Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pruitthealth-crystal Coast during CMS and state inspections, most recent first.
Failure to assess and monitor suicidal ideation: A resident admitted with a painful hip fracture and no prior MH dx voiced that he would be better off dead on a PHQ-9 and later told therapy he would kill himself if he had the means. The SW documented the statements but did not notify admin, the DON, or the MD, and no MH referral or suicide precautions were implemented. Staff across disciplines were not informed of the prior suicidal comments, and the resident was later found unresponsive in bed with a cord around his neck; EMS determined the event was intentional self-harm and the death certificate listed suicide.
A resident with chronic respiratory failure, COPD, CHF, partial lung absence, and dependence on supplemental O2 had a physician order and care plan for continuous O2 at 3 LPM via nasal cannula. On multiple observations, the resident’s O2 concentrator was set at 2 LPM instead of the ordered 3 LPM, while the cognitively intact resident did not know the correct flow rate. Nursing staff acknowledged knowing the correct order but reported they might not have checked the concentrator settings due to workload or unfamiliarity with the hall, despite an expectation that O2 settings be verified against MD orders each shift.
A resident with severe cognitive impairment and a history of falls was not provided with adequate supervision or effective interventions to prevent further falls after being readmitted from the hospital. Despite being at high risk for falls, the facility's staff were unaware of specific fall prevention strategies, and the Director of Nursing lacked training on fall prevention policies, leading to another unwitnessed fall with injuries.
The facility failed to notify physicians and responsible parties of significant changes in residents' conditions, including weight loss and skin integrity issues. One resident experienced a 7.31% weight loss without physician notification, while another had a 5.27% loss. A third resident had severe weight loss and pressure areas, with no communication to the physician or family. Additionally, a resident's family was not informed of their decline and medication changes, leading to confusion and hallucinations.
Residents in a facility were unable to personalize their rooms due to restrictions on hanging items on walls or doors, and bringing personal furniture. These limitations, communicated during a Resident Council meeting, left residents feeling their rooms were not homelike. Interviews revealed residents' desires to display family pictures and holiday decorations, but the facility followed corporate directives to maintain the new building's appearance.
The facility failed to label opened food items in the walk-in refrigerator with the date opened and a use-by or expiration date, potentially affecting food quality. The ADM confirmed the labeling policy, while the DM suggested staff might have felt rushed, leading to non-compliance. The Administrator expected adherence to labeling and discarding policies.
A facility failed to accurately code the MDS for a resident receiving hospice care. The resident, admitted with dementia and chronic obstructive pulmonary disease, had a physician's order for hospice services. Despite documentation indicating hospice care, the admission MDS was incorrectly coded, which was confirmed as an oversight by the MDS Coordinator.
A resident with dysphagia did not receive the appropriate diet upgrade to mechanical soft/finger foods with thin liquids due to communication failures between the dietary manager, speech therapy, and physician. Despite successful eating trials and a physician's order for the diet change, the resident continued to receive a pureed diet because the dietary manager did not receive the necessary communication form until days later.
The facility failed to maintain appropriate temperatures in resident and day rooms, with temperatures recorded as low as 61 degrees Fahrenheit. Residents expressed discomfort due to the cold, and interviews revealed they were unaware of how to adjust thermostats. The issue was linked to ongoing HVAC system problems since the building's opening, requiring frequent repairs.
A medication cart on a dementia unit was left unlocked and unattended, with a cup of pills on top. The nurse responsible admitted to leaving the cart unsecured, contrary to facility policy. The Administrator confirmed that medication carts should be locked unless in use and that medications should not be left unattended.
Failure to assess and monitor suicidal ideation
Penalty
Summary
The facility failed to ensure a resident who had voiced suicidal ideations received a mental health evaluation, monitoring, and suicide precautions after multiple staff members documented or heard statements that he would be better off dead or would kill himself if he had the means. The resident was admitted after a fall with a non-operable left hip fracture, acute pain, and moderate protein-calorie malnutrition, and he had no mental health diagnoses on admission. His baseline care plan did not include goals or interventions for depression or mental health. He also had a history of opioid and fentanyl exposure and a blood alcohol level of 15 at the hospital, and the Medical Director later documented a long-term depression history and alcohol use. On the resident’s depression screening, the Social Worker documented that the resident said he would be better off dead because of the amount of pain he was experiencing, and the PHQ-9 score was 10, indicating moderate depression. The Social Worker did not notify administration, the Medical Director, or nursing, did not begin monitoring, and did not make a mental health referral. Two days later, therapy staff documented that the resident stated he would kill himself if he had the means. Therapy staff reported the statement to the Therapy Manager and a nurse, but the information was not escalated to administration, the Medical Director, or other leadership at that time. The Medical Director later saw the resident and documented that he was miserable, upset, distraught, and in severe pain, but the depression was deferred until pain was controlled. The resident’s suicidal statements were not communicated consistently across disciplines, and staff interviews showed that multiple nurses and aides were unaware of the earlier suicidal comments. The Social Worker later met with the resident after administration learned of the statement and reported that he was no longer suicidal, but no formal assessment or psychiatric referral was completed. On the evening of the incident, the resident was described as irritated and wanting to be left alone; he also asked for his phone to be unplugged and did not want to talk with family. Later that night, he was found unresponsive in bed with the bed control cord wrapped tightly around his neck, without breathing or a pulse. EMS determined the cardiac arrest was associated with intentional self-harm by hanging, and the death certificate listed the manner of death as suicide by self-strangulation with the bed control cord.
Failure to Administer Oxygen at Prescribed Flow Rate
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen at the physician-prescribed rate for a resident with significant respiratory and cardiac conditions, including chronic respiratory failure with hypoxia, COPD with acute exacerbation, chronic diastolic CHF, partial lung absence, and dependence on supplemental oxygen. The physician’s order, written on 1/8/26, specified oxygen at 3 LPM via nasal cannula, and the care plan initiated on 1/9/26 identified the resident as requiring continuous oxygen use with an intervention of oxygen as ordered. On multiple observations, the resident was noted to be receiving oxygen via nasal cannula from a concentrator set at 2 LPM instead of the ordered 3 LPM. During an interview, the resident, who was cognitively intact, did not know what the oxygen flow rate was supposed to be. Nursing staff interviews confirmed that the oxygen flow rate was not consistently checked against the physician’s orders each shift as expected. Nurse #2, who cared for the resident on 1/20/26, acknowledged knowing the order was for 3 LPM but stated she might not have checked the concentrator settings due to having a lot going on that day. On 1/21/26, Nurse #1, who was assigned to the resident that day, stated that nurses were supposed to verify oxygen settings once a shift but admitted she had not done so when she was in the room earlier that morning and that it was her first time working on that hall. When she reviewed the physician’s orders, she confirmed the concentrator should have been set at 3 LPM, while observations showed it remained at 2 LPM until it was adjusted later. The DON and Administrator both stated their expectation that nursing staff follow MD orders and facility policy regarding oxygen therapy and check concentrator settings every shift.
Inadequate Fall Prevention for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent falls for a severely cognitively impaired resident, identified as Resident #3. This resident was at high risk for falls due to generalized weakness, lack of coordination, and impaired judgment. Despite being readmitted from the hospital after a fall, the facility did not enhance fall prevention measures, leading to another unwitnessed fall where the resident was found on the floor with injuries. Resident #3 had a complex medical history, including Alzheimer's disease, vascular dementia, and a history of falls resulting in injuries. Upon readmission from the hospital, the resident's care plan included interventions such as frequent rounds and cueing for safety awareness. However, these measures were insufficient, as staff interviews revealed a lack of awareness and implementation of specific fall prevention strategies. The resident's condition, including severe cognitive impairment and frequent attempts to climb out of bed, was not adequately addressed by the facility's interventions. Interviews with nursing staff and the Director of Nursing highlighted a lack of training and awareness regarding fall prevention policies. The Director of Nursing admitted to not being fully aware of the facility's fall prevention policy and had not been trained on implementing interventions after a fall. This lack of knowledge and training contributed to the facility's failure to prevent further falls for Resident #3, who continued to experience falls despite being identified as a high fall risk.
Failure to Notify Physician and Family of Resident Changes
Penalty
Summary
The facility failed to inform the physician and responsible parties of significant changes in the residents' conditions, specifically regarding nutritional status and skin integrity. For Resident #4, there was a notable weight loss of 7.31% over a month, yet the physician was not notified. Interviews with the physician, Dietary Manager (DM), Director of Nursing (DON), and Administrator confirmed that the physician should have been informed of such weight changes, but this did not occur due to oversight by the DM. Resident #41 experienced a weight loss of 5.27% over a similar period, and again, there was no documentation of physician notification. The physician expressed a preference for checks and balances to be in place to address such issues. The DM acknowledged the oversight in not notifying the physician, and the DON and Administrator reiterated the protocol for notifying the physician of significant weight changes. Resident #45 suffered from severe weight loss and developed pressure areas, yet neither the physician nor the responsible party was informed. The responsible party was shocked to discover the weight loss and pressure areas upon visiting. The DM admitted to not notifying the physician or responsible party, and the Wound Care Nurse did not communicate new skin issues to the responsible party. Similarly, Resident #81's family was not informed of the resident's decline, new orders, or the discontinuation of anxiety medication, which led to confusion and hallucinations. The Administrator confirmed that families should be notified of such changes.
Restrictions on Personalization in Resident Rooms
Penalty
Summary
The facility failed to honor residents' rights to a homelike environment by imposing restrictions that prevented them from personalizing their living spaces. The restrictions included prohibitions on hanging items on walls or doors, using tape or nails on walls, placing items on the floor, and bringing personal furniture or refrigerators. These limitations were communicated to residents during a Resident Council meeting in preparation for a move to a new building. Residents expressed dissatisfaction, stating that these restrictions made it impossible to make their rooms feel like home, as they could not display family pictures or holiday decorations. Interviews with residents revealed their frustration with the inability to personalize their rooms. One resident expressed a desire to hang family pictures on the walls, while another wanted to decorate for the holidays. The Ombudsman confirmed that residents had raised these concerns and noted that the restrictions were directives from the corporate office. The facility administrator acknowledged the restrictions, explaining that they were part of the admission packet and were intended to maintain the appearance of the new building. Despite the presence of a wardrobe and bedside table for displaying items, residents felt these measures were insufficient for creating a homelike environment.
Failure to Label and Date Opened Food Items
Penalty
Summary
The facility failed to properly label opened food items stored in their walk-in refrigerator, which could potentially affect the quality of food served to residents. During an observation, it was found that several food items, including thawed crab cakes, shredded cheddar cheese, cheese slices, sliced ham, and croissants, were either not labeled with the date opened or lacked a use-by or expiration date. The Assistant Dietary Manager (ADM) confirmed that opened food items should be labeled with both the date opened and a use-by or expiration date, and should be discarded after three days. The Dietary Manager (DM) acknowledged that the staff had been trained multiple times to label and date opened food items. However, she suggested that the failure to do so might be due to the staff feeling rushed to complete their tasks while accommodating residents' requests during mealtimes. The Administrator also stated that it was her expectation for the kitchen staff to label and date any newly opened food items and discard them according to the facility's policy.
Inaccurate MDS Coding for Hospice Care
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident receiving hospice care. Resident #6, who was admitted with diagnoses including dementia and chronic obstructive pulmonary disease, had a physician's order dated 8/31/24 to admit to hospice services. The resident's face sheet and care plan both indicated hospice as the primary payer and that hospice services were being received. However, the admission MDS, dated [DATE], incorrectly indicated that the resident was not on hospice care, despite documentation in the Care Area Assessment and supporting notes that suggested otherwise. An interview with the MDS Coordinator confirmed that the resident was admitted to hospice care on 8/31/24 and that the incorrect coding was an oversight.
Failure to Provide Appropriate Diet for Resident with Dysphagia
Penalty
Summary
The facility failed to provide food in a form that met the individual needs of a resident with a physician's order to upgrade their diet to mechanical soft/finger foods with thin liquids. The resident, who was admitted with a diagnosis of dysphagia, was initially on a pureed diet. Despite expressing a desire to upgrade their diet and undergoing successful eating trials with a mechanically soft diet without signs of aspiration, the resident continued to receive a pureed diet. This was due to a lack of communication and follow-up between the dietary manager, speech therapy, and the physician. The speech therapy note indicated that the resident had no swallowing issues and recommended a diet upgrade, which was ordered by the physician. However, the dietary manager did not receive the necessary communication form to implement the diet change until several days later. Interviews with the dietary manager, speech therapist, and director of nursing revealed a breakdown in communication and follow-up procedures, resulting in the resident not receiving the appropriate diet in a timely manner.
Facility Fails to Maintain Appropriate Room Temperatures
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by not keeping resident rooms and day rooms at the required temperature range of 71 to 81 degrees Fahrenheit. Observations revealed that the temperatures in several day rooms and resident rooms were significantly below the required range, with temperatures recorded as low as 61 degrees Fahrenheit. Residents expressed discomfort due to the cold temperatures, with some wearing extra layers to keep warm. Interviews with residents indicated that they were unaware of how to operate the thermostats and had not requested staff assistance to adjust them. The issue was attributed to ongoing problems with the facility's heating, ventilation, and air conditioning (HVAC) system, which had been problematic since the building opened. The Maintenance Director confirmed frequent issues with the HVAC system, requiring regular contact with the installation company for repairs and adjustments. Despite the Maintenance Director's efforts to address the temperature issues, the facility continued to experience difficulties in maintaining appropriate temperatures in resident and day rooms.
Failure to Secure Medications in Dementia Unit
Penalty
Summary
The facility failed to secure resident medications stored in an unattended medication cart on a unit with residents with dementia. During an observation of the 800 hall medication cart, it was noted that the cart was parked midway down the hall, not visible from the nurse's station, and left unlocked. Nurse #1, who was responsible for the cart, was not present at the cart and was instead in a resident's room two doors down the hall. Upon returning to the cart, Nurse #1 admitted to leaving it unlocked and acknowledged that it should have been locked when not in use. Additionally, there was an unattended medication cup of pills left on top of the unlocked medication cart. Nurse #1 confirmed that the pills should have been secured in the cart before she walked away. The facility's Administrator confirmed that medication carts should remain locked unless in use by the nurse and that the nurse assigned to the cart is responsible for its security throughout their shift. The Administrator also stated that medications should not be left unattended and should be locked in the cart if not being administered immediately.
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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 Beaufort
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Embassy At Morehead City | 13.3 mi | — | 0 | 0 |
| Crystal Bluffs Rehabilitation And Health Care Cent | 13.3 mi | ★★★★★ | 4 | 0 |
| Croatan Ridge Nursing And Rehabilitation Center | 19.8 mi | ★★★★★ | 0 | 0 |
| Cherry Point Bay Nursing And Rehabilitation Center | 22 mi | ★★★★★ | 0 | 0 |
| Grantsbrook Nursing And Rehabilitation Center | 31 mi | ★★★★★ | 1 | 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 August 2026) and official state health department websites.