Inspection Reports for Wilora Lake Healthcare Center – NC West
6001 Wilora Lake Rd, Charlotte, NC 28212, NC, 28212
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 8
Date: Feb 20, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, abuse prevention, medication misappropriation, transfer and discharge procedures, assessment accuracy, fall prevention, safe transfers, and infection control practices.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy during care, failure to protect residents from abuse, inadequate investigation of medication misappropriation, incomplete transfer/discharge notices, refusal to readmit a resident post-hospitalization based on behavior, inaccurate Minimum Data Set assessments, failure to implement fall prevention interventions, unsafe mechanical lift use, and improper disinfection of glucometers.
Deficiencies (8)
Failed to provide personal privacy during incontinent care when a Nurse Aide left a resident exposed with the door open.
Failed to protect a resident from resident-to-resident abuse when one resident hit another with a metal cane.
Failed to maintain documented evidence of a thorough investigation of alleged medication misappropriation for two residents.
Failed to provide a complete written notice of transfer/discharge including the Nursing Home Hearing Request form to a resident and representative.
Failed to allow a resident to return to the facility after hospitalization based on behaviors.
Failed to ensure accurate Minimum Data Set assessments related to prognosis and discharge location for two residents.
Failed to implement fall prevention interventions consistent with care plans for residents and failed to provide safe mechanical lift transfers.
Failed to disinfect a resident's dedicated glucometer according to manufacturer's guidelines.
Report Facts
Residents reviewed for abuse: 3
Residents reviewed for misappropriation: 4
Residents reviewed for transfer/discharge: 3
Residents reviewed for assessment accuracy: 27
Falls reported: 2
Fall mat orders: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #3 | Observed cleaning glucometer improperly and stated she completed glucometer training | |
| Nurse #4 | Interviewed about Resident #6 fall risk and care | |
| Nurse #5 | Interviewed about Resident #6 and Resident #5 fall mats and care | |
| Nurse Aide #4 | Interviewed about Resident #6 fall mat observation | |
| Nurse Aide #8 | Involved in mechanical lift incident with Resident #36 | |
| Nurse Aide #7 | Assisted with mechanical lift incident involving Resident #36 | |
| Director of Nursing | DON | Interviewed multiple times regarding privacy, abuse, medication investigation, transfer/discharge, fall prevention, and glucometer cleaning |
| Administrator | Interviewed regarding abuse, medication investigation, transfer/discharge, readmission refusal, fall prevention, and glucometer training | |
| Nurse #6 | Interviewed and suspended during medication misappropriation investigation | |
| Nurse #7 | Interviewed and did not report to work during medication misappropriation investigation | |
| Nurse Practitioner | NP | Interviewed regarding Resident #36 fall incident notification |
| Social Worker | Interviewed regarding resident abuse incident and discharge planning | |
| Hospital Case Manager | Interviewed regarding Resident #20 hospital stay and placement | |
| Former Director of Nursing | Interviewed regarding medication misappropriation investigation and Resident #36 fall | |
| Housekeeping District Manager | Interviewed regarding fall mat cleaning and handling | |
| Director of Maintenance | Interviewed regarding mechanical lift inspection after Resident #36 fall |
Inspection Report
Routine
Deficiencies: 10
Date: Feb 20, 2025
Visit Reason
The inspection was conducted to evaluate compliance with federal regulations regarding resident care, safety, and facility operations, including investigation of complaints and review of care plans, resident safety, abuse prevention, discharge procedures, assessment accuracy, fall prevention, dialysis care, and infection control.
Findings
The facility was found deficient in multiple areas including failure to ensure resident participation in care planning, inadequate privacy during care, failure to prevent resident-to-resident abuse, incomplete investigations of medication misappropriation, improper discharge notification, refusal to readmit a resident post-hospitalization, inaccurate resident assessments, inadequate fall prevention measures, unsafe mechanical lift use, inconsistent dialysis site monitoring, and improper disinfection of glucometers.
Deficiencies (10)
Failed to ensure residents were given the right to participate in the revision of their person-centered care plans for 2 of 2 residents reviewed.
Failed to provide personal privacy during incontinent care when a resident was left exposed with the door open.
Failed to protect a resident's right to be free from resident-to-resident abuse when one resident hit another with a metal cane.
Failed to maintain documented evidence of a thorough investigation of an allegation of misappropriation of medication for 2 residents.
Failed to provide a complete written notice of transfer/discharge including the Nursing Home Hearing Request form for a resident.
Failed to allow a resident to return to the facility after hospitalization based on behaviors prior to discharge.
Failed to ensure accurate Minimum Data Set (MDS) assessments including prognosis and discharge location for 2 residents.
Failed to implement fall prevention interventions consistent with resident care plans and failed to provide safe mechanical lift transfers for 3 residents.
Failed to maintain ongoing communication with dialysis center and failed to consistently document dialysis access site assessments post dialysis for 1 resident.
Failed to disinfect a resident's dedicated glucometer according to manufacturer's guidelines for cleaning and disinfecting.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Discussed dialysis access site assessment and documentation | |
| Nurse #3 | Observed improperly disinfecting glucometer | |
| Nurse #4 | Described fall risk observations and interventions for Resident #6 | |
| Nurse #5 | Interviewed about resident abuse incident and fall mat observation | |
| Nurse #8 | Involved in mechanical lift incident with Resident #36 | |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding care planning, fall prevention, dialysis, and glucometer disinfection |
| Administrator | Administrator | Provided multiple interviews regarding discharge notices, readmission refusal, fall prevention, and glucometer training |
| Social Services Director | Social Services Director | Described care plan conference notification process |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding Resident #36 fall and dialysis communication |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 9, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction report for Wilora Lake Healthcare, summarizing the findings of a regulatory survey completed on 11/09/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Deficiencies: 2
Date: Jun 23, 2022
Visit Reason
The inspection was conducted to assess compliance with medication management and food safety standards, including checking for expired medications and proper food storage temperatures.
Findings
The facility failed to discard expired medications on 2 of 3 medication carts and failed to maintain milk at the proper temperature and remove expired yogurt from a nourishment refrigerator. These issues posed minimal harm or potential for actual harm to some residents.
Deficiencies (2)
Failed to discard expired medications on 2 of 3 medication carts (400 hall and 100 hall).
Failed to maintain and serve milk at or below 41 degrees Fahrenheit and failed to remove expired yogurt from nourishment refrigerator.
Report Facts
Medication carts with expired medications: 2
Milk temperature: 45.6
Expired yogurt containers: 8
Residents potentially affected: 9
Total residents in facility: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Responsible for checking medication cart and discarding expired medications; missed expired medications on 400 hall cart | |
| Nurse #2 | Responsible for checking medication cart daily; expired medication found on 100 hall cart | |
| Director of Nursing | Director of Nursing (DON) | Stated nurses are responsible for monitoring expiration dates and removing expired medications |
| Pharmacist | Conducts monthly audits of medication carts; noted expired medications should not have been given | |
| Medical Director | Medical Director | Stated no harm to residents from expired medications; recommended better monitoring |
| Administrator | Administrator | Stated nurses responsible for checking medication carts daily and discarding expired medications; pharmacy checks monthly; also stated facility policy to discard expired food items |
| Dietary Aide #1 | Dietary Aide (DA) | Handled milk cartons during lunch tray line; placed milk on cart and added ice |
| Certified Food Manager | Certified Food Manager (CFM) | Monitored milk temperature and food storage; observed expired yogurt in refrigerator |
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