Below average — CMS composite of the measures below.
The next survey window likely opens around May 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 Edgecombe Health Center By Harborview during CMS and state inspections, most recent first.
A resident with COPD, CHF, CAD, diabetes, atrial fibrillation, and other chronic illnesses returned from the ED with orders for Prednisone and Lasix. A nurse entered the Prednisone order but did not activate the stop date, so the steroid stayed active on the MAR and was given beyond the intended 5-day course. The NP documented routine and follow-up visits but did not review the MAR, so the ongoing Prednisone administration was not identified.
Failure to Enter and Honor Prednisone Stop Date: A resident with multiple chronic conditions returned from the ED with a Prednisone order for COPD exacerbation, but the nurse did not enter a stop date and the pharmacy also failed to add one. The order stayed active, the medication was refilled multiple times without a physician order, and the resident received 60 mg daily far beyond the intended 5-day course.
Pharmacy MRR Failed to Identify Medication Irregularities: A resident with multiple chronic conditions was prescribed Prednisone 60 mg daily for 5 days after an ED visit for COPD exacerbation, but the stop date was not entered and the medication continued to be administered beyond the intended course. The pharmacist’s monthly MRR did not identify the irregularity because the MAR was not reviewed. A second resident’s Duloxetine recommendation also was not followed up in a timely manner, with the MAR showing continued 30 mg daily dosing despite a pharmacist recommendation for dose reduction.
Failure to Stop Time-Limited Prednisone Order: A resident with multiple chronic conditions returned from the ED with a short-term prednisone order for COPD, but an LPN failed to enter a stop date in the EMR. As a result, the steroid remained active on the MAR and was administered daily far beyond the intended 5-day course. The resident later deteriorated with hypoxia, RSV, sepsis, and acute respiratory failure, and the physician stated prolonged steroid use could have reduced the resident’s ability to fight infection and may have contributed to the resident’s death.
Missed Physician-Ordered Daily Weights for Residents with CHF: The facility failed to obtain and document ordered daily weights for residents with CHF and other cardiac conditions. Records showed repeated gaps in MARs, weight sheets, and EMRs, and staff interviews confirmed that when no weight was documented, the weight often had not been done. The DON acknowledged missed weights had occurred, and the physician and NP stated daily weights were important for monitoring fluid status and CHF.
MDS assessments were not accurately coded for hydration and IV therapy. One resident received dermoclysis with 0.9% NS for rehydration, and another resident had a peripheral IV catheter and IV NS for hydration, but the MDS did not reflect these nutritional approach or IV access items. The MDS Coordinator said she did not code these areas unless there was a critical BUN, and the Administrator stated MDS assessments should accurately reflect resident IV status.
A resident with dysphagia, dementia, and Alzheimer’s disease had an order for a pureed diet with thin liquids, but was served a soaked dinner roll that remained in whole form and did not appear pureed. Staff, dietary leadership, and the ST described the item as a slurried or soaked roll, while the ST stated that a puree order should be presented as puree consistency and not require chewing. The resident and family did not recognize the item, and the resident did not eat it.
The facility failed to accurately code MDS assessments for four residents, leading to errors in documenting anticoagulant and antiplatelet use, as well as discharge status. Interviews with staff confirmed these discrepancies, with the MDS Coordinator acknowledging the mistakes and the Administrator emphasizing the need for accurate assessments.
A facility failed to document discussions about advance directives for a resident with stroke, hypertension, and thyroid disorder, leading to a deficiency. Staff interviews revealed confusion over responsibility for these discussions, with the Admission Director, Admission Nurse, and Social Worker each believing it was another's duty. The Administrator expected the Social Worker to handle and document these conversations, but this was not done.
A facility failed to provide a NOMNC to a resident's RP within the required time frame. The resident was scheduled for discharge, and the NOMNC indicated that Medicare coverage would end, potentially leaving the resident liable for costs. Despite multiple discussions about the discharge plan, the SW did not provide the form until the discharge day, citing missed opportunities as the RP had left the facility. The RP wanted to be informed of her rights earlier, and the Administrator acknowledged the oversight.
The facility failed to develop comprehensive care plans for three residents, omitting critical information about side rail use and anticoagulant medication. Two residents using side rails did not have this documented in their care plans, and staff were unaware of the requirement. Another resident on anticoagulant medication had no care plan addressing the associated bleeding risk, despite staff acknowledging the need for such documentation.
The facility failed to attempt alternative measures before installing side rails for two residents, leading to a deficiency. One resident with a seizure disorder and a history of stroke was observed with side rails raised without documented attempts to use alternatives. Similarly, another resident with a cerebral infarction diagnosis was found with side rails raised without prior attempts to use alternatives. Interviews with staff revealed a lack of awareness of the requirement to try alternatives before using side rails.
A resident on Levothyroxine for hypothyroidism did not receive a baseline thyroid function test as recommended by a consultant pharmacist. Despite orders from a nurse practitioner, the test was scheduled but not completed twice, with no documented reason for the omissions. The DON and NP acknowledged the oversight, but no negative outcome was reported for the resident.
NP Failed to Review MAR During Visits, Allowing Prolonged Prednisone Administration
Penalty
Summary
The facility failed to ensure that Nurse Practitioner visits were comprehensive and included review of the Medication Administration Record (MAR). Resident #162 had multiple chronic conditions including vascular dementia, CHF, CAD, diabetes mellitus, hypothyroidism, hyperlipidemia, valvular heart disease, COPD, atrial fibrillation, pulmonary hypertension, lymphedema, hypertension, CVA, and a history of viral pneumonia. After an ED visit for shortness of breath, dyspnea, COPD exacerbation, and fluid overload, the resident returned to the facility with orders for Prednisone 60 mg daily for 5 days and Lasix 20 mg daily for 3 days. The Prednisone order was entered into the electronic record by a nurse, but the 5-day stop date was not activated. As a result, Prednisone remained active on the MAR and was administered beyond the intended duration. The MAR showed the resident received the medication daily for the original 5 doses and then continued to receive additional doses after the ordered course should have ended. The NP completed follow-up and routine visits after the ED encounter and documented reviewing medications and other resident information, but there was no documentation that the MAR was reviewed, and the ongoing Prednisone administration was not identified or corrected. During later routine and follow-up visits, the NP again did not review the MAR and did not recognize that Prednisone was still being administered. The NP stated that he did not mention Prednisone in his notes because it was not one of the disease processes he was looking at during that time frame. The physician later stated that steroids given for any length of time can cause bone loss, adrenal issues, and euphoria, and that long-term steroids decrease the immune response and could have contributed to the resident’s demise. The resident later developed cold-like symptoms, was transferred to the hospital, admitted with sepsis, and subsequently expired.
Failure to Enter and Honor Prednisone Stop Date
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications. Resident #162, who had diagnoses including vascular dementia, CHF, CAD, COPD, atrial fibrillation, pulmonary hypertension, diabetes mellitus, and hypertension, returned from the ED after being treated for shortness of breath, dyspnea, COPD exacerbation, and fluid overload. The ED physician prescribed Prednisone 20 mg, 3 tablets daily for 5 days, but the nurse who transcribed the order into the electronic record did not enter a stop date, and the pharmacy also did not enter the 5-day stop date when the order was reviewed. Because the stop date was not entered, the order remained active and was transmitted to the pharmacy. The pharmacy delivered an initial 15-tablet supply, and facility nursing staff later ordered three refills for Prednisone without a physician order. The pharmacy then filled and delivered additional quantities of 15 tablets, 90 tablets, and 90 tablets after the 5-day stop date. Resident #162 received Prednisone 60 mg daily for 66 days total, including 61 days beyond the intended stop date. The record also showed that the resident later developed worsening respiratory symptoms and was transferred to the hospital with hypoxia, respiratory distress, RSV, sepsis, and multi-system organ failure. The physician interviewed stated that steroids given for any length of time can cause loss of bone, adrenal issues, and euphoria, and that long-term steroids decrease the immune response and could have contributed to the resident’s demise. The pharmacy quality assurance manager stated the pharmacy should have dispensed only 15 tablets for the 5-day regimen and that the pharmacist should have identified and added the missing stop date during review.
Pharmacy MRR Failed to Identify Medication Irregularities
Penalty
Summary
The facility failed to ensure that the licensed pharmacist completed monthly medication regimen reviews that included review of the resident’s medical record and MAR to identify medication irregularities. For Resident #162, the pharmacist’s monthly medication regimen reviews did not identify that Prednisone 20 mg, 3 tablets daily for 5 days had remained active and was being administered beyond the intended duration. The resident had multiple chronic diagnoses, including vascular dementia, CHF, CAD, diabetes mellitus, hypothyroidism, hyperlipidemia, valvular heart disease, COPD, atrial fibrillation, pulmonary hypertension, lymphedema, hypertension, CVA, and viral pneumonia. After an ED visit for shortness of breath, dyspnea, COPD exacerbation, and fluid overload, the resident was prescribed Prednisone 60 mg daily for 5 days. The order was transcribed into the eMAR, but the stop date was not scheduled, and the medication continued to be documented as administered daily beyond the intended 5-day course. The pharmacist’s medication regimen reviews during that period did not identify the ongoing Prednisone order as an irregularity, and the pharmacist stated during interview that he reviewed physician orders but did not review the MAR. The report also identified a separate failure involving Resident #139. That resident had diagnoses including traumatic brain dysfunction, hypertension, diabetes, hyperlipidemia, Alzheimer’s disease, and PTSD. The medical record showed an order for Duloxetine 30 mg daily for depression, and the pharmacist recommended a dose reduction to 15 mg at HS. Although the recommendation was reviewed and signed by the NP, the MARs showed the resident continued to receive Duloxetine 30 mg daily across multiple review periods, and the recommendation was not followed up in a timely manner. The DON, pharmacist, Medical Director, NP, and Administrator each described delays or missed follow-up related to the pharmacy recommendation.
Failure to Stop Time-Limited Prednisone Order
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident with vascular dementia, CHF, CAD, CVA, diabetes mellitus, COPD, atrial fibrillation, pulmonary hypertension, valvular heart disease, bipolar disorder, and hypertension. After an ED visit for shortness of breath, dyspnea, COPD exacerbation, and fluid overload, the resident returned to the facility with an order for Prednisone 20 mg, 3 tablets daily for 5 days. A nurse transcribed the order into the electronic medical record but did not enter a stop date or otherwise activate the time limit for the medication order. Because the stop date was not entered, nursing staff continued to administer Prednisone 60 mg daily beyond the intended 5-day course. The medication was given for a total of 66 days, including 61 days beyond the ordered stop date. The MAR reflected the original short-term order, but the resident continued to receive the medication as if it remained active. Interviews with nursing staff confirmed that when a time-limited order is entered, the nurse must either select a stop date or enter the number of days so the system can calculate the stop date, and that if neither is entered the medication will continue without stopping. The resident later developed worsening respiratory symptoms, was sent to the ED, and was admitted with hypoxia, SIRS, RSV, sepsis, acute respiratory failure, and other acute problems. The resident was transferred to the medical intensive unit and died after not responding to treatment. The physician stated that prolonged steroid use could have reduced the resident’s ability to fight infection and could have contributed to the resident’s demise. The report also states that the facility’s nursing leadership was not aware the prednisone continued beyond the ordered duration and that the order should have been followed as written by the ED physician.
Missed Physician-Ordered Daily Weights for Residents with CHF
Penalty
Summary
The facility failed to obtain daily weights as ordered by the physician for 3 residents with cardiac-related diagnoses. Resident #17 had CHF and a physician order for daily weights before breakfast, with instructions to call the physician for a 3-pound gain in 1 day or 5 pounds in 1 week. Her care plan also directed staff to monitor weight per the physician’s order and report signs of fluid overload. Review of the MAR, electronic record, and Daily Weight Sheet showed multiple dates in March, April, and May 2026 with no documentation that the daily weights were completed or refused. Resident #35 had CHF and HTN, and the physician ordered daily weights every morning at 6:00 AM with instructions to document refusals and contact the provider for significant weight gain. His care plan included monitoring for SOB, edema, and weight changes. The MAR, electronic record, and Daily Weight Sheet showed several dates in April 2026 with no documentation that the ordered daily weights were completed or refused. Resident #129 had diagnoses including MI, stroke, and HTN, and the physician ordered daily weights at 6:00 AM with instructions to call the physician for a 3-pound gain in 1 day or 5 pounds in 1 week. Her care plan directed staff to monitor weight and notify the physician of significant changes. The MAR, electronic record, and Daily Weight Sheet showed multiple dates in April and May 2026 with no documentation that the ordered daily weights were completed or refused. Staff interviews indicated that NAs were generally responsible for obtaining the weights and nurses documented them, but several staff members stated that if no weight was documented, the weight had not been done. The DON acknowledged that some residents’ daily weights had been missed and that the facility did not have a plan of correction in place at the time of the follow-up interview.
MDS assessments were not accurately coded for IV and hydration therapies
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for nutritional approaches for Resident #79. Resident #79 was admitted to the facility and had a Hydration Evaluation dated 3/24/26 that identified her as being at risk for dehydration related to medications, feeding assistance needs, and a pressure wound, and noted she would benefit from additional hydration support. A physician ordered 0.9% Sodium Chloride solution at 60 ml/hr intravenously for rehydration for 1 day, with dermoclysis to be discontinued after completion. Nursing documentation showed a dermoclysis infusion needle was placed in the resident’s left abdomen and normal saline was initiated, and the MAR documented 200 ml of 0.9% Sodium Chloride administered via dermoclysis. However, the quarterly MDS did not indicate that she received parenteral or intravenous feeding. The MDS Coordinator stated she coded the nutritional approach section and did not code the fluids because she had been instructed not to code that section unless the resident had a critical BUN, and Resident #79 had no lab testing during the look-back period. The facility also failed to accurately code intravenous access for Resident #160. Resident #160 had diagnoses including respiratory failure, anemia, hypertension, peripheral vascular disease, malnutrition, dysphagia, and hypokalemia. Her orders included insertion of a peripheral IV catheter one time only for hydration and 0.9% Sodium Chloride solution at 75 ml/hour intravenously for 24 hours for re-hydration. The MAR showed the order was completed as ordered on 4/14/26, but the quarterly MDS did not assess her as having intravenous access within the prior 14-day look-back period. The MDS Coordinator stated the IV access was not captured because she had been instructed not to code that section unless the resident had a critical BUN, and the Administrator stated MDS assessments should accurately reflect resident intravenous status.
Pureed Diet Food Served in Incorrect Form
Penalty
Summary
The facility failed to serve food in a form designed to meet an individual resident’s needs for 1 of 1 resident reviewed. Resident #14 had diagnoses including dysphagia, dementia, Alzheimer’s disease, and failure to thrive, and had a physician’s order for a pureed texture with thin liquids. Her MDS indicated severe cognitive impairment and that she required setup or clean-up assistance with eating, and her care plan identified her as at risk for altered nutritional status with diet as ordered as an intervention. During a lunch observation, Resident #14 was seated in her wheelchair with the meal tray on the bedside table. One item on the tray was identified on the meal ticket as a soaked dinner roll, but it did not appear to be pureed. The top of the roll was hard and appeared wet in a clear syrupy liquid. When the item was mixed with a fork, it remained in whole form. Resident #14, her family members, and the observer did not know what the item was and had never seen it before, and Resident #14 did not eat it. Interviews showed that staff and dietary leadership described the item as a soaked or slurried dinner roll, with preparation involving bread soaked in liquid or thickener solution. The Speech Therapist stated that if a diet specified puree consistency, it should be presented as puree consistency, and that if the food item must be chewed, it would not be considered puree. Nurse aides reported they had never seen the item served before and that the resident’s family was upset because they believed it was a choking hazard. The Administrator stated the soaked dinner roll should have been pureed prior to meal delivery.
Inaccurate MDS Coding for Medications and Discharge Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in the documentation of anticoagulant use, antiplatelet use, and discharge status. Resident #109 was incorrectly coded as receiving anticoagulant medication, despite the medication administration record indicating otherwise. Resident #138's discharge was planned, but the MDS assessment inaccurately reflected it as unplanned. Resident #80 was taking aspirin, an antiplatelet medication, but the MDS assessment did not reflect this due to a misunderstanding about dosage requirements for coding. Resident #139 was discharged home, but the MDS assessment incorrectly stated the resident was discharged to a short-term general hospital. Interviews with the MDS Coordinator, Director of Nursing, and Administrator confirmed these coding errors. The MDS Coordinator acknowledged the mistakes in coding for each resident, and the Administrator emphasized that MDS assessments should accurately reflect the residents' statuses. These inaccuracies in the MDS assessments were identified through record reviews and staff interviews, highlighting a failure in the facility's assessment processes.
Failure to Document Advance Directive Discussions
Penalty
Summary
The facility failed to document discussions regarding advance directives for a resident, leading to a deficiency in honoring residents' rights. The facility's policy requires staff to determine if a resident has an advance directive upon admission and to document any discussions or offers to formulate one. However, for one resident, there was no documentation in the medical record indicating that the facility staff had spoken with the resident or their responsible party about advance directives. The resident was admitted with diagnoses including stroke, hypertension, and thyroid disorder, and was noted to have a full code status. Interviews with facility staff revealed a lack of clarity and communication regarding who was responsible for discussing advance directives with residents and their responsible parties. The Admission Director, Admission Nurse, and Social Worker each believed it was the responsibility of another staff member to have these discussions. The facility Administrator expected the Social Worker to follow up with families lacking advance directives and document these conversations, but this expectation was not met, resulting in the deficiency.
Failure to Provide Timely NOMNC to Resident's Responsible Party
Penalty
Summary
The facility failed to provide a Centers for Medicare and Medicaid (CMS) Form 10123-Notice of Medicare Non-Coverage (NOMNC) to a resident's Responsible Party (RP) within the required time frame. The resident, identified as Resident #129, was admitted to the facility and was scheduled for discharge. The NOMNC form indicated that Medicare coverage for the resident's skilled nursing and therapy services would end on 3/11/25, and the resident might have to pay for services received after that date. However, the form was not signed by the RP until 3/12/25, the day of the resident's discharge. Interviews with the Social Worker (SW) and the RP revealed that although there were multiple conversations regarding the resident's discharge plan, the SW did not provide the NOMNC form to the RP until the day of discharge. The SW reported that attempts to provide the form earlier were unsuccessful as the RP had already left the facility each time. The RP expressed a desire to have been informed of her rights regarding the discharge before the day it occurred. The facility's Administrator acknowledged that the SW should have ensured the NOMNC form was provided to the RP prior to the discharge day.
Deficiencies in Comprehensive Care Plans for Side Rails and Anticoagulant Use
Penalty
Summary
The facility failed to develop individualized, person-centered comprehensive care plans for three residents, leading to deficiencies in addressing the use of side rails and anticoagulant medication. Resident #82, who was admitted with a history of cerebral infarction, had an assessment indicating the use of bilateral one-quarter length side rails. However, the care plan did not reference the use of side rails, and both the MDS nurse and the Director of Nursing were unaware that side rails needed to be addressed in the care plan. Similarly, Resident #119, also admitted with a cerebral infarction, was using bilateral quarter length side rails, but the care plan did not include this information. Observations confirmed the use of side rails for both residents, yet the care plans remained incomplete. Resident #129, admitted with atrial flutter, was prescribed Eliquis, an anticoagulant medication. The resident's care plan did not address the risk of bleeding associated with the medication, despite the MDS indicating its use. The MDS Coordinator acknowledged the omission as an error, and the Director of Nursing confirmed that anticoagulants require additional safety monitoring, which should have been reflected in the care plan. These oversights highlight a lack of communication and awareness among staff regarding the necessity of including specific medical interventions and risks in comprehensive care plans.
Failure to Attempt Alternatives Before Using Side Rails
Penalty
Summary
The facility failed to attempt alternative measures before installing side rails for two residents, leading to a deficiency in compliance with regulatory requirements. Resident #82, who was admitted with a seizure disorder and a history of cerebral infarction, was observed with side rails in the raised position without any documented attempts to use alternatives. The side rail/entrapment risk evaluation for this resident did not include questions about trying alternatives, and the care plan lacked any reference to side rail usage. Interviews with the Unit Manager, Director of Nursing, and Administrator revealed a lack of awareness that attempting alternatives was a requirement. Similarly, Resident #119, admitted with a diagnosis of cerebral infarction, was also found with side rails raised without prior attempts to use alternatives. The resident's assessment and care plan did not address the use of side rails or alternatives. Interviews with facility staff, including the Unit Manager and Director of Nursing, confirmed that no alternative interventions were tried before implementing side rails, as they were unaware of this requirement. This oversight resulted in a deficiency due to the facility's failure to comply with the necessary assessment and consent procedures before using side rails.
Failure to Obtain Baseline Thyroid Function Test for Resident on Levothyroxine
Penalty
Summary
The facility failed to obtain a baseline thyroid function test for a resident who was prescribed Levothyroxine Sodium for hypothyroidism. The resident was admitted with a diagnosis of hypothyroidism and was ordered Levothyroxine Sodium. A consultant pharmacist recommended a baseline thyroid function test to be completed and repeated yearly. Despite the nurse practitioner writing an order for the lab test, the test results were not documented in the resident's medical record. The Director of Nursing acknowledged that the pharmacy recommendations were received and placed in the physician's box for response. The baseline thyroid function test was scheduled twice, but neither appointment was fulfilled, and the Director of Nursing was unaware of the reasons for these omissions. The Nurse Practitioner noted that the routine lab should have been completed within 1 to 2 weeks, but there was no negative outcome for the resident due to the missed labs. The Administrator confirmed that labs should be completed as ordered.
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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 Tarboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tarboro Health And Rehabilitation Llc | 0.1 mi | ★★★★★ | 5 | 0 |
| Rocky Mount Rehabilitation Center | 16.9 mi | ★★★★★ | 15 | 0 |
| The Carrolton Of Nash | 17 mi | ★★★★★ | 6 | 0 |
| Scotland Manor Health And Rehabilitation Center | 17.5 mi | ★★★★★ | 3 | 0 |
| Bryan Health And Rehab | 17.8 mi | ★★★★★ | 2 | 0 |
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