Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Goldsboro Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dysphagia, and a history of impulsive, rapid self-feeding was left unsupervised with a meal tray by a newly assigned nurse aide who was unaware of the resident's need for assistance. Despite clear care plan instructions and repeated staff education, the resident was found unresponsive with food in his mouth, leading to a fatal choking event. Staff interviews confirmed the resident's supervision requirements were known, but not followed at the time of the incident.
A resident with multiple chronic conditions did not have documentation of a required monthly medication regimen review (MRR) by a licensed pharmacist. Staff interviews confirmed that the October MRR could not be located, and the DON stated the resident was not included in the monthly review list provided by the pharmacy.
Two nurse aides failed to wear gowns, as required by Enhanced Barrier Precautions, while providing urinary catheter care to a resident with an indwelling catheter. Although gloves were used and PPE was available, both staff members neglected to don gowns despite signage and prior education on EBP protocols.
A resident with osteoarthritis and spinal stenosis did not receive necessary pain medication due to a lapse in obtaining a narcotic refill prescription. The medication ran out, and the resident's requests for it over the weekend and a holiday were unmet. The nursing staff failed to follow procedures for reordering medications and were unfamiliar with the electronic dispensing system, which could have served as a backup.
Failure to Supervise Resident During Meals Resulting in Fatal Choking Incident
Penalty
Summary
A facility failed to provide necessary supervision to prevent an avoidable accident involving a resident with severe cognitive impairment, a history of stroke, dementia, and dysphagia, who was on a pureed diet with nectar thick liquids. The resident required staff assistance with eating due to an inability to control the speed and quantity of food intake, as documented in the care plan, Kardex, and speech therapy notes. Despite clear instructions and repeated education to staff that the resident needed supervision during meals to prevent rapid, impulsive self-feeding and reduce the risk of aspiration or choking, a nurse aide left a meal tray in front of the resident and exited the room to deliver other trays. Shortly after the meal trays were distributed, another nurse aide found the resident unresponsive and not breathing, with food in his mouth. Nursing staff initiated CPR and called EMS, who arrived and took over resuscitation efforts. The resident was transported to the hospital, where he was intubated after a second cardiac arrest and admitted to the ICU. Hospital records and the death certificate confirmed that the cause of death was airway occlusion by a bolus of food. Interviews with staff, including nurse aides, nurses, the speech therapist, the DON, the administrator, the nurse practitioner, and the medical director, confirmed that the resident was known to require supervision during meals due to impulsive eating behaviors and high risk of choking. The nurse aide who left the tray was new, had not previously worked with the resident, and had been incorrectly informed by other aides that the resident could feed himself without assistance. The failure to provide required supervision directly led to the resident being left alone with food, resulting in choking and subsequent death.
Removal Plan
- Resident #132 was provided with his breakfast tray by Nurse Aide #8, who walked out of the resident's room.
- The charge nurse completed a Risk Management and Situation Background Assessment Recommendation (SBAR). The Administrator, Director of Nursing, Medical Director, and Responsible Party were all notified.
- Resident #132's diet consistency, supervision needs, and feeding requirements were reviewed by the Director of Nursing and Administrator. The Registered Dietician confirmed that Resident #132 was appropriate for a puree diet with thickened liquids, with staff supervision required during meals.
- A root cause analysis was determined by the Administrator, Director of Nursing, and Eastern Regional Administrator that Nurse Aide #8 did not provide resident supervision during meal. Nurse Aide #8 was suspended pending investigation.
- Nurse Management/designee reviewed all residents' kardex and audited the assistance level required while feeding. It was concluded that 9 residents were dependent on staff for feeding and 7 residents required supervision of staff.
- DON #1/designee completed observation rounds during lunch and dinner meals on the identified residents that needed feeding assistance with no other concerns identified.
- Nurse Management initiated a facility-wide education for all licensed nurses/NAs on meal delivery and feeding assistance, focusing on proper resident identification, verification of correct diet orders, and adherence to required supervision levels during meals.
- Licensed nurses/NAs were educated on utilizing the kardex to locate information needed to determine supervision required with feeding.
- No licensed nurses/NAs are permitted to work without education in meal tray delivery until they have completed this required education.
- All licensed nurses/NAs were educated by Nurse Management or the Administrator via phone or with one-on-one in-service.
- The only staff that pass resident meal trays are NAs/licensed nurses.
- This training has been added to the orientation program for all licensed nurses/NAs.
- The Director of Nursing, Nurse Manager, and Administrator will conduct audits of resident meal tray delivery. These audits include validation of accurate meal tickets, correct resident identification, and confirmation that residents receive the correct diet with the required level of assistance as indicated on the resident Kardex and diet order.
- Audits are done two meals per day, five days per week for six weeks. Any concerns identified will be addressed and corrected immediately.
- Results of these audits will be reviewed during the QAPI meeting to determine whether additional monitoring is needed.
- The Administrator is responsible for ensuring completion and oversight of this Plan of Correction.
Missing Monthly Medication Regimen Review Documentation
Penalty
Summary
A deficiency occurred when the facility failed to have documentation of a monthly medication regimen review (MRR) by a licensed pharmacist for one resident. The resident, who had a history of hypertension, hyperlipidemia, stroke, peripheral vascular disease, chronic kidney disease, depression, and insomnia, was readmitted to the facility and did not have an MRR available for the month of October 2025. During the survey, staff and pharmacist interviews confirmed that the required documentation for the MRR could not be located for this resident. Pharmacist #1 reported that Pharmacist #2, who was responsible for the review, claimed to have paper notes for the October MRR, but these could not be found. The DON stated that she typically received monthly MRRs and recommendations from the pharmacist, with residents not requiring recommendations listed generally and specific recommendations documented separately. However, the resident in question was not included in the October MRR list provided to the DON. The administrator also confirmed that the MRR should have been completed in a timely manner by the pharmacy representative.
Failure to Use Required PPE During Urinary Catheter Care on Enhanced Barrier Precautions
Penalty
Summary
Nurse Aide (NA) #4 and NA #5 failed to follow the facility's Enhanced Barrier Precautions (EBP) policy during urinary catheter care for a resident who had an indwelling urinary catheter and was on EBP. Both staff members performed hand hygiene and donned gloves but did not wear the required gowns, despite clear signage on the resident's door indicating the need for gloves and gowns during high-contact care activities such as urinary catheter care. The necessary PPE, including gowns and gloves, was readily available at the entrance to the resident's room. Interviews with NA #4 and NA #5 revealed that both were aware of the EBP requirements and had received education on the use of PPE for such procedures. NA #5 stated she forgot to use the gown, and NA #4 indicated she was nervous and also forgot to don the gown. The Infection Preventionist and the Administrator confirmed that staff were responsible for checking signage and using appropriate PPE as indicated, and acknowledged that the required procedures were not followed during the observed care.
Failure to Provide Pain Medication Due to Refill Lapse
Penalty
Summary
The facility failed to provide necessary pain medication for a resident with osteoarthritis and spinal stenosis due to a lapse in obtaining a narcotic refill prescription. The resident was admitted with a physician's order for oxycodone-acetaminophen to be administered as needed for pain. However, the medication ran out, and the last dose was given on a Friday night. The resident requested the medication over the weekend and on a holiday, but it was unavailable. The facility did not dispense any doses from the electronic medication system during this period. The deficiency was attributed to the failure of the nursing staff to follow the established procedure for reordering medications when the supply was low. Nurse #1, who administered the last dose, was unable to obtain a new prescription from the Nurse Practitioner or the on-call service. Additionally, she was not familiar with the electronic medication dispensing system, which could have served as a backup. The Director of Nursing confirmed that the nurses were responsible for ordering medications and should have accessed the backup system when the resident complained of pain. The facility had recently changed pharmacies, and it was noted that Nurse #1 might have missed the training on the new system.
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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 Goldsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Creek Nursing And Rehabilitation Center | 0.7 mi | ★★★★★ | 10 | 0 |
| O'berry Neuro-medical Treatment Center | 3.6 mi | ★★★★★ | 2 | 0 |
| Mount Olive Center | 14.7 mi | ★★★★★ | 14 | 1 |
| Greendale Forest Nursing And Rehabilitation Center | 17.9 mi | ★★★★★ | 5 | 0 |
| Nc State Veterans Home-kinston | 21.1 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.