O'Berry Neuro-Medical Treatment Center

400 Old Smithfield Road · Goldsboro, NC · 27533 · 9195814001

144 certified beds Government - State

Why this verdict

  • Inspection record is far worse than the national median (deficiency count and severity).
  • Inspection results have improved across recent cycles.

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Red flags

Special Focus Facility candidate

CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.

8 immediate-jeopardy citations in prior inspection cycles

Serious past findings — check whether the underlying problems were fixed and stayed fixed.

3 abuse-related citations at the actual-harm level

Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.

Medicare/Medicaid payments were denied

CMS refused payment for new admissions for a period — one of its strongest enforcement tools.

Score breakdown

Inspection record 30% of score 17
Serious harm & abuse 20% 60
Staffing 20% 60
Federal penalties 15% 37
Trend 10% 92
Context 5% 35

Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.

CMS ratings & staffing

Overall: 1 of 5 Inspections: 1 of 5 Staffing: not rated Quality measures: 3 of 5

Total nurse hours / resident-day3.48 min · 4.1 strong
RN hours / resident-day0.55–0.75
Weekend hours / resident-day≈ weekday level
Nursing turnover / yearmedian 45%
Fines (3-yr window)1 · $167,242

Inspection citations (28 in the current record)

  • Potential for harm · D October 9, 2025 · found via complaint

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Past Non-Compliance · Quality of Life and Care

  • Immediate jeopardy · J February 7, 2025 · found via complaint

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Corrected February 21, 2025 · Resident Rights

  • Immediate jeopardy · J February 7, 2025 · found via complaint

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Corrected February 21, 2025 · Quality of Life and Care

  • Immediate jeopardy · J February 7, 2025 · found via complaint

    Ensure that residents are free from significant medication errors.

    Corrected February 24, 2025 · Pharmacy Service

  • Potential for harm · D February 7, 2025 · found via complaint

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    Corrected February 21, 2025 · Resident Assessment and Care Planning

  • Immediate jeopardy · J December 16, 2024 · found via complaint

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Corrected February 21, 2025 · Resident Rights

  • Immediate jeopardy · J December 16, 2024 · found via complaint

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Corrected February 7, 2025 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · E December 16, 2024

    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

    Corrected February 7, 2025 · Resident Rights

  • Potential for harm · D December 16, 2024

    Ensure each resident receives an accurate assessment.

    Corrected January 16, 2025 · Resident Assessment and Care Planning

  • Potential for harm · D December 16, 2024

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Corrected February 7, 2025 · Resident Assessment and Care Planning

  • Potential for harm · E December 16, 2024

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Corrected February 7, 2025 · Pharmacy Service

  • Potential for harm · D December 16, 2024

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

    Corrected February 7, 2025 · Pharmacy Service

  • Potential for harm · D December 16, 2024 · found via complaint

    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

    Corrected February 7, 2025 · Quality of Life and Care

  • Potential for harm · D December 16, 2024 · found via complaint

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    Corrected February 21, 2025 · Resident Assessment and Care Planning

  • No harm found · B December 16, 2024

    Honor the resident's right to manage his or her financial affairs.

    Corrected January 16, 2025 · Resident Rights

  • No harm found · B December 16, 2024

    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

    Corrected January 16, 2025 · Resident Rights

  • No harm found · C December 16, 2024

    Post nurse staffing information every day.

    Corrected January 16, 2025 · Nursing and Physician Services

  • Immediate jeopardy · K April 21, 2024 · found via complaint

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Corrected May 17, 2024 · Freedom from Abuse, Neglect, and Exploitation

  • Immediate jeopardy · K April 21, 2024 · found via complaint

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Corrected May 17, 2024 · Quality of Life and Care

  • Potential for harm · E April 21, 2024 · found via complaint

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    Corrected May 17, 2024 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · E April 21, 2024 · found via complaint

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

    Corrected May 17, 2024 · Administration

  • Immediate jeopardy · K February 23, 2024 · found via complaint

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Corrected May 17, 2024 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · E February 23, 2024 · found via complaint

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

    Corrected May 17, 2024 · Administration

  • Potential for harm · D November 7, 2023 · found via complaint

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Corrected November 20, 2023 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D November 7, 2023 · found via complaint

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

    Corrected November 20, 2023 · Freedom from Abuse, Neglect, and Exploitation

Showing the 25 most recent. The Safety Report includes every citation with full findings.

Federal penalties

DateTypeAmount / length
February 23, 2024Fine$167,242
February 23, 2024Payment Denial50 days

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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 34A002 · certified since March 29, 2010. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.