Gastonia Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to submit a request for an evaluation for a Level II Preadmission Screening and Resident Review (PASRR) for residents with new mental health diagnoses for 6 of 6 residents (Resident #8, Resident #9, Resident #18, Resident #19, Resident #22, and Resident #42) reviewed for PASRR.The findings include:a. Review of Resident #8's medical record revealed PASRR level I was completed on 3/06/24 prior to admission with a recommendation to resubmit paperwork for PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. Resident #8 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, bipolar disorder, and major depressive disorder.There was no evidence in the medical record that a request was submitted for an evaluation for Level II PASRR. b. Review of Resident #9's medical record revealed PASRR level I was completed on 2/03/25 prior to admission to the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the Nurse Aide Registry forms, and staff interviews, the facility failed to monitor the North Carolina (NC) Nurse Aide Registry to ensure that 1 of 37 Nursing Assistants (NA) that were employed at the facility remained listed on the on the NC Nurse Aide Registry with an active Nurse Aide I recertification (NA#1).The findings included:NA #1 was hired by the facility on [DATE] to work with residents in need of care and treatment. Review of NA #1's personnel file indicated that NA #1's Nurse Aide Certification had expired on [DATE]. A review of the staffing schedule sheets from [DATE] to [DATE] revealed NA #1 had worked with an expired Nurse Aide Certification during the timeframe of schedules reviewed. On [DATE] the Administrator was notified that NA#1's Nurse Aide Certification had expired on [DATE], and NA #1's timecard for [DATE] was requested. Review of NA #1's timecard for [DATE] revealed NA #1 had worked the following days and time at the facility after her Nurse Aide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and resident and staff interviews, the facility failed to provide incontinence care to a resident prior to her wetting through her brief, turn sheet, and bed sheet for 1 of 3 dependent residents reviewed for activities of daily living (ADL) (Resident #1). The findings included:Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included atrial fibrillation, diabetes mellitus, decreased mobility, osteoarthritis and non-Alzheimer's dementia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact with no behaviors and no impairment of her upper or lower extremities and used a wheelchair for mobility. The assessment also revealed the resident was dependent for toileting, required 2 persons assistance with toileting and was incontinent of both bladder and bowel.A urinary incontinence care plan last revised on 10/14/25 revealed Resident #1 was incontinent of urine. The goal was for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to develop comprehensive individualized care plans in activities of daily living (ADL) for 1 of 4 residents (Resident #47). Findings included: Resident #47 was admitted to the facility on [DATE] with diagnoses which included non-Alzheimer's dementia. Resident #47's quarterly Minimum Data Set (MDS) dated [DATE] revealed he had moderately impaired cognition and displayed no moods or rejection of care. He was coded for partial assistance with oral hygiene. Resident #47's care plan dated 6/30/24 had a problem category for ADL Functional Status related to weakness and limited mobility. Approaches included assisting with activities of daily living, dressing, grooming, toileting, feeding and oral care. There was no denture care noted on the care plan. Resident #47 was not interviewable. An interview with Nurse #1 conducted in conjunction with an observation of Resident #47 on 10/22/24 at 12:49 PM revealed she was unaware if Resident #47 had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to provide oral care for 1 of 4 dependent residents reviewed for activities of daily living (Resident #47). Findings included: Resident # 47 was admitted to the facility on [DATE] with diagnoses which included non-Alzheimer's dementia. Resident #47's quarterly Minimum Data Set (MDS) dated [DATE] revealed he had moderately impaired cognition. He was coded for partial staff assistance with oral hygiene. He was coded for no behaviors or rejection of care. Resident #47's care plan dated 6/30/24 had a problem category for ADL Functional Status related to weakness and limited mobility. Approaches included assisting with activities of daily living to include oral care. There was no other oral care or denture care noted on the care plan. Resident #47 was not interviewable. An interview with Nurse #1 conducted in conjunction with an observation of Resident #47 on 10/22/24 at 12:49 PM revealed she was unaware if Resident #47 had dentures. She…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews the facility failed to remove an unidentified resident's medications, failed to remove loose and unsecure pills and failed to remove debris of paper shavings and rubber bands from medication cart (medication cart #2) and failed to remove loose and unidentified pills and debris of paper shavings and rubber bands from medication cart (medication cart #1) for 2 of 2 medication carts reviewed for medication storage. The findings included: a. On 10/23/24 at 3:12 PM an observation was made of medication cart #2 along with Nurse #1. Stored in the narcotic drawer was a resident's personal weekly medication container that contained no resident name or information that had 6 pills in the Thursday's slot, 7 pills in the Friday's slot and 7 pills in the Saturday's slot. The medication cart also had 21 loose and unidentifiable pills in the bottom of the drawers along with debris of paper shavings and rubber bands. An interview was conducted with Nurse #1 on 10/23/24 at 3:12 PM. The Nurse explained that the medication container was in the narcotic box…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation surveys that occurred on 02/17/22 and 07/12/23. This failure was for two deficiencies that were originally cited in the areas of Nutrition/Hydration Status Maintenance (F692) and Infection Prevention and Control (F880) and were subsequently recited on the current complaint investigation and revisit survey of 09/13/23. The repeat deficiencies during multiple surveys of record show a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referred to: F692: Based on observations, record review, resident, and staff interviews, the facility failed to follow a physician order for a nutritional supplement for 1 of 3 sampled residents reviewed for nutrition (Resident #2). During the recertification and complaint investigation survey conducted on 07/12/23, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record reviews, and staff interviews, the facility failed to follow their COVID-19 Testing Guidance within their Policy and Procedure when the staff failed to provide testing of residents and staff after a positive COVID-19 test was obtained on a symptomatic resident (Resident #5) on 09/02/23 at 1:30 AM. The findings included: Review of the facility's COVID Testing Guidance under section Testing Summary - under the column Testing Trigger - newly identified COVID-19 positive staff or resident in a facility that is unable to identify close contacts/Broad Based approach. Under the column Staff/Healthcare Personnel (HCP), the guidance read, Test all staff, regardless of vaccination status, facility-wide or at a group level if staff are assigned to a specific location where the new case occurred (e.g., unit, floor, or other specific area(s) of the facility). If negative, test again 48 hours later, and if negative 48 hours after the second test. In general, testing should continue every 3-7 days until 14 days have passed without any new cases. Under the column…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident, and staff interviews, the facility failed to follow a physician order for a nutritional supplement for 1 of 3 sampled residents reviewed for nutrition (Resident #2). The findings included: 1. Resident #2 was admitted to the facility on [DATE]. A care plan dated 05/25/23 had a focus area for increased nutrition/hydration due to poor by mouth intake. The goal was for the resident to be adequately nourished within limits of her end stage illness. Interventions included providing supplements per order. An annual Minimum Data Set, dated [DATE] revealed Resident #2 was cognitively intact. The resident was coded as receiving a therapeutic diet. Resident #2 was not coded for weight loss or weight gain. A Physician order dated 12/01/22 read, Nutritional supplement three times a day 90 milliliters three times daily, offer non-vanilla flavor, unable to swallow vanilla. Resident #2's Medication Administration Record (MAR) dated September 2023 revealed a physician order dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection or injury for 1 of 3 residents (Resident #40) reviewed with indwelling catheters. The findings included: Resident #40 was admitted to the facility on [DATE]. Resident #40 was currently being followed by Hospice and had an indwelling urinary catheter for comfort. A review of Resident #40's care plan dated 03/21/2023 revealed a focus area for indwelling urinary catheter. The interventions included check tubing for kinks each shift, and position catheter bag and tubing below the level of the bladder and provide a privacy cover. A review of Resident #40's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, required extensive to total assistance with all activities of daily living (ADL) except eating and had an indwelling urinary catheter. A review of the physician orders for Resident #40 dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interview the facility failed to follow a physician order for a nutritional supplement for 2 of 2 sampled residents reviewed (Resident #20 and Resident #7). The findings included: 1. Resident #20 was admitted into the facility on [DATE]. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #20 was alert and oriented. The resident was coded as receiving a therapeutic diet. Resident #20 was not coded for weight loss or weight gain. A care plan dated 05/25/23 had a focus area for increased nutrition/hydration due to poor by mouth intake. The goal was for the resident to be adequately nourished within limits of her end stage illness. Interventions included providing supplements per order. Resident #20's Medication Administration Record (MAR) dated July 2023 revealed a physician order dated 12/01/22 which read, Nutritional supplement three times a day 90 milliliter's three times daily. On 07/12/23 Nurse #1 documented Resident #20 had refused the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident interview, and staff interviews the facility failed to maintain a continuous supply of supplemental oxygen for 1 of 1 resident reviewed for oxygen therapy (Resident #246). The findings included: Resident #246 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD) with exacerbation and abnormalities of breathing. A physician order dated 07/03/23 revealed Resident #246 was ordered supplemental oxygen at 2 liters per minute continuously every day and night shift. The admission evaluation dated 07/05/23 revealed Resident #246 was alert and oriented and required one person assist for majority of activities of daily living (ADL). The admission evaluation further revealed Resident #246 was coded for oxygen use. An observation and interview conducted with Resident #246 on 07/10/23 at 11:50 AM revealed Resident #246 was sitting in her bed with oxygen running through nasal cannula. Resident #246 stated she had told…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.