Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Pruitthealth-carolina Point during CMS and state inspections, most recent first.
Surveyors identified improper food storage and unsanitary conditions in the dietary department, including expired milk left available for service, an open bag of shredded cheese, an undated and open bag of rice, and improperly sealed and undated frozen chicken patties and ground beef in the freezer. They also observed a cutting board rack with dark brown debris contacting some boards, a stove/oven side with heavy grease buildup, a refrigerator door edge with thick dust and debris, and a visibly soiled condiment and silverware cart with dried debris and crumbs. Interviews with the DM and regional dietary leadership confirmed that staff were not consistently labeling, dating, sealing food items, or thoroughly cleaning equipment and workstations.
A resident with type 2 DM, neuropathy, circulatory issues, and hemiplegia, who required extensive assistance with ADLs, did not receive needed toenail care or podiatry services over several months. Facility records, including nurse notes, shower books, and weekly skin assessments, contained no indication that long, thick, jagged toenails were identified or addressed, and the resident was not placed on podiatry lists. CNAs reported they could not cut toenails and were supposed to notify nurses, but one CNA had not informed the nurse despite observing the condition. The charge nurse, SW, DON, and administrator each acknowledged the resident had not been identified for podiatry, despite facility expectations that nurses assess feet, arrange nail care, and ensure residents with DM are referred to the podiatrist.
A resident with diabetes, end stage renal disease, and a history of CVA, who required assistance with ADLs and personal hygiene, did not receive appropriate nail care despite a care plan directing staff to ensure clean, neatly trimmed nails and scheduled baths. Over multiple days, the resident’s fingernails were observed to be long with thick black debris underneath, while bath documentation sheets were missing for several months. NAs and the assigned nurse reported they had not noticed or reported the nail condition, and unit leadership and the DON acknowledged that nail care should have been completed with scheduled baths but had not assessed this resident’s nails or identified the lack of documentation.
A resident with a seizure disorder did not receive a prescribed dose of Lacosamide 50 mg for seven days because the medication was unavailable due to an expired prescription. Multiple nurses documented the missed doses but did not consistently notify the provider or pharmacy, leading to a delay in obtaining a new prescription. The resident continued to receive other antiseizure medications and showed no adverse effects during this period. The deficiency resulted from inadequate systems for ensuring medication availability and timely communication.
A cognitively impaired male resident in a LTC facility was found attempting to sexually abuse a female resident, who was also cognitively impaired and unable to defend herself. The male resident, with a history of socially inappropriate behavior, was seen naked in the hallway but was not stopped by staff. He entered the female resident's room, leading to the incident. Staff failed to intervene or notice the male resident's actions, resulting in a significant deficiency in resident protection.
The facility failed to accurately code MDS assessments for PASRR Level II for four residents, despite determinations from the North Carolina Department of Health and Human Services. Interviews with the Case Mix Director and Administrator revealed expectations for correct coding were not met, leading to deficiencies in the assessment process.
The facility failed to maintain cleanliness in the dry goods storage area and did not label or date food in the walk-in refrigerator. Additionally, a Dietary Aide was observed preparing food without a beard covering. The Dietary Manager and DON confirmed the need for immediate cleaning of spills, proper labeling of food, and adherence to hygiene standards.
A facility failed to develop an individualized ADL care plan for a resident requiring total assistance. Despite the resident's need for substantial to maximum assistance with various ADLs, the care plan did not address this requirement. Interviews with the MDS Coordinator and DON confirmed the omission, which contradicted facility protocols.
The facility failed to provide appropriate meal modifications for two residents with specific dietary needs. One resident with dysphagia did not receive a mechanically soft diet with adequate gravy, leading to difficulty swallowing. Another resident, who required food cut into bite-sized pieces, did not have this modification reflected on meal tickets, causing difficulty in eating. The dietary manager acknowledged errors in transferring special instructions to the meal tracker software.
A resident with intact cognition experienced a medication change due to increased facial pain, but neither the resident nor the Responsible Party (RP) were informed. The Nurse Practitioner (NP) instructed the nurse to discuss the changes with the resident, but the nurse failed to do so, citing being occupied with other tasks. The resident and RP later reported not being informed, and the Director of Nursing (DON) confirmed the notification should have occurred.
The facility failed to convey the personal funds of two deceased residents to their estates within the required 30-day period. A resident's $125.22 and another's $2,349.50 were not forwarded to the Clerk of Court or communicated to the families in time. These oversights were discovered during audits, revealing lapses in the facility's financial management processes.
A cognitively impaired, quadriplegic resident with a history of traumatic brain injury and aphasia was sexually abused by a cognitively intact resident with Parkinson's disease. The incident was discovered by a Nursing Assistant who found the perpetrator fondling the victim. The victim, unable to move or call for help, was examined and transferred to another facility. The perpetrator admitted to the abuse and left the facility against medical advice after being questioned by law enforcement. The facility was found to be in immediate jeopardy due to the failure to protect the resident from abuse.
The facility failed to protect a cognitively impaired resident from sexual abuse by another resident and did not effectively implement, monitor, and revise their quality assurance action plan. A previous incident also showed failure to protect a resident from mistreatment by staff.
Improper Food Storage and Unsanitary Dietary Equipment
Penalty
Summary
The deficiency involves failure to properly label, date, seal, and remove expired food items, as well as failure to maintain cleanliness of dietary equipment and storage areas. During an initial tour of the dietary department, surveyors observed two crates of chocolate milk cartons in the walk-in cooler that were past their expiration date but still available to be served, and a partially used 5-pound bag of shredded cheddar cheese left open to air, though dated as opened. In the dry food storage room, an undated bag of rice was found in an open plastic bag. In the walk-in freezer, an open cardboard box of frozen chicken breast patties with an open inner plastic bag was observed, with patties showing light edges suggestive of freezer burn, and three 5-pound rolls of frozen ground beef placed on a wire rack without any dates. Additional observations showed that equipment and surfaces in the dietary department were not adequately cleaned. The free-standing rack for cutting boards had a dark brown buildup of debris between sections where cutting boards were stored, with some boards touching the debris. One side of the stove/oven had a dark brown, sticky grease buildup. The bottom edge of a free-standing refrigerator door had thick dust and debris, and a utility cart holding condiments and silverware was visibly soiled with dried debris and crumbs between compartments and along the edges. Interviews with the Dietary Manager and the Regional Director of Dietary Services confirmed that staff had not been consistently checking dates, sealing and labeling food, or ensuring that cleaning tasks were completed according to expectations.
Failure to Provide Podiatry Services and Foot Care for Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate foot care and podiatry services to a resident with type 2 diabetes, neuropathy, circulatory complications, and hemiplegia/hemiparesis following a subarachnoid hemorrhage. The resident had moderately impaired cognition and required substantial to maximum assistance with activities of daily living. Review of the care plan, quarterly MDS, nurse progress notes, shower book, and weekly skin assessments from December through early February showed no documentation that the resident’s long toenails were identified, addressed, or that a podiatry appointment was arranged. The skin assessment sections attached to shower sheets were not checked to indicate a need for nail trimming, and the resident’s name did not appear on podiatry lists for the prior six months. On observation, the resident called out for help and reported toe pain; her great toenails and remaining toenails were noted to be long, thick, and jagged, and she was not wearing socks. Nurse aides reported that they could not cut the resident’s toenails and that their role was to inform the nurse when toenails needed cutting, especially for residents with diabetes who must be seen by a podiatrist. One nurse aide acknowledged she had not informed the nurse that this resident’s toenails needed cutting, and the charge nurse stated she had not cut the resident’s toenails and had not been asked to do so. The social worker reported the resident had not been identified as needing podiatry, and the DON stated that residents with diabetes should have their nails cut by podiatry and that nurses should assess feet and either cut nails or place residents on the podiatry list. The administrator stated he was unaware the resident needed podiatry and that nurses were responsible for ensuring the social worker received a current list of residents needing podiatry services.
Failure to Provide Required Nail and Personal Hygiene Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nail care and personal hygiene assistance to a resident who required staff support with activities of daily living. The resident was admitted with recent partial amputation of two fingers, end stage renal disease, Type 2 diabetes mellitus, and a history of cerebrovascular accident. The admission MDS documented that the resident was cognitively intact, required substantial assistance for toileting hygiene, and needed set up/clean up assistance with personal hygiene. The care plan identified an ADL self-care deficit and included interventions to check nails to ensure they were clean and neat in appearance and to provide showers per schedule. Despite this, repeated observations over several days showed the nails on the resident’s left hand extended approximately a quarter inch beyond the fingertips with thick black matter under each nail. Record review showed the resident was scheduled for baths twice weekly on the night shift, but there were no shower or personal hygiene sheets for the resident from November through February. Night-shift NAs assigned on the resident’s bath days stated they relied on the posted bath schedule and a Bath Check List to document completion of care and to note nail care needs, but they reported they had not noticed the condition of the resident’s fingernails. Another NA who provided a bed bath reported no personal care issues and did not recall long or dirty nails. The nurse assigned to the resident was unaware of any nail care needs, stated no NA had reported concerns, and had not observed the nails. The Unit Manager and DON both stated that nail care was expected to be completed with scheduled baths and that NAs should notify nurses, especially for residents with diabetes, but they had not assessed this resident’s nails and did not know why no bath sheets existed for the resident. The Administrator stated it was unacceptable for residents to have dirty fingernails and that nursing staff were responsible for ensuring neat and clean nails.
Failure to Administer Prescribed Antiseizure Medication Due to Lapsed Prescription and Communication Gaps
Penalty
Summary
A deficiency occurred when a resident with a history of seizure disorder and traumatic brain injury did not receive a prescribed twice-daily dose of an antiseizure medication, Lacosamide 50 mg, for seven consecutive days. The medication was not available due to an expired prescription, and multiple nursing staff documented the missed doses in the Medication Administration Record (MAR) but did not consistently notify the provider or pharmacy in a timely manner. Communication about the missing medication was fragmented, with some nurses leaving messages for the pharmacy or provider, while others assumed the issue had already been addressed by previous shifts. During this period, the resident continued to receive other antiseizure medications, including Lacosamide 200 mg, Levetiracetam, and Depakote, and did not exhibit any signs of seizure activity, agitation, or changes in vital signs. The resident and family were eventually notified about the missed doses, and the Medical Director was informed after several days, at which point a new prescription was sent to the pharmacy and the medication was delivered to the facility. Interviews with nursing staff, the Medical Director, and pharmacy personnel revealed that the lack of a systematic process for ensuring medication availability and prompt communication regarding missing medications contributed to the delay. Documentation in the MAR and communication logs showed that the issue persisted across multiple shifts, with inconsistent follow-up and escalation, resulting in a significant medication error for the resident.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a cognitively impaired female resident from sexual abuse by a cognitively impaired male resident. The incident occurred when a male resident, who was severely cognitively impaired and had a history of socially inappropriate behavior, was found naked in the room of a female resident. The male resident was observed attempting to place his fingers inside the female resident's vagina. The female resident, also severely cognitively impaired, was unable to defend herself or call for help due to her condition. The male resident had been admitted with diagnoses including schizoaffective disorder and Parkinsonism, and his care plan included interventions for socially inappropriate behavior. However, on the night of the incident, a nurse aide failed to intervene when the male resident was seen in the hallway with only a towel around his waist. Subsequently, the male resident entered the female resident's room, leading to the incident of abuse. The female resident, who had dementia and was dependent on staff for most activities of daily living, was found in a vulnerable state, with her incontinence brief on the floor. The facility's video recordings and staff interviews revealed that the nurse on duty did not notice the male resident leaving his room or entering the female resident's room. The nurse aide assigned to the hallway did not address the male resident's inappropriate state of dress, and the nurse was reportedly inattentive at the nursing station. These lapses in supervision and intervention contributed to the occurrence of the abuse, highlighting a significant deficiency in the facility's ability to protect residents from harm.
Inaccurate MDS Coding for PASRR Level II
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for Level II Preadmission Screening and Resident Review (PASRR) for four residents. These residents, identified as Resident #43, Resident #45, Resident #58, and Resident #61, were all determined to require a Level II PASRR by the North Carolina Department of Health and Human Services Division of Mental Health, Developmental Disabilities and Substance Abuse Services. However, their comprehensive MDS assessments did not reflect this requirement, as they were not coded for PASRR Level II or for Level II PASRR screening and conditions as mandated by the Resident Assessment Instrument (RAI) manual. Interviews with the Case Mix Director and the Administrator revealed that the MDS assessments were either coded inaccurately or the necessary information was not available at the time of coding. Both the Case Mix Director and the Administrator expressed that it was their expectation for all MDS assessments to be coded correctly according to the RAI manual. Despite these expectations, the facility did not meet the required standards for accurately coding the MDS assessments for the residents in question.
Deficiencies in Food Storage and Staff Hygiene
Penalty
Summary
The facility failed to maintain cleanliness and proper labeling in the dry goods storage area and the walk-in refrigerator. During an observation, a large white container without a lid was found in the dry goods storage area, with a significant amount of sugar spilled on the floor. The Dietary Manager acknowledged that the sugar was accidentally dropped during breakfast preparations and should have been cleaned immediately. Additionally, in the walk-in refrigerator, several opened cartons of thickened liquids and a container of diced fruit were found without labels or dates. The Dietary Manager confirmed that these items should be labeled with an opened date and discarded within 72 hours as per manufacturer recommendations. Furthermore, the facility did not ensure that dietary staff adhered to proper hygiene standards during food preparation. A Dietary Aide was observed working near the food preparation station without a beard covering, despite having facial hair. The aide admitted to forgetting to wear a beard covering at the start of his shift, although beard coverings were available in the dietary manager's office. The Director of Nursing reiterated the requirement for all male staff with facial hair to wear beard coverings while in the kitchen, and confirmed the necessity of dating thickened liquids and discarding them within the specified timeframe.
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 total assistance with ADL. The resident, admitted with diagnoses including spondylosis, muscle weakness, lymphedema, and chronic pain syndrome, had intact cognition and required substantial to maximum assistance with various ADLs as per the quarterly Minimum Data Set (MDS) assessment. However, the resident's comprehensive care plans, last revised on 7/23/24, did not include a plan addressing her need for ADL assistance. Interviews with the MDS Coordinator and the Director of Nursing revealed that the ADL assistance plan was not included, despite the facility's protocol to provide such plans for all residents requiring assistance.
Failure to Provide Appropriate Meal Modifications for Residents
Penalty
Summary
The facility failed to provide appropriate meal modifications for two residents with specific dietary needs. Resident #68, who was admitted with dysphagia and assessed as severely cognitively impaired, was supposed to receive a mechanically soft diet with cream gravy mix. However, during dining observations, the resident was served meals that were too dry and not in the specified form, leading to difficulty in swallowing. The dietary staff did not ensure the meal tray matched the meal ticket instructions, resulting in the resident receiving inadequate meal modifications. Similarly, Resident #22, who had dysphagia and was assessed as cognitively intact, was supposed to have her food cut into bite-sized pieces as per physician orders. However, the meal tickets did not reflect these instructions, and the resident struggled to cut her food with a fork due to having only one tooth. The dietary manager acknowledged that the special instructions were not transferred correctly to the meal tracker software, leading to human error in meal preparation. The Director of Nursing confirmed that meal tickets should match physician orders to ensure residents receive the correct diet.
Failure to Notify Resident and Responsible Party of Medication Change
Penalty
Summary
The facility failed to notify a resident and the resident's Responsible Party (RP) of a medication change. The resident, who was admitted with diagnoses including stroke and atypical facial pain, was assessed with intact cognition. On a specific date, the resident complained of increased facial pain, prompting a nurse to contact a Nurse Practitioner (NP) who prescribed a change in medication. The NP instructed the nurse to discuss the changes with the resident, who was considered his own RP. However, the nurse did not inform the resident or the RP about the medication changes due to being occupied with other tasks. The resident later reported not being informed about the medication change and expressed confusion about the reason for the change. The RP also stated that they were not notified about the medication adjustments. Interviews with the NP and the Director of Nursing (DON) confirmed that the resident should have been informed of the changes and asked if they wanted their RP to be notified. The interim Administrator acknowledged that the nurse should have notified both the resident and the RP about the medication changes.
Failure to Convey Resident Funds Timely
Penalty
Summary
The facility failed to convey the personal funds of two deceased residents to their respective estates within the required 30-day period. Resident #281 had a trust account balance of $125.22 that was not forwarded to the Clerk of Court or communicated to the family within the stipulated time frame following the resident's death. This oversight was discovered during an audit conducted at the end of the month, revealing that the funds had not been appropriately managed as per federal regulations. Interviews with the Financial Counselor and the former Administrator confirmed that the responsibility for ensuring timely disbursement of funds lay with the Financial Counselors, who failed to perform the necessary audits and communications. Similarly, Resident #134 had a trust account balance of $2,349.50 that was not conveyed to the resident's estate within 30 days of death. The Financial Counselor admitted that the funds were not sent to the Clerk of Court, and the family was not informed about the availability of the funds. This discrepancy was also identified during an end-of-month audit. The Area President and the Financial Counselor acknowledged the failure to adhere to the policy requiring funds to be sent to the Clerk of Court within the designated period, highlighting a lapse in the facility's financial management processes for deceased residents.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a cognitively impaired resident (Resident #1) from sexual abuse by a cognitively intact resident (Resident #2). On 3/19/24, Resident #2 was found in Resident #1's room by Nursing Assistant #1, observed fondling Resident #1's penis with skin-to-skin contact. Resident #1, who was quadriplegic, had limited ability to move and was non-verbal, making him unable to stop the abuse or call for help. Resident #1's medical history included quadriplegia, traumatic brain injury, and aphasia, rendering him dependent on assistance for all activities of daily living. Resident #2, admitted with Parkinson's disease, had intact cognition and no prior behavioral issues documented upon admission. The incident was immediately reported to the Interim Director of Nursing, who separated Resident #2 from Resident #1 and initiated an investigation. Resident #1 was examined, sent to the emergency room, and later transferred to another facility. Resident #2 admitted to the abuse and left the facility against medical advice after being questioned by law enforcement. The police officer involved confirmed Resident #2's admission of the abuse and indicated that the case would be presented to the District Attorney for prosecution. The facility was found to be in immediate jeopardy due to the failure to protect Resident #1 from sexual abuse, which was only removed after implementing corrective actions.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility's quality assurance process failed to implement, monitor, and revise the action plan developed for the recertification/complaint investigation survey dated 7/13/22, resulting in a repeated deficiency in the area of abuse. During a complaint investigation survey on 4/9/24, it was found that the facility failed to protect a cognitively impaired dependent resident from sexual abuse by a cognitively intact resident. On 3/19/24, a nursing assistant found the cognitively intact resident fondling the dependent resident's penis. The dependent resident was unable to stop the abuse due to his limited mobility and inability to call for help. This incident affected one of three residents reviewed for abuse. In a previous survey on 7/13/22, the facility failed to protect a resident's right to be free from mistreatment, resulting in a resident sustaining a scratch on her face and nose from an altercation with staff. The resident was crying and stated that the altercation made her feel scared and anxious. The Administrator stated that the abuse incident on 3/19/24 was an unusual circumstance and different from the prior abuse incident on 7/13/22, and that the staff addressed the situation as best they could under the circumstances.
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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) |
|---|---|---|---|---|
| Pruitthealth-durham | 2.7 mi | ★★★★★ | 0 | 0 |
| The Forest At Duke Inc | 2.8 mi | ★★★★★ | 0 | 0 |
| University Health And Rehabilitation Center | 3.1 mi | ★★★★★ | 8 | 0 |
| Carol Woods | 3.2 mi | ★★★★★ | 0 | 0 |
| Parkview Health And Rehabilitation Center | 3.4 mi | ★★★★★ | 3 | 0 |
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