Inspection Reports for Pineville Rehabilitation & Living Center
1010 Lakeview Dr, Pineville, NC 28134, NC, 28134
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
131% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jun 6, 2025
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with professional standards of quality, supervision to prevent accidents, infection prevention and control, and medication administration practices at Pineville Rehabilitation and Living Center.
Findings
The facility was found deficient in ensuring Resident #9 swallowed all prescribed medications before leaving the room, failed to provide adequate supervision for storage of smoking supplies for Resident #31, and did not follow proper hand hygiene and infection control practices during wound care by Nurse #2. These deficiencies were associated with minimal harm or potential for actual harm affecting a few residents.
Deficiencies (3)
Failed to ensure Resident #9 swallowed all prescribed medications before leaving the room.
Failed to provide supervision for storage of smoking supplies for Resident #31, who kept cigarettes and lighter in his backpack contrary to facility policy.
Failed to follow hand hygiene policy during wound care; Nurse #2 did not change gloves or sanitize hands between treating two wounds on Resident #14.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Staff observed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Named in medication administration deficiency for leaving medication unattended with Resident #9 | |
| Nurse #2 | Named in infection control deficiency for improper hand hygiene during wound care on Resident #14 | |
| Assistant Director of Nursing | ADON | Interviewed regarding medication administration practices for Resident #9 |
| Director of Nursing | DON | Interviewed regarding medication administration and smoking policy compliance |
| Administrator | Interviewed regarding medication administration and smoking policy compliance |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jun 6, 2025
Visit Reason
The inspection was conducted as part of a regulatory survey to assess compliance with healthcare facility standards, including care planning, assessment accuracy, medication administration, supervision, medication storage, and infection control.
Findings
The facility was found deficient in multiple areas including failure to conduct and document care plan conferences involving residents and representatives, inaccurate coding of Minimum Data Set (MDS) assessments, failure to ensure medication administration supervision, inadequate supervision of smoking supplies, improper labeling of medication vials, and failure to follow hand hygiene protocols during wound care.
Deficiencies (6)
Failed to conduct a care plan conference and offer the resident and resident representative the right to participate in the person-centered care planning process for Resident #346.
Failed to accurately code the Minimum Data Set (MDS) assessment in the areas of discharge location (Resident #345) and respiratory treatment (Resident #147).
Failed to ensure Resident #9 swallowed all prescribed medications before leaving the room.
Failed to provide supervision for storage of smoking supplies for Resident #31, who kept cigarettes and lighter in his backpack contrary to facility policy.
Failed to label an open vial of Tuberculin Purified Protein Derivative medication with the open date in medication storage room.
Failed to follow hand hygiene policy when Nurse #2 did not doff gloves, perform hand hygiene, and don clean gloves between dressing changes on Resident #14.
Report Facts
Residents reviewed for care plans: 5
Residents reviewed for accuracy of assessment: 19
Medication storage rooms reviewed: 2
Staff observed for infection control practices: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Named in medication administration deficiency for leaving medication unattended with Resident #9 and in medication storage observation. | |
| Social Worker #1 | Responsible for care plan conference invitations and meeting schedule; unable to locate documentation of care plan conference for Resident #346. | |
| Director of Nursing | DON | Interviewed regarding care plan conference process, MDS coding accuracy, medication administration supervision, smoking policy, and infection control. |
| Assistant Director of Nursing | ADON | Interviewed regarding medication administration supervision and medication labeling. |
| Nurse #2 | Observed and interviewed regarding failure to follow hand hygiene during wound care on Resident #14. | |
| Nurse Aide #1 | Interviewed regarding Resident #31 smoking supplies. | |
| Nurse Aide #2 | Interviewed regarding Resident #31 smoking supplies. | |
| Administrator | Interviewed regarding care plan conference rights, MDS coding, medication administration supervision, smoking policy, and infection control expectations. | |
| Infection Preventionist | Observed wound care and commented on infection control deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 26, 2024
Visit Reason
The inspection was conducted following a complaint investigation regarding the use of physical restraints on Resident #1, who was found restrained with a pillowcase tied around his wrists, restricting movement and causing injury.
Complaint Details
The complaint investigation substantiated that Resident #1 was restrained with a pillowcase tied around his wrists, causing a minimally displaced scaphoid fracture. Staff reported using restraints as behavioral management. The facility substantiated the use of the pillowcase as a restraint and terminated the involved staff.
Findings
The facility failed to protect Resident #1's right to be free from physical restraints, resulting in actual harm including a minimally displaced fracture of the right wrist. Staff involved were suspended and terminated. The facility implemented corrective actions including staff education, resident assessments, and monitoring to prevent recurrence.
Deficiencies (1)
Failure to ensure residents are free from physical restraints unless medically necessary, evidenced by Resident #1's wrists being restrained with a pillowcase causing injury.
Report Facts
Residents Affected: 3
Residents Affected: 1
Date of incident: Oct 2, 2024
Date of survey completed: Nov 26, 2024
Completion date for corrective action: Oct 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nurse Aide | Applied pillowcase restraint to Resident #1's wrists |
| NA #2 | Nurse Aide | Reported placing Resident #1's hands inside his shirt; employment terminated |
| Director of Nursing | Director of Nursing (DON) | Assessed Resident #1, ordered x-rays, conducted staff education, and participated in investigation |
| Nurse Practitioner | Nurse Practitioner (NP) | Conducted acute visit and evaluation of Resident #1 |
| Physician Assistant | Physician Assistant (PA) | Provided care to Resident #1 in Emergency Department and commented on fracture age |
| Administrator | Facility Administrator | Participated in investigation and corrective action planning |
Inspection Report
Routine
Deficiencies: 4
Date: Jan 25, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident discharge notifications, provision of care including nail care, nutrition and weight monitoring, and behavioral health services.
Findings
The facility failed to provide timely written discharge notification to a resident's responsible party, failed to provide adequate nail care for residents dependent on staff, failed to assess and address significant weight loss in a resident, and failed to obtain timely mental health services for a resident with depression.
Deficiencies (4)
Failed to provide a written discharge notification to the resident's responsible party for 1 of 1 resident reviewed for discharge.
Failed to provide nail care for 2 of 9 residents dependent on staff for activities of daily living.
Failed to assess and address weight loss for 1 of 3 residents reviewed for nutrition.
Failed to obtain mental health services for 1 of 1 resident reviewed for behavioral and emotional status.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Weight measurements: 218
Weight measurements: 170.2
Weight measurements: 179.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Nurse | Mentioned in relation to Resident #64's depression and psychiatric consultation |
| Director of Nursing | Director of Nursing (DON) | Provided information on Resident #335 discharge and Resident #1 nail care and weight loss |
| Marketing Director | Marketing Director | Mentioned in relation to discharge notification delivery to Resident #335 |
| Administrator #2 | Administrator | Mentioned in relation to emergency discharge notice for Resident #335 |
| Nurse Aide #1 | Nurse Aide | Provided information on nail care for Resident #44 |
| Nurse Aide #2 | Nurse Aide | Provided information on nail care and feeding for Resident #1 |
| Nurse Aide #3 | Nurse Aide | Assigned to provide nail care to Resident #1 |
| Registered Dietician | Registered Dietician (RD) | Discussed weight loss monitoring and failure to assess Resident #1 |
| Nurse Practitioner | Nurse Practitioner (NP) | Provided medical care and orders for Resident #64's depression and psychiatric referral |
| Social Services Director | Social Services Director (SSD) | Responsible for arranging psychiatric consults and obtaining consents for Resident #64 |
| Mental Health Services Representative | Mental Health Services Representative (MHSR) | Discussed issues with psychiatric referral and consent forms for Resident #64 |
| Administrator | Administrator | Discussed issues with psychiatric referrals and follow-up |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Jan 25, 2024
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to provide timely discharge notification, incomplete and late Minimum Data Set (MDS) assessments, incomplete baseline care plans, failure to develop individualized care plans addressing ADLs, psychotropic drug use, and tube feeding, inadequate nail care for dependent residents, failure to assess and address significant weight loss, failure to obtain timely mental health services, and failure to remove expired food from the kitchen. The Quality Assessment and Assurance (QAA) Committee failed to sustain effective corrective actions from prior surveys.
Deficiencies (10)
Failed to provide a written discharge notification to the resident's responsible party for 1 of 1 resident reviewed for discharge.
Failed to complete admission and annual Minimum Data Set (MDS) assessments within regulated time frames for 5 of 6 residents reviewed.
Failed to complete quarterly MDS assessments within regulated time frames for 5 of 6 residents reviewed.
Failed to complete a baseline care plan within the required timeframe for a new admission for 1 of 3 residents.
Failed to develop and implement individualized person-centered care plans addressing ADLs, psychotropic drug use, and tube feeding for 2 of 9 residents.
Failed to provide nail care for 2 of 9 residents dependent on staff for activities of daily living.
Failed to assess and address weight loss for 1 of 3 residents reviewed for nutrition.
Failed to obtain mental health services for 1 of 1 resident reviewed for behavioral and emotional status.
Failed to remove expired food stored for use from 1 of 3 refrigerators in the kitchen.
Failed to maintain implemented procedures and monitor interventions following prior surveys, showing inability to sustain an effective Quality Assessment and Assurance program.
Report Facts
Residents reviewed for MDS assessments: 6
Residents reviewed for quarterly MDS assessments: 6
Residents reviewed for baseline care plan: 3
Residents reviewed for individualized care plans: 9
Residents reviewed for nail care: 9
Weight measurements for Resident #1: 14
Residents reviewed for nutrition: 3
Residents reviewed for mental health services: 1
Refrigerators inspected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #3 | Nurse | Initiated baseline care plan for Resident #288 |
| MDS Coordinator #2 | MDS Coordinator | Responsible for developing and updating care plans, acknowledged missing care plans for Resident #7 |
| Director of Nursing | Director of Nursing (DON) | Provided multiple interviews regarding care plan deficiencies, discharge notification, and mental health services |
| Marketing Director | Marketing Director | Delivered discharge notification to Resident #335 at hospital |
| Administrator #2 | Administrator | Issued emergency discharge notice for Resident #335 |
| Nurse #1 | Nurse | Notified about Resident #64's depression and psychiatric consult |
| Registered Dietician | Dietician | Responsible for dietary care plans and acknowledged failure to assess Resident #1's weight loss |
| Social Services Director | Social Services Director | Responsible for arranging psychiatric consults, obtained consents for Resident #64 |
| Mental Health Services Representative | Mental Health Services Representative | Discussed consent form changes and referral process for psychiatric services |
| Dietary Manager | Dietary Manager | Observed expired lettuce in walk-in refrigerator |
| Nurse Aide #1 | Nurse Aide | Provided nail care for Resident #44 |
| Nurse Aide #2 | Nurse Aide | Provided personal care to Resident #1, noted thick nails |
| Nurse Aide #3 | Nurse Aide | Assigned to provide nail care to residents, cleaned Resident #1's nails |
Inspection Report
Deficiencies: 0
Date: Jul 6, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Pineville Rehabilitation and Living Center, summarizing the findings of a regulatory survey completed on 07/06/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Apr 3, 2023
Visit Reason
The inspection was conducted due to complaints regarding unsafe and disorderly discharge practices for residents, specifically focusing on discharge planning, home health service referrals, and transportation issues for dialysis patients.
Complaint Details
The complaint investigation focused on unsafe discharge practices for residents, including failure to ensure access to necessary home health services, transportation for dialysis, and complete discharge documentation. Immediate jeopardy was identified related to Resident #1's discharge without access to dialysis and wound care, and Resident #2's discharge without confirmed wound vac delivery.
Findings
The facility failed to provide a safe and orderly discharge for two residents, resulting in missed dialysis treatments and lack of wound care services post-discharge. The facility also failed to ensure complete and accurate discharge summaries and proper communication with home health agencies. Immediate Jeopardy was identified but later removed after corrective actions. Additional deficiencies were noted in care planning, food service, and quality assurance processes.
Deficiencies (9)
Failed to provide a safe and orderly discharge for Resident #1 and Resident #2, including lack of home health nursing services and inadequate discharge planning.
Failed to complete an admission Minimum Data Set assessment for Resident #13 that assessed his vision with the use of his glasses.
Failed to develop and implement a care plan for Resident #3 who frequently refused scheduled hemodialysis treatments.
Failed to ensure discharge summaries were complete and communicated necessary information to residents and receiving providers for Resident #1 and Resident #2.
Failed to provide food portions per menu specifications, serving smaller portions than required.
Failed to provide palatable foods at appropriate temperature and taste for residents #4, #5, #6, and #7.
Failed to maintain and serve potentially hazardous food at safe temperature (pureed vegetables at 103°F).
Failed to provide effective leadership and oversight to ensure safe and orderly discharge processes and communication.
Failed to maintain effective Quality Assessment and Assurance (QAA) program to sustain compliance with previous citations.
Report Facts
Dialysis missed treatments: 2
Discharge date: 2023
Meal portion sizes: 3
Food temperature: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #6 | Nurse | Assigned nurse during Resident #1 discharge; did not provide wound care education or supplies. |
| Social Worker | Social Worker | Responsible for discharge referrals and paperwork; incomplete referrals for nursing services. |
| Former Administrator | Administrator | Oversaw discharge process; aware of apartment accessibility issues but proceeded with discharge. |
| Assistant Director of Nursing | ADON | Did not provide home health with nursing orders for Resident #1's wound care post-discharge. |
| Regional Clinical Director | Regional Clinical Director | Provided education on new discharge process and oversight after immediate jeopardy. |
| Dietary Manager | Dietary Manager | Monitored food portions and taste; noted staff serving incorrect portions and salty food. |
| Cook #1 | Cook | Served incorrect food portions using wrong sized utensils. |
| Nurse #1 | Nurse | Discharged Resident #2 but provided blank discharge summary. |
Inspection Report
Routine
Deficiencies: 15
Date: Jul 29, 2022
Visit Reason
The inspection was a routine survey of Pineville Rehabilitation and Living Center to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, care plan implementation, bathing and hygiene assistance, medication administration errors, infection control practices, pest control, and documentation of care. Specific issues included failure to provide privacy for urinary catheters, inadequate call light accessibility, missed showers, failure to report abnormal lab results, incomplete grievance documentation, inaccurate MDS coding, inadequate ADL assistance, improper medication administration, failure to elevate pressure ulcers, inadequate foot and nail care, failure to maintain physician orders for oxygen, poor food quality and temperature, and lapses in infection prevention protocols.
Deficiencies (15)
Failed to treat a resident in a dignified and respectful manner and failed to promote dignity and privacy by not providing a cover for urinary catheter.
Failed to implement care plan intervention for call lights for 1 of 3 residents reviewed.
Failed to honor residents' preferences for bathing and showering for 2 of 3 residents reviewed.
Failed to report an abnormally high white blood cell count to the provider, resulting in delayed hospital admission for systemic inflammatory response syndrome.
Failed to record and investigate a grievance and failed to provide a written grievance summary for residents reviewed.
Failed to document a resident's discharge in the medical record for hospitalization.
Failed to accurately code the Minimum Data Set (MDS) assessment in the area of cognition for a resident reviewed for MDS accuracy.
Failed to provide shaving assistance, nail care, and skin care for dependent residents.
Failed to provide appropriate treatment and care according to orders, resident’s preferences and goals, including checking blood glucose before meals as ordered.
Failed to store controlled substances in a permanently affixed compartment of the refrigerator and failed to remove expired medication from central supply.
Failed to serve food that was palatable, attractive, and at a safe and appetizing temperature.
Failed to provide safe and appropriate respiratory care by not having a physician order for oxygen use.
Failed to maintain a complete and accurate medical record by failing to document the completion of wound care.
Failed to implement CDC guidelines for use of personal protective equipment and hand hygiene, resulting in potential cross contamination.
Failed to implement an effective pest control program to control the presence of flies, gnats, and roaches in resident care areas.
Report Facts
Medication error rate: 15.38
Weight loss: 20.6
Pressure ulcer size: 7
Pressure ulcer size: 7.5
Medication dose: 45
Medication dose: 81
Medication dose: 5000
Medication dose: 600
Medication dose: 400
Oxygen flow rate: 2
Medication administration errors: 4
Medication administration opportunities: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #3 | Named in disrespectful communication and dignity deficiency with Resident #64 | |
| Nurse #5 | Involved in medication administration errors and infection control lapses | |
| Nurse #2 | Interviewed regarding medication error and nail care | |
| Nurse #4 | Charge Nurse | Involved in shaving and nail care deficiencies |
| Nurse #8 | Provided wound care but failed to document completion | |
| Nurse #9 | Interviewed regarding lab reporting failure | |
| Nurse #10 | Interviewed regarding lab reporting failure | |
| Nurse #11 | Interviewed regarding lab reporting failure | |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding lab reporting failure, medication administration, and oxygen order |
| Administrator | Administrator | Interviewed regarding multiple deficiencies including staff conduct and grievance process |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including lab reporting, grievance process, wound care documentation, medication administration, infection control, and foot care |
| Nurse Aide #2 | Nurse Aide | Failed hand hygiene and involved in nail care deficiencies |
| Nurse Aide #5 | Nurse Aide | Interviewed regarding toenail care deficiency |
| Nurse Aide #6 | Nurse Aide | Interviewed regarding nail care deficiency |
| Nurse Aide #7 | Nurse Aide | Reported resident complaints about pests |
| Social Worker | Social Worker | Grievance official who failed to document grievance |
| Unit Coordinator #2 | Unit Coordinator | Observed swatting gnats and unaware of hand hygiene lapse |
| Dietary Manager | Dietary Manager | Interviewed regarding food temperature and quality concerns |
| Activity Director | Activity Director | Interviewed regarding nail care responsibilities |
| Maintenance Director | Maintenance Director | Interviewed regarding pest control issues |
| Supply Clerk | Supply Clerk | Interviewed regarding expired medication in supply room |
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