Johnston Health
An acute care hospital in Smithfield, North Carolina 27577
509 Bright Leaf Blvd, Smithfield, North Carolina 27577. (919) 934-8171.
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The short answer
Record last released by CMS on Oct 20, 2026.
- 4of 5 CMS’s overall rating
- 4of 5 patient survey rating
- 1 deficiency cited in the last three years
- 175 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Jun 25, 2026: a complaint inspection.
1 deficiency cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
1 deficiency in 1 month of the last 36. Last cited Apr 2025. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Apr 30, 2025: complaint inspection1 deficiency
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Respiratory Care Services Policies
The inspectors’ words, 824 words
“RESPIRATORY CARE SERVICES POLICIES CFR(s): 482.57(b) Services must be delivered in accordance with medical staff directives. This Standard is not met as evidenced by: 50111 Based on review of hospital policies, medical records and staff interviews, respiratory therapy staff failed to ensure scheduled medications were administered according to provider orders and hospital policies for 2 of 2 sampled medical records for patients receiving respiratory medications (Patient #27, Patient #14). The findings include: Review on 05/01/2025 of hospital policy “Medication Administration,” effective 03/2022 and last revised on 03/2025 with no changes, revealed, “... B. ... The therapist will verify the computerized order, dosage, frequency, and route of administration. ... Schedule for Medication Administration ... Q6 (every 6 hours) = (equals) 0400, 1000, 1600, 2200 ...” Review on 05/01/2025 of hospital policy “Timely Administration of Scheduled Medications,” effective 03/2020 and last revised on 08/2023 with no changes, revealed, “... 2. ... the time schedule allowed when administering non-time critical scheduled medications ... Medications prescribed more frequently than daily, but no more frequently than every 4 hours [:] Within 1 hour- Administer within 1 hour before or after the scheduled time ...” 1. Open medical record review on 05/01/2025 for Patient #27 (Pt) revealed a 55-year-old male that arrived in the Emergency Department (ED) on 04/29/2025 at 1517 with a complaint of shortness of breath. Pt #27 was admitted to the hospital on 04/29/2025 at 2253 for chronic obstructive pulmonary disease (COPD) exacerbation (a sudden and severe worsening of respiratory symptoms in patients with COPD). Review revealed a hospitalist provider order on 04/29/2025 at 2324 for ipratropium-albuterol (a respiratory medication that treats COPD by opening the airway and reducing inflammation) 3 ml (milliliters) to be given by nebulization (conversion of liquid medication to a fine mist for inhalation) every 6 hours by respiratory therapy. Review of the Medication Administration Record (MAR) revealed ipratropium-albuterol was scheduled to be administered at 0400, 1000, 1600, and 2200. Review of the MAR on 04/30/2025 revealed scheduled ipratropium-albuterol was administered at 0034, 0340 (3 hours and 6 minutes after the last dose) and at 0853. At 1000, the scheduled dose of ipratropium-albuterol was cancelled. The MAR revealed ipratropium-albuterol was not given at 1528 with a comment stating the patient was not available. The next dose of ipratropium-albuterol was administered at 1941. Interview on 05/01/2025 at 0942 with Supervisor #1 revealed respiratory therapists should administer scheduled medications within 1 hour of the scheduled dose, up to 1 hour before or after the scheduled dose time. Interview revealed any doses of ipratropium-albuterol that were administered PRN (as needed) should have been documented as a PRN dose. Interview on 05/01/2025 at 1657 with Director #2 revealed respiratory medications should be given according to the “Medication Administration” policy and the “Timely Administration of Scheduled Medications” policy. Interview revealed medications given outside of the policy parameters were considered medication errors. 2. Closed medical record review on 04/29/2025 for Patient #14 (Pt) revealed a 75-year-old male that arrived in the ED on 08/31/2022 at 2047 with a complaint of shortness of breath and a history of COPD. Review of the ED Timeline revealed a decision to admit Pt #14 to inpatient on 09/01/2022 at 0245. Review revealed a hospitalist provider order on 09/01/2022 at 0332 for ipratropium-albuterol 3 ml to be given by nebulization every 6 hours by respiratory therapy. Review of the MAR revealed ipratropium-albuterol was scheduled to be administered at 0400, 1000, 1600, and 2200. Pt #14 was transferred to an inpatient unit at 0404. Review of the MAR on 09/01/2022 revealed scheduled ipratropium-albuterol was administered at 0442 and 0815 (3 hours and 33 minutes after last dose), 1511, and 2039. On 09/02/2022, scheduled ipratropium-albuterol was administered at 0351, 0721 (3 hours and 29 minutes after the last dose), 1625 (9 hours and 4 minutes after the last scheduled dose), and 2048 (4 hours and 23 minutes after the last dose). On 09/03/2022, ipratropium-albuterol was administered at 0405 (7 hours and 17 minutes after the last dose), 0826 (4 hours and 21 minutes after the last dose), 1627 (8 hours and 1 minute after the last dose) and 2015 (3 hours and 48 minutes after the last dose). On 09/04/2022, ipratropium-albuterol was administered at 0328 (7 hours and 13 minutes after the last dose) and 0849. Pt #14 was discharged home on 09/04/2022 at 1529. Interview on 05/01/2025 at 0942 with Supervisor #1 revealed respiratory therapists should administer scheduled medications within 1 hour of the scheduled dose, up to 1 hour before or after the scheduled dose time. Interview revealed any doses of ipratropium-albuterol that were administered PRN (as needed) should have been documented as a PRN dose. Interview on 05/01/2025 at 1657 with Director #2 revealed respiratory medications should be given according to the “Medication Administration” policy and the “Timely Administration of Scheduled Medications” policy. Interview revealed medications given outside of the policy parameters were considered medication errors. NC00204996, NC00193670, NC00222463, NC00193645, NC00195332, NC00205383, NC00188287”
All 7 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Jun 25, 2026 | Complaint inspection | No deficiencies cited |
| Aug 22, 2025 | Complaint inspection | No deficiencies cited |
| Aug 21, 2025 | Complaint inspection | No deficiencies cited |
| Aug 20, 2025 | Complaint inspection | No deficiencies cited |
| Aug 19, 2025 | Complaint inspection | No deficiencies cited |
| May 1, 2025 | Complaint inspection | No deficiencies cited |
| Apr 30, 2025 | Complaint inspection | 1 deficiency cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 4 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 7; safety of care, 1 better and 0 worse of 7; readmission, 0 better and 0 worse of 10.
- Patients rate it 4 of 5 in CMS’s patient survey (1,891 surveys completed, Oct 1, 2024 to Sep 30, 2025): 76% rated it 9 or 10 out of 10, and 73% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): central line bloodstream infections (CLABSI), no different than national benchmark; catheter urinary tract infections (CAUTI), no different than national benchmark; surgical site infections after colon surgery, no different than national benchmark; MRSA bloodstream infections, no different than national benchmark; C. diff infections, better than the national benchmark.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 11.9%, heart failure 12.9%, pneumonia 15.3%, COPD 8.9%, stroke 9.2%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 13.3%, heart failure 21.6%, pneumonia 16.3%, COPD 20.4%, hip or knee replacement 5.7%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; hospital admissions after outpatient chemotherapy, no different than the national rate; emergency visits after outpatient chemotherapy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 187 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 4% left before being seen.
- 65% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 0.95 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 4 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 4 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Jul 1, 1966.
- Ownership: government - hospital district or authority.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- Government - Hospital District or Authority.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
- 1 deficiency cited in the last three years came from an inspection that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 4 of 5.
- 97% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- University of North Carolina Health Care System owns 100% directly since Jul 1, 2025.
- University of North Carolina Health Care System runs it.
- 19 owners or officers are people: William Massengill (corporate director, 0%); Shawn Wilford Beane (managing employee (on the payroll), 0%); Patricia Jones (corporate director, 0%); Kevin Cielinski (corporate officer, 0%); Tracey Boykin Carson (corporate officer, 0%); Jeffrey Parlier (corporate director, 0%); Carolyn Finch Ellis (managing employee (on the payroll)); Lori Martin (managing employee (on the payroll)); Robert Bradford Oakes (corporate director, 0%); David Mills (corporate director, 0%); Michael Chad Setliff (corporate director, 0%); Rodney L Mccaskill (corporate director, 0%); Richard Alioto (corporate director, 0%); Lacey Barnes (corporate director, 0%); Teddy Gilbert Godwin (corporate director, 0%); Marilyn R Pearson (corporate director, 0%); Benjamin J Mathew (corporate director, 0%); Tommy Williams (corporate officer, 0%); Hasan Ahmad Baloch (corporate director).
- CMS’s Provider of Services file records 2 changes of ownership, the latest on Feb 1, 2014.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| University of North Carolina Health Care System | Owns 5% or more directly | 100% | Jul 1, 2025 |
| University of North Carolina Health Care System | Runs it (operational or managerial control) | 100% | Feb 1, 2014 |
How does it compare nearby?
- No other hospital CMS lists is in Johnston County.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.