Above 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 Croasdaile Village during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, atrial fibrillation, and an order and care plan requiring mechanical-lift transfers was manually transferred from a wheelchair to bed by an agency NA who assumed the resident was a stand-pivot transfer because no sling was in place. During this non-lift transfer, the resident’s leg became caught behind a blunt, protruding part of the wheelchair near the footrest, resulting in a large lower-leg laceration with significant bleeding. An RN responded, applied pressure to control the bleeding, and the resident was sent to the hospital, where the wound—measuring 25 cm long and 20 mm deep—was sutured and dressed before later resolving with wound care.
A quarterly MDS assessment was not completed within the required 92-day period for a resident who experienced multiple discharges and readmissions. Staff confirmed that the assessment was missed and not transmitted as required.
Two residents' quarterly MDS assessments were not transmitted within the required timeframe due to issues during the facility's transition to a new electronic medical records system. The MDS Coordinator indicated that the transmission process was not triggered, resulting in delayed or missed submissions, despite the expectation that assessments be completed and transmitted promptly.
The facility failed to transmit Quarterly MDS assessments on time for two residents. The assessments were completed and signed but not transmitted until much later due to a failure to trigger the transmission process. The facility's practice of bi-weekly transmissions contributed to the delay.
Unsafe Transfer Without Mechanical Lift Causes Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe transfer for a resident who was care planned and ordered to be transferred only with a mechanical lift. The resident had Alzheimer’s dementia, atrial fibrillation, and a physician’s order specifying the need for a mechanical lift for all transfers, which was also reflected in the active care plan and a quarterly MDS showing severe cognitive impairment and total dependence for transfers. The resident was prescribed Eliquis 2.5 mg twice daily for atrial fibrillation, which increases the risk of bruising and bleeding, and had been receiving it up to the morning dose on 1/8/2026, with doses held for several days following the incident and later resumed. On the date of the incident, NA #1, an agency nurse aide who had previously cared for the resident and reported being familiar with her needs, transferred the resident from a wheelchair to the bed without using the required mechanical lift. NA #1 stated in an undated witness statement that when she prepared to transfer the resident, there was no sling under the resident, so she assumed the resident was a stand-pivot transfer and proceeded to transfer her without difficulty, reporting that the resident participated and showed no signs or symptoms of pain during or immediately after the transfer. While placing the resident’s legs in the bed, NA #1 observed blood dripping and immediately stopped and sought assistance from the nurse because she did not know the source of the bleeding. Nurse #1, who had been assigned to the resident and knew the resident had always required a mechanical lift during her approximately two years of employment, reported that NA #1 had transferred the resident without the mechanical lift when the laceration occurred. Nurse #1 stated that NA #1 ran from the room to get her, and upon entering the room she observed a large amount of blood from the resident’s lower left leg with the skin split, and she had to apply significant pressure to control the bleeding while the resident grimaced in pain. The facility’s investigation documented that during the transfer the resident’s left leg went behind a blunt, protruding part of the wheelchair where the footrest attached, causing a laceration. The resident was sent to the hospital, where records showed an extensive left lower leg laceration measuring 25 cm in length and 20 mm in depth with uncontrolled bleeding, which was closed with 11 sutures and dressed. Subsequent wound care documentation indicated the wound resolved later in the month.
Quarterly MDS Assessment Not Completed Within Required Timeframe
Penalty
Summary
The facility failed to complete a quarterly Minimum Data Set (MDS) assessment within the required 92-day timeframe for one resident. Record review showed that after the resident's admission MDS assessment was completed, there was no quarterly MDS assessment available within the mandated period. Staff interviews confirmed that the resident had been discharged and readmitted multiple times within two months, but the quarterly MDS assessment, which should have been scheduled and completed within 92 days of the admission assessment, was missing. The MDS Coordinator and Administrator both acknowledged that the assessment was not completed or transmitted as required.
Failure to Timely Transmit MDS Assessments Due to EMR Transition
Penalty
Summary
The facility failed to transmit quarterly Minimum Data Set (MDS) assessments within the required time frame for two residents. For one resident, the quarterly MDS assessment was completed and signed by the MDS Coordinator, but due to a transition from an old to a new electronic medical records program, the transmission process was not triggered, resulting in the assessment being transmitted over a month late. The MDS Coordinator stated that all completed MDS assessments were transmitted every other week, but the transition process led to this particular assessment being missed until it was discovered and transmitted later. For another resident, the quarterly MDS assessment was also affected by the transition to the new electronic medical records system. The assessment was signed late and, similarly, the transmission process was not triggered, resulting in the assessment not being transmitted to the national database as required. Both the MDS Coordinator and the Administrator acknowledged during interviews that MDS assessments should be completed and transmitted in a timely manner, but the transition process led to delays for these two residents.
Delayed Transmission of MDS Assessments
Penalty
Summary
The facility failed to transmit Quarterly Minimum Data Set (MDS) assessments within the required time frame for two residents. Resident #16's most recent MDS assessment had an Assessment Reference Date (ARD) of 5/8/24 and was completed and signed by the MDS Coordinator on 5/9/24. However, the assessment was not transmitted to the national database until 7/10/24, well past the required submission date of 5/23/24. The delay occurred because the nurse who signed the completed MDS assessment did not trigger the transmission process, and the MDS Coordinator only discovered the oversight later. Similarly, Resident #67's MDS assessment had an ARD of 5/5/24 and was completed and signed on 5/6/24, but it was also not transmitted until 7/10/24, missing the submission deadline of 5/20/24. The MDS Coordinator indicated that the same issue occurred, where the nurse did not initiate the transmission process. The facility's practice of transmitting completed MDS assessments every other week contributed to the delay. The Administrator expected timely completion and transmission of all MDS assessments.
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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 Durham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| University Health And Rehabilitation Center | 1.9 mi | ★★★★★ | 8 | 0 |
| Accordius Health At Rose Manor Llc | 2.3 mi | ★★★★★ | 1 | 0 |
| Pruitthealth-durham | 2.6 mi | ★★★★★ | 0 | 0 |
| Carver Living Center | 2.7 mi | ★★★★★ | 1 | 0 |
| Pettigrew Rehabilitation Center | 2.8 mi | ★★★★★ | 0 | 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.