Gastonia Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Gastonia Health & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 13, 2023

  Based on record review and resident and staff interviews the facility failed to protect a resident's right to be free from abuse for 1 of 1 resident (Resident #1). Resident # 1 reported she started to cry, was scared, was upset the aide was hurting her. The findings included: Resident #1 was originally admitted to the facility on [DATE] with diagnoses which included muscle weakness, hypertension, lack of coordination, and renal failure. Diagnoses further revealed Resident #1 had a fracture to the right tibia dated 06/30/23 with orders to wear a brace. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact and required two plus assist with transfers. The MDS further revealed Resident #1 was not coded for behaviors. […]

• Immediate jeopardy, isolatedF607Sep 13, 2023

  Based on record review, and resident and staff interviews, the facility failed to follow their abuse policy for protection and reporting. Nurse Aide (NA) #2 failed to protect the resident from further abuse and immediately report abuse to the Administrator. This deficient practice affected one of one resident reviewed for abuse (Resident #1). The findings included: A review of the facility policy and procedure titled North Carolina Resident Abuse, with a revised date of 10/03/22 read in part facility staff must immediately report all such allegations to the Administrator/ Abuse Coordinator. The Administrator/ Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy. […]

• Immediate jeopardy, isolatedF580Feb 17, 2022

  Based on record reviews, responsible party, staff, and Nurse Practitioner interviews, the facility failed to notify the physician of the deterioration of a stage 2 decubitus ulcer (also known as a bed sore that is an injury to the skin and underlying tissues resulting from prolonged pressure on the area) to a stage 4 decubitus ulcer with tunneling and [CONDITION(S)]. The facility also failed to notify the Responsible Party (RP) of the development and deterioration of a pressure ulcer. This was for 1 of 3 residents (Resident #106) reviewed for notification of changes. Immediate jeopardy began on [DATE] when Resident #106 was observed by staff with a deteriorated pressure ulcer with tunneling of the wound and staff failed to notify the physician. […]

• Immediate jeopardy, isolatedF686Feb 17, 2022

  Based on observations, record reviews, staff, Nurse Practitioner, and Wound Physician interviews, the facility failed to complete skin assessments as ordered, effectively assess, and monitor a pressure ulcer, and ensure treatments were ordered by the Nurse Practitioner in accordance with the treatment plan (Resident #106). Resident #106 was hospitalized on [DATE] with a stage 4 pressure ulcer (full-thickness skin and tissue loss) with tunneling (passageway of tissue destruction under the skin surface). The facility also failed to provide pressure ulcer care as ordered by the physician (Resident #44). This was for 2 of 3 residents reviewed for pressure ulcers (Residents #106 and #44). […]

• Actual harm, isolatedF689Oct 23, 2025

  Based on observation, record review, and resident, staff, manufacturer 's representative, Nurse Practitioner (NP) and Medical Director interviews, the facility failed to: a.) supervise Resident #1 during a shower when Nurse Aide (NA) #1 turned away from Resident #1 to gather supplies on 09/18/25 and Resident #1 fell from the shower chair to the shower room floor. No pain or injury was noted from this incident; b.) provide a safe transfer for Resident #1 when NA #1 was transferring the resident from the bed to wheelchair using the mechanical lift. During the transfer and while Resident #1 was suspended approximately 4 to 5 feet from the floor, the lift tilted to one side and the resident fell while still in the sling onto the floor on her back. […]