Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Pettigrew Rehabilitation Center during CMS and state inspections, most recent first.
The facility's Dietary Department failed to maintain proper sanitation and food safety standards, affecting food served to 74 residents. Issues included inadequate chlorine concentration in the dish machine, improper glove use by staff, expired and unlabeled food items, and lack of beard covers for staff with facial hair. Additionally, kitchen equipment and vents were not kept clean, with grease buildup and food debris noted.
The facility failed to manage medications properly, with undated insulin vials, expired insulin pens, and loose pills found in medication carts. Nurses admitted to not checking or cleaning carts as required, leading to deficiencies in medication safety protocols.
A resident with a DNR order was resuscitated after being found unresponsive due to the nursing staff's inability to locate the DNR documentation in the transport binder. Despite the resident's severe cognitive impairment and multiple health conditions, CPR was initiated, and the EMS team continued resuscitation efforts without success. The facility's protocol to verify the DNR status in the electronic medical records was not followed.
A facility failed to accurately code the MDS assessment for a resident with a PASRR Level II status, incorrectly indicating a Level I status. The error was confirmed by the MDS Coordinator and acknowledged by the Administrator during interviews.
The facility did not provide the required RN coverage for at least 8 consecutive hours on a specific day. The absence of coverage was due to the RN being off and the scheduler's inability to secure agency coverage. The scheduler incorrectly assumed that the MDS Nurse could count as coverage. The Administrator noted that the presence of leadership staff might have led to this misunderstanding.
The facility did not post daily nurse staffing data for three consecutive days. An observation revealed that the staffing sheet dated 02/28/25 was still displayed on 03/03/25. The Scheduler, responsible for posting the sheets, admitted to forgetting to remind the Weekend Supervisor to update them. The Administrator confirmed that the data should be posted daily.
The facility failed to complete annual performance reviews and provide in-service education based on these reviews for three nursing assistants. This oversight was attributed to recent turnover in the Staff Development Coordinator position and a focus on new employee orientation, resulting in missing documentation for the required evaluations.
The facility failed to provide adequate foot care and arrange podiatry services for two dependent residents, resulting in neglected foot conditions. Despite regular skin assessments, there was no documentation or scheduling for podiatry consultations, and staff failed to communicate and address the residents' needs.
The facility failed to verify and document advance directives for two residents. One resident's code status was not entered into the EHR, and another resident had conflicting code status information between the EHR and care plan. Staff interviews revealed lapses in the verification and updating process.
The facility failed to complete the Interview for Activity Preferences of the comprehensive MDS for two cognitively impaired residents. The Activity Director confirmed the omission and indicated a lack of formal training on the MDS assessment. The Administrator and Regional Director of Operations acknowledged the incomplete activity sections on the MDS.
The facility failed to provide an ongoing activity program that met the individual interests and needs of two cognitively impaired residents. Both residents were observed spending significant time without social stimulation or activities, and there was a lack of documentation and assessments for their activity preferences and participation. The Activity Director and staff confirmed the deficiency, and the Administrator acknowledged the absence of proper documentation and assessments.
The facility failed to secure medications for a resident with multiple diagnoses, resulting in Nystatin powder being stored in the resident's bathroom, bedside table, and drawer without proper physician orders.
Deficiencies in Dietary Department Sanitation and Food Safety
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in the Dietary Department, which had the potential to affect the food served to 74 of 79 residents receiving an oral diet. The dishwashing process was compromised as the chemical sanitizing solution in the dish machine was not maintained at the correct concentration according to the manufacturer's recommendations. The Dietetic Technician (DTR) discovered that the chlorine concentration was inadequate when tested, leading to a temporary halt in dishwashing until the issue was resolved. Additionally, Dietary Aide #1 did not change gloves or wash hands between handling soiled and clean dishes, risking cross-contamination. Further observations revealed that the facility did not properly manage food storage and labeling. Expired food items were found in the walk-in cooler, and opened food items were not sealed, labeled, or dated. This included a box of frozen waffles and a stack of lunch meat in the freezer, as well as chicken salad and half and half cream in the cooler. The Dietary Manager acknowledged these issues and discarded the undated and expired foods. The facility also failed to ensure that all Dietary staff adhered to hygiene protocols. Four staff members involved in food preparation were observed with facial hair but without beard covers, which they only donned after being observed. Additionally, the kitchen equipment and vents were not kept clean, with grease buildup and food debris noted on various surfaces, including the hood, oven, and ice machine. The Maintenance Director confirmed that the vents needed cleaning, but this task had not yet been completed.
Medication Management Deficiencies in Medication Carts
Penalty
Summary
The facility failed to properly manage and label medications in several medication administration carts, leading to deficiencies in medication safety protocols. Observations revealed that multi-dose vials of insulin were opened and undated in two of the five medication carts, specifically on the Long and Short halls. Additionally, expired insulin pens were found in one of the medication carts on the Short hall. Loose pills were also discovered in the medication cart drawers on the Rehabilitation, Long, and Short halls. These findings were confirmed through staff interviews, where nurses acknowledged their responsibility for checking and cleaning the medication carts each shift but admitted to not performing these tasks. Nurses #3, #5, and #6 were unable to identify the loose pills found in their respective medication carts and admitted to not checking the dates of opening on insulin vials at the beginning of their shifts. The Director of Nursing and the Administrator both indicated that it was the nurses' responsibility to ensure no loose pills or expired medications were left in the carts. The failure to date opened vials, discard expired medications, and remove loose pills from the carts indicates a lapse in adherence to medication management protocols, as outlined by the facility's training and competency requirements.
Failure to Honor Resident's DNR Order
Penalty
Summary
The facility failed to honor a resident's advance directive to not be resuscitated when she was found unconscious and without pulse or respirations. The resident, who was severely cognitively impaired and had multiple diagnoses including diabetes mellitus, congestive heart failure, stroke, end-stage renal disease, tube feeding status, and dementia, had a documented Do Not Resuscitate (DNR) order. However, when the resident was discovered unresponsive, the nursing staff could not locate the DNR documentation in the transport binder, leading them to initiate cardiopulmonary resuscitation (CPR). Nurse #1, who was on duty during the incident, assessed the resident as less responsive with a significantly elevated blood sugar level and received an order to send the resident to the hospital. Despite checking the transport binder, Nurse #1 could not find the DNR paper. Upon returning to the resident's room, the resident was found non-responsive and not breathing, prompting Nurse #1 to initiate a Code Blue. Nurse #2 confirmed the absence of the DNR paper, and both nurses began CPR until the Emergency Medical Service (EMS) team arrived and took over. The EMS team continued resuscitation efforts for thirty minutes without success, and the resident was pronounced dead. Interviews with the nursing staff and facility management revealed that the DNR order was not verified in the electronic medical records before resuscitation was initiated. The Interim Director of Nursing and the Medical Director both indicated that the DNR information should have been checked in the electronic medical records, and the absence of the DNR paper in the transport binder should have been addressed. The facility's protocol required verification of the resident's code status before initiating resuscitation, which was not followed in this case.
Inaccurate PASRR Level Coding on MDS Assessment
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident with a Preadmission Screening and Resident Review (PASRR) Level II status. The resident, who was admitted with diagnoses including anxiety disorder, bipolar disorder, and residual schizophrenia, had a PASRR Level II Determination Notification indicating a serious mental illness. However, the resident's most recent comprehensive MDS assessment incorrectly reported a PASRR Level I status instead of Level II. Interviews with the facility's Interim MDS Coordinator and Administrator revealed that the MDS assessment for the resident was inaccurately coded. The MDS Coordinator confirmed the error upon reviewing the resident's assessment, and the Administrator acknowledged the expectation for accurate coding of PASRR levels on MDS assessments. This deficiency was identified during a review of the resident's annual MDS assessment.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least 8 consecutive hours per day, 7 days per week, as required. On one of the days reviewed, there was no RN coverage for eight consecutive hours. The facility's daily staffing sheet confirmed the absence of RN coverage on that day. During an interview, the facility scheduler admitted she was unable to assign an RN for the required hours due to the RN being off and was unsuccessful in obtaining coverage from an agency. She mistakenly believed that the Minimum Data Set (MDS) Nurse, who was an RN, could count as coverage. The Administrator acknowledged the lack of coverage and explained that the presence of the MDS Coordinator, Nurse Consultant, and Interim Director of Nursing (DON) might have led to the assumption that leadership could suffice as coverage.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to post daily nurse staffing data for three consecutive days, specifically on 03/01/25, 03/02/25, and 03/03/25. An observation on 03/03/25 at 10:41 AM revealed that the staffing sheet displayed was dated 02/28/25, indicating that the data had not been updated. The staffing sheet was located in a case on the wall near the lobby area. During an interview on 03/06/25, the Scheduler, who was responsible for posting the daily staffing sheets, admitted to typically printing out the sheets for the weekend on Friday and placing them behind the current sheet. She acknowledged forgetting to remind the Weekend Supervisor to change the sheets over the weekend. The Administrator confirmed in an interview on 03/06/25 that the nurse staffing data should be posted daily.
Failure to Complete Annual Performance Reviews for Nursing Assistants
Penalty
Summary
The facility failed to complete annual performance reviews and provide in-service education based on the outcomes of these reviews for three of five nursing assistants reviewed. Specifically, the employee files for three nursing assistants did not include the required annual performance review documents for the years corresponding to their dates of hire. This deficiency was identified through record reviews and staff interviews, revealing that the facility had not conducted the necessary evaluations and training updates for these staff members. During interviews, the Staff Development Coordinator (SDC) and the Administrator acknowledged the oversight, attributing it to recent turnover in the SDC position and the SDC's current focus on new employee orientation. The Regional Clinical Director also confirmed that annual performance reviews and skill assessments were expected but had not been completed. The facility was unable to provide documentation to indicate that the required annual performance reviews and skill competencies evaluations had been conducted for the nursing assistants in question.
Failure to Provide Adequate Foot Care and Podiatry Services
Penalty
Summary
The facility failed to provide adequate foot care and arrange podiatry services for two dependent residents, Resident #4 and Resident #81. Resident #4, who had diagnoses including cognitive impairment, Parkinson's disease, chronic pulmonary obstructive disease, and diabetes, was found to have a buildup of skin between her toes and curled toenails extending 1.5 inches beyond the base of the nail. Despite multiple skin assessments, there was no documentation regarding the condition of her feet, and she had not been scheduled for a podiatry consultation. Resident #4 reported that her feet were hurting and that she had informed the aides and nursing staff several times, but no action was taken. The Director of Nursing confirmed the need for foot care and stated that it was the responsibility of nurse aides to report such needs to nursing staff, who should then document and address them during weekly skin assessments. Resident #81, who had severe cognitive impairment, diabetes, hemiparesis, hemiplegia, and cerebral infarction, was also found to have neglected foot care. His toenails were long, dirty, and growing into the next toe, with thick layers of skin and a foul odor detected. Despite regular skin assessments, there was no documentation of the condition of his feet, and he had not been scheduled for a podiatry consultation. The Unit Manager confirmed the poor condition of Resident #81's feet and stated that nurse aides were expected to provide foot care during baths/showers and report any changes to the nursing staff. However, the current skin check form did not allow for documentation of foot care unless a skin impairment was observed. Interviews with various staff members, including the Social Work Director, Administrator, and Regional Clinical Nurse, revealed a lack of communication and documentation regarding the need for podiatry services. The Social Work Director and Regional Clinical Nurse confirmed that neither Resident #4 nor Resident #81 had been scheduled for podiatry services due to the absence of notifications from nursing staff. The Administrator emphasized that nurse aides and nursing staff were responsible for ensuring residents' feet were checked and cleaned, and for notifying social workers when podiatry services were needed. The deficiency in foot care was attributed to inadequate documentation and communication among the staff.
Failure to Verify and Document Advance Directives
Penalty
Summary
The facility failed to obtain and verify advance directives (code status) for two residents. Resident #191 was admitted to the facility with a hospital discharge summary indicating a full code status, but no active order for code status was found in the resident's electronic health record (EHR). Interviews with staff revealed that the Unit Manager was responsible for verifying and entering the code status into the EHR, but this was missed for Resident #191. The Administrator confirmed that code status should be entered at admission and care planned accordingly, but this was not done for Resident #191. Resident #75 had conflicting information regarding their code status. The electronic medical record and a physician's order indicated a do not resuscitate (DNR) status, while the care plan indicated a full code status. Interviews with staff revealed that the interdisciplinary team was responsible for updating the care plan, but this was not done for Resident #75. The Unit Manager acknowledged the discrepancy and updated the care plan during the survey. The Administrator confirmed that the code status and care plan should match and that Unit Managers should ensure the care plan reflects the correct and current code status.
Failure to Complete Interview for Activity Preferences
Penalty
Summary
The facility failed to complete the Interview for Activity Preferences of the comprehensive Minimum Data Set (MDS) for two cognitively impaired residents. Resident #12 was admitted with cognitive impairment and required assistance with activities. The admission MDS did not include the Interview for Activity Preferences. The Activity Director (AD) confirmed that while completing the Preferences for Customary Routine and Activities assessment, she did not conduct the Interview for Activity Preferences for Resident #12. The AD indicated she was not formally trained on the completion of the MDS assessment. Similarly, Resident #81 was admitted with cognitive impairment and required assistance with activities. The admission MDS also did not include the Interview for Activity Preferences. An admission activity assessment revealed no information about Resident #81's preferences or interests in activities. The AD confirmed that she did not conduct the Interview for Activity Preferences for Resident #81 and indicated a lack of formal training on the MDS assessment. The Administrator and the Regional Director of Operations acknowledged that the activity section on the MDS for both residents was incomplete and could not provide further information.
Failure to Provide Adequate Activity Program for Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide an ongoing activity program that met the individual interests and needs of two cognitively impaired residents. Resident #12, diagnosed with encephalopathy and having moderate cognitive impairment, was not engaged in any activities despite her care plan indicating a need for simple, structured activities. Observations revealed that Resident #12 spent significant time in her room without any form of social stimulation or activities, and there were no documented activity notes or preferences listed for her. Interviews with staff confirmed that Resident #12 was not involved in group activities or provided with one-to-one activities as required by her care plan. Similarly, Resident #81, who had severe cognitive impairment and required assistance with activities, was also not engaged in any meaningful activities. Despite his care plan indicating a preference for spending time outdoors and participating in favorite activities, observations showed that Resident #81 spent time in his room or doorway without any social interaction or sensory stimulation. Interviews revealed that Resident #81 was not aware of the activities being offered and was not provided with in-room activities or assistance to attend group activities. The Activity Director admitted to not having a specific schedule for one-to-one activities and confirmed the lack of documentation for both residents' activity participation. The Administrator and Regional Director of Operations acknowledged the deficiency and the absence of proper documentation and assessments for the residents' activity preferences and participation. The facility's failure to develop and implement a comprehensive activity program resulted in the residents not receiving the necessary social and recreational stimulation as per their care plans.
Failure to Secure Medications
Penalty
Summary
The facility failed to secure medications stored in the room and bathroom for a resident diagnosed with osteoarthritis, hypertension, chronic pain, and spinal stenosis. The resident had a physician's order for Nystatin External Powder to be applied topically twice a day for yeast. During an observation of ADL care, a nursing assistant applied the Nystatin powder to the resident's skin folds. Subsequent observations revealed multiple bottles of Nystatin powder stored in the resident's bathroom, on the bedside table, and in a drawer. The facility administrator confirmed that medications should not be stored at the bedside without physician orders.
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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) |
|---|---|---|---|---|
| Hillcrest Convalescent Center | 0.1 mi | ★★★★★ | 0 | 0 |
| University Health And Rehabilitation Center | 1.7 mi | ★★★★★ | 8 | 0 |
| Pruitthealth-durham | 1.7 mi | ★★★★★ | 0 | 0 |
| The Forest At Duke Inc | 2.7 mi | ★★★★★ | 0 | 0 |
| Croasdaile Village | 2.8 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.