Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Carolina Rehab Center Of Burke during CMS and state inspections, most recent first.
Advance Directive Paperwork Not Sent With Emergent Transfer: A resident with dementia, falls, and weakness was found after an unwitnessed fall with a head laceration and was sent to the hospital. Facility staff gave EMS only a face sheet and med list and told them the resident was full code because they did not have the DNR/MOST paperwork. The resident was intubated and placed on a ventilator until the advance directive forms were later brought to the hospital and the resident’s DNR/DNI wishes were recognized.
A deficiency was cited when a resident's right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and formulate an advance directive was not honored by the facility. The facility did not ensure these rights were upheld as required.
Surveyors found expired influenza vaccine vials stored in a medication room refrigerator, an undated opened insulin pen, and a cup containing loose pills with a resident's name in a medication cart. The Infection Preventionist and DON confirmed that expired medications should have been removed during regular checks, and staff acknowledged that medications were not properly dated or stored according to policy.
The facility did not post required daily nurse staffing census information for nearly all days reviewed, as the responsible Scheduler was unaware of the requirement until recently informed by the DON. Both the DON and Administrator were also unaware that the census section had not been completed on the staffing sheets.
The facility failed to accurately code MDS assessments for several residents, leading to discrepancies in medical records. A resident with pneumonia did not have their oxygen therapy reflected in the MDS, while another with a fractured arm was inaccurately shown as having no impairment. A resident on dialysis was not recorded as receiving it, and a diabetic resident's insulin administration was not reflected. Additionally, a resident receiving hospice care was not coded for a life expectancy of less than six months, and a resident with schizophrenia had an unrecorded PASRR Level II determination.
A facility failed to maintain emergency tracheostomy supplies at the bedside for a resident and did not post oxygen cautionary signs for residents receiving supplemental oxygen. Observations showed a lack of ambu bags and obturators in a resident's room, and interviews revealed staff were unaware of the need for these supplies. Additionally, oxygen cautionary signage was not posted on room doors, as the facility believed signage at the main entrance was sufficient.
A facility failed to ensure emergency tracheostomy supplies were available for a resident with respiratory issues. The resident lacked an ambu bag and obturator in their room, and staff were not adequately trained on emergency procedures. The DON believed storing an ambu bag on the crash cart was sufficient, but this did not meet the expectations of some staff. The last training on emergency tracheostomy care was over a year ago.
The facility was found to have deficiencies in food storage and cleanliness, including undated and spoiled food items in coolers and storage areas, and unclean refrigerators in nourishment rooms. The Dietary Manager and Administrator acknowledged the expectations for proper food handling and cleanliness, which were not met.
A facility failed to notify a resident's Responsible Party (RP) of a medication change involving Lorazepam, instead discussing it with the resident's private sitter, who was not authorized to make care decisions. The RP, who had requested weekly updates, was not informed until after the resident fell. Staff assumed the sitter would inform the RP, leading to a communication lapse acknowledged by the Director of Nursing and Administrator.
A facility failed to request a PASRR reevaluation for a resident with schizophrenia after a significant change in condition. The oversight occurred due to a change in Social Worker employment and the new Social Worker being in training. The Regional Social Worker confirmed the lapse, while the DON was not knowledgeable about the PASRR process. The Administrator expected the Social Worker to handle PASRR requests.
A resident with fractures requiring substantial assistance with ADLs did not have an individualized care plan. The care plan only included general therapy evaluations without specific interventions for the resident's needs. Facility staff acknowledged the oversight, and the Administrator confirmed that care plans should reflect residents' needs.
A facility failed to update a resident's advance directive care plan to reflect a DNR status, despite physician orders indicating DNR/DNI. The resident, who was severely cognitively impaired, had a care plan inaccurately showing a full code status. The MDS Coordinator acknowledged the oversight, and the Administrator expected accurate care plan updates.
Advance Directive Paperwork Not Sent With Emergent Transfer
Penalty
Summary
The facility failed to ensure that a resident’s DNR goldenrod form and MOST form, both indicating DNR and DNI status, were provided to EMS during an emergent transfer to the hospital after the resident fell and sustained a head injury. The resident had been admitted with diagnoses including dementia, history of falls, and muscle weakness, and the electronic health record contained a physician order showing DNR status. A change in condition note documented that the resident was found on the floor at bedside, lying face down with profuse bleeding from the right forehead, and EMS was called for transport. EMS records show that facility staff handed over only a face sheet and medication list and told EMS the resident was full code to the best of their knowledge because they had no other paperwork. EMS questioned staff about code status and was advised that no paperwork had been provided to suggest anything other than full code. The resident was transported to the hospital, where records show he arrived with a low Glasgow Coma Scale score, was intubated, and placed on mechanical ventilation as part of treatment. Hospital documentation later noted that the resident was actually DNR and DNI once the facility paperwork was brought in. The resident’s Responsible Person stated the resident had been very specific about not wanting resuscitation or intubation and wanted comfort measures only. The Responsible Person and the facility’s Director of Marketing both reported that the advance directive paperwork had not been sent with the resident at the time of transfer, and the Director of Marketing later retrieved the original forms from the facility and brought them to the hospital.
Failure to Honor Resident Rights Regarding Treatment and Advance Directives
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to request, refuse, or discontinue treatment, to participate in or refuse experimental research, and to formulate an advance directive. The report notes that the facility did not ensure these resident rights were upheld, as required by regulations. Specific actions or omissions by facility staff led to this deficiency, but no further details about the residents involved or their medical conditions are provided in the report. The deficiency centers on the lack of adherence to protocols that protect resident autonomy in making decisions about their care and participation in research, as well as the formulation of advance directives.
Expired Vaccines, Undated Insulin, and Loose Pills Found During Medication Storage Audit
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of drugs and biologicals. In one medication room, five unopened and two opened vials of influenza vaccine were found in the refrigerator, all labeled with an expiration date that had already passed. These expired vials were still available for use. The Unit Manager acknowledged that the expired vials should have been returned to the pharmacy after expiration. The Infection Preventionist, who is responsible for weekly checks of medication rooms, stated she had recently checked the room but did not observe the expired vials. The Director of Nursing confirmed that the Infection Preventionist is tasked with removing expired medications during weekly checks and after resident discharges, and expressed surprise that the expired vials were present, as no flu shots had been administered since the end of the previous flu season. Additionally, in a medication cart, an opened insulin pen was found without a date indicating when it was opened, despite manufacturer instructions that the pen expires 28 days after opening. The nurse responsible for the cart admitted the pen should have been dated and was unaware of its status. In the same cart, a plastic cup containing 18 loose pills labeled with a resident's name was found in the narcotic drawer. The nurse stated she did not place the loose pills there and had not noticed them during narcotic counts. The Director of Nursing confirmed that loose pills should not be kept in medication carts and that daily checks are required.
Failure to Post Daily Nurse Staffing Census Information
Penalty
Summary
The facility failed to post required daily nurse staffing census information for 322 out of 323 days reviewed. Record review showed that from October 2024 through August 18, 2025, the daily nurse staffing sheets did not have census information entered. Observation on August 19, 2025, confirmed that the census was entered on that day's sheet, but not on previous days. During interviews, the Scheduler, who had been in the position for about two years, stated she was unaware that census information needed to be completed on the daily nurse staffing sheet until informed by the DON on August 19, 2025. The DON also stated she was not aware that the census had to be completed for all three shifts or that it had not been done since October 2024. The Administrator was similarly unaware that the census had not been entered and believed it was adjusted throughout the day as residents were admitted or discharged.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for six residents, leading to discrepancies in their medical records. Resident #23, who was admitted with pneumonia, had a physician's order for oxygen therapy, which was administered as per the Treatment Administration Record (TAR). However, the admission MDS did not reflect the oxygen therapy received during the assessment period, which was confirmed as an oversight by the MDS Coordinator. Similarly, Resident #71, admitted with a displaced fracture of the right humerus, had orders for a non-weight bearing status and a sling, but the MDS assessment inaccurately showed no impairment of the upper extremities. Resident #130, diagnosed with end-stage renal disease and dependent on dialysis, had orders for dialysis three times a week. The admission MDS inaccurately indicated that the resident did not receive dialysis while at the facility, which was acknowledged as an oversight by the MDS staff. Resident #74, with a diagnosis of diabetes, had multiple physician orders for insulin, which were administered as per the Medication Administration Record (MAR). However, the MDS assessment failed to reflect the administration of hypoglycemic medication during the look-back period. Resident #38, who began receiving hospice services, was not coded in the MDS as having a life expectancy of less than six months or as receiving hospice services, despite a significant change in status. This was identified as an oversight by the MDS Coordinator. Lastly, Resident #6, with a diagnosis of schizophrenia, had a PASRR Level II determination, but the MDS assessment did not reflect this status. The Regional Social Worker confirmed the oversight, and the Administrator expressed an expectation for accurate MDS assessments to reflect the residents' conditions accurately.
Deficiencies in Respiratory Care and Safety Signage
Penalty
Summary
The facility failed to maintain necessary emergency tracheostomy supplies at the bedside for a resident with a tracheostomy, which is crucial for immediate use in case of an unplanned extubation. Observations revealed that a resident with a tracheostomy was receiving oxygen therapy but did not have an ambu bag or obturator readily available in their room. The Infection Prevention (IP) Nurse later placed an ambu bag in the room, but initially, there was uncertainty about the availability of an obturator. Interviews with staff, including the IP Nurse and the Staff Development Coordinator (SDC) Nurse, indicated a lack of awareness and training regarding the necessity of having these emergency supplies accessible. Additionally, the facility did not post cautionary and safety signs indicating the use of oxygen for residents receiving supplemental oxygen therapy. Observations showed that several residents were receiving oxygen therapy without any signage on their room doors or doorframes to indicate oxygen use. Interviews with staff revealed that the facility had decided not to post these signs for dignity reasons and because it was a non-smoking facility. The Director of Nursing confirmed that the facility only posted oxygen cautionary signage at the main entrance and exit doors, based on the belief that this was sufficient. These deficiencies affected multiple residents who were reviewed for respiratory services, highlighting a systemic issue in the facility's approach to respiratory care and safety protocols. The lack of emergency tracheostomy supplies and appropriate signage for oxygen use could potentially compromise resident safety in emergency situations.
Deficiency in Emergency Tracheostomy Care Supplies
Penalty
Summary
The facility failed to ensure that emergency tracheostomy supplies were immediately available for a resident with a tracheostomy, leading to a deficiency in care. The resident, admitted with respiratory failure, hypoxia, and pneumonia, did not have an ambu bag or obturator in their room, which are critical for emergency tracheostomy care. Observations confirmed the absence of these supplies, and interviews with staff revealed a lack of education and awareness regarding the necessity of having these items readily available. The Staff Development Coordinator Nurse, responsible for educating nursing staff, admitted to not providing education on emergency tracheostomy procedures due to time constraints and reliance on respiratory therapy personnel, who had not conducted such training since the resident's admission. The Infection Preventionist Nurse and several other nurses also reported not receiving adequate training on emergency procedures for tracheostomy dislodgement, highlighting a gap in the facility's educational practices. The Director of Nursing acknowledged that every resident with a tracheostomy should have an obturator and ambu bag accessible, but considered storing an ambu bag on the crash cart as sufficient. However, this practice did not align with the expectations of some staff members, who were accustomed to having these supplies at the bedside. The deficiency was further compounded by the lack of recent training sessions on emergency tracheostomy care, as the last documented training occurred over a year prior.
Deficiencies in Food Storage and Cleanliness
Penalty
Summary
The facility failed to adhere to proper food storage and handling protocols, as observed during a survey. In the walk-in cooler, a 3-pound bag of sliced ham was found undated and open to air, and a box of tomatoes showed signs of spoilage. The Dietary Manager confirmed that all opened food items should be dated and covered, and produce should be checked daily for spoilage. In the reach-in cooler, an opened and undated bottle of prune juice and nine thawed milkshakes without labels indicating their removal date from the freezer were found. The Dietary Manager stated that opened beverages should be dated, and milkshakes should be labeled with the date they were thawed, as they are only good for 14 days post-thawing. In the dry storage room, several expired boxes of honey thickened beverages and undated bags of rice and elbow noodles were discovered. The Dietary Manager acknowledged that staff should date items when opened and discard expired items. Additionally, an undated bin of sugar was found in the kitchen's food preparation area. The nourishment room refrigerators on three different halls were observed to have multiple dried stains, indicating a lack of cleanliness. The Dietary Manager stated that dietary staff should clean these refrigerators daily. The Administrator expected dietary staff to follow the facility's policies on food dating, storage, and cleanliness.
Failure to Notify Responsible Party of Medication Change
Penalty
Summary
The facility failed to immediately notify a resident's Responsible Party (RP) of a medication change for a resident with severe cognitive impairment. The resident, who was admitted with a diagnosis of dementia, had a medication change involving Lorazepam, which was altered from an as-needed basis every 8 hours to every 12 hours, and a scheduled dose was added. This change was discussed with the resident's private sitter, who was not authorized to make decisions regarding the resident's care, instead of the RP. The RP was not informed of the medication change until after the resident experienced a fall. Interviews revealed that the facility staff assumed the private sitter would inform the RP, as the sitter was actively involved in the resident's care and appeared to be communicating with the RP via text. However, the RP had previously requested weekly email updates from the facility regarding the resident's condition and any medication changes. The Director of Nursing and the Administrator acknowledged the communication lapse, noting that the staff should have directly informed the RP about the medication change rather than relying on the private sitter.
Failure to Request PASRR Reevaluation After Significant Change
Penalty
Summary
The facility failed to request a Preadmission Screening and Resident Review (PASRR) re-evaluation for a resident with a serious mental health diagnosis after a significant change in condition. Resident #6, diagnosed with schizophrenia, was admitted with a Level II PASRR determination that required reevaluation upon any change in condition. Despite a significant change in the resident's condition in April 2024, no PASRR reevaluation request was made. The Regional Social Worker confirmed the oversight, attributing it to a change in employment status of the previous Social Worker and the new Social Worker still being in training. The Director of Nursing stated that PASRR was the responsibility of the Social Worker, and she was not knowledgeable about the process. The Administrator expected PASRR requests to be completed by the Social Worker.
Failure to Develop Individualized ADL Care Plan
Penalty
Summary
The facility failed to develop an individualized, person-centered Activities of Daily Living (ADL) care plan for a resident who required substantial to maximum assistance with various ADL tasks. The resident, who was admitted with a displaced fracture of the surgical neck of the right humerus and a displaced fracture of the base of the neck of the right femur, had intact cognition and needed significant assistance with toileting hygiene, personal hygiene, showering/bathing, dressing, footwear, bed mobility, and transfers. Despite these needs, the resident's comprehensive care plan only included a general intervention for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) to evaluate and treat as needed, without specific interventions tailored to the resident's care requirements. During interviews, both the MDS Assistant and the MDS Coordinator acknowledged that the care plan lacked specific interventions addressing the resident's care needs, attributing this to an oversight. The MDS Assistant noted that the care plan should have included details such as transfer status and the use of bed rails to guide staff in providing the appropriate level of care. The facility's Administrator also confirmed that care plans are expected to accurately reflect residents' needs, indicating a failure in the facility's process to ensure comprehensive and individualized care planning for the resident.
Failure to Update Advance Directive Care Plan
Penalty
Summary
The facility failed to revise the advance directive care plan for a resident who was severely cognitively impaired. The resident was admitted to the facility on 08/24/22, and a significant change in status Minimum Data Set (MDS) assessment indicated severe cognitive impairment. A Medical Orders for Scope of Treatment (MOST) form dated 06/18/24 showed that the resident had Do Not Resuscitate (DNR) physician orders. However, the resident's electronic medical record contained a physician order dated 06/19/24 for Do Not Resuscitate/Do Not Intubate (DNR/DNI). Despite these orders, the resident's advance directive care plan, last revised on 07/16/24, inaccurately reflected a full code status, which involves providing life-saving measures. The care plan included interventions to honor the resident's advance directive choices and to refer to the physician as needed for changes. An interview with the MDS Coordinator revealed that the care plan should have been updated on 06/18/24 to reflect the DNR status, but it was not revised. The Administrator confirmed the expectation for care plans to accurately reflect the resident's status.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| College Pines Health And Rehabilitation | 3.7 mi | ★★★★★ | 2 | 0 |
| Hickory Falls Health And Rehabilitation | 6.3 mi | ★★★★★ | 0 | 0 |
| Trinity Ridge | 6.4 mi | ★★★★★ | 1 | 0 |
| The Greens At Viewmont | 7.7 mi | ★★★★★ | 1 | 1 |
| Autumn Care Of Drexel | 8 mi | ★★★★★ | 3 | 0 |
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