Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harborview Lumberton during CMS and state inspections, most recent first.
Surveyors found that medications and biologicals were not properly labeled, stored, or discarded as required. Unopened Latanoprost drops were not refrigerated, inhalers lacked opened dates or exceeded use periods, and expired medications were present on medication carts and in storage rooms. Nursing and supply staff acknowledged responsibility but cited oversights and lack of awareness regarding specific storage and labeling requirements.
Surveyors found an open package of sliced turkey in the walk-in refrigerator that was not labeled or dated, as well as expired containers of 2% milk in two nourishment rooms. The Dietary Manager confirmed that staff were responsible for labeling and removing expired items, but expired milk was not removed due to lack of weekend checks.
The facility failed to consistently implement and document wound care and weight monitoring as ordered for several residents with complex medical conditions, including those with chronic wounds, CHF, and recent amputations. Wound treatments and daily or weekly weights were frequently missed or not recorded, often due to unclear staff responsibilities and lack of backup systems, resulting in incomplete care and inaccurate records.
A resident with hypotension received Midodrine outside of prescribed blood pressure parameters on multiple occasions due to staff misinterpretation, oversight, and documentation errors. Several medication aides and nurses administered the drug incorrectly, and facility leadership, including the DON and Administrator, were unaware of the ongoing errors until the survey. The Consultant Pharmacist identified some errors but did not fully communicate the extent to the facility, and the Medical Director was not notified. The resident did not experience significant adverse outcomes.
A resident was admitted with a Stage IV pressure wound and other serious health conditions, but the Wound Care Physician was not notified of the wound for several weeks despite documentation and ongoing wound care by nursing staff. The wound was only brought to the physician's attention after a significant delay, with facility leadership unaware of the lapse until it was discovered during the survey.
The facility did not ensure complete and accurate documentation for two residents: one with hypertension did not have pulse readings recorded prior to administration of hydralazine as required by physician order, and another with congestive heart failure had daily weights inaccurately documented by an LPN who copied previous entries instead of obtaining new measurements. These actions resulted in incomplete medical records for both residents.
Two residents with severe cognitive impairment and existing pressure ulcers did not receive consistent wound assessments or daily wound care as ordered. Initial wound assessments with measurements were delayed or missing, and daily treatments were not documented or completed on multiple occasions due to unclear staff responsibilities and communication lapses. The Wound Care Physician was not notified of a stage IV ulcer on admission, and the DON was unaware of missed treatments, resulting in deficiencies in pressure ulcer care.
A resident admitted with severe cognitive impairment, malnutrition, and a Stage IV pressure wound, and who was receiving enteral tube feedings, did not have weekly weights obtained as required by facility policy and physician orders. The Restorative Aide, responsible for weights, was unable to complete them due to other assignments, and the assigned nurse did not obtain the weights in her absence. This resulted in missed documentation of the resident's weight on admission and during a required weekly interval.
A pharmacist did not identify or report repeated errors in the administration of Midodrine for a resident with hypotension, despite clear medication parameters. The medication was given outside of prescribed blood pressure limits dozens of times over several months, but these errors were not documented in monthly reviews or communicated to facility leadership. Nursing and administrative staff were unaware of the errors, and no staff education on medication parameters was provided. The resident experienced no significant outcome.
A resident admitted after a stroke and with a sacral pressure ulcer did not receive ordered physical, occupational, or speech therapy services. Therapy was withheld due to the absence of a PRAFO boot, which was not ordered by a physician and was incorrectly made a prerequisite for therapy. The resident, who was cognitively intact and expressed a desire for therapy, was not evaluated or treated as required by her care plan, and staff interviews revealed confusion about therapy initiation and equipment requirements.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in medication storage and labeling across several medication carts and storage rooms. On the 400-hall medication cart, an unopened bottle of Latanoprost ophthalmic drops was not refrigerated as required by manufacturer guidelines, and two Fluticasone propionate salmeterol inhalers were found—one without an opened date and another with an opened date exceeding the recommended one-month use period. Additionally, expired Hemorrhoidal suppositories were present. Nursing staff interviewed acknowledged responsibility for checking for expired medications and proper labeling but admitted these tasks had not been completed due to workload or lack of awareness regarding specific storage requirements. On the 800-hall medication cart, an opened bottle of Latanoprost ophthalmic drops lacked an opened date, and a bottle of Lansoprazole suspension was present with a use-by date that had passed, contrary to manufacturer instructions for refrigeration and timely disposal. In the 300-hall and 400-hall medication storage rooms, expired wound cleansers and Lansoprazole suspension were found. Staff interviews revealed confusion and oversight regarding responsibility for checking both prescription and over-the-counter medications, with multiple staff members indicating that expired medications had not been identified or removed as required.
Failure to Label Opened Food and Remove Expired Milk from Nourishment Rooms
Penalty
Summary
During a survey, it was observed that an open package of sliced turkey in the walk-in refrigerator was not labeled or dated, contrary to facility policy requiring all open food items to be labeled with an opened date and an expiration date. Additionally, expired containers of 2% milk were found in the East Wing and Secured Unit nourishment rooms. The Dietary Manager confirmed that dietary staff were responsible for stocking and removing expired items from these rooms, and acknowledged that the expired milk should have been removed. The Administrator stated that no one was assigned to check the nourishment rooms on weekends, which resulted in the expired milk remaining in place.
Failure to Provide Ordered Wound Care and Weight Monitoring
Penalty
Summary
The facility failed to implement and consistently provide wound care and weight monitoring as ordered for multiple residents with complex medical needs. For one resident with a chronic venous wound and congestive heart failure, there was a delay in initiating wound treatment upon admission and after readmission, with daily wound care treatments frequently missed or undocumented over several months. Nursing staff often believed that wound care was the responsibility of the treatment nurse or aide, leading to confusion and missed treatments. The resident, who was cognitively intact and did not refuse care, reported not receiving wound care every day, and documentation confirmed multiple days where treatments were not completed or recorded. The Wound Care Physician and Medical Director were unaware that orders were not being followed as prescribed. Additionally, the same resident had physician orders for daily weights due to congestive heart failure and fluid restrictions, but daily weights were not consistently obtained or documented. The Restorative Aide, primarily responsible for obtaining weights, was sometimes unavailable due to other assignments, and nurses did not obtain weights in her absence. One nurse admitted to recording previous weights on the Medication Administration Record (MAR) without actually obtaining new weights, resulting in inaccurate documentation. The Registered Dietitian and physician confirmed that daily weights were necessary for monitoring the resident's condition, but the process for ensuring weights were obtained was not followed. For another resident with arterial ulcers and a history of amputation, wound care treatments were not completed as ordered on multiple days, particularly when there was no assigned treatment nurse. Floor nurses did not always complete or document the required wound care, and the Wound Care Nurse did not review the Treatment Administration Records (TARs) for completion. This resident also did not have weekly or daily weights obtained as ordered following readmission, despite significant changes in condition, including edema and elevated BNP levels. The Restorative Nursing Assistant, responsible for weights, reported difficulty obtaining all required weights due to other duties and a lack of a backup system or notification process for new admissions and readmissions.
Failure to Follow Medication Administration Parameters for Midodrine
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not adhering to the prescribed parameters for administering Midodrine, a medication used to treat hypotension. The resident had active orders specifying that Midodrine should be held if the systolic blood pressure (BP) was greater than 120 mm Hg or the diastolic BP was greater than 80 mm Hg. However, medication administration records revealed that the medication was frequently given when the resident's BP readings were above the specified parameters and held when the readings were below, contrary to the physician's orders. Multiple medication aides and nurses administered Midodrine in error, either by not noticing the parameters, misunderstanding the order, or documenting incorrectly. Several staff members admitted during interviews that they were aware of the parameters but failed to follow them due to oversight, misinterpretation, or the hectic nature of their assignments. Some staff also reported being unfamiliar with the specific requirements of the order or being distracted by other duties, leading to the administration of the medication outside the prescribed parameters. The errors were not identified or reported by the facility's leadership, including the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and the Administrator, all of whom stated they were unaware of the medication errors until notified during the survey. The Consultant Pharmacist noted the errors but did not report the full extent to the facility, believing the issue was not clinically significant and that staff education was already underway. The Unit Manager also did not receive pharmacy recommendations regarding the errors. The Medical Director confirmed that she was not notified of the errors and expected medications to be administered according to the ordered parameters. Despite the significant number of errors, the resident did not experience a significant outcome.
Failure to Notify Wound Care Physician of Stage IV Pressure Wound on Admission
Penalty
Summary
The facility failed to notify the Wound Care Physician for evaluation and treatment of a Stage IV pressure wound on the left trochanter that was present upon admission for a resident with multiple diagnoses, including protein calorie malnutrition and anemia. Documentation showed that the resident was admitted with a Stage IV pressure wound, and physician orders were in place for wound care. Progress notes indicated the need for a wound care specialist consultation, but there was no evidence in the medical record that the Wound Care Physician was notified of the wound from admission through several weeks of the resident's stay. Interviews confirmed that the Wound Care Physician was not made aware of the resident's Stage IV wound until weeks after admission, despite the wound being documented and treated by nursing staff. The Wound Treatment Nurse, who was only present part-time, did not provide an explanation for the lack of notification, and the DON and Administrator were unaware of the failure until it was brought to their attention. The deficiency centers on the lack of timely notification to the Wound Care Physician for a serious wound present at admission.
Failure to Maintain Accurate Medical Records for Vital Signs and Weight Monitoring
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in deficiencies related to documentation of vital signs and weight monitoring. For one resident with a history of stroke and hypertension, there was a physician order for hydralazine with specific parameters to hold the medication if the systolic blood pressure was less than 100, diastolic less than 50, or heart rate less than 60. Although the medication was administered and blood pressure readings were documented, there was no documentation of the resident's pulse or heart rate prior to administration, as required by the order. Multiple nurses confirmed that while they did check the pulse before giving the medication, the electronic Medication Administration Record (eMAR) did not require or provide a field to record the pulse, and this omission was due to an error in the transcription of the order by the DON. Another resident with diagnoses including congestive heart failure and chronic kidney disease had a physician's order for daily weights. Review of the Medication Administration Record revealed that the same weight was repeatedly documented over several days, and in some cases, the weight was not updated for over a week. During an interview, a nurse admitted to copying the previous weight from the record rather than obtaining and recording an actual daily weight, citing uncertainty about the method used by the Restorative Aide to obtain the weight. The nurse acknowledged that she had not obtained or documented accurate weights for the resident. Interviews with the DON, Administrator, and Nurse Practitioner confirmed that the expectations were for accurate and complete documentation of vital signs and weights as per physician orders. The lack of required documentation for the pulse prior to medication administration and the failure to obtain and record daily weights as ordered led to incomplete and inaccurate medical records for both residents.
Failure to Provide Consistent Pressure Ulcer Care and Assessment
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. For one resident admitted with a Stage IV pressure ulcer to the left trochanter, the facility did not conduct an initial wound assessment with a wound description and measurements upon admission. There was also a lack of documentation of wound assessments for both the stage IV hip and sacrum wounds for several days after admission. Additionally, daily wound care treatments were not consistently performed or documented according to physician orders, with multiple days where treatments were not signed off as completed. Staff interviews revealed confusion regarding responsibility for wound care, with some nurses believing the treatment nurse was responsible, while others thought the assigned nurse should complete the care in the absence of the treatment nurse. The Wound Care Physician was not notified of the stage IV wound upon admission, and the Director of Nursing was unaware that daily treatments were not being completed. Another resident with a Stage IV pressure ulcer to the sacrum and an unstageable ulcer to the right second toe did not consistently receive daily wound care treatments as ordered. The Treatment Administration Record showed multiple days where wound care was not documented as completed. Assignment sheets indicated that on these days, there was no assigned treatment nurse, and a Medication Aide was assigned to the resident with a nurse overseeing. However, both the Medication Aide and the overseeing nurse assumed the other was responsible for completing the wound care, resulting in missed treatments. The Wound Care Nurse, who was working part-time due to resignation, stated that floor nurses were responsible for wound care in her absence, but this was not consistently carried out. Both residents had significant medical histories, including severe cognitive impairment, malnutrition, and immobility, placing them at high risk for pressure ulcer development and complications. The lack of clear responsibility and communication among staff, as well as failure to follow physician orders for wound care, led to deficiencies in the care and monitoring of pressure ulcers. The Wound Care Specialist and Medical Director confirmed that wound care treatments were not completed as ordered, and the Director of Nursing was not aware of the lapses in care.
Failure to Obtain Weekly Weights for New Admission on Tube Feeding
Penalty
Summary
The facility failed to obtain weekly weights as ordered for a newly admitted resident who was receiving enteral tube feedings. The resident was admitted with diagnoses including a Stage IV pressure wound, protein calorie malnutrition, and anemia, and was identified as being at risk for dehydration. Facility policy and physician orders required weekly weights for new admissions, especially those on tube feedings, to monitor nutritional status. However, the resident's medical record showed missing weights on the admission date and on one of the required weekly intervals. Interviews with staff revealed that the Restorative Aide was primarily responsible for obtaining weights, but due to being assigned additional duties such as nurse aide tasks and transporting residents, weights were not always completed as required. The DON confirmed that if the Restorative Aide was unavailable, the assigned nurse was responsible for obtaining the weights, but this did not occur. The Registered Dietitian and the physician both confirmed the importance of weekly weights for this resident, and acknowledged that the required monitoring was not performed as ordered.
Pharmacist Failed to Identify and Report Repeated Medication Administration Errors
Penalty
Summary
A licensed pharmacist failed to identify and address repeated medication administration errors during monthly drug regimen reviews for a resident prescribed Midodrine for hypotension. The resident had specific parameters for administration, requiring the medication to be held if systolic blood pressure exceeded 120 or diastolic exceeded 80. Despite these parameters, the medication was administered outside of the prescribed limits 38 times in January, 44 times in February, and 35 times in March. The pharmacist's monthly reviews did not document these errors, and the majority of the errors went unreported to facility leadership. The pharmacist only partially acknowledged some errors in a February recommendation to nursing staff, listing a small sample of dates but not the full extent of the errors. No recommendations or notifications were made regarding the errors in January or March. Interviews with the pharmacist revealed she did not consider the errors clinically significant and believed that education provided to nursing staff would resolve the issue, though no such education had actually occurred. The pharmacist's monthly summary reports for all three months stated that no medication errors were noted. Facility leadership, including the DON, Unit Manager, Staff Development Nurse, and Administrator, were unaware of the medication errors until informed during the survey process. None of the nursing leadership had received reports or recommendations regarding the errors, nor had any education been provided to staff about medication parameters. The Medical Director confirmed that the pharmacist should have reported the errors as soon as they were discovered. The resident involved did not experience any significant outcome as a result of the errors.
Failure to Provide Required Rehabilitation Services per Care Plan
Penalty
Summary
The facility failed to provide required rehabilitation services to a resident who was admitted following a hospital stay for a stroke and sacral pressure ulcer. The hospital discharge summary recommended continued physical and occupational therapy due to the resident's significant mobility and activities of daily living (ADL) limitations. Upon admission, physician orders were in place for speech, occupational, and physical therapy evaluations and treatment as indicated. However, the therapy screening form was not fully completed, and therapy services were not initiated. The justification for not evaluating the resident was the absence of a PRAFO boot, which the facility was in the process of obtaining, despite there being no physician order for the device. The resident did not receive any occupational, physical, or speech therapy services after admission, despite being cognitively intact, expressing a desire to participate in therapy, and having no documented refusal of care. Interviews with staff revealed a lack of clarity regarding the resident's therapy status. The Therapy Director stated that therapy was withheld because the resident required total assistance and a PRAFO boot was needed, which the resident was expected to partially pay for. The Therapy Director also indicated that therapy services would not begin until the PRAFO boot was obtained, and was unable to explain why upper body therapy could not proceed in the meantime. Further interviews with the Nurse Practitioner and Administrator revealed that there was no physician order for the PRAFO boot and that it was not required for therapy participation. The Administrator was unaware that the resident had been asked to pay for the device and stated that the facility preferred insurance or the resident to cover the cost. Despite clear recommendations and orders for therapy, the resident did not receive the necessary rehabilitative services as required by her care plan.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 52 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lumberton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Carrolton Of Lumberton | 1.1 mi | ★★★★★ | 9 | 0 |
| Wesley Pines Retirement Community | 1.9 mi | ★★★★★ | 7 | 0 |
| Woodhaven Nursing Center | 2 mi | ★★★★★ | 7 | 0 |
| Glenflora | 4.4 mi | ★★★★★ | 2 | 0 |
| Pembroke Center | 11.5 mi | ★★★★★ | 23 | 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 July 2026) and official state health department websites.