Lenoir Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Lenoir Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 13, 2025

  Based on record review, interviews with staff, Nurse Practitioner (NP), Medical Director, Drug Enforcement Administration (DEA) agent, Adult Protective Services (APS) Supervisor, and hospital Social Worker the facility failed to protect Resident #1's right to be free an injury of unknown source; and abuse/neglect. During the investigation the source of injury to Resident #1 was not observed by anyone, the source of injury could not be explained by the resident, and the injury was suspicious due to the unexplained rapid change in condition that was later identified as dehydration, therefore no perpetrator was identified. Resident # 1 was dependent on staff. On 01/27/2025, Resident #1's family member was visiting with the resident. […]

• Immediate jeopardy, isolatedF689Jul 9, 2021

  Based on observations, record review, and resident, staff, Legal Guardian, [CONDITION(S)] Nurse and Nurse Practitioner interviews the facility failed to prevent Resident #49's unauthorized and unsupervised exit from the facility. Resident #49 was ruled incompetent, had a legal guardian and had verbalized the desire to leave to several staff members. This affected 1 of 3 residents (Resident #49) reviewed for supervision to prevent accidents. Resident #49 was unsupervised and eloped from the facility's fenced in patio/smoking area the night of 6/17/21. The facility failed to communicate the 6/17/21 elopement to the [CONDITION(S)] center and Resident #49 was left unsupervised outside the [CONDITION(S)] center waiting on transportation on 6/25/21. […]

• Actual harm, patternF550Jul 9, 2021

  Based on record review, observations and resident and staff interviews, the facility failed to provide incontinence care to 4 of 4 residents (Resident #5, Resident #66, Resident #36, and Resident #35) reviewed for incontinence. The residents expressed feelings of being upset, humiliated, being forgotten about and feeling like the staff members didn't care about them. The findings included: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 was cognitively intact, required extensive physical assistance with bed mobility, toilet use and personal hygiene. […]

• Actual harm, patternF725Jul 9, 2021

  Based on observations, record reviews, resident and staff interviews, the facility failed to provide sufficient nursing staff, resulting in missed showers for dependent residents (Resident #'s 238, 66, 48, 71, 30, 36, and 60), and incontinence care not being provided (Resident #'s 5, 66, 36 and 35) for 10 of 10 residents reviewed for staffing. The findings included: This tag is cross referred to: 1. F 550: Based on record review, observations and resident and staff interviews, the facility failed to provide incontinence care to 4 of 4 residents (Resident #5, Resident #66, Resident #36, and Resident #35) reviewed for incontinence. The residents expressed feelings of being upset, humiliated, being forgotten about and feeling like the staff members didn't care about them. 2. […]

• Actual harm, isolatedF760Feb 5, 2026

  Based on observation, record review, staff, resident, Nurse Practitioner, Medical Director, Pharmacist, and Regional Pharmacy Consultant interviews, the facility failed to ensure a resident was free of significant medication errors when they failed to administer the medication Gabapentin for diabetic polyneuropathy (a chronic nerve disorder caused by long-term high blood sugar in diabetes, leading to damage of multiple peripheral nerves, especially in the feet and legs) for 1 of 3 residents reviewed for medication errors (Resident #1). Resident #1 missed a total of 8 doses of Gabapentin over a 4-day period. Resident #1 stated the pain in his legs was extremely bad and rated his pain at a 10 on a 0-10 scale (0 is no pain 10 is worst pain). […]