Barbour Court Nursing And Rehabilitation Center
Barbour Court Nursing and Rehabilitation Center in Smithfield, NC — inspection on February 26, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Receptionist sorted mail delivered on Saturday on most Mondays for residents or that residents had
minimal harm completed about timely mail delivery.
single dose of Pneumovax (Pneumovax, also known as Pneumococcal Polysaccharide Vaccine or
MDS Nurse #1 stated she coded Resident #18's MDS assessment dated [DATE] to indicate Resident
explain she had just gone back to the Resident Assessment Instrument (RAI) manual and checked the most recent Centers for Disease Control and Prevention (CDC) guidelines and discovered a single historical dose of Pneumovax would not make Resident #18's pneumococcal vaccine up to date. MDS Nurse #1 reported she could not find a record indicating Resident #18 had received any other pneumococcal vaccines.
She reported she must have looked at old CDC guidelines when she coded Resident #18's 11/15/25 MDS assessment.
During an interview on 2/26/26 at 11:19 AM the Director of Nursing (DON) stated resident MDS assessments should be coded accurately.
During an interview on 2/26/26 at 11:31 AM the Administrator stated resident MDS assessments should be coded accurately.
345237 02/26/2026
Barbour Court Nursing and Rehabilitation Center 515 Barbour Road Smithfield, NC 27577
failed to ensure the resident's need for insulin (a hormone that regulates blood sugar levels)
insulin.
This deficient practice affected 1 of 5 residents (Resident #8) reviewed for unnecessary medications.
Findings included:Resident #8 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus type 2 (DM II).A current active physician's order for Resident #8 with a start date of 3/18/25 revealed Novolog injection solution (a type of fast acting insulin)100 units per milliliter inject 10 units subcutaneously (SQ is beneath the skin) with meals and to hold (do not give) for blood sugar (BS) less than 150 (a normal adult BS before eating is between 70 to 99.A review of Resident #8's December 2025 Medication Administration Record (MAR) revealed documentation by Nurse #1 indicating that Resident #8's BS at 6:30 AM on 12/13/25 was 122 and she administered 10 units of Novolog insulin to Resident #8. Resident #8's BS at 11:30 AM on 12/13/25 was 236. On 12/15/25 at 6:30 AM Nurse #1 documented Resident #8's BS was 122 and she administered 10 units SQ to Resident #8. Resident #8's BS at 11:30 AM on 12/15/25 was 205. On 12/27/25 at 6:30 AM Nurse #1 documented Resident #8's BS was 122 and she administered 10 units SQ to Resident #8. Resident #8's BS at 11:30 AM on 12/27/25 was 134. On 12/29/25 at 6:30 AM Nurse #1 documented Resident #8's BS was 106 and she administered 10 units SQ to Resident #8. Resident #8's refused to have his BS checked at 11:30 AM on 12/29/25. On 2/25/26 at 9:25 AM in a telephone interview Nurse #1 stated she was familiar with Resident #8.
She reported she did not recall Resident #8 having any parameters for the administration of his Novolog insulin.
She stated normally, if a resident had BS parameters for the administration of insulin, it would show on the resident's electronic MAR on her computer screen.
She went on to say her documentation on Resident #8's December 2025 MAR on 12/13/25, 12/15/25, 12/27/25 and 12/29/25 would indicate she administered 10 units of Novolog insulin SQ to Resident #8 at 6:30 AM each of those days.Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. He had no behaviors or rejection of care. He received injections, and insulin injections on 5 of the 7 look back period days of the assessment.On 2/26/26 at 10:58 AM an interview with the NP indicated she was familiar with Resident #8.
She reported he frequently refused his BS checks and his insulin despite many conversations with him on the importance of these for managing his DM II.
She stated because of this, his BS tended to run on the higher side.
She went on to say as a result the instances of administration of 10 units of Novolog insulin to Resident #8 when his BS was less than 150 had not caused Resident #8 any harm.
She reported there was always the possibility of harm to a resident, which included an unsafe drop in BS level, if insulin was administered to them outside of the parameters of the physician's order as this insulin would not be needed.
She stated nurses should always follow the parameters for administering insulin.On 2/25/26 at 1:53 PM in an interview the Director of Nursing stated she would consider the administration of insulin to a resident outside the parameters of the physician's order to be a serious medication error.
She reported that the potential harm to a resident receiving insulin that was not indicated by their blood sugar level would be an unsafe lowering of their blood sugar. On 2/25/26 at 3:14 PM an interview with the Administrator indicated nurses should be adhering to the parameters in the physician's order when administering insulin. He stated the facility did not have a corrective action plan in place for this.
345237 02/26/2026
Barbour Court Nursing and Rehabilitation Center 515 Barbour Road Smithfield, NC 27577