Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Accordius Health At Rose Manor Llc during CMS and state inspections, most recent first.
A resident with multiple medical conditions rolled off her bed and sustained pain after a nurse aide failed to position herself correctly and guide the resident during incontinence care. The aide was on the opposite side of the bed and had not begun the turning process when the resident, holding the transfer bar, rolled off and fell. The incident resulted in the resident being transported to the hospital for evaluation.
The facility did not ensure that cleaned dishes were air dried and instead stacked wet dishes, failing to follow professional standards. Dishwashing equipment did not consistently reach the required minimum temperature or sanitization level, and staff continued to use and serve dishes that had not been properly sanitized or dried. These deficiencies were observed and confirmed through staff interviews and review of temperature logs.
The facility did not maintain an effective pest control program, as evidenced by repeated observations of live cockroaches in the kitchen, hallways, and resident rooms, ongoing sanitation issues such as spilled food and incomplete repairs, and poor communication between pest control, maintenance, and dietary staff regarding problem areas and follow-up actions.
The facility failed to accurately code MDS assessments for four residents, including not documenting a fall for a resident with a recent incident, and not properly recording antipsychotic use and GDR status for three residents receiving such medications. The errors were due to incomplete review of medical records and lack of interdisciplinary review before MDS submission.
Surveyors observed that two of three dumpsters had doors left open after waste disposal. The dumpsters, shared by all departments, were supposed to have doors closed after use, as confirmed by the CDM. On the day of the incident, a housekeeper left the doors open by mistake, and the Administrator was not present to check the area.
A resident with multiple serious diagnoses had conflicting code status information in the medical record due to a failure to promptly communicate and update a change from DNR to full code after a new MOST form was signed. The Social Worker obtained the updated form but did not notify nursing leadership as required, resulting in inconsistent documentation.
A resident was admitted with depression and later diagnosed with bipolar disorder, leading to a new prescription for an antipsychotic. Despite this significant change, the required PASRR Level II referral was not resubmitted because the new diagnosis was not communicated to the staff responsible for initiating the process.
A resident was readmitted with multiple diagnoses and began receiving Risperdal for a new diagnosis of bipolar disorder. The care plan was not updated to address the antipsychotic use or the new mental health diagnosis, as required. Staff interviews revealed that this omission resulted from a breakdown in communication and lack of notification to the MDS Nurse.
A resident with a history of stroke and depression was prescribed Risperdal for a newly documented bipolar disorder, but the facility failed to provide supporting documentation or evaluation for the new diagnosis. Multiple psychiatric NPs referenced the diagnosis without clear evidence of its origin, and the DON was not notified, resulting in incomplete medical records and lack of proper communication among staff.
A resident with hemiplegia, contractures, and cognitive impairment did not receive a physician-ordered right-hand palm guard as required. Staff failed to apply the device at night and did not document refusals, with the order missing from the MAR and confusion among staff about responsibility for its use. The deficiency was identified through observations, interviews, and record review.
The facility did not follow its abuse policy by failing to immediately report and investigate abuse allegations involving two residents. In one instance, a resident's report of being struck by a nurse aide was not promptly escalated to the Administrator, causing delays in required notifications. In another case, a resident's post-discharge allegation of inappropriate touching by a staff member was not reported internally or investigated until authorities notified the facility. Staff interviews revealed confusion about reporting responsibilities, leading to delayed action.
Surveyors found that multiple resident rooms had unaddressed maintenance and cleanliness issues, including scraped paint, wall damage, a persistent black film in a bathroom sink, and a red splattered substance on a wall. Staff interviews confirmed that repairs and deep cleaning had not been completed in these rooms, and maintenance records showed no recent work for the affected areas.
Resident Fall During Incontinence Care Due to Improper Supervision and Positioning
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and had diagnoses including a left lower leg wound, anxiety disorder, and arthritis, rolled off her bed while receiving incontinence care from a nurse aide. The incident happened as the nurse aide was preparing to assist the resident with turning, but had not yet started the usual countdown or physically assisted the resident. The resident, while holding the transfer bar, moved her legs off the bed and subsequently rolled off, landing on the floor and hitting her face against the wall. The nurse aide was positioned on the opposite side of the bed at the time and had intended to move to the other side before turning the resident. Following the fall, the resident complained of significant knee pain and was unable to be moved back to bed by staff due to her discomfort. Emergency Medical Services were called, and the resident was transported to the hospital for evaluation. Medical assessments, including imaging and laboratory tests, were performed and found to be negative for acute injury. The resident reported pain in her head, back, and knees, and subsequently refused to return to the facility, remaining in the hospital awaiting alternate placement. Interviews with staff and the resident revealed inconsistencies in the sequence of events, but it was confirmed that the nurse aide did not follow proper procedure by ensuring the resident was turned towards her and by not being on the correct side of the bed during care. The Director of Nursing and the facility administrator both acknowledged that the nurse aide should have positioned herself appropriately and guided the resident through the care process to prevent such an accident.
Failure to Air Dry Dishes and Maintain Proper Dishwashing Temperature and Sanitization
Penalty
Summary
The facility failed to implement proper procedures for air drying cleaned dishes and did not follow the manufacturer's instructions for minimum temperature and sanitization levels in the dishwashing process. Observations revealed that cleaned dishes, including plate warmers, domes, bowls, coffee cups, and juice cups, were stacked while still wet and nesting, rather than being air dried. Staff interviews confirmed that the Certified Dietary Manager (CDM) instructed dietary aides to stack dishes immediately after cleaning due to limited space, and that air drying was not practiced as required. Further observations and interviews indicated that the dish machine was not consistently reaching the required minimum temperature of 120 degrees Fahrenheit, with recorded temperatures as low as 115.7 degrees Fahrenheit. Additionally, the sanitization level did not meet the minimum requirement of 50 parts per million (ppm) during several checks, as indicated by testing strips that showed no color change. Staff members, including dietary aides, were aware of the temperature and sanitization deficiencies but continued to use the dish machine and serve dishes that had not been properly sanitized or dried. The maintenance assistant was not informed of the dish machine's failure to meet temperature and sanitization requirements on the day of the observations, and the temperature monitoring equipment was not always functional. The administrator later acknowledged that dishes should have been air dried and that available kitchen space could have been used for this process. The issues with the dish machine were attributed to a malfunctioning heating unit and improper chemical flow, which were not addressed in a timely manner.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by repeated observations and documentation of cockroach activity and unsanitary conditions. Pest control invoices from February to April 2025 consistently noted sanitation issues in the kitchen, such as spilled food material on the floor that remained untouched for months, as well as structural concerns like loose or missing floor tiles, baseboards, and gaps near doors and equipment. Despite the pest control service not observing cockroach activity during their visits, the facility's pest activity logs recorded multiple sightings of cockroaches in various areas, including resident rooms, activity rooms, nursing stations, and conference rooms. Direct observations by staff and surveyors further confirmed the presence of live cockroaches in the facility. On several occasions, live roaches were seen in the kitchen, CDM's office, hallways, and resident rooms. Staff interviews revealed that sightings were not always reported, and there was a lack of consistent communication between the pest control technician, maintenance, and dietary staff regarding problem areas and necessary cleaning or repairs. The pest control technician reported that identified issues, such as spilled food and structural gaps, had not been addressed over several months, and that staff did not accompany him during his visits to ensure follow-up on recommendations. Maintenance staff indicated that some repairs had been made, such as sealing holes and replacing tiles and baseboards, but these repairs were often incomplete, with visible gaps remaining. There was also a lack of documentation or work orders to verify completed repairs. The kitchen continued to have food debris and structural deficiencies, and staff reported ongoing sightings of cockroaches, particularly in the kitchen and tray line areas. The lack of effective coordination and follow-through on pest control recommendations contributed to the ongoing pest problem within the facility.
Inaccurate MDS Coding for Falls, Antipsychotic Use, and GDR Documentation
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents in the areas of falls, gradual dose reduction (GDR), and diagnoses. For one resident with a history of falls and a recent fall incident, the MDS was not updated to reflect the fall, despite documentation in the progress notes and care plan. The MDS Coordinator acknowledged that the assessment should have been coded for falls, and the DON confirmed the expectation for accurate and timely MDS completion. Another resident, who was receiving antipsychotic medication for paranoid schizophrenia, was incorrectly coded on the MDS as not receiving an antipsychotic. The MDS Nurse admitted to missing the correct coding for antipsychotic use and GDR questions, citing being the sole MDS nurse for an extended period. The DON and Administrator both stated that the MDS should have been coded accurately and that the interdisciplinary team should have reviewed the assessment. Two additional residents receiving antipsychotic medications were coded on their MDS assessments as not having a GDR attempted and without documentation of a GDR being clinically contraindicated, despite psychiatric notes indicating that a GDR was contraindicated. The MDS Nurse did not identify the documentation in the medical record, and both the DON and Administrator indicated that the MDS should have reflected the clinical contraindication for GDR. All errors were attributed to incomplete review of the medical records and lack of interdisciplinary review prior to MDS submission.
Failure to Properly Close Dumpster Doors After Waste Disposal
Penalty
Summary
The facility failed to ensure that the doors to dumpsters containing waste were properly closed, as observed during a survey. Specifically, both doors to the middle dumpster and the right door to the far-left dumpster were left open. The dumpsters were shared by all facility departments, and staff had been educated to keep the doors closed. During the observation, a housekeeper was seen discarding trash and left the doors open by mistake. The Certified Dietary Manager confirmed the expectation for all staff to close the dumpster doors after use. The Administrator stated that he routinely checked the dumpsters to ensure compliance but was not present at the time of the incident.
Inconsistent Documentation of Resident Code Status
Penalty
Summary
The facility failed to ensure that a resident's code status information was consistent throughout the medical record. The resident, who had diagnoses including lung cancer, brain metastasis, cerebral edema, and seizure disorder, was cognitively intact and had previously signed an Advance Directive and had physician orders indicating Do Not Resuscitate (DNR) status. However, a later signed Medical Orders for Scope of Treatment (MOST) form indicated a change to full code status, meaning resuscitation should be attempted. Despite the resident's clear communication and understanding of the change in code status, the updated MOST form was not promptly communicated to the appropriate nursing staff or reflected in the electronic medical record (EMR). The Social Worker obtained the new MOST form but did not verbally notify anyone about the change. The facility's process required immediate notification of the DON or Unit Manager for such changes, but this did not occur, resulting in inconsistent documentation of the resident's code status across the medical record.
Failure to Resubmit PASRR Level II After New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level II referral was resubmitted after a resident received a new mental health diagnosis. The resident was originally admitted with a diagnosis of depression and had a PASRR Level I completed, with a Level II process that was halted. Upon readmission, the resident was diagnosed with bipolar disorder and was prescribed Risperdal, an antipsychotic medication, for this new diagnosis. Medical records and assessments confirmed the new diagnosis and the administration of antipsychotic medication. Despite these significant changes, the required PASRR Level II resubmission was not initiated. Interviews with facility staff, including the psychiatric nurse practitioner, DON, and Administrator, revealed that the new diagnosis was not communicated to the appropriate personnel responsible for initiating the PASRR Level II process. As a result, the necessary referral and review were not completed in a timely manner following the resident's change in mental health status.
Failure to Revise Care Plan for Antipsychotic Use and New Mental Health Diagnosis
Penalty
Summary
The facility failed to revise the care plan for a resident who was readmitted with diagnoses including stroke and depression, and who subsequently received a new diagnosis of bipolar disorder. A physician ordered Risperdal, an antipsychotic, for the resident, and a psychiatric nurse practitioner documented that a gradual dose reduction (GDR) was clinically contraindicated. However, the resident's annual MDS assessment indicated the use of an antipsychotic without a GDR attempt and lacked documentation from the physician stating that a GDR was clinically contraindicated. Record review revealed that the resident's care plan was not updated to address the new diagnosis of bipolar disorder or the initiation of Risperdal. Interviews with the MDS Nurse and DON confirmed that the care plan should have included both the antipsychotic medication and the associated diagnosis, but these were omitted due to a breakdown in communication and lack of notification to the MDS Nurse about the changes. The administrator also acknowledged that the care plan should have reflected these updates.
Lack of Documentation for New Mental Illness Diagnosis with Antipsychotic Use
Penalty
Summary
The facility failed to provide adequate documentation supporting a newly diagnosed mental illness for a resident who was prescribed an antipsychotic medication. The resident, who had a history of stroke and depression, was readmitted and later assessed by a psychiatric nurse practitioner (NP) who noted auditory hallucinations and continued Risperdal, but did not document the basis for a new bipolar disorder diagnosis. The order for Risperdal was entered for bipolar disorder, but the supporting evaluation or rationale for this diagnosis was missing from the medical record. Subsequent psychiatric assessments referenced the bipolar disorder diagnosis, but the origin and justification for the diagnosis were unclear, and the diagnosis appeared to be automatically generated in documentation without direct clinical substantiation. Interviews with psychiatric NPs, the pharmacist, and the Director of Nursing (DON) revealed that the new diagnosis was not communicated to the DON, and there was no evidence that the diagnosis was properly assessed or documented. The pharmacist relied on the presence of the diagnosis in the order without further verification, and the DON was unaware of the new diagnosis, which prevented appropriate updates to the resident's medical record and notifications to relevant staff. The annual MDS assessment also indicated the use of an antipsychotic without a documented attempt at gradual dose reduction or a clinical contraindication, further highlighting the lack of comprehensive documentation and communication regarding the resident's mental health status and medication management.
Failure to Apply Physician-Ordered Palm Guard for Resident with Contractures
Penalty
Summary
A deficiency occurred when staff failed to apply a physician-ordered right-hand palm guard (green carrot) for a resident with a history of cerebral infarction, hemiplegia affecting the left side, contractures, and cognitive communication deficit. The order specified that the palm guard should be placed on the resident's right hand at night and removed in the morning. However, observations and interviews revealed that the device was not applied as ordered, and there was no documentation of refusal by the resident. Record reviews showed that the order for the palm guard was not present on the Medication Administration Record (MAR) for April and part of May, and there was no documentation in the nursing progress notes regarding the resident's refusal to use the device. Staff interviews indicated confusion about which shift was responsible for placing and removing the palm guard, and some staff were unaware of the resident's needs or the location of the device. The palm guard was found in the resident's nightstand rather than in use, and the resident confirmed that it had not been applied as ordered. Further interviews with nursing assistants, the unit manager, and the DON confirmed that the palm guard was not consistently applied or documented. The occupational therapy director stated that the nursing staff had been in-serviced on the use of the device, but the resident was not currently on therapy caseload. The lack of application and documentation of the palm guard represented a failure to provide appropriate care to maintain or improve the resident's range of motion and prevent complications associated with contractures.
Failure to Immediately Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its abuse policy regarding the immediate reporting and investigation of abuse allegations for two residents. In the first case, a cognitively intact resident was alleged to have been struck by a nurse aide. The incident was initially reported by a nurse aide to a nurse, but there was confusion among staff about who was responsible for escalating the report. As a result, the Administrator was not notified until several hours after the initial disclosure, and the required notifications to authorities were delayed until the Administrator became aware of the incident. In the second case, another cognitively intact resident reported to Adult Protective Services and law enforcement after discharge that a female staff member had inappropriately touched him. The police investigator attempted to contact the facility's Administrator but was unsuccessful and instead spoke with the Social Worker Director, who did not recognize the staff description and did not report the allegation internally. The Director of Nursing and Administrator were unaware of the allegation until it was reported by the state, and no internal investigation was initiated until that point. Both cases demonstrate that the facility did not follow its own policy requiring immediate reporting of abuse allegations to the Administrator or management, nor did it ensure timely initiation of investigations. Staff interviews revealed a lack of clarity and communication regarding the proper procedures for reporting abuse, resulting in delayed notifications and investigations.
Failure to Maintain Safe and Clean Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment in several resident rooms. Specific deficiencies included missing and scraped paint on doorways, bathroom doors, and walls; a red splattered substance on a wall; and a bathroom sink with a persistent black film. These issues were identified in three out of seven resident rooms reviewed on one of four halls. The observations were confirmed on two separate dates, indicating that the deficiencies were ongoing and had not been addressed between visits. Interviews with the Maintenance Director and Housekeeping Manager revealed that while there was an ongoing process to repaint and repair resident rooms, progress was slow due to resident preferences and competing maintenance priorities. The Housekeeping Manager acknowledged that certain cleaning tasks, such as removing the black film from the sink, required specific tools and had not been completed with routine cleaning. Review of work history reports showed no documented repairs for the affected rooms during the relevant period. The Administrator confirmed that there was an established cleaning process and that room improvements were being prioritized alongside other major repairs.
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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.
Illustrative
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Nursing homes near Durham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carver Living Center | 0.7 mi | ★★★★★ | 1 | 0 |
| Croasdaile Village | 2.3 mi | ★★★★★ | 8 | 0 |
| Pettigrew Rehabilitation Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Hillcrest Convalescent Center | 3.1 mi | ★★★★★ | 0 | 0 |
| University Health And Rehabilitation Center | 3.5 mi | ★★★★★ | 8 | 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 July 2026) and official state health department websites.