Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Croatan Ridge Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with diabetes did not receive a scheduled insulin dose because the medication was unavailable, and the nurse failed to notify the NP for authorization to use the backup supply. The NP was not informed until the following day, and the DON confirmed the nurse should have contacted the NP via phone and text.
A Pharmacy Consultant failed to report irregularities in the medication regimen reviews for two residents, leading to deficiencies in the administration of PRN Ativan. One resident had an extended order for Ativan without a documented rationale, and the Consultant did not question this due to a lack of awareness. Another resident under hospice care had an extended order without a 14-day stop date, which the Consultant did not report, mistakenly believing hospice residents could have extended orders. The DON and Administrator were not informed of these irregularities, despite expecting accurate reporting.
The facility failed to comply with regulations for PRN psychotropic medications for two residents. One resident received Ativan without a documented rationale for extended use beyond 14 days, while another was prescribed Ativan for 90 days without an initial 14-day stop date. Interviews revealed a lack of awareness among staff regarding these requirements.
Two residents experienced medication administration errors, resulting in a 6.9% error rate. A resident with Parkinson's disease received an incorrect dosage of Voltaren gel due to the absence of a dosing card, while another resident with COPD was not assisted in rinsing their mouth after Advair inhalation, contrary to physician orders.
A resident with diabetes did not receive their prescribed insulin dose due to an empty pen and a delay in pharmacy delivery. The nurse was unaware that backup insulin could be used, leading to a lapse in medication administration. The DON was not informed of the missed dose, and the facility had backup insulin available but it was not utilized.
A resident's cell phone was misappropriated by a staff member, Nurse Aide #1, who took the phone and made unauthorized calls. The resident, who was moderately cognitively impaired, reported the phone missing, and it was later found in the staff member's car. The facility confirmed the incident and terminated the staff member for violating company policy.
Failure to Notify Physician of Missed Insulin Dose
Penalty
Summary
The facility failed to notify the physician when a resident missed a dose of insulin due to the medication being unavailable for administration. This deficiency affected a resident who was admitted with a diagnosis of diabetes and was prescribed insulin to be administered at bedtime. On a specific date, the resident did not receive the scheduled dose of insulin because it was not available, and the nurse did not obtain authorization to administer insulin from the backup supply. The nurse attempted to contact the Nurse Practitioner (NP) by phone but did not leave a voice message or send a text message for authorization. The NP was not informed about the missed medication until the following day. The Director of Nursing confirmed that the nurse should have contacted the NP by phone and text message to receive authorization to administer insulin from the backup kit. The Administrator was unaware of the incident until later and stated that it was the responsibility of the nurses to contact the NP for authorization.
Pharmacy Consultant Fails to Report Medication Irregularities
Penalty
Summary
The Pharmacy Consultant failed to report irregularities in the medication regimen reviews for two residents, leading to deficiencies in the administration of PRN Ativan, a psychotropic medication. Resident #22, diagnosed with dementia and anxiety, had a physician's order for Ativan 0.5 mg every 6 hours as needed, which was extended without a documented rationale. The Pharmacy Consultant, despite being aware of the order, did not question the rationale for the extended use, as she was unaware that a physician needed to assess the resident for the rationale prior to the extended order. This oversight was confirmed during interviews with the Pharmacy Consultant, the Director of Nursing (DON), and the Administrator, who all expected irregularities to be reported. Similarly, Resident #47, also severely cognitively impaired and under hospice care, had an order for Ativan 1 mg as needed every 4 hours for anxiety/agitation for 90 days without a 14-day stop date. The Pharmacy Consultant did not report this irregularity, mistakenly believing that hospice residents could have extended orders. Interviews with the DON and the Administrator revealed that they did not receive any report concerning the PRN medication for Resident #47, and they expected the Pharmacy Consultant to accurately report all irregularities during her reviews.
Non-compliance with PRN Psychotropic Medication Regulations
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of PRN psychotropic medications for two residents. Resident #22, who was admitted with dementia and anxiety, was prescribed Ativan 0.5 mg every 6 hours as needed for anxiety. The physician's order extended the use of Ativan beyond the initial 14-day period without a documented rationale for the extension. The medication was administered multiple times in August and September 2024, but the care plan did not include a rationale for the extended use. Interviews with the Director of Nursing and the Nurse Practitioner revealed a lack of awareness regarding the need for a rationale after the initial 14-day order. Similarly, Resident #47, admitted with dementia and mood disturbances, was prescribed Ativan 1 mg as needed for anxiety/agitation for 90 days as part of end-of-life care. The order did not include a 14-day stop date, and the medication was administered frequently in December 2024 and January 2025. Interviews with the Director of Nursing and the Medical Director indicated a misunderstanding of the requirement for an initial 14-day order and the need for a rationale and duration for extending the order. The Administrator acknowledged the oversight and expressed a desire for staff to adhere to regulations regarding PRN medications.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6.9% error rate during medication administration for two residents. Resident #44, diagnosed with Parkinson's disease, was prescribed Voltaren external gel to be applied to the left ankle using a dosing card. However, Nurse #2 applied an incorrect amount of the gel without using the dosing card, as it was missing. The nurse used her judgment to apply a nickel-sized amount instead. The pharmacist confirmed that the dosing card should be used with each administration, and the Director of Nursing (DON) stated that the nurse should have followed the physician's orders and reported any issues. Resident #45, diagnosed with chronic obstructive pulmonary disease (COPD), was prescribed Advair inhalation with instructions to rinse the mouth after use. During medication administration, Nurse #1 failed to assist the resident in rinsing her mouth, contrary to the physician's orders. The nurse incorrectly believed that rinsing was unnecessary. The DON and the Quality Improvement (QI) Nurse confirmed that the nursing staff were trained to follow these procedures, and the Administrator expected adherence to physician orders.
Failure to Administer Insulin as Prescribed
Penalty
Summary
The facility failed to administer medication as ordered by the physician for a resident with diabetes mellitus, leading to a significant medication error. The resident, who was cognitively intact and required insulin, did not receive their prescribed dose of Toujeo Solostar Insulin Glargine on the evening of 2/4/25 because the medication was not available. The resident expressed concern about the missed dose, and it was revealed that the insulin pen was empty. Although the medication had been re-ordered two days prior, it had not been delivered by the pharmacy due to a back order. Nurse #3, who was responsible for administering the medication, was unaware that backup insulin could be used because it was a different brand from the prescribed medication. The Director of Nursing was not informed of the missed dose and was unaware of the situation until after the fact. The facility had backup insulin available, but it was not utilized, resulting in the resident missing their insulin dose. The pharmacy confirmed that the resupply request was made on 2/4/25 and filled the following day, but the delay contributed to the lapse in medication administration.
Misappropriation of Resident's Property by Staff Member
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property when a staff member, Nurse Aide #1, took a cell phone from Resident #12. Resident #12, who was moderately cognitively impaired, reported that his phone went missing but was later found. He described the perpetrator as Nurse Aide #1, although he could not recall if he gave the phone to her or if she took it without his permission. Attempts to contact Nurse Aide #1 for clarification were unsuccessful. Nurse #3 revealed that Resident #12 had complained about his missing phone, and when questioned, Nurse Aide #1 denied taking it. However, the family of Resident #12 used a tracker to locate the phone in the parking lot, leading to Nurse Aide #1's car. After a search involving the police, Nurse Aide #1 retrieved the phone from her car and returned it. It was discovered that she had made several calls from the phone, which was against company policy. The Director of Nursing (DON) and the Administrator confirmed the events, stating that Nurse Aide #1 was terminated for violating company policy by using the resident's property. The incident was reported to the police, Adult Protective Services, and the North Carolina Department of Health and Human Services. The facility conducted in-service training for all staff on the misappropriation of resident property following the incident.
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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 Newport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cherry Point Bay Nursing And Rehabilitation Center | 5.6 mi | — | 0 | 0 |
| Embassy At Morehead City | 8 mi | — | 0 | 0 |
| Crystal Bluffs Rehabilitation And Health Care Cent | 8.3 mi | — | 1 | 0 |
| Pruitthealth-crystal Coast | 19.8 mi | — | 1 | 0 |
| Riverpoint Crest Nursing And Rehabilitation Center | 20.1 mi | — | 9 | 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 August 2026) and official state health department websites.