Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chowan River Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Expired influenza vaccine and frozen Prevnar 20 were found in Refrigerator #3 during a medication room observation. The DON confirmed the expired doses and removed them, and the refrigerator also contained Prevnar 20 encased in ice despite manufacturer instructions to keep it refrigerated between 2 to 8 C and not frozen. Night shift nurses were responsible for checking refrigerator temperatures and expired meds, but one nurse said she did not verify every medication’s expiration date and neither nurse reported seeing the ice or frozen vaccines.
Failure to obtain a physician order for an indwelling urinary catheter for a resident admitted with urinary retention-related diagnoses. The resident’s hospital discharge summary showed the catheter was in place, the MDS coded catheter use, and nursing documented catheter care needs, but record review found no physician order. Staff interviews showed the admitting nurse reviewed the discharge paperwork and catheter care needs, another nurse noted the missing order and documented the catheter size in a progress note, and the MD, DON, and administrator confirmed a catheter order was required.
An ineffective pest control program allowed roaches to remain present in a staff bathroom and a resident’s room. Residents and staff reported the problem was ongoing, with roaches seen in rooms and bathrooms, often at night, despite weekly pest control treatments for German roaches and general pests. The DON, maintenance director, and Administrator all acknowledged the persistent roach issue in the facility.
The facility failed to keep the Facility Assessment accurate by leaving the former Administrator listed on the document even after it was reviewed with QAPI. The current Administrator stated he was not employed at the time of the review and acknowledged he mistakenly did not update the administrative staff. This affected 58 of 58 residents.
Failure to Provide Transfer Notices and Bed-Hold Info: The facility did not provide written notice to residents’ RRs or the Ombudsman after hospital transfers, and it did not notify one resident and/or RR of the bed-hold policy. Residents involved had conditions including sepsis, altered mental status, uncontrolled pain, rectal bleeding, low BP, SOB, and visual hallucinations; one resident had cognitive impairment while another was cognitively intact.
A facility failed to notify the physician and responsible party upon the initial observation of maggots in a resident's heel wound. The nurse observed the maggots but did not immediately inform the physician or the family member present, instead notifying the DON who did not act until two days later. This delay led to a lapse in timely medical intervention and family notification.
A resident with multiple diagnoses, including diabetic foot ulcers, had maggots observed in a heel wound on multiple occasions. Facility staff failed to document and promptly report the issue, leading to a delay in appropriate medical intervention. The physician confirmed the presence of maggots and noted the wound was not infected upon inspection.
Expired and Frozen Vaccines Found in Medication Refrigerator
Penalty
Summary
The facility failed to remove expired medications and failed to store vaccines according to the manufacturer’s recommendations in Refrigerator #3. During an observation of the medication room with the DON, Refrigerator #3 was found to contain 31 doses of influenza high dose vaccine with an expiration date of 6/2026, and the DON confirmed the vaccines were expired and removed them. The DON stated night shift nurses were responsible for checking medication refrigerators for expired medications and for discarding them or returning them to the pharmacy. A review of the manufacturer’s package insert for Prevnar 20 showed it should be refrigerated between 2 to 8 C and not frozen. During the same observation, Refrigerator #3 contained 3 boxes of Prevnar 20 injections encased in ice, and ice was also observed on the chiller compartment. The DON removed the pneumococcal vaccines. Interviews with night shift nurses showed they were responsible for checking refrigerator temperatures and expired medications, but one nurse stated she did not look at every medication to verify expiration dates and neither nurse reported seeing the frozen vaccines or ice in Refrigerator #3.
Failure to Obtain Physician Order for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to obtain a physician order for an indwelling urinary catheter for one resident who was admitted with diagnoses including obstructive and reflux uropathy and an enlarged prostate. The resident’s hospital discharge summary showed the catheter had been placed during the hospital stay and was discharged in place, but it did not specify the catheter size. On admission, the resident was cognitively intact and was coded on the MDS for use of an indwelling urinary catheter. A nursing progress note documented the catheter in place draining clear yellow urine, and the care plan identified the need for catheter care, changing the catheter per physician orders and/or facility protocol, and maintaining a closed drainage system with unobstructed urine flow. Record review showed no physician order for the indwelling urinary catheter. During observation, the resident was sitting in a wheelchair with the catheter drainage bag hung from the wheelchair rail and below bladder level. Interviews revealed the admitting nurse reviewed the discharge summary, entered medication and catheter care orders, and checked with the physician, but could not explain why no catheter order was entered. Another nurse stated she found no catheter order and documented the catheter size in a progress note because she did not know she could enter the order. The medical director stated the catheter required a physician order and should have been entered upon admission, and the DON and administrator stated nursing was responsible for ensuring physician orders were in place for the catheter.
Pest Control Program Ineffective With Ongoing Roach Presence
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by roaches being observed in a staff bathroom in the lobby and in a resident’s room. During a tour, a live light brown roach approximately an inch long was seen on the floor of the staff bathroom next to the reception office, crawling toward the commode and then back toward the cabinet below the sink. In Resident #44’s room, a roach the size of a pea was observed crawling on the floor toward the hallway door and was stepped on by housekeeping staff. Resident #44 stated she saw roaches of that size 2 to 3 times a week in her room and larger roaches a couple of times a month. Record review showed the pest control company had provided weekly services over many months, including spot treatments in bathrooms, resident rooms, dining rooms, the kitchen, and interior and exterior doorways for German roaches and general pest control, with dead roaches noted in the dining and storage area in hall two. Interviews with residents and staff described the problem as ongoing, with residents reporting roaches were seen more at night and in rooms, and a nursing aide stating she had seen roaches in resident rooms and reported them to nursing. The maintenance director stated the roach problem was ongoing and persistent, the DON stated roaches continued to show up in resident rooms, and the Administrator stated he had noticed the problem and believed the exterminator was not doing a good job.
Facility Assessment Listed Former Administrator
Penalty
Summary
The facility failed to maintain an accurate Facility Assessment that reflected the current administrative staff. The Facility Assessment had been updated and reviewed with the QAPI committee on 3/30/26, but page 1 still listed the former Administrator. During an interview on 7/30/26 at 4:45 PM, the Administrator stated he was not employed by the facility when the Facility Assessment was reviewed and updated on 3/30/26 and acknowledged that he had reviewed the current Facility Assessment but mistakenly did not update the administrative staff. This deficient practice was identified as affecting 58 of 58 residents.
Failure to Provide Written Transfer Notices and Bed-Hold Information
Penalty
Summary
The facility failed to notify residents and/or their resident representatives in writing of the reason for transfer or discharge to the hospital and failed to send a copy of the discharge notice to the Ombudsman for 4 of 5 residents reviewed. The report also identified that the facility failed to notify a resident and/or the resident representative of the facility’s bed-hold policy for 1 of 5 residents reviewed for hospitalization. Resident #57 was admitted to the facility on 3/28/25 and had moderately impaired cognitive skills for daily decision-making, with inattention and an altered level of consciousness noted on the quarterly MDS. On 6/18/26, the resident was sent to the hospital at 5:28 PM with increased temperature and decreased oxygen saturation and did not return to the facility. The next day, the resident was documented as admitted to the hospital with sepsis. The facility was unable to provide documentation that written notification of the hospital transfer was sent to the resident representative or the Ombudsman. Resident #24 had moderate cognitive impairment. On 2/15/26, the resident was sent to the hospital at 8:43 PM for altered mental status and uncontrolled pain, then returned to the facility on 2/18/26 in stable condition. On 6/1/26, the resident was again sent to the hospital for altered mental status and visual hallucinations and later readmitted. The facility could not provide documentation that written notification of either transfer was sent to the resident representative, and the Ombudsman did not receive notification of the June transfer. Resident #2 was cognitively intact and had multiple hospital transfers for decreased blood pressure and shortness of breath, active rectal bleeding, nausea with dizziness and low blood pressure, and a large burgundy-colored stool. For each of these transfers, the facility was unable to provide documentation that written notification was sent to the resident representative, and the Ombudsman received delayed notification for the transfers reviewed. The report also states the facility did not provide documentation of written notification to the resident representative or Ombudsman for Resident #8’s hospital transfer and did not notify the resident and/or representative of the bed-hold policy.
Failure to Notify Physician and Family of Maggots in Wound
Penalty
Summary
The facility failed to notify the physician and responsible party upon the initial observation of maggots in and on the dressing of a heel wound for a resident. The resident, who had multiple diagnoses including Type 2 Diabetes Mellitus with diabetic peripheral neuropathy, chronic kidney disease, and diabetic foot ulcers, was under the care of Nurse #2. During a wound care session, Nurse #2 observed maggots on the resident's heel wound and dressing but did not immediately inform the physician or the family member present in the room. Instead, Nurse #2 cleaned the wound and informed the Director of Nursing (DON), assuming the DON would handle the notifications. However, Nurse #2 did not document this notification, and the DON was not made aware of the maggots until two days later when another nurse aide reported seeing maggots in the resident's bed and on the floor. The DON then informed the responsible party and the physician, but this was not done immediately as required by protocol. The DON confirmed that she was only made aware of the maggots on the bed and floor on the second day and not the initial observation by Nurse #2. The responsible party for the resident was informed by the DON about the maggots and the steps being taken to prevent recurrence, but this notification was delayed. The physician, upon being informed, reviewed the wound care notes and inspected the wound, finding no evidence of maggots and noting that the wound was doing well. The physician stated that he would have wanted to be notified immediately upon the initial observation of maggots to ensure proper wound care. Interviews with the nursing staff and the responsible party revealed a lack of immediate and proper communication regarding the resident's condition. The failure to promptly notify the physician and the responsible party about the maggots in the wound led to a delay in appropriate medical intervention and family notification. This deficiency highlights a significant lapse in the facility's protocol for handling changes in a resident's condition and ensuring timely communication with all relevant parties.
Failure to Address Maggots in Resident's Wound
Penalty
Summary
The facility failed to determine if a higher level of care was needed when maggots were observed in a heel wound for a resident. The resident was admitted with multiple diagnoses, including Type 2 Diabetes Mellitus with diabetic peripheral neuropathy, chronic kidney disease, and diabetic foot ulcers. The resident had a physician's order for wound care, which included cleaning the left heel ulcer with normal saline/dermal wound cleanser, applying Aquacel Ag, and covering it with a dry dressing every other day and as needed. Despite these orders, maggots were found in the resident's left heel wound on multiple occasions, and the facility staff failed to take appropriate action in a timely manner. On 5/14/2024, Nurse #2 observed ten to twenty maggots in the resident's left heel wound during wound care but did not document the observation or notify the physician immediately. Instead, Nurse #2 informed the DON, who claimed not to have been notified until 5/16/2024. On 5/16/2024, NA #1 observed maggots in the resident's bed and on the floor, and Nurse #1 confirmed the observation and notified the DON. The DON then took steps to clean the resident and the room and informed the resident's responsible party and physician. The physician confirmed the presence of maggots and noted that the wound was not infected upon inspection. The failure to document and promptly report the presence of maggots in the resident's wound led to a delay in appropriate medical intervention. The physician stated that he would have wanted to be notified immediately on 5/14/2024 to ensure the wound was cleaned properly and to evaluate the treatment provided. The resident's responsible party requested that the resident be sent to the emergency room for further evaluation, which confirmed no new orders were needed. The lack of timely communication and documentation by the facility staff contributed to the deficiency in providing appropriate care for the resident's wound.
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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 Edenton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hertford Rehabilitation And Healthcare Center | 10.4 mi | ★★★★★ | 1 | 0 |
| The Carrolton Of Plymouth | 17.2 mi | ★★★★★ | 1 | 0 |
| Three Rivers Health And Rehabilitation Center | 19.5 mi | ★★★★★ | 9 | 0 |
| Windsor Rehabilitation And Healthcare Center | 19.5 mi | ★★★★★ | 20 | 0 |
| Gates Health And Rehabilitation Center | 22.9 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 October 2026) and official state health department websites.