Monday's appearance was postponed when she complained of chest pains and was rushed to the hospital. Police arrested Almore at her Cary home Monday.
Almore is charged with one count of second-degree murder and six counts of felony patient abuse for her are of patients at Britthaven of Chapel Hill.
Investigators say Almore over medicated seven patients with morphine.
"The state's position is the morphine was probably given to make the patients more manageable," Orange County District Attorney Jim Woodall said.
Woodall says an investigation began after UNC Hospitals noticed a pattern of treating patients from Britthaven.
ABC11 Eyewitness News learned Monday some patients were never prescribed morphine. Investigators don't know where Almore may have gotten the drug.
"I called for an investigation," Woodall said. "A couple of days later the SBI became involved, and about three to four weeks ago we came to the conclusion there was sufficient evidence for a charge in this case."
Almore is accused of killing 84-year-old Rachel Alice Smith Holliday in February. Prosecutors say Almore gave Holliday a lethal dose of morphine, and overdosed six other patients, who survived.
"At this point there's nothing to indicate anyone else was involved," Woodall added.
This is not the first time Britthaven has been the subject of an investigation. Officials ruled staff wasn't properly trained after citing the facility in 2002. In that incident, a patient died from being stuck between a mattress and side rail.
And in 1997, Britthaven was fined $510,000 after another patient died by strangulation from restraint straps.
The Medicaid Investigations Unit of the attorney general's office says its investigation into Britthaven of Chapel Hill is complete.
Almore's bond remains at $500,000. The judge also assigned her a court appointed attorney.
Her next appearance is scheduled for July 13.