Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Barbour Court Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that MDS assessments were inaccurately coded for several residents regarding medication use and pneumococcal vaccination status. One resident’s insulin injections were underreported in the MDS compared to the MAR, while another resident receiving a non-insulin injectable for diabetes was incorrectly coded as receiving insulin. A third resident was coded as receiving anticoagulants despite no corresponding orders or MAR entries. Additionally, a resident with only a single historical PPSV23 dose documented was incorrectly coded as having up-to-date pneumococcal vaccination, with the MDS nurse later acknowledging she had relied on outdated CDC guidance.
A resident with DM II had a physician order for Novolog 10 units SQ with meals, to be held if blood sugar (BS) was less than 150, yet a nurse documented multiple BS readings below 150 and still administered the full insulin dose on several mornings. The nurse later reported she did not recall any BS parameters for the insulin and believed such parameters would appear on the electronic MAR. The resident was cognitively intact and regularly received insulin injections, while the NP, DON, and Administrator all acknowledged that insulin should be administered according to ordered parameters and that giving insulin outside those parameters constitutes a serious medication error.
The facility failed to ensure residents’ right to timely access to their mail, including delivery on the day it was received and on Saturdays. Multiple residents reported that regular mail, including magazines and catalogues, was inconsistently delivered and often sat for days in the activities room, sometimes for about a week, before being given to them or picked up. Staff interviews revealed that the receptionist retrieved and sorted mail on weekdays and typically did not sort Saturday mail until Monday, after which it was placed in the activities room for activities staff to deliver. The Activities Director stated that activities staff were expected to sort and deliver mail daily but acknowledged that some items, such as bills, might be held until the receptionist could review them. The Administrator stated he expected daily mail delivery, including Saturdays, and was unaware of delays or concerns because no grievances had been submitted.
The facility failed to include a resident's POA document in the medical record and did not provide advance directive education or opportunities for several residents. Discussions were limited to code status, and documentation was lacking, as confirmed by interviews with staff.
The facility failed to conduct and document care plan meetings for several residents, including those with cognitive impairments and dementia. Residents and their representatives were not invited to participate in these meetings, and the social worker admitted to not maintaining proper documentation. The administrator was unaware of these lapses, leading to a deficiency in care planning.
A resident's controlled medication was misappropriated in an LTC facility. The resident, who was on a scheduled pain medication regime, had a card of 30 doses of oxycodone/acetaminophen go missing. The incident involved several staff members, including a new nurse and a central supply clerk, with discrepancies noted in the controlled substance count. Despite the missing medication, the resident did not miss any doses, and the facility reported the incident to authorities.
A resident with dementia and Parkinson's disease, who was fully dependent on staff for personal care, was found with long, jagged fingernails. Despite receiving regular bed baths, the resident's nails were not trimmed as needed. Staff interviews confirmed the oversight, and both the DON and Administrator acknowledged the nails should have been cut promptly.
Expired Antacid Liquid was found on a medication cart in the facility. The Unit Manager, responsible for weekly checks, missed the expired medication during her last inspection. Both the DON and Administrator confirmed that expired medications should not be available for use.
Inaccurate MDS Coding for Medications and Pneumococcal Vaccination
Penalty
Summary
The deficiency involves inaccurate coding of the Minimum Data Set (MDS) assessments for multiple residents in the areas of medications and pneumococcal vaccination status. For one resident, physician orders and the Medication Administration Record (MAR) showed Novolog insulin injections were administered on multiple days within the assessment look-back period, but the quarterly MDS was coded as receiving injections and insulin injections on only 5 of 7 days instead of 7 of 7 days; the MDS nurse later acknowledged this was an error. Another resident had an order for Dulaglutide, a non-insulin injectable medication for Type 2 diabetes, administered once during the look-back period, with no insulin orders in place, yet the quarterly MDS was coded to show both an injection and an insulin injection on 1 of 7 days; the MDS nurse stated she coded it as insulin because it was prescribed for diabetes. A third resident had no physician orders or MAR documentation for anticoagulant medications during the January and February look-back periods, but the annual MDS was coded to indicate anticoagulant use; the responsible MDS nurse stated this was an error and confirmed the resident had not received anticoagulants during the assessment period. For another resident, the quarterly MDS indicated pneumococcal vaccination was up to date, while the medical record showed only a single historical dose of PPSV23 (Pneumovax) from 2014 with no documentation of additional pneumococcal vaccines. The MDS nurse later stated that coding the vaccine status as up to date was incorrect and that she had relied on outdated CDC guidelines when completing that assessment. The DON and the Administrator both stated that resident MDS assessments should be coded accurately.
Insulin Administered Outside Ordered Blood Sugar Parameters
Penalty
Summary
The facility failed to ensure insulin was administered according to physician-ordered blood sugar (BS) parameters for a resident with diabetes mellitus type 2. The resident had an active order for Novolog insulin 10 units subcutaneously with meals, with instructions to hold the dose if BS was less than 150. Review of the December 2025 MAR showed that on four separate mornings, the nurse documented BS readings below 150 (122 on three dates and 106 on one date) and still administered 10 units of Novolog insulin at approximately 6:30 AM each time. Subsequent BS readings later those days were also documented, including elevated values and one instance where the resident refused a later BS check. During a telephone interview, the nurse stated she did not recall any parameters for the resident’s Novolog insulin and believed that if parameters existed, they would appear on the electronic MAR. She confirmed that her documentation indicated she administered 10 units of Novolog on the identified dates and times. The resident’s MDS showed he was cognitively intact, had no behaviors or rejection of care, and received insulin injections on most days in the look-back period. The NP reported familiarity with the resident, noting he frequently refused BS checks and insulin and that his BS tended to run high, but acknowledged that insulin should be given according to ordered parameters. The DON stated that administering insulin outside the physician’s parameters was considered a serious medication error, and the Administrator stated nurses should adhere to physician parameters when administering insulin.
Failure to Ensure Timely Delivery and Privacy of Resident Mail
Penalty
Summary
The facility failed to ensure residents’ right to timely access to their mail, including delivery on Saturdays and on the date it was received. During a Resident Council meeting, multiple residents reported that regular mail was not delivered as the facility received it, and that Saturday mail was not delivered until Monday or later. The Resident Council President stated that regular mail was delivered to the receptionist Monday through Friday, then sorted and passed to the activities department, but delivery to residents was inconsistent. He reported that his trade and outdoor sporting magazines and product catalogues had remained in the activities room for about a week before he collected them himself, and that these delays did not coincide with times when he was out of the facility or hospitalized. Another resident confirmed reading the President’s outdoor sporting magazines in the activities room before informing him they were there. Another resident reported visiting the activities room daily after lunch and observing that the rack holding sorted resident mail was often full, with the same items, such as the President’s magazines, remaining there for about a week before disappearing. She stated there was no set pattern for when mail was removed from the activities room, but it was obvious to her that some items sat there for multiple days before being delivered or picked up. The receptionist stated she retrieved and sorted mail Monday through Friday, placing residents’ mail in a box in the activities room, and that Saturday mail was placed in her box and typically sorted on Monday, at which time it was then placed in the activities room for delivery. The Activities Director stated that when she worked Saturdays, mail was sorted and delivered, and that activities staff present daily were expected to sort and deliver Saturday mail; however, she acknowledged that items such as bills might be held for the receptionist until Monday. The Administrator stated his expectation was that mail was delivered daily, including Saturdays, and that he was unaware of delays or resident concerns, as no grievances had been filed about timely mail delivery.
Failure to Document and Educate on Advance Directives
Penalty
Summary
The facility failed to ensure that a copy of a resident's advanced directive was included in the medical record and did not provide written advance directive information or an opportunity to formulate an advance directive for several residents. Specifically, Resident #10, who was admitted with a diagnosis of respiratory failure, did not have her Power of Attorney (POA) document included in her medical record. Despite being aware of the existence of the POA, the Admissions Director did not request a copy from the resident or her family. The Administrator noted that the Business Office Manager, who typically handled such requests, was on leave, which contributed to the oversight. Additionally, Residents #18, #51, and #84 did not receive education or an opportunity to formulate an advance directive upon admission. Their medical records lacked documentation of any discussion beyond code status. Interviews with the Admissions Director and Social Worker #1 revealed that discussions were limited to code status, and there was no documentation of the residents' understanding or decisions regarding advance directives. The Administrator confirmed that only the Do Not Resuscitate (DNR) form and physician order verification were included in the residents' charts.
Failure to Conduct and Document Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings or invite residents to their care plan meetings for four residents. Resident #39, who was admitted with Alzheimer's disease and aphasia, had not had a care plan meeting since 2018, despite the requirement for quarterly meetings. The resident's representative was not invited to any care plan meetings since admission, and the social worker acknowledged the oversight. The administrator was unaware of the lapse in care plan meetings for this resident. Resident #100, who was moderately cognitively impaired, did not recall being invited to a care plan meeting since admission. The social worker responsible for arranging these meetings admitted to not inviting the resident or documenting any meetings. The Director of Nursing confirmed the absence of documentation for care plan meetings for this resident. Similarly, Resident #40, who was cognitively intact, was not invited to any care plan meetings, and there was no documentation of such meetings since admission. The social worker again admitted to not inviting the resident or maintaining documentation. Resident #117, with diagnoses including vascular dementia and diabetes, had care plan meetings documented, but the resident was not invited due to the social worker's assessment of her cognitive status. The resident expressed a desire to be involved in her care planning. The assistant administrator explained the process of inviting residents based on their cognitive status, but the administrator expected all residents to be invited to care plan meetings. The facility's failure to invite residents and their representatives to care plan meetings and maintain proper documentation led to the deficiency.
Misappropriation of Controlled Medication
Penalty
Summary
The facility failed to protect a resident's right to be free from the misappropriation of controlled medication. Resident #40, who was cognitively intact and on a scheduled pain medication regime for chronic pain, was prescribed oxycodone/acetaminophen to be administered four times daily. A discrepancy was discovered when a card of 30 doses of this medication and the corresponding controlled substance count record sheet went missing from the medication cart. The incident involved several staff members, including nurses and a central supply clerk. On 7/3/24, Nurse #3, who was new to the facility, completed a controlled substance reconciliation count with Nurse #4, but a discrepancy in the number of controlled medication cards was noted. Despite this, Nurse #3 signed off on the count. Later, Central Supply Clerk #1 was given keys to the medication room by Nurse #3, which was against protocol, and Nurse #4 later took the keys from the clerk. The missing medication was discovered the following day during a shift change count by Nurse #2 and Nurse #4. Interviews with staff revealed inconsistencies in the handling and reconciliation of controlled substances. Nurse #4, who had a previous reprimand on her nursing license related to narcotic medications, was implicated in the incident, although it could not be proven. The facility's administrator confirmed the missing medication and reported the incident to relevant authorities, including the NCBON and law enforcement.
Failure to Provide Adequate Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care for a dependent resident, identified as Resident #18, who was unable to perform activities of daily living independently. Resident #18, who was readmitted to the facility with diagnoses including dementia, Parkinson's disease, and early onset cerebellar ataxia, was observed to have approximately half-inch long fingernails with jagged edges on both thumbs. Despite being totally dependent on staff for bathing and grooming, the resident's nails were not trimmed as needed, which was confirmed during an observation and interview with the resident on 11/12/24. Nurse Aide (NA) #1, who was responsible for providing bed baths to Resident #18, stated that she had cleaned the resident's nails but did not believe they required trimming. However, upon further observation and interview, NA #1 acknowledged the need to cut the resident's nails. Nurse #1 and the Director of Nursing (DON) both confirmed that the nails should have been trimmed due to their jagged condition. The facility's Administrator also acknowledged that the nails should have been cut in a timely manner if needed.
Expired Medication Found on Medication Cart
Penalty
Summary
The facility failed to discard expired medication that was available for use on one of the medication carts. During an observation of the Upper 300 Hall medication cart, an opened bottle of Antacid Liquid with an expiration date of July 2024 was found. The Unit Manager, who was responsible for checking the medication cart weekly for expired medications, acknowledged that the medication was expired and should not have been available for use. She admitted to having missed this bottle during her last check on November 11 or 12, 2024. The Director of Nursing confirmed that the Unit Manager was responsible for monitoring the carts weekly to ensure expired medications were discarded, and the Administrator also stated that expired medications should not be on the carts.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Smithfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Smithfield Manor Rehabilitation And Healthcare Cen | 2.4 mi | ★★★★★ | 12 | 1 |
| Springbrook Nursing And Rehabilitation Center | 8.2 mi | ★★★★★ | 0 | 0 |
| Clayton Rehabilitation And Healthcare Center | 9.2 mi | ★★★★★ | 19 | 1 |
| Liberty Commons Nursing & Rehabilitation Center Of | 14 mi | ★★★★★ | 12 | 0 |
| Bellarose Nursing And Rehab | 16.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.