did not inform her about the allegation of staff to resident abuse involving Resident #23 in a timely manner. The incident occurred on 11/15/25 at 5:45 AM and she was notified on 11/16/25 at 1:40 PM.
The Administrator stated the staff should have notified her immediately of any suspected or witnessed allegation of abuse or neglect. The Administrator indicated that an investigation would have been immediately initiated had staff notified her when it occurred. The Administrator explained that abuse and neglect training were provided annually to all staff with additional training when needed. The Administrator further added one on one education was provided to staff who did not report the incident within the appropriate time frame. The Administrator indicated that NA #1 and NA #2 had been suspended during the investigation. NA #1 was an agency staff and was terminated from the facility. NA #2 was returning to work
on her next scheduled day. The Administrator stated the allegation was unsubstantiated and investigation report had been submitted to the State Agency.
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
11/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lenoir Health and Rehabilitation Center
322 Nuway Circle Lenoir, NC 28645
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-Tag F0637
Federal health inspectors cited Lenoir Health and Rehabilitation Center in Lenoir, NC for a deficiency under regulatory tag F-F0637 during a standard health inspection conducted on 2025-11-24.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Assess the resident when there is a significant change in condition
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 11 deficiencies cited during this inspection of Lenoir Health and Rehabilitation Center.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2025-12-19.
F-Tag F0684
F 0684
questions regarding resident wound care could be directed to the Unit Manager.
Level of Harm - Minimal harm or potential for actual harm
An interview was conducted with Unit Manager #1 on 11/16/25 at 11:25 AM. She stated the facility Wound Nurse performed resident wound care Monday through Friday and nursing staff were responsible for performing wound care scheduled for the evenings and on weekends. She revealed she was not aware of nursing staff refusing to perform wound care or resident wound care not being performed as ordered. UM #1 stated she would investigate why Resident #105's wound care had not been performed as ordered on
the weekends and would speak with nursing staff immediately to ensure Resident #105's wound dressing was changed as soon as possible.
Residents Affected - Few
An interview was conducted with the Nurse Practitioner (NP) on 11/18/25 at 1:29 PM. The NP revealed that
she expected the facility nursing staff to follow her wound care orders as written. She stated she also expected the nursing staff to notify her with any questions or concerns regarding any resident's wound care orders and to inform her of any issues involving resident's wounds. The NP revealed Resident #105's wound care should be provided daily and as needed especially if the wound was draining to keep the wound from becoming infected.
An interview on 11/19/25 at 9:31 AM with the Director of Nursing (DON). The DON stated she expected the wound treatments to be done as ordered. She stated she also expected that if nursing staff were not able to complete a wound treatment that they notify their nursing supervisor immediately. The DON revealed Resident #105 should have received his wound treatments daily and as needed per his wound orders.
An interview was conducted with the facility's Medical Director on 11/19/25 at 4:53 PM. The Medical Director stated that he expected the nursing staff to follow physician orders for dressing changes and wound care.
An interview was conducted with the Administrator on 11/20/25 at 11:01 AM. The Administrator revealed that she expected nursing staff to follow all orders, procedures, and protocols for providing resident wound care and should have provided Resident # wound care as ordered. She stated if nursing staff had questions regarding wound care orders or were not able to provide a resident's wound care as ordered then she expected them to inform their supervisor immediately.
FORM CMS-2567 (02/99) Previous Versions Obsolete
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
11/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lenoir Health and Rehabilitation Center
322 Nuway Circle Lenoir, NC 28645
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-Tag F0693
Federal health inspectors cited Lenoir Health and Rehabilitation Center in Lenoir, NC for a deficiency under regulatory tag F-F0693 during a standard health inspection conducted on 2025-11-24.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 11 deficiencies cited during this inspection of Lenoir Health and Rehabilitation Center.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2025-12-19.
F-Tag F0695
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, record reviews, and Nurse Practitioner and staff interviews, the facility failed to obtain a physician's order for a resident who was admitted from the hospital on continuous oxygen (Resident #126).
The facility also failed to post cautionary signage outside of resident rooms that indicated the use of oxygen for 1 of 5 residents reviewed for respiratory care (Resident #126).Findings included: Resident #126 was admitted on [DATE REDACTED] with diagnoses that included pneumonia.A review of Resident #126's admission orders revealed that Unit Manager #2 completed the admission.Resident #126's physician orders revealed no order for oxygen use. Resident #126's admission Minimum Data Set (MDS) dated [DATE REDACTED] revealed that Resident #126 was admitted [DATE REDACTED] and MDS was in progress at time of review. No oxygen or respiratory information was complete. A review of Resident #126's care plan updated on 11/14/25 revealed a plan for risk of respiratory complications. The stated goal was that Resident #126 would be free from respiratory complications. Interventions included administer oxygen as ordered, monitor for signs of respiratory distress, and check vital signs as needed. a. An observation of Resident #126 in her room on 11/16/25 at 12:41 PM revealed oxygen concentrator in use via nasal cannula at 2 liters per minute. A second
observation of Resident #126 in her room on 11/17/25 7:54 AM revealed oxygen concentrator in use via nasal cannula at 2 liters per minute. A third observation of Resident #126 in her room on 11/18/25 7:42 AM revealed the oxygen concentrator in use via nasal cannula at 2 liters per minute. b. An observation of Resident #126 in her room on 11/16/25 at 12:41 PM revealed no cautionary oxygen in use signage was noted outside of Resident #126's room indicating oxygen was in use.A second observation of Resident #126 in her room on 11/17/25 7:54 AM revealed no cautionary oxygen in use signage outside of Resident #126's room indicating oxygen was in use.A third observation of Resident #126 in her room on 11/18/25 7:42 AM revealed no cautionary oxygen in use signage outside of Resident #126's room indicating oxygen was in use.An interview with Medication Aide #1 was conducted on 11/18/25 at 1:08 PM. Medication Aide #1 stated Resident #126 received oxygen continuously. Medication Aide #1 indicated, she did not see an order for oxygen on the medication administration record and indicated she did not know who was responsible for applying the oxygen in use cautionary signs to resident rooms. Medication Aide #1 verbalized she had not noticed that Resident #126 did not have an oxygen in use sign on door.An interview was completed with Unit Manager #2 on 11/20/25 at 7:47 AM. Unit Manager #2 revealed that she could not recall if she completed the admission orders for Resident #126. Unit Manger #2 stated that orders were received from the hospital via discharge paperwork and entered into facility electronic medical record. Unit Manger #2 stated there were many admissions that day, and she could not remember if she initiated Resident #126's oxygen or not. Unit Manager #2 stated whoever initiated the oxygen should have placed
the cautionary signage on Resident #126's door. An interview with the Nurse Practitioner (NP) was completed on 11/18/25 at 2:28 PM. The NP stated that Resident #126 was admitted from the hospital, and any orders on discharge paperwork would be entered by the nurse admitting the resident. The NP stated that she assessed Resident #126 on Monday 11/17/25 and stated that she was on oxygen via nasal cannula at time of assessment. The NP stated that Resident #126 had no respiratory difficulty or shortness of breath on assessment. The NP stated she did not know how the order for oxygen got overlooked. An
interview was conducted with the Director of Nursing (DON) on 11/20/25 at 10:19 AM. The DON stated that oxygen orders should have been in place for oxygen use for Resident #126 prior to initiating oxygen. The DON further stated that oxygen-in-use cautionary signage should be posted outside the doors of all residents' rooms who used continuous oxygen.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
F-Tag F0732
Federal health inspectors cited Lenoir Health and Rehabilitation Center in Lenoir, NC for a deficiency under regulatory tag F-F0732 during a standard health inspection conducted on 2025-11-24.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Post nurse staffing information every day.
Scope/Severity Level B: isolated, no actual harm with potential for minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Lenoir Health and Rehabilitation Center.
Correction Status: No revisit needed.
The facility reported correction as of 2025-12-19.
F-Tag F0761
Federal health inspectors cited Lenoir Health and Rehabilitation Center in Lenoir, NC for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-11-24.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled 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 11 deficiencies cited during this inspection of Lenoir Health and Rehabilitation Center.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2025-12-19.
F-Tag F0812
Federal health inspectors cited Lenoir Health and Rehabilitation Center in Lenoir, NC for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-11-24.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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 11 deficiencies cited during this inspection of Lenoir Health and Rehabilitation Center.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2025-12-19.
F-Tag F0880
Federal health inspectors cited Lenoir Health and Rehabilitation Center in Lenoir, NC for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-11-24.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
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 11 deficiencies cited during this inspection of Lenoir Health and Rehabilitation Center.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2025-12-19.
Lenoir Health and Rehabilitation Center in Lenoir, NC inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Lenoir, NC, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Lenoir Health and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.