Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Nc State Veterans Home-kinston during CMS and state inspections, most recent first.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility's failure to follow the established care plan.
Surveyors found that an area was not free from accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet safety standards, increasing the risk of accidents.
A resident on anticoagulants experienced an unwitnessed fall with a head injury, but the facility failed to notify the physician immediately. The resident continued to receive anticoagulant medication, leading to a severe brain injury and eventual death. The delay in notification was due to reliance on a communication log not reviewed until after the weekend.
A resident with severe cognitive impairment and on anticoagulants fell and showed signs of head injury but refused hospital evaluation. The facility failed to inform the resident and their responsible party of the risks, and the resident continued receiving anticoagulants. A change in the resident's condition was not promptly recognized, leading to a severe brain injury and subsequent death.
The facility failed to maintain accurate advanced directive documentation for two residents, resulting in discrepancies in their code status. One resident's records showed conflicting full code and DNR statuses, while another's care plan contained contradictory instructions regarding resuscitation. Staff interviews revealed an inability to explain or correct these inconsistencies, indicating a deficiency in managing advanced directives.
The facility failed to accurately code behaviors and medication use in the MDS assessments for two residents. One resident with dementia was not coded for rejecting care, despite documentation indicating such behavior. Another resident, prescribed Aspirin as an antiplatelet, was not coded for antiplatelet use due to a misclassification of the medication. Both errors were acknowledged as oversights by the staff involved.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure a safe and abuse-free environment for all residents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents occurring. Specific actions or inactions by staff or details about the residents involved are not provided in the report. The deficiency centers on the lack of proper accident hazard controls and insufficient supervision in the specified area, as observed by surveyors during their review.
Failure to Notify Physician of Fall with Head Injury for Resident on Anticoagulant
Penalty
Summary
The facility failed to notify the physician or nurse practitioner immediately of an unwitnessed fall with a head injury for a resident who was prescribed an anticoagulant. The resident fell on a Saturday, but the physician was not informed until the following Monday. During this period, the resident continued to receive his anticoagulant medication, which increased the risk of bleeding. The resident later experienced an acute change in condition and was sent to the hospital, where he was diagnosed with a severe traumatic brain injury. The resident, who had a history of atrial fibrillation, congestive heart failure, cognitive communication deficit, and hypertension, was found on the floor with an abrasion and indentation on his head. Despite being on blood thinners, the nursing staff did not notify the physician immediately, relying instead on a communication log that was not reviewed until after the weekend. The resident's condition deteriorated, and he was eventually transferred to a hospital where a CT scan revealed a large subdural hematoma and other serious brain injuries. Interviews with facility staff revealed a lack of understanding of the risks associated with anticoagulant use and the importance of timely physician notification following a fall with a head injury. The medical director indicated that the resident's death could have been preventable if he had been sent to the hospital immediately after the fall. The facility's failure to notify the physician promptly contributed to the resident's severe brain injury and subsequent death.
Removal Plan
- The Director of Health Services or the Nurse Supervisor will review all events during the morning clinical meeting to verify the physician or the physician extender has been notified of changes in condition to include falls with head injury for residents on anticoagulants.
- The Director of Health Services or Clinical Competency Coordinator will educate all licensed nursing staff to immediately notify the physician or physician extender in person or by phone of a fall with head injury for a resident on an anticoagulant for the physician or physician extender to make an informed decision regarding continued use anticoagulant or need to transfer the resident to an acute care facility.
- The physician or physician extender should be notified immediately in person or by phone if any significant change in condition, to include falls with head injury, for residents prescribed an anticoagulant.
- Licensed nurses will be educated regarding health risk for residents on anticoagulants and the importance of notification of physician or physician extender in person or by phone.
- Staff education will be completed or prior to the staff working their next scheduled shift.
- The education will be added to the licensed nurse written orientation program.
Failure to Address Resident's Refusal of Hospital Evaluation After Fall
Penalty
Summary
The facility failed to adequately inform a severely cognitively impaired resident and their responsible party about the life-threatening risks associated with refusing hospital evaluation after an unwitnessed fall with signs of head injury. The resident, who was on an anticoagulant, refused to go to the hospital, and the staff did not effectively communicate the potential consequences of this decision to the resident or the responsible party. As a result, the resident continued to receive anticoagulant medication without further evaluation. Following the fall, the resident exhibited a change in condition, including altered behavior and responsiveness, which was not promptly recognized as serious by the staff. The resident was not assessed by a nurse until several hours after the change in condition was first noted. When the nurse finally assessed the resident, they were only responsive to painful stimuli, indicating a significant decline in their condition. The delay in recognizing the seriousness of the resident's condition and the failure to seek immediate medical care resulted in the resident being diagnosed with a severe traumatic brain injury at the hospital. The resident's condition deteriorated, leading to their death from complications related to a subdural hematoma. This incident highlights the facility's deficiency in managing the resident's care and ensuring timely medical intervention.
Removal Plan
- Education by the Director of Health Services to all licensed staff on identification of change in condition and what constitutes a change in condition. The education will include the use of the Interact Change in condition tool. Nurses will be educated regarding notification of physician when a change in resident condition occurs. The education will be added to the licensed nurse orientation.
- Licensed staff will be educated regarding a resident with any cognition level that refuses hospital transport once a physician and/or physician extender order has been received, that the physician and/or physician extender and resident representative must be notified of the refusal. The education will be added to the licensed nurse orientation.
- Licensed staff will be educated in their responsibility to educate the resident and the resident representative regarding refusal of follow-up at an acute care facility to ensure the resident and resident representative are making an informed decision. The resident and resident representative education will be documented by the licensed nurse in the medical record. The Director of Health Services and the Administrator will be notified when a resident refuses an ordered transport to an acute care facility. The education will be added to the licensed nurse orientation.
- Certified Nursing Assistants and the Therapy Department staff will be educated by the Director of Health Service or the Clinical Competency Coordinator on reporting to the licensed nurse, any changes they notice in a resident they feel are outside of the resident's usual behavior, physical appearance or vital signs. The education will be added to the certified nursing assistant and Therapy Department orientation.
- The Supervisor and/or Director of Health Services will review events during morning meetings to ensure significant changes in condition are recognized by nursing staff, the need for urgent medical attention is recognized and physician and/or physician extender and family were notified of change of condition and/or refusal of transfer.
Discrepancies in Advanced Directive Documentation
Penalty
Summary
The facility failed to maintain accurate advanced directive documentation for two residents, leading to discrepancies in their code status. Resident #86, who was admitted with dementia and hypertension, had conflicting information in their medical records. While the electronic medical record and physician orders indicated a full code status, the care plan stated that CPR would not be initiated, reflecting a DNR status. Interviews with the nursing staff and the Director of Nursing (DON) revealed that the discrepancy was not identified or corrected in a timely manner, and the reason for the inconsistency could not be explained. Similarly, Resident #20, admitted with conditions including paroxysmal atrial fibrillation and osteoarthritis, also had conflicting code status documentation. The electronic medical record and physician orders confirmed a DNR status, but the care plan contained contradictory instructions to both attempt and not attempt resuscitation. The DON and Social Worker were unable to provide an explanation for the discrepancy, indicating a failure in the process of updating and reviewing care plans accurately. These inconsistencies highlight a significant deficiency in the facility's management of advanced directives.
Inaccurate MDS Coding for Behaviors and Medications
Penalty
Summary
The facility failed to accurately code behaviors and medication use in the Minimum Data Set (MDS) assessments for two residents. Resident #27, who was admitted with a diagnosis of dementia, exhibited behaviors of rejecting care, as noted in a nursing progress note. However, the most recent quarterly MDS assessment did not reflect this behavior. Interviews with the MDS Nurse and Social Work Assistant revealed that the behavior section of the MDS was the responsibility of the social workers, and the omission was an oversight. The Administrator confirmed that the MDS assessment should have been coded correctly for behaviors. Resident #17, admitted with a history of myocardial infarction, was prescribed Aspirin Delayed Release, an antiplatelet medication. Despite receiving this medication daily, the quarterly MDS assessment did not code for antiplatelet use. The MDS Nurse initially misclassified the medication as a nonsteroidal anti-inflammatory drug (NSAID) and acknowledged the error after reviewing the Resident Assessment Instrument (RAI) guidelines. The Administrator also confirmed that the MDS assessment should have been coded correctly for antiplatelet use.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 34 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
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 Kinston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmony Hall Nursing And Rehabilitation Center | 2.4 mi | ★★★★★ | 6 | 0 |
| Signature Healthcare Of Kinston | 3.4 mi | ★★★★★ | 8 | 0 |
| Greendale Forest Nursing And Rehabilitation Center | 10.6 mi | ★★★★★ | 0 | 0 |
| Ayden Court Nursing And Rehabilitation Center | 16.4 mi | ★★★★★ | 6 | 1 |
| Pruitthealth-farmville | 20.4 mi | ★★★★★ | 5 | 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 July 2026) and official state health department websites.