Wesley Pines Retirement Community

Federal health inspectors cited Wesley Pines Retirement Community in Lumberton, NC for a deficiency under regulatory tag F-F0580 during a standard health inspection conducted on 2026-01-30.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

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 7 deficiencies cited during this inspection of Wesley Pines Retirement Community.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2026-02-26.

Federal health inspectors cited Wesley Pines Retirement Community in Lumberton, NC for a deficiency under regulatory tag F-F0658 during a standard health inspection conducted on 2026-01-30.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Ensure services provided by the nursing facility meet professional standards of quality.

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 7 deficiencies cited during this inspection of Wesley Pines Retirement Community.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2026-02-26.

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

family wanted to wait until the Hospice provider came to the facility and assessed the resident. When the Hospice provider and EMS (Emergency Management Systems) arrived, the resident was taken to the hospital. Nurse #6 stated she was familiar with Resident #5 and knew he became combative during ADL care. She remarked that since the last fall having two staff members present for all care has helped along with the side rails on the bed for the resident to grab during care. Nurse #6 could not recall NA #2 asking for help on the night he fell. She stated the accident could have potentially been avoided had two staff members been in the room.Review of the hospital emergency department physician progress note dated 04/10/25 revealed Resident #5 was treated for a soft tissue skin tear to the forehead. The wound was cleansed and steri-strips were applied. Diagnostic imaging of the head was nonacute. A plain film of the pelvis was also ordered and showed no acute fracture. A head CT exam was performed and was negative for any new injury. Resident #5 was released back to the nursing home from the emergency room on [DATE REDACTED] to follow up with his provider as needed.An interview with the Nurse Practitioner was conducted on 1/29/26 at 10:32 AM. Stated she cared for Resident #5. She stated she assessed Resident #5 the next day

on 04/11/25 and he was at his baseline with no new issues or concerns.An interview was conducted with

the Director of Nursing (DON) on 01/29/26 at 9:45 AM. She stated she was notified on 04/10/25 that Resident #5 had fallen during care. She explained that when she returned to work on 04/11/25 she interviewed NA #2 to learn what had happened. The DON learned from the interview with NA #2 that NA #2 had called for help on her radio from other staff members when Resident #5 became combative and agitated during incontinence care. While NA #2 waited for assistance to arrive she was able to calm the resident and NA #2 resumed incontinence care. The DON stated that NA #2 explained to her that Resident #5 was holding onto the bed frame during care and pulled himself off the bed. The [NAME] stated that NA #2 who was standing behind him to wipe his rectal area could not hold onto him as he fell. The DON determined there had been no deviation from NA #2's practice identified because Resident #5 was not determined to be a 2 person assist for incontinent care prior to the fall on 04/10/25 and NAs were trained according to the facility procedure guide to turn a resident on his or her side away from the caregiver. The DON explained NA #2 had worked with Resident #5 for many years and she was usually able to calm Resident #5 and provide incontinent care to him. The DON reiterated that during the second brief change NA #2 had been able to calm the resident before she proceeded but that Resident #5 then pulled himself off the bed.An interview was conducted with the Administrator on 01/28/26 at 3:43 PM. She stated she conducted a full investigation and NA #2 explained to her that it was dinnertime and NA #2 wanted to provide incontinence care to the resident prior to the evening meal being served. NA #2 explained to the Administrator that Resident #5 began to be resistive to care so she called over the radio for assistance and while NA #2 waited for assistance the resident calmed down so she resumed care. The Administrator stated that the fall may have potentially been avoided had there been another staff member on the other side of the bed or if he had quarter side rails to grab onto, but the side rails had been removed previously

during a re-evaluation of side rail use assessment that determined that it was unsafe to have rails on the bed because he was putting his arms through the bed rails.

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Federal health inspectors cited Wesley Pines Retirement Community in Lumberton, NC for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2026-01-30.

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 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 7 deficiencies cited during this inspection of Wesley Pines Retirement Community.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2026-02-26.

Federal health inspectors cited Wesley Pines Retirement Community in Lumberton, NC for a deficiency under regulatory tag F-F0814 during a standard health inspection conducted on 2026-01-30.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Dispose of garbage and refuse properly.

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 7 deficiencies cited during this inspection of Wesley Pines Retirement Community.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2026-02-26.

Federal health inspectors cited Wesley Pines Retirement Community in Lumberton, NC for a deficiency under regulatory tag F-F0842 during a standard health inspection conducted on 2026-01-30.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

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 7 deficiencies cited during this inspection of Wesley Pines Retirement Community.

Correction Status: No revisit needed.

The facility reported correction as of 2026-02-26.

Federal health inspectors cited Wesley Pines Retirement Community in Lumberton, NC for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2026-01-30.

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 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 7 deficiencies cited during this inspection of Wesley Pines Retirement Community.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2026-02-26.