Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Signature Healthcare Of Kinston during CMS and state inspections, most recent first.
Lunch was served approximately two hours late to all dining areas after kitchen staffing shortages led to unwashed dishes from the previous dinner service, which delayed both breakfast and lunch meal times. The interim dietary manager confirmed the delays were due to staff quitting without notice, and the administrator was aware of prior late meal services but had not previously identified staffing as the cause.
A resident admitted with multiple serious mental health diagnoses, including bipolar disorder, PTSD, depression, and anxiety, did not receive a required Level II PASRR evaluation despite ongoing psychiatric symptoms and medication changes. The facility relied on a prior Level I screening and did not reassess the need for a Level II evaluation, as confirmed by staff interviews and record review.
A resident with a tracheostomy did not have an Ambu bag at the bedside as required by policy and physician orders, and nursing staff were unable to immediately locate the Ambu bag on the crash cart. Additionally, a nurse performed tracheostomy care without maintaining sterile technique after contaminating her gloves, and staff training and competency checks were found to be insufficient.
A resident with dysphagia and physician orders for a pureed diet did not receive the required pureed bread item as specified on the dietitian-approved menu. Staff confirmed the omission during meal service, and the issue was only addressed after surveyor intervention.
A resident who was cognitively intact and independently mobile in a wheelchair was verbally abused and threatened by a housekeeper, who used profane and racially charged language and physically pushed her cart into the resident's wheelchair. Multiple staff witnessed the incident, intervened to separate the individuals, and confirmed the abusive behavior, which was substantiated by the facility's investigation.
Two residents experienced misappropriation and exploitation when staff solicited and used their funds for personal gain. One resident with dementia lost over $2,200 after giving her debit card to a nurse aide, who made unauthorized purchases. Another cognitively intact resident gave $65 to a nurse aide who requested money for her children and was not reimbursed. Both incidents were substantiated, and the staff involved were terminated.
The facility did not notify Adult Protective Services (APS) of substantiated cases of misappropriation of property and verbal abuse involving three residents, despite facility policy requiring such reporting. Incidents included a resident's debit card being misused by a nurse aide, another resident being verbally abused and physically threatened by a housekeeper, and a third resident reporting a missing valuable ring. Documentation and staff interviews confirmed APS was not notified in these cases.
A resident's MDS assessment was inaccurately coded when a physician-documented contraindication to gradual dose reduction (GDR) of a psychotropic medication was not properly recorded. The MDS nurse acknowledged the error during an interview, confirming that the section should have indicated the GDR was clinically contraindicated as documented by the physician.
The facility failed to accurately code MDS assessments for several residents, including a resident with diabetes not coded for hypoglycemic medications, a smoker not coded for tobacco use, a resident with a colostomy not coded for an ostomy, and a resident with dementia not coded for a gradual dose reduction of antipsychotic medication. These errors were acknowledged by the MDS Nurse and confirmed by the Interim Director of Nursing and the Administrator.
A resident was left with medications on her overbed table without an assessment for self-administration. The resident, who was cognitively intact, had Acetaminophen and Ciprofloxacin left in medication cups to take at her discretion. Nurse #1 admitted to leaving the medications unsupervised, and both the Assistant Director of Nursing and the Interim Director of Nursing confirmed the lack of assessment and supervision.
A facility failed to provide the required CMS Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (ABN) for a resident with moderate cognitive impairment. The resident's Medicare Part A skilled services ended, but the benefit was not exhausted, and there was no evidence that the necessary notices were given. The Business Office Manager indicated that the former Receptionist was responsible for the forms, but they were not completed or uploaded.
A facility failed to refer a resident with a new PTSD diagnosis for a PASARR evaluation. The resident, initially admitted with adjustment disorder, was not screened for PASARR despite a new PTSD diagnosis. The Social Worker did not make the referral, believing the resident was doing well and unaware of her nightmares. The Administrator confirmed that a new psychiatric diagnosis should have prompted a referral.
A facility failed to document the administration of Acetaminophen for a resident with peripheral vascular disease. A nurse administered 650 mg of Acetaminophen, but this was not recorded in the resident's MAR. The nurse believed he had documented it, and the Interim DON confirmed it should have been documented.
A resident's room in the facility was found to have a scuffed bathroom door with peeling paint and a buildup of black debris on the grout at the base of the doorway. Despite the resident's complaints to staff, no maintenance work order was found, and staff interviews revealed a lack of awareness of the issues. The facility's maintenance and housekeeping procedures failed to address the resident's concerns.
Delayed Meal Service Due to Staffing and Dishwashing Issues
Penalty
Summary
The facility failed to serve lunch at the scheduled times for all dining areas on 12/01/25, with meals being delivered approximately two hours later than the posted mealtimes. The posted schedule indicated lunch service was to begin at 12:00 PM in the dining room and continue in staggered intervals across the 500, 400, 300, 200, and 100 halls, but actual service did not begin until 2:15 PM in the dining room and was completed at 2:40 PM on the 100 hall. The Regional Dietary Manager, acting as interim dietary manager, confirmed that the delay was due to staffing issues in the kitchen, specifically that dietary aides had quit without notice on the night of 11/20/25, resulting in unwashed dishes that had to be cleaned the morning of 12/01/25. This caused breakfast to also be served two hours late, which in turn delayed lunch service. The Administrator acknowledged awareness of previous late dining services but had not identified staffing as the cause prior to this incident.
Failure to Submit PASRR Level II Evaluation for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident who was admitted with multiple serious mental health diagnoses. Documentation showed that the resident had a history of bipolar disorder, post-traumatic stress disorder (PTSD), depression, and anxiety, and was receiving several psychiatric medications, including antidepressants, antianxiety medications, and an antipsychotic. Despite these diagnoses and ongoing psychiatric symptoms, such as hallucinations, there was no evidence in the medical record that a Level II PASRR evaluation had been requested or completed. The resident's care plan addressed mood alterations, PTSD, and the risk of drug-related side effects, and included interventions such as psychiatric consultations and monitoring for medication effects. However, the care plan did not reference the need for a PASRR Level II evaluation. Medical and psychiatric notes documented ongoing symptoms, medication adjustments, and the addition of antipsychotic and antianxiety medications, but there was no indication that these changes prompted a reassessment of the resident's PASRR status. Interviews with facility staff revealed that the social worker relied on the hospital's PASRR Level I screening, which did not identify a serious mental illness, and assumed that all relevant diagnoses had been entered into the screening tool. The social worker acknowledged not submitting a Level II PASRR request after admission, despite the resident's diagnoses, medication changes, and reports of hallucinations. The administrator deferred to the social worker regarding PASRR requirements, and the clinical coordinator confirmed that no Level II evaluation had been submitted, as the Level I determination did not indicate a serious mental illness and there was no significant change in the resident's condition.
Failure to Maintain Emergency Tracheostomy Equipment and Sterile Technique
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with a tracheostomy by not ensuring that required emergency tracheostomy equipment, specifically an Ambu bag, was kept at the bedside as ordered and as required by facility policy. Observations revealed that while spare trach tubes and an obturator were present at the bedside, the Ambu bag was missing from the resident's room and could not be located by nursing staff on the crash cart. The Director of Nursing (DON) was also unaware of the facility's trach policy and confirmed the absence of the Ambu bag at the bedside after searching the room and surrounding areas. The Ambu bag was eventually found inside the crash cart, which was located 143 feet away from the resident's room, and staff were unable to immediately locate it when needed. Additionally, the facility failed to ensure proper infection-control practices during tracheostomy care for the resident. During an observed tracheostomy care procedure, a nurse contaminated her sterile gloves by holding the resident's hands and moving non-sterile items, but did not change gloves or reestablish sterility before continuing the procedure. The nurse proceeded to complete the tracheostomy care, including cleaning the stoma site and changing the inner cannula, while wearing contaminated gloves. The nurse reported having received training from another nurse on the floor and had shadowed for several days prior to performing tracheostomy care independently. Interviews with the Medical Director and Staff Development Coordinator confirmed concerns regarding the lack of sterile technique and the adequacy of staff training. The Staff Development Coordinator stated that new nurses were trained by more experienced floor nurses and received annual refresher training, but did not follow up to ensure correct training unless a deficiency was brought to her attention. The DON, who was new to the facility, acknowledged the importance of following proper protocol but was not familiar with the exact policy.
Failure to Serve Dietitian-Approved Pureed Bread Item
Penalty
Summary
The facility failed to follow the approved menu for a resident on a pureed diet. The dietitian-approved menu for Week 2 specified that residents requiring a pureed diet should receive pureed cornbread. One resident, admitted with dysphagia and physician orders for a pureed diet, was observed during tray line service to have received pureed chicken, pureed broccoli, and pureed candied yams, but no pureed cornbread or any pureed bread product was included on the tray. Staff confirmed that a pureed bread item was not prepared or served, and the omission was only addressed after surveyor intervention. Attempts to contact the Registered Dietitian at the time were unsuccessful.
Resident Subjected to Verbal Abuse and Threats by Housekeeper
Penalty
Summary
A resident with a history of cerebral vascular accident (stroke), who was cognitively intact and able to independently propel himself in a wheelchair, was subjected to verbal abuse by a staff member. The incident occurred when the resident was moving down a crowded hallway and was confronted by a housekeeper who became upset that the resident was blocking her cart. Multiple staff members witnessed the housekeeper cursing at the resident in a threatening tone, using profane and racially charged language, and physically pushing her housekeeping cart into the back of the resident's wheelchair. The housekeeper also yanked the resident's wheelchair and continued to verbally threaten and insult him, escalating the situation and causing the resident to become visibly upset. Witness statements from two nurse aides confirmed the sequence of events, including the housekeeper's repeated use of profanity, threats to physically harm the resident, and physical contact with the resident's wheelchair. The incident was substantiated as verbal abuse by the facility's investigation, with corroborating accounts from staff who intervened to separate the housekeeper from the resident and de-escalate the situation. The resident was taken to his room and calmed down after the incident. The facility's investigation confirmed the occurrence of verbal abuse and threats by the housekeeper toward the resident.
Failure to Protect Residents from Misappropriation and Exploitation
Penalty
Summary
The facility failed to protect residents from misappropriation of property and exploitation in two separate incidents involving two residents. In the first case, a resident with a diagnosis of dementia, assessed as moderately cognitively impaired, reported that her debit card account was depleted after she gave her card to a nurse aide to pay a utility bill. The nurse aide used the card for unauthorized purchases totaling over $2,200, including groceries, retail items, and rent payments. The resident became aware of the missing funds after checking her account balance and confronted the aide, who did not provide an explanation. Multiple staff members were informed of the incident, and the matter was reported to local law enforcement. The aide was suspended and later terminated following the investigation, and the resident was reimbursed for the unauthorized transactions. In the second incident, another resident, who was cognitively intact and had multiple medical diagnoses, was approached by a nurse aide who requested money to feed her children. The resident gave the aide $65 after being told $20 would not be sufficient. The aide promised to repay the money but did not do so and instructed the resident to misrepresent the reason for the transaction to other staff. The aide was suspended and subsequently terminated after the incident was reported and substantiated by facility staff. However, the facility did not reimburse the resident for the money given to the aide, with the administrator stating that the money was given voluntarily. Both incidents were substantiated through staff interviews, resident statements, and review of facility records. The facility's failure to prevent staff from soliciting or misusing residents' funds resulted in financial loss and emotional distress for the residents involved. The facility's policies defined such actions as exploitation and misappropriation of property, yet the protections in place were insufficient to prevent these occurrences.
Failure to Notify APS of Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and misappropriation of property/exploitation to Adult Protective Services (APS) for three residents. According to the facility's policy, the Administrator is responsible for reporting all investigation results of such incidents to the appropriate state agencies as required by law. However, documentation and staff interviews revealed that APS was not notified in several substantiated cases involving misappropriation of property and verbal abuse. In one case, a resident alleged that a nurse aide borrowed her debit card under the pretense of paying a bill, but subsequently, nearly the entire balance was depleted without authorization. The facility substantiated the misappropriation, reimbursed the resident, and notified law enforcement and the state agency, but there was no documentation that APS was informed. In another incident, a resident with a history of stroke was verbally abused and threatened by a housekeeper, who also physically pushed a cart into the resident's wheelchair. The facility substantiated the verbal abuse, but again, APS was not notified as required. A third resident, diagnosed with bipolar disorder and anxiety, reported a valuable ring missing after showing it to a nurse aide. The investigation noted the resident did not witness the theft but believed the aide was the only person aware of the ring's location. The facility's investigation report documented that APS was not notified of this allegation either. Interviews with former administrators and nursing staff confirmed a lack of clarity and adherence to the policy regarding APS notification in these cases.
Inaccurate Coding of Physician-Documented GDR Contraindication on MDS
Penalty
Summary
The facility failed to accurately code a physician-documented gradual dose reduction (GDR) as clinically contraindicated on the Minimum Data Set (MDS) assessment for one resident. Record review showed that the psychiatric provider documented that a dosage reduction to the resident's psychotropic regimen was likely to impair function and worsen the underlying psychiatric condition. However, the annual MDS assessment did not reflect that the physician had documented the GDR as clinically contraindicated. During interviews, the MDS nurse confirmed she completed the relevant section of the MDS and acknowledged that she incorrectly marked the GDR as not clinically contraindicated, which was an error. The administrator confirmed the expectation for MDS assessments to be accurate.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents in various areas, including medications, smoking, elimination, and behaviors. Resident #14, who was diagnosed with Diabetes Mellitus, was not coded for receiving hypoglycemic medications despite having multiple physician orders for insulin and other diabetes medications. The MDS Nurse acknowledged the error, attributing it to human error, and both the Interim Director of Nursing and the Administrator confirmed that the MDS should have been coded accurately. Resident #17, who had a history of smoking, was not coded for tobacco use in the MDS assessment, despite being cognitively intact and actively using the facility's designated smoking area. The MDS Nurse admitted to clicking the wrong answer on the MDS screen, and both the Interim Director of Nursing and the Administrator agreed that the assessment should have reflected the resident's smoking status. Resident #2, with a diagnosis of colostomy, was not coded for an ostomy in the MDS assessment, which was acknowledged as an error by the MDS Coordinator and the Interim Director of Nursing. Additionally, Resident #13, who had dementia, was not coded for a gradual dose reduction attempt of antipsychotic medication, despite documentation in the care plan and a pharmacy consultant report indicating such an attempt. The MDS Nurse recognized this as an oversight, and the Interim Administrator confirmed the assessment should have been coded to reflect the dose reduction attempt.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications before leaving medications on the overbed table in the resident's room. The resident, who was cognitively intact, had medications left on her overbed table to take at her discretion, without a documented assessment or physician's order for self-administration. The medications included Acetaminophen and Ciprofloxacin, which were left in separate medication cups on the overbed table. Nurse #1 admitted to leaving the medications on the overbed table after observing the resident with a medication cup at her mouth. The nurse acknowledged that he should have stayed with the resident to ensure the medications were taken. The Assistant Director of Nursing and the Interim Director of Nursing confirmed that the resident had not been assessed for self-administration and that the nurse should have supervised the medication administration.
Failure to Provide Required CMS Notices
Penalty
Summary
The facility failed to provide the required Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (ABN) for a resident reviewed for beneficiary protection notification. The resident was admitted with Medicare Part A skilled services and had moderate cognitive impairment. Her Medicare Part A skilled services ended, but her benefit was not exhausted, and she remained in the facility. There was no evidence that the resident or her responsible party received the necessary NOMNC or ABN notices. The Business Office Manager stated that the former weekday Receptionist was responsible for completing the required forms, but the Receptionist was no longer employed, and the forms were not uploaded to the facility system. Blank forms were found in the resident's folder. The Administrator confirmed that the resident should have received the CMS-10123-NOMNC and CMS-ABN as required by federal guidelines.
Failure to Refer Resident for PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident with a new diagnosis of mental illness for a Preadmission Screening and Resident Review (PASARR) evaluation. Resident #33, who was admitted with a diagnosis of adjustment disorder, was newly diagnosed with post-traumatic stress disorder (PTSD) on June 27, 2024. Despite this new diagnosis, the resident's quarterly Minimum Data Set (MDS) assessment did not indicate that she was screened for a PASARR evaluation. The resident's care plan, last reviewed on July 29, 2024, included interventions for behaviors related to a traumatic event, but did not include a referral for a PASARR evaluation. Interviews conducted during the investigation revealed that the facility's Social Worker did not refer Resident #33 for a PASARR evaluation because she believed the resident was doing well and was unaware of the resident's nightmares. The resident reported experiencing nightmares after being contacted by a family member who had previously assaulted her. The facility Administrator confirmed that a new psychiatric diagnosis should have prompted a referral to the North Carolina Medical Uniform Screening Tool (NC MUST) for a PASARR application, which the Social Worker failed to do.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident, specifically in documenting the administration of medication. Resident #18, who was admitted with a diagnosis of peripheral vascular disease, had a physician's order for Acetaminophen 325 mg tablets, to be given as needed for pain or fever. On October 14, 2024, Nurse #1 was observed administering 650 mg of Acetaminophen to Resident #18, but this administration was not recorded in the resident's Medication Administration Record (MAR) for October 2024. Additionally, there was no nursing documentation in the medical record indicating that the medication was administered. In a subsequent interview, Nurse #1 stated that he believed he had documented the administration on the MAR, while the Interim Director of Nursing confirmed that the documentation should have been completed after the medication was given.
Failure to Maintain Safe and Clean Environment in Resident's Room
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for a resident, as evidenced by the condition of the bathroom door and doorway in the resident's room. Observations revealed that the bathroom door was scuffed and had peeling paint, exposing a wood-like color underneath. Additionally, there was a buildup of black debris on the grout at the base of the bathroom doorway. The resident expressed dissatisfaction with the condition of the bathroom and reported having informed staff about these issues multiple times, although she could not recall specific staff members or dates. Interviews with facility staff, including the Assistant Maintenance Director, Housekeeping Supervisor, Maintenance Director, Administrator, and interim Director of Nursing, revealed a lack of awareness and documentation regarding the resident's complaints. The Assistant Maintenance Director confirmed that room inspections were conducted monthly, and maintenance issues were logged in a book at the nurse's station and an electronic work order system, both checked weekly. However, no work order for the resident's room was found. The Housekeeping Supervisor was unaware of the discoloration, and the Administrator, who conducted daily ambassador rounds, did not notice any issues. The interim DON stated that nursing staff were expected to notify housekeeping and maintenance of any cleaning or repair needs.
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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 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 | 1.9 mi | ★★★★★ | 6 | 0 |
| Nc State Veterans Home-kinston | 3.4 mi | ★★★★★ | 0 | 0 |
| Greendale Forest Nursing And Rehabilitation Center | 11.3 mi | ★★★★★ | 0 | 0 |
| Ayden Court Nursing And Rehabilitation Center | 14 mi | ★★★★★ | 6 | 1 |
| Pruitthealth-farmville | 19.8 mi | ★★★★★ | 5 | 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.