Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Harnett Woods Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not prevent the use of unnecessary psychotropic medications or medications that could restrain a resident's ability to function, resulting in residents receiving drugs without adequate justification or in a manner that could limit their functional abilities.
A resident with severe cognitive impairment was transferred to the hospital on two occasions, but the facility did not provide written notification to the resident's representative regarding the reasons for these transfers. Staff interviews revealed a lapse in communication about responsibility for sending these notifications, resulting in the representative not being informed as required.
The facility failed to refer two residents with newly evident mental health diagnoses for PASRR level II screening. One resident had depression added as a diagnosis, and another had a new diagnosis of psychotic disorder. The DON and Administrator acknowledged the oversight and indicated a lack of familiarity with the PASRR process.
The facility failed to apply for a level II PASRR screening for two residents with mental health diagnoses. One resident with anxiety disorder and severe cognitive impairment, and another with a psychotic disorder, were not properly screened due to staff unfamiliarity with the PASRR process.
A resident with severe cognitive impairment and functional limitations did not receive consistent range of motion exercises or therapy, leading to worsening contractures. Staff and family interviews confirmed the resident was rarely out of bed and lacked a proper restorative maintenance program.
A resident with dementia, polyosteoarthritis, and dorsalgia fell and developed pain and bruising in the rib area. Despite multiple complaints of pain, the nurse did not notify the physician until three days later when bruising and a palpable mass were observed, leading to an x-ray that revealed rib fractures.
A resident with dementia and chronic pain conditions experienced a fall and subsequently complained of rib pain and showed signs of bruising. Despite multiple complaints and assessments by staff, the resident's rib fractures were not identified until two days later, following an x-ray ordered after a physical therapist noted bruising and a palpable mass.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were administered psychotropic drugs without adequate justification or in a manner that could limit their functional abilities. The report does not provide specific details about the residents involved, their medical histories, or their conditions at the time of the deficiency.
Failure to Notify Resident Representative of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to the resident's representative regarding the reasons for two unplanned hospital transfers for a resident who was severely cognitively impaired. Record review showed that the resident was transferred to the hospital on two separate occasions and returned to the facility after each event. There was no documentation in the medical record indicating that the resident's representative was notified in writing of the reasons for these transfers. Staff interviews revealed that the Administrator had previously handled these notifications during the Social Worker's leave but ceased doing so upon the Social Worker's return, without informing the Social Worker that this responsibility had shifted back. As a result, the resident's representative was not notified by mail for either hospital transfer.
Failure to Refer Residents for PASRR Level II Screening
Penalty
Summary
The facility failed to refer residents with newly evident mental health diagnoses for Preadmission Screening and Resident Review (PASRR) level II screening for two residents. Resident #44 was admitted without any mental health diagnoses, but later had depression added as a diagnosis. Despite this significant change, no referral for a PASRR level II screening was made. The Director of Nursing (DON) and the Administrator both acknowledged the oversight and indicated a lack of familiarity with the PASRR process as a contributing factor. Similarly, Resident #63 was admitted with diagnoses including Parkinson's disease and anxiety disorder. A new diagnosis of psychotic disorder was later identified, but no referral for a PASRR level II screening was made. The DON and the Administrator again acknowledged the oversight and indicated that the staff responsible for PASRR screenings were on leave, contributing to the failure to complete the necessary referral.
Failure to Apply for PASRR Level II Screening for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to apply for a level II Preadmission Screening and Resident Review (PASRR) screening for two residents who had mental health diagnoses. Resident #63 was admitted with diagnoses including Parkinson's disease and anxiety disorder. The PASRR level I screen did not include the anxiety disorder diagnosis, and the resident was not considered for a level II PASRR despite having behavioral symptoms and severe cognitive impairment. The Director of Nursing (DON) acknowledged the oversight and indicated a lack of familiarity with the PASRR process, which contributed to the failure to complete the screening accurately before admission. Resident #71 was admitted with a diagnosis of psychotic disorder, but the PASRR level I screen did not reflect this mental health diagnosis. The resident was coded as moderately cognitively impaired and was not considered for a level II PASRR. The DON confirmed that the mental health diagnosis was present at the time of screening but was not included due to unfamiliarity with the PASRR process. Both the DON and the Administrator acknowledged the oversight and indicated that staff education on the PASRR process would be necessary to prevent recurrence.
Failure to Provide Restorative Maintenance Program
Penalty
Summary
The facility failed to provide a restorative maintenance program to prevent further decrease in range of motion and mobility for a resident diagnosed with cerebrovascular accident and epilepsy. The resident was severely cognitively impaired and dependent on staff for all activities of daily living. Despite having functional limitations in both upper and lower extremities, the resident did not receive consistent range of motion exercises or therapy to prevent contractures from worsening. Observations revealed that the resident's legs were contracted at the knees, and no range of motion exercises were performed during repositioning by staff. Interviews with staff and the resident's representative indicated that the resident was rarely out of bed and had not received therapy since being discharged from the hospital. The Therapy Director confirmed that the resident was not picked up for therapy upon returning to the facility, and no discharge plan was developed to educate nursing assistants on performing range of motion exercises. The resident's roommate and multiple staff members corroborated that the resident was not regularly transferred out of bed and that range of motion exercises were not consistently provided. The Physical Therapist attempted to measure the degree of knee joint limitation but was unable to do so due to severe spasming. The Activity Director noted that the resident participated in in-room activities but was always in bed during these sessions. The facility's Administrator acknowledged that residents should not stay in bed all the time and that therapy involvement was necessary to determine appropriate transfer and mobility devices. However, there was no evidence that range of motion exercises were being provided to the resident, leading to a deficiency in maintaining and improving the resident's range of motion and mobility.
Failure to Notify Physician of Resident's Pain and Bruising After Fall
Penalty
Summary
The facility failed to notify the physician when a resident developed pain and bruising in the rib area following a fall. The resident, who had a history of dementia, polyosteoarthritis, and dorsalgia, was found sitting on the floor and initially assessed to have no bumps, bruises, or pain. However, later in the day, the resident reported a burning sensation under her breast, which was treated as a yeast infection by the nurse without notifying the physician. The resident continued to complain of pain in the rib area over the next few days, but the physician was not notified until bruising and a palpable mass were observed, leading to an x-ray that revealed rib fractures. On the day following the fall, the resident complained of pain multiple times, but the nurse did not observe any bruising or significant pain upon assessment and did not notify the physician. The resident's pain was reported by the nursing aides, but the nurse attributed it to a yeast infection and continued to apply Nystatin powder. The resident's pain was documented by the psychiatric nurse practitioner and the physical therapist, but the physician was still not notified. It was not until three days after the fall, when the physical therapist noted bruising and the resident complained of pain during a transfer, that an x-ray was ordered. The x-ray revealed acute fractures of the left 4th and 5th ribs and a suspected occult fracture of the left 6th rib. The physician confirmed that the nurses should have contacted him earlier when the resident first reported pain, and the facility identified issues with physician notification through their quality assurance program.
Failure to Conduct Comprehensive Assessment After Resident Fall
Penalty
Summary
The facility failed to ensure a complete assessment was done when a resident started complaining of rib pain and showing signs of bruising following a fall. The resident, who had a history of dementia, polyosteoarthritis, and dorsalgia, was found sitting on the floor and initially assessed to have no bumps, bruises, or skin tears. Despite the resident's complaints of a burning sensation under her breast, which was treated as a yeast infection, no further comprehensive assessment was conducted to identify potential rib injuries. On the following day, the resident continued to complain of pain under her breast and sharp rib pain during care activities. Multiple staff members, including nurses and nurse aides, documented the resident's complaints of pain, but the assessments conducted did not identify any bruising or significant injuries. The resident's pain was managed with routine acetaminophen, and no additional diagnostic measures were taken at that time. It was not until two days after the fall that a physical therapist noted bruising and a palpable mass in the resident's rib area, leading to an x-ray that revealed acute fractures of the left 4th and 5th ribs and a suspected occult fracture of the left 6th rib. The delay in identifying and diagnosing the rib fractures resulted from inadequate initial assessments and failure to recognize the resident's persistent pain as indicative of a more serious injury.
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Illustrative
What surveyors actually found near you
We read the 85 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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
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Illustrative
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Nursing homes near Dunn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Carrolton Of Dunn | 1.4 mi | ★★★★★ | 5 | 0 |
| Liberty Healthcare Services Of Golden Years Nursin | 8.2 mi | ★★★★★ | 7 | 0 |
| Liberty Commons Nursing & Rehabilitation Center Of | 8.7 mi | ★★★★★ | 12 | 0 |
| Lillington Health And Rehabilitation Center | 9.4 mi | ★★★★★ | 0 | 0 |
| Emerald Health & Rehab Center | 10.9 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.