Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pruitthealth-durham during CMS and state inspections, most recent first.
Failure to Maintain Resident Privacy and Dignity During Personal Care: A cognitively intact resident with multiple diagnoses was left naked in bed with the door open and his genitals exposed after a wound nurse left to get supplies and did not return promptly. Another resident was observed in bed wearing only an incontinence brief with the door open while calling for a sheet or blanket, and staff left the room without providing coverage. A third resident was exposed during a bed bath when a nurse opened the door and allowed another aide to enter while the resident’s bare bottom remained visible; staff also noted the privacy curtain would not fully close.
A resident admitted with a stage 4 ischial pressure ulcer and multiple wound care needs did not receive consistent weekly wound assessments or measurements. The wound nurse said she was reassigned to floor duties and often forgot or lacked time to complete assessments, while the NP documented the skin as intact and did not actively follow the wound. The wound later measured much larger when the wound provider assessed it, and staff interviews confirmed the wound had worsened without timely reporting or ongoing monitoring.
A resident with a stage 4 pressure ulcer did not receive ongoing wound assessments, and staff failed to recognize that the ulcer was not improving or involve a wound provider. The wound increased significantly in size between admission and the later wound provider assessment, and the deficiency was linked to inadequate staffing and lack of licensed nurse oversight on shift.
Lack of Qualified Food and Nutrition Services Leadership: The facility failed to employ a qualified food and nutrition services manager with the competencies and skills needed to run dietary services for 115 of 116 residents receiving meal trays. The RD worked part-time and only came in once a month, the Dietary Supervisor lacked CDM certification and dietary education, and a Housekeeping Manager with ServSafe certification was only helping as needed with meal tickets, production sheets, ordering, and resident food preferences after the CDM quit without notice.
A resident with intact cognition and diagnoses including hepatic encephalopathy and malnutrition received meal tickets that still listed seafood and shrimp allergies despite the medical record showing NKDA, and his trays did not match the posted menu, ordered double portions, or built-up utensils. Another resident with dysphagia and feeding difficulties was served food that did not meet the ordered mechanical soft/mechanically ground texture. During tray line observation, staff also served Shepherd's Pie in 3-ounce portions instead of the required 6 ounces, and the kitchen was preparing meals without printed recipes or production sheets.
Kitchen sanitation and food handling deficiencies were observed throughout the dietary area. Floors, walls, the oven, stove, deep fryer, and steam table backsplash had grease, burnt food, and stains; food items in the reach-in refrigerator and on the prep area were left unlabeled or improperly stored; trash containers were uncovered; cleaning tools were kept near clean dishes; chipped plates and cups with dried food were on the tray line; two dietary staff with facial hair were not wearing beard covers; and the kitchen ceiling had peeling paint.
Dumpster Area Not Kept Clean or Contained Surveyors observed 3 of 3 dumpsters with trash and debris scattered around the area, including unbagged food waste, cardboard protruding from a dumpster, and flies on exposed waste. Trash items such as plates, cups, condiment packets, napkins, bottles, and juice cartons were on the ground, and a squirrel was seen foraging in food waste. Staff interviews confirmed the lids and side doors should remain closed, but the area was not being regularly monitored or assigned to a specific department.
Resident Council Concerns Not Addressed: The facility failed to resolve repeated concerns raised by Resident Council members about cold coffee, missing snacks and ice, call lights not being answered, linen not being stocked, overcooked food, and staff behavior. Minutes showed the same issues were brought up at multiple council meetings, but no grievance reports were completed, and residents later stated nothing ever changed and they were not getting responses to their concerns.
Surveyors found multiple environmental failures affecting resident rooms and shared bathrooms. Bath basins and urinals were left unlabeled and not stored in separate plastic bags, while several rooms had sticky or soiled floors, a privacy curtain that dragged on the floor and was stained with residue, a PTAC unit with debris inside and around the vents, and a wall with peeling paint and damaged drywall. Staff interviews showed inconsistent training and unclear follow-through for cleaning, storage, and reporting of environmental concerns.
MDS assessments were inaccurately coded for tobacco use, an indwelling urinary catheter, insulin, and dental status for multiple residents. A remote MDS nurse relied only on the EMR and missed documented smoking status, a catheter present after hospital return, insulin administration shown on the MAR, and dental problems noted in assessments and observation. The DON stated the MDS should accurately reflect residents’ current smoking status, care needs, and medications.
A facility failed to complete required smoking assessments for residents who smoked and did not secure smoking materials for multiple residents. One resident with COPD and tobacco use lacked a quarterly smoking assessment and was observed keeping cigarettes and a lighter with her, while two other residents were found with cigarettes, lighters, and a vape device in their rooms despite staff stating smoking materials should be stored at the nurses’ station. The facility also left a full oxygen cylinder unsecured in a resident’s room, and staff confirmed it should have been stored upright and secured.
A resident with traumatic brain injury, post traumatic seizures, and severely impaired cognition had anticonvulsant orders transcribed and administered incorrectly after readmission. The ADON entered the correct zonisamide and lacosamide doses from the final verified hospital discharge summary, but the DON later changed the orders using a preliminary discharge summary and did not clarify the discrepancy with the hospital or the admitting nurse. The MAR showed repeated administration of lower-than-ordered doses before the orders were later corrected.
Nourishing bedtime snacks were not consistently provided when the gap between dinner and breakfast was 15 hours. Residents reported they were not regularly offered a snack at bedtime, and staff on multiple halls described evening snacks as cookies, crackers, sweets, and drinks rather than a nourishing option. The RD, DON, and Administrator all stated that these items did not constitute a nourishing bedtime snack, and sandwiches were not available on the halls during the evening.
Incomplete and inaccurate wound documentation was found for multiple residents. A nurse documented wound care on behalf of another staff member, an NP charted no wound despite observing one, and another resident’s TAR and skin assessment did not match the dressing observed on the leg. In another case, wound care orders from the hospital discharge summary were not entered into the chart at admission, and wound care was not documented until later.
Influenza vaccine education and offering were not documented for multiple residents. Several residents, including some with impaired cognition and one cognitively intact resident, had MDS entries showing the flu shot was not received because it was not offered, yet the EMR and hard chart lacked documentation that the resident or RP received education on benefits and side effects or that the vaccine was accepted or refused. RPs and a resident could not recall being offered the vaccine, while the IP and DON described delays in vaccine availability, discarded doses, and reliance on the EMR Preventative Health tab for tracking.
Failure to offer and document COVID-19 booster vaccinations for six residents was identified. Residents with diagnoses such as COPD, CHF, dementia, CKD, diabetes, and chronic respiratory failure had MDS entries showing they were not up to date, yet their records lacked documentation that they were offered, given, or refused additional doses. The IP stated she used the EMR Preventative Health tab instead of a tracking log and overlooked the residents, while the DON said she was unaware the residents had not received education or the opportunity for an updated booster.
Undignified Communication With Resident During Call Bell Interaction: A resident with hemiplegia/hemiparesis after CVA and moderate cognitive impairment was observed with her call bell left on the floor after staff assistance. When the resident began touching the call bell, an NA spoke sternly and told her not to hit it, despite standing nearby. The resident said the interaction upset her, and the DON stated the NA spoke inappropriately and the resident had the right to be spoken to in a dignified manner.
A resident with bipolar disorder and major depressive disorder, but noted as cognitively intact on MDS, refused facility-administered Cipro for a UTI and said she was taking her own antibiotic obtained from urgent care. Staff documented repeated refusals, saw the resident keep the medication at bedside, and did not observe her self-administering the drug. The resident stated she had never been formally assessed for independent medication administration, and the DON, UM, nurses, and NP all described gaps in observation and assessment of her ability to safely self-administer medications.
Failure to honor residents’ choices to get out of bed. One resident with incomplete quadriplegia, TBI, and severe mobility impairment asked an NA to get him into his wheelchair after lunch, but the NA walked away and forgot to follow up until later in the day. Another resident with hemiplegia/hemiparesis after CVA said she had asked multiple staff to get her up over the prior week, but they told her no and she had not been out of bed for several days; an NA said staff avoided getting her up because she often wanted to go back to bed.
Delayed Refund of Resident Funds After Discharge: A resident was discharged to another SNF, but the facility did not distribute the resident’s funds within 30 days of discharge. The HCPOA reported the resident was owed about $1000, and the BOM stated the refund was initiated only after the accepting facility reported the funds had not been received. The BOM acknowledged the transfer occurred more than 30 days after discharge, and the Administrator stated the refund should have occurred per regulation.
The facility failed to develop individualized care plans for a resident with dementia-related behavioral symptoms and psychotropic medication use, and for another resident’s dental problems. One resident had documented disrobing and wandering behaviors, severe cognitive impairment, and antipsychotic/antidepressant use, but the care plan did not address these concerns. Another resident had obvious dental decay and broken teeth noted on assessment and observation, yet no dental care plan was included.
A resident admitted with current tobacco use was assessed as a safe smoker and was cognitively intact, but the medical record showed no smoking care plan within the required timeframe after the admission MDS. The DON stated the nurse completing the admission assessment should have initiated the smoking care plan and expected smoking to be addressed in the care plan on admission.
A resident with DM received insulin lispro outside the ordered BG parameters on multiple occasions. Staff gave half doses even when BG values were above the threshold for dose reduction, and an RN confirmed several of the discrepancies. The Medical Director and DON stated staff were expected to follow the physician’s orders as written.
Failure to provide ordered wound care for a resident with a skin tear on the lower leg. The resident was cognitively intact and had a physician order for antiseptic cleansing, medi-honey, and a silicone bordered foam dressing with changes every 3 days and PRN, but the dressing remained unchanged for days and the resident reported staff had not changed it. Interviews showed the Wound Nurse was unaware of the wound, the ADON was unsure whether it had been communicated, and the nurse listed on the TAR denied completing the care.
Failure to Apply Ordered Palmar Guard Orthosis: A resident with hemiplegia, hemiparesis, and right hand/wrist contractures was supposed to receive PROM followed by a right palmar guard orthosis for up to 4 hours daily, but staff documentation was inconsistent and the resident was repeatedly observed without the splint in place. The OT later found two palmar guards stored in a drawer under personal items, while the DON and Physician confirmed the splint should have been applied as directed.
A resident with dysuria and concern for a UTI was seen by an NP, who documented an order for a UA with C&S, but the order was not found in the physician orders and the test was never completed in the facility. The resident later went to urgent care, where she was diagnosed with a UTI and started on antibiotics. Staff interviews showed the NP could not enter orders directly, and the DON and UM did not recall receiving or seeing the order.
A resident with type 2 DM was admitted on Metformin, and the hospital discharge list also included accuchecks three times daily. The facility transcribed the Metformin order but failed to transcribe the BG monitoring order on admission. The admitting nurse said it was an oversight, and the NP stated the monitoring should have been entered so BG results could be reviewed for medication management.
Unsecured medications were found in two residents’ rooms. One resident with severe cognitive impairment had multiple containers of prescribed triamcinolone cream sitting on the nightstand even though the cream should have been kept in the locked med cart and the resident had not been assessed for self-administration. Another resident had ciclopirox topical nail lacquer on the desk despite no order for that medication and no self-administration order; staff and the DON were unaware it was in the room, and the physician stated residents should not have medication in their room.
Failure to Follow Documented Food Preferences: A cognitively intact resident with documented dislikes and a vegetarian preference was served a meal containing beef despite the meal ticket indicating no beef or pork. The resident reported repeatedly receiving unwanted meats at meals, and staff interviews confirmed the tray was served in error and did not match the resident’s documented preferences.
Hand hygiene was not consistently performed during wound care for a resident with clustered wounds on the left buttocks and scrotal excoriation. A wound care nurse removed soiled dressings, changed gloves multiple times, and applied wound products and ointment without hand hygiene between glove changes or between separate wound care areas. The PA noted the wounds were close together and had no signs of infection, while the nurse and DON stated hand hygiene should have been done with each glove change and separate gauze should have been used for each wound.
Failed privacy curtain during bed bath: A resident’s privacy curtain would not fully close because multiple hooks were missing, leaving a gap that prevented full visual privacy while the resident’s bare bottom was exposed during ADL care. A nurse opened the room door while care was in progress, and a hospice NA entered and walked past the resident while the resident remained visible. Staff gave conflicting accounts about who was responsible for the curtain and work order process, and no TELS work order was found for the issue.
Inaccurate Daily Nurse Staffing Sheets: The facility failed to accurately post licensed nursing hours on daily staffing sheets reviewed across multiple shifts. The posted totals for RNs and LPNs did not match the actual scheduled hours, and the Staffing Coordinator stated she calculated hours by counting staff in the building and multiplying by 12 rather than using each nurse’s actual hours worked. The Administrator stated he expected the staffing sheet to accurately reflect current staffing.
A resident with significant medical history experienced a fall and subsequent inability to bear weight, but staff failed to document the incident, assess the change in condition, or notify the provider and family in a timely manner. The resident's pain and functional decline went unaddressed until a hospice nurse intervened, leading to the discovery of a femoral neck fracture. X-ray results were also not promptly communicated to the provider, resulting in delayed care.
A resident who experienced a fall was not properly assessed for ongoing changes in condition, including pain, inability to bear weight, and abnormal leg positioning. Staff failed to recognize the need for medical evaluation, did not communicate effectively, and delayed notifying the provider of both the change in condition and x-ray results showing a femoral neck fracture.
A resident with a history of stroke and cancer experienced a fall while attempting to use the bathroom. Facility staff failed to document the incident, notify the physician or family, or conduct thorough post-fall assessments. The resident's pain and inability to bear weight were not recognized or communicated between shifts, leading to a delay in identifying an acute femoral neck fracture. The fracture was only discovered after the family and hospice nurse escalated concerns, resulting in delayed treatment and hospital transfer.
The facility did not ensure proper documentation of falls and pain medication administration for two residents. In both cases, nurses failed to record assessments, vital signs, and medication administration in the electronic medical record, despite performing some of these actions. Discrepancies were also found between controlled drug records and the MAR, and one nurse cited unfamiliarity with the EMR system as a reason for incomplete documentation.
A resident with multiple psychiatric and cognitive diagnoses reported inappropriate sexual conduct by a nurse aide to several staff members. The Activity Director, after being told of the allegation, became distracted and failed to immediately notify the Administrator as required by policy. The allegation was only reported to the Administrator at the end of a nurse aide's shift, resulting in a delay in the required notification process.
A resident with glaucoma missed multiple doses of prescribed timolol maleate eyedrops after nursing staff failed to locate the medication, believing it had not been delivered by the pharmacy. The medication was actually present in the medication refrigerator, but staff were unaware of its storage location, resulting in repeated missed administrations documented as unavailable.
A dietary staff member failed to cover facial hair while handling food, and kitchen equipment including the convection oven and deep fryer were not cleaned as required, with visible residue and food particles present. Both the Dietary Manager and Administrator confirmed that proper hygiene and cleaning protocols were not followed.
A resident with hemiplegia and contractures did not receive a prescribed left-hand splint after discharge from OT, as recommended for daily use. Staff were unaware of any active orders or training for splint application, and the splint was not found in the resident's room, resulting in the intervention not being provided.
A resident who was dependent on tube feeding received formula from a bottle that was not properly shaken or labeled by nursing staff, as required by facility policy. The bottle was observed to have sediment and lacked the necessary date, time, and staff initials. Staff interviews confirmed the failure to follow protocol, with one nurse admitting to skipping these steps due to being in a hurry.
Surveyors identified that opened multi-dose insulin pens were not dated and expired insulin pens were not removed from two medication carts. Nurses acknowledged responsibility for dating and discarding multi-dose vials but had not checked the insulin vials at the start of their shifts. The DON and Administrator confirmed that all nurses are expected to check and remove expired medications from carts each shift.
A significant medication error occurred when a nurse administered 40 mg of morphine instead of the prescribed 5 mg to a resident with a history of schizophrenia, dysphagia, and chronic pain. The error was due to a misinterpretation of a blurry medication label and unfamiliarity with the resident. The resident remained stable, and the error was reported to the on-call doctor and the DON, who completed a medication error report.
Failure to Maintain Resident Privacy and Dignity During Personal Care
Penalty
Summary
The facility failed to maintain resident privacy and dignity for three residents during personal care and while residents were in their rooms. The report states that Resident #17, who was cognitively intact and dependent on staff for toileting hygiene, was left naked in bed with the room door fully open and his genital area exposed and visible from the hallway while no staff were present in the room. The resident had diagnoses including bladder cancer, muscle weakness, epilepsy, cerebral palsy, neurogenic bowel, colostomy status, and a Stage 4 pressure ulcer on the left ischium. For Resident #17, the wound nurse reported that she discovered the resident’s colostomy bag had burst and that feces were on the resident and his clothing. She removed the clothing, left the room to get bags, and did not return because she was pulled away to assist another resident. The resident stated he felt angry and embarrassed, said he was left naked with the door open, and reported that he tried unsuccessfully to cover himself with the edge of the sheet. The DON and Administrator both stated that resident privacy should be maintained during personal care by closing the door or using a privacy curtain. Resident #80, who was cognitively intact and had diagnoses including muscle weakness, reduced mobility, unspecified pain, and rash, was observed sitting in bed wearing only an adult incontinence brief with the bedroom door wide open to the hallway. He was visible to staff passing by and repeatedly called out for a sheet or blanket for about 10 minutes. NA #3 stated the resident often refused a privacy curtain or closed door and that she did not close the door or curtain after providing incontinence care because she believed he liked to sit that way. The resident stated he wanted a sheet or blanket to cover himself so people passing by could not see him exposed and said he felt like he was on display. Resident #57, who was cognitively intact and needed partial to moderate assistance with bathing, was receiving a bed bath when Nurse #1 opened the room door and allowed hospice NA #1 to enter while the resident’s bare bottom remained exposed. The privacy curtain near the door could not fully close because of missing hooks, and hospice NA #1 walked past the resident while her bottom was visible. NA #2 stated the curtain would not pull all the way around, Nurse #1 stated she did not know care was in progress, and the UM stated hospice NA #1 should have waited outside until Resident #57’s care was completed. The DON stated staff should have provided privacy for Resident #57 even if it meant using a blanket or towel.
Failure to Monitor and Assess a Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to ensure ongoing assessment and monitoring of a stage 4 pressure ulcer for a resident admitted with multiple wound care needs, including a left ischial pressure injury present on admission. The resident had diagnoses including bladder cancer, muscle weakness, epilepsy, and cerebral palsy, and was dependent on staff for toileting hygiene, bathing, dressing, transfers, and wheelchair mobility. Admission documentation identified the left ischial wound at 2.5 cm by 1.5 cm by 0.5 cm, and the care plan included treatment as ordered, wound consultation as needed, and reporting any failure to improve or decline in the wound to the provider. The medical record did not show weekly wound assessments or pressure ulcer assessments being completed on multiple weeks after admission. The NP progress notes documented the resident’s skin as clean, dry, and intact and indicated no open wounds, despite the resident having a documented stage 4 pressure ulcer. The wound nurse acknowledged she was expected to complete weekly wound assessments and measurements but did not do so, stating she was frequently reassigned to floor nursing duties and often did not have time or forgot to complete the assessments. She also stated she did not notify the physician or wound provider of changes in the wound before the initial wound assessment because she had not completed the weekly measurements. When the wound provider first assessed the wound, it measured 10 cm by 2.5 cm by 1 cm and included 40% granulation tissue, 30% necrotic tissue, and moderate serous drainage. The wound provider documented the wound as pressure-related and later noted the resident refused one evaluation, while the facility continued to lack documented weekly wound assessments on several dates. The wound provider, NP, DON, facility provider, and administrator all stated that wound measurements and assessments were necessary to track progression or deterioration, and the NP and DON acknowledged the wound had increased in size and that the resident’s wound was not being followed closely enough. Interviews also showed a weekend RN observed the wound worsening but did not report the increase in size or deterioration because he believed it represented normal wound deterioration.
Inadequate monitoring of worsening stage 4 pressure ulcer
Penalty
Summary
The facility failed to provide adequate nursing oversight for a resident with a stage 4 pressure ulcer and failed to recognize that the wound was not improving or involve a wound provider in a timely manner. On admission, the resident’s pressure ulcer measured 2.5 cm in length, 1.5 cm in width, and 0.5 cm in depth, but when the wound provider assessed it later, the wound had increased to 10 cm in length, 2.5 cm in width, and 1 cm in depth. The report states the facility failed to ensure ongoing assessments of the pressure ulcer and failed to recognize the lack of improvement, and it also cites inadequate staffing as part of the deficiency.
Lack of Qualified Food and Nutrition Services Leadership
Penalty
Summary
The facility failed to employ a qualified food and nutrition services manager with the competencies and skill sets required to carry out food and nutrition services for 115 of 116 residents who received meal trays. During interview, the Registered Dietitian stated she had been hired about a month before the survey and worked part-time, coming to the facility once a month and being available by phone if staff needed assistance. The Dietary Supervisor stated he had been supervising the kitchen for the past month after the Dietary Manager quit without notice. He said he did not have CDM certification and was scheduled to begin a ServSafe course later in the month, and he reported having no certification or dietary education. Corporate staff stated that if the facility did not have a CDM or full-time dietitian, it could reach out to sister facilities or a consultant dietitian for assistance. The Housekeeping Manager, who had ServSafe certification, stated she was helping with printing meal tickets, production sheets, ordering food, and taking resident food preferences, but said she was only helping as needed and was not assigned to the kitchen to oversee and monitor staff. The Administrator stated the facility had a CDM who quit without notice about a month earlier and that the facility was actively trying to hire a new Dietary Manager with CDM certification.
Incorrect meal tickets, diet textures, and portioning
Penalty
Summary
The facility failed to ensure resident menus and individual food plans matched ordered diets, food preferences, and documented allergy information for two residents. Resident #89 was admitted with diagnoses including hepatic encephalopathy, mild protein-calorie malnutrition, dietary zinc deficiency, and unspecified vitamin deficiency, and was cognitively intact. Although the medical record later showed no known allergies, the tray tickets continued to list seafood and shrimp allergies. The resident reported that he had told facility leadership that the allergy information was incorrect and that he was receiving single portions instead of ordered double portions. During meal observations, his lunch trays did not match the posted menu, included standard metal utensils instead of built-up utensils, and were served as single portions rather than the ordered double portions. He also stated he had not been served fish because of the incorrect allergy listing, even though fish and shellfish were among his preferred foods. Resident #116 was admitted with traumatic brain injury, gingivitis, dysphagia of the oropharyngeal phase, and feeding difficulties, and was documented as cognitively intact. He reported that meals often did not match the meal ticket and that he received foods he could not chew because of poor dentition. During an observed lunch, the meal ticket documented a mechanically ground meat and mechanical soft diet, but the beef was served in large chunks and the green beans were served in pieces the resident said were too tough to chew. The ADON attempted to feed the resident food that did not meet the ordered texture, and when reminded of the ordered diet, removed the tray and ordered the correct diet from dietary services. The facility also failed to follow standard recipes and serving sizes during tray line operations. On observation, the lunch menu item Shepherd's Pie was portioned using a 3-ounce scoop even though the meal ticket required a 6-ounce serving. Staff were observed plating only 3 ounces instead of the required double portion, and one dietary aide stated she had not reviewed the meal ticket and had overlooked the required quantity. In addition, the tray line ran out of Shepherd's Pie before all trays for the third floor were plated, causing a delay while a new batch was prepared. Staff stated there were no printed recipe books available in the kitchen, no printed production sheets were being used, and the cook was estimating the meal preparation rather than following printed recipes or production guidance.
Kitchen sanitation, food storage, and staff grooming deficiencies
Penalty
Summary
The kitchen was observed with floors and walls that were not kept clean behind the deep fryer and stove. The floor near the stove and preparation area had a wet appearance and was scattered with paper and food particles, and the area between the stove and deep fryer and the wall behind the deep fryer had a thick layer of oil and dried food. Staff stated they were cleaning after breakfast and before lunch, and one dietary staff member said the area had been greasy for so long that it was very difficult to remove. Multiple pieces of kitchen equipment were observed with burnt food, oil, and food stains. The oven had dark brown burnt stains on the inside of the door, shelves, base, and racks, and burnt food particles were on top of the oven. The stove had oil and food stains on the front panel, knobs, and side splash guard. The deep fryer had burnt food in the oil and on the fryer, and the steam table backsplash had white stains. Staff stated there was no cleaning schedule for dietary staff to follow, and that cleaning of the oven, stove, fryer, and backsplash was done by staff after cooking or on a weekly basis. Food storage and kitchen sanitation issues were also observed. In the reach-in refrigerator, individual cups of food were left unlabeled and undated, and an opened cardboard box of soda cans was stored on top of cups intended for lunch service. A transparent bin of powdered thickening product was left uncovered with a scoop resting in the product, and opened bread items were observed without labels or dates. Trash containers in the kitchen were observed without lids, cleaning equipment was stored near clean dishes and drying racks, and cleaning tools were hung below the rack holding clean dishes. On the tray line, chipped plates and cups with dried food were observed. Two dietary staff members with facial hair were observed without facial hair coverings, and the kitchen ceiling had multiple areas of peeling paint, including large sections above the tray line and meal preparation areas.
Dumpster Area Not Kept Free of Trash and Debris
Penalty
Summary
The facility failed to keep the dumpster area free of accumulated trash and debris for 3 of 3 dumpsters observed. On 6/8/26 at 10:40 AM, surveyors observed three large green dumpsters behind the facility. The middle dumpster contained broken down cardboard protruding from an opening in the front, and the dumpster on the right had its lid and side sliding door open with food waste not contained in bags, bagged waste, and flies on the waste. Non-contained debris, including disposable plates, cups, condiment packets, and soiled napkins, was scattered on the ground around the dumpsters, and food waste was also on the ground with a squirrel foraging in it. Behind the dumpsters, leaf litter was observed approximately 3 inches deep with various trash items and debris, including empty plastic bottles and juice cartons. The Maintenance Assistant stated he had seen the dumpster area on 6/8/26 when he arrived at work and reported there was trash everywhere, including cups, plates, bowls, and other paper trash. He stated the area was the worst he had ever seen it and later reported that on 6/8/26 around 11:00 AM he cleaned up what he could, but trash including empty plastic bottles, cups, lids, condiment packets, plastic utensils, and food waste remained on the ground in front of, behind, and between the dumpsters. The Maintenance Assistant also reported that the dumpsters did not have numbers, that the left and right dumpsters were for normal waste including kitchen and food waste, and the middle dumpster was for cardboard. He confirmed the lids and side doors of all dumpsters should always remain closed to prevent attracting insects and animals. He further reported that regular monitoring and cleaning of the dumpster area was not something he recalled ever being assigned. The Administrator stated the trash on the ground and the aluminum cans on the side should not be present and described the issue as a sanitation issue, while also stating maintenance staff should be doing frequent monitoring of the dumpster area and keeping it clean and free from debris.
Resident Council Concerns Not Addressed
Penalty
Summary
The facility failed to honor residents’ right to organize and participate in Resident Council by not resolving concerns raised during multiple council meetings. Resident Council minutes from January through May 2026 were reviewed, and minutes from 3/30/26, 4/23/26, 5/20/26, and 5/27/26 showed repeated complaints about cold coffee, linen not being stocked on all floors, call lights not being answered, snacks and ice not being passed out, residents not being given a choice of cereal, staff being on their phones during work hours, staff not going to the first floor to get sandwiches, and food being overcooked. The minutes also showed the Administrator was present at the 4/23/26 and 5/27/26 meetings. No grievance reports were located for the concerns voiced at those Resident Council meetings. During a 6/9/26 Resident Council meeting, five cognitively intact members, including the Resident Council President, stated that although they had raised the same concerns at prior meetings, nothing ever changed and they were not getting responses to their concerns. In a 6/10/26 interview, the Activities Director stated she had repeatedly heard the same complaints, had started holding Resident Council twice monthly in May 2026 to try to ensure issues were responded to, and did not complete written grievance forms for concerns expressed during Resident Council meetings. The Administrator stated that concerns expressed by the Resident Council would definitely be grievances and that he did not know why grievance forms were not being completed in accordance with the facility’s grievance policy.
Unsafe and Unclean Resident Room Conditions
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for multiple residents by not labeling and properly storing resident bath basins and urinals. In shared bathrooms for residents who lived together, surveyors observed bath basins sitting on sinks or beside sinks without resident identifiers, and urinals hanging on a handrail or stored without names. One urinal contained approximately 100 milliliters of brown liquid. A nursing assistant who was providing direct care for several of the affected residents stated she was new to the facility, was not familiar with the facility’s storage practices, and knew the basins and urinals should have resident names and be kept in separate plastic bags to prevent cross contamination. She also stated the supply closet on the hall was not fully stocked and that she had not checked other storage closets on other halls. The facility also failed to keep resident rooms clean and free of environmental concerns. In one resident’s room, the floor was observed to be sticky and tacky throughout the room, and the privacy curtain was dirty, dragged on the floor, and had black sticky residue and dark brown and black staining on the lower portion. The curtain was observed to be physically stuck to the floor and had to be pulled free. In another resident’s room, the floor was sticky and tacky and visibly soiled with a dried discolored liquid approximately the size of a watermelon. These conditions remained present on follow-up observations. Housekeeping staff stated she had been assigned to those rooms and reported completing routine cleaning tasks, but also stated she was still in training and had not learned the procedure for reporting or replacing soiled curtains. The assistant housekeeping manager stated she had not yet trained the staff member on the process for reporting soiled curtains and described a deep-cleaning process that took several weeks to complete all rooms on a unit. Additional environmental deficiencies were observed in other resident rooms. In one resident’s room, the PTAC unit had brown and white fuzzy debris around the outer perimeter and chunky brown debris inside the unit and across the vents, and the condition remained unchanged on repeated observations while the unit was running. Staff stated the outside of the PTAC should be wiped down during daily cleaning, while deeper cleaning inside required maintenance and specialty tools. In another resident’s room, the wall surface had peeling paint and damaged drywall over an area approximately 3 feet by 2 feet, and the resident stated the damage had been present for a couple of months. In another room, the floor remained sticky despite no visible spills. The housekeeping director stated the sticky floors were related to a vendor-provided floor-cleaning product and that the issue had been recurring. The administrator stated the expectation was for resident rooms and care areas to be kept clean, sanitary, and free of environmental hazards, and for rooms to be maintained in good repair.
MDS Assessments Incorrectly Coded for Tobacco, Catheter, Insulin, and Dental Status
Penalty
Summary
The facility failed to accurately code MDS assessments for tobacco use, indwelling urinary catheter use, insulin administration, and dental status for 4 residents reviewed for MDS accuracy. The report states that MDS Nurse #1 and MDS Nurse #3 relied on documentation in the medical record to complete assessments, and in several cases the assessments did not match resident observations, nursing notes, physician orders, or medication records. The DON stated that the MDS should accurately reflect residents’ current smoking status, care needs, and medications. Resident #100 was admitted with a diagnosis of tobacco use, and a smoking observation form documented that the resident was a smoker with a history of smoking and was determined to be an unsupervised smoker. However, the significant change MDS assessment coded the resident as not having current tobacco use. During interviews, MDS Nurse #1 acknowledged that the facility had been documenting smokers as nonsmokers because it was a smoke-free facility, and the DON stated that the resident was a smoker and the MDS should reflect current tobacco use. Resident #76 returned from the hospital with an indwelling urinary catheter documented in the discharge order, nursing readmission note, and physician order, but the quarterly MDS did not document the catheter and instead coded the resident as incontinent of urine. Resident #62’s admission assessment noted obvious or likely cavities or broken natural teeth, the resident stated he had continued smoking since admission, and observation showed missing teeth and poor remaining dentition, yet the annual MDS did not code current tobacco use or oral/dental problems. Resident #6’s MAR showed insulin lispro was administered on 7 days during the lookback period, but the quarterly MDS coded 0 days of injections and 0 days of insulin injections. MDS Nurse #3 stated she completed these assessments remotely using the electronic record and acknowledged the coding errors for Resident #6 and the missed tobacco and dental findings for Resident #62.
Smoking Assessments Not Completed and Smoking Materials and Oxygen Cylinder Left Unsecured
Penalty
Summary
The facility failed to complete smoking assessments and failed to secure smoking materials for residents who smoked. Resident #100 had diagnoses including gastroparesis, severe protein-calorie malnutrition, COPD, and tobacco use. The record showed a smoking observation form dated 12/7/25 and completed on 6/8/26, but no quarterly smoking assessment was found. The resident was identified as an unsupervised smoker, and staff interviews showed uncertainty about when smoking assessments were required and whether they were being completed quarterly. Resident #100 was observed keeping cigarettes and a lighter in an open bag tied to her walker and later in a labeled plastic bag on the medication cart. She stated she kept her smoking materials with her and smoked near the bus stop without staff observation. Staff interviews showed that some nurses believed smoking materials were kept locked in the medication cart, while others were unsure of the policy. The DON stated the facility was smoke-free, residents who smoked signed out, retrieved smoking materials from staff, smoked off the premises, and returned the materials afterward, but the resident was observed with smoking materials in her possession. Resident #104, who was cognitively intact and used a walker, was assessed as a safe smoker and later as an unsupervised smoker. During observation, cigarettes and a lighter were found in the open drawer of the resident’s bedside table, and the resident stated he had kept them in his room since admission. Although staff later stated he had turned in smoking materials for storage, additional cigarette packs were still observed in his room. Resident #62, who had hemiplegia and hemiparesis affecting the dominant right side, had an admission smoking assessment showing a history of tobacco use but not current use, yet later was found with cigarettes, a lighter, and a vape device in his room. The resident stated he continued to smoke and kept his smoking materials in his room, while staff stated smoking materials should be stored at the nurses’ station and that smoking assessments should be completed when the facility became aware a resident was smoking. The facility also failed to secure oxygen equipment for Resident #99, who had COPD and was receiving continuous oxygen at 3 liters per minute. Two oxygen cylinders were observed in the resident’s room, including one full cylinder stored in a canvas bag that was leaning against a chair and not secured. A nurse confirmed the cylinder was full and removed it after being notified. Staff stated oxygen cylinders should be stored upright in the designated oxygen closet or secured in a transport caddy if in a resident’s room, and the DON stated unsecured oxygen cylinders in a resident’s room were not safe.
Incorrect transcription and administration of anticonvulsant medications
Penalty
Summary
The facility failed to prevent a significant medication error when anticonvulsant medications for a resident with traumatic brain injury, post traumatic seizures, and severely impaired cognition were transcribed and administered incorrectly. Resident #127 had physician orders for zonisamide and lacosamide after a hospitalization for seizure activity, and the verified hospital discharge summary indicated the doses had been increased during the hospital stay because of subtherapeutic levels and seizure activity. After the resident returned to the facility, the admitting nurse entered the correct anticonvulsant orders from the final verified discharge summary. However, the DON later reviewed a preliminary discharge summary instead of the verified final summary and changed the resident’s zonisamide and lacosamide orders back to the lower pre-hospital doses. The DON stated she did not realize she was using the preliminary discharge summary and did not clarify the orders with the admitting nurse or the hospital. The ADON stated she had entered the correct orders from the final verified discharge summary and was unsure why the DON changed them back. The MAR showed that the incorrect doses were then administered on multiple occasions for both medications. Zonisamide was entered at 40 mg instead of 100 mg and lacosamide was entered at 50 mg instead of 100 mg before later being corrected. The Medical Director, NP, Pharmacist, and Administrator all stated that the verified final discharge summary should have been used for the resident’s admission medication orders, and the MD noted the resident did not exhibit ill effects from the incorrect dosing that was entered.
Nourishing Bedtime Snack Not Provided
Penalty
Summary
The facility failed to serve a nourishing bedtime snack to residents when the scheduled time between dinner and breakfast was 15 hours. During a Resident Council meeting, five cognitively intact residents stated they were not regularly offered a snack at bedtime, although they could get one if they asked, and they reported they had not approved of a meal schedule with more than 14 hours between dinner and breakfast the next morning. Interviews and observations on the evening of 06/09/2026 showed that snack carts on the 100, 200, and 300 halls contained items such as ice cream, crackers, fig bars, oatmeal pies, pudding, applesauce, fruit juice, and zero sugar ginger ale, but no sandwiches were available on the halls at that time. Staff on the halls reported that evening snacks were usually cookies, cakes, crackers, and sweets, and that sandwiches were not normally available on the evening shift. Dietary staff stated the kitchen made turkey and cheese sandwiches daily and sent them to some halls around 1:00 PM, but no additional sandwiches or other snacks would be sent up later in the evening. Resident interviews the next day showed mixed experiences: one resident reported being offered applesauce at bedtime, while others stated they were not offered a snack before bed and had to rely on personal food supplies or ask staff if they wanted something. The Registered Dietitian stated it was hard to say whether the available snacks constituted a nourishing bedtime snack and explained that a nourishing snack would include fats, protein, and complex carbohydrates. The DON and Administrator both stated that cookies, crackers, rice crispy treats, and soda were not a nourishing bedtime snack, and the Administrator acknowledged that the facility’s process was supposed to include obtaining sandwiches because of the more than 14-hour gap between dinner and breakfast.
Incomplete and inaccurate wound care documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for wound care for three residents. For one resident with a Stage 4 pressure ulcer to the left buttock/ischium, wound treatment was documented on the MAR by a nurse on multiple dates in April, May, and June 2026, but the wound nurse stated she performed the treatments and often forgot to document them. She also stated that Nurse #6 sometimes signed the MAR on her behalf when she had not completed the documentation. Nurse #6 stated he sometimes documented wound treatments after verbally confirming with the wound nurse that the care had been completed, and acknowledged that it was not best practice to document care performed by another staff member. For another resident with a history of an enterocutaneous fistula, urostomy, and colostomy, the NP progress note dated 5/4/26 documented two ostomies with leakage and a chronic fistula draining stool, but also stated the exposed skin was clean, dry, and intact and that no open wounds were noted. The NP later stated this documentation was incorrect and that she had observed the wound during her assessment. She stated she should have completed an addendum to correct the record, but did not do so because she could not bill for it. For a third resident readmitted on 5/25/26 with a wound on the lower right leg, the physician orders included wound care every 3 days and as needed. The TAR showed wound care documented as completed by Nurse #9 on 6/6/26, but Nurse #9 stated she did not change the dressing and did not know why her initials were on the TAR. A skin assessment on 6/8/26 documented no skin alterations and no skin treatments, even though the resident was observed with a dressing on the right lower leg and reported staff were changing it every couple of days. For another resident, the record also showed no wound care orders in February 2026 despite the resident reporting daily wound care since admission, and staff interviews confirmed the wound care orders from the hospital discharge summary were not entered until 3/4/26.
Influenza Vaccine Education and Offering Not Documented for Multiple Residents
Penalty
Summary
The facility failed to provide influenza vaccine education with documentation in the medical record and failed to offer the influenza immunization during the influenza season for 6 of 7 residents reviewed. The facility policy stated that residents without medical contraindications were to be offered the influenza vaccine annually, that pertinent information about the significant risks and benefits of the vaccine would be provided to patients and/or family members, and that current and newly admitted patients would be offered the vaccine beginning on the first day of the year and while influenza viruses were circulating and vaccine was available. Resident #38 was admitted to the facility and had moderately impaired cognition on a quarterly MDS assessment. The MDS indicated the influenza vaccine was not received in the facility because it was not offered. The medical record contained no documentation in the EMR or hard chart showing that the resident or RP received education about the benefits and potential side effects of the influenza vaccine for the influenza season, and no documentation showing the resident received or refused the vaccine. Attempts to contact the RP were unsuccessful. Resident #39 was admitted to the facility and had severely impaired cognition on a quarterly MDS assessment. The MDS also indicated the influenza vaccine was not received in the facility because it was not offered. There was no documentation in the EMR or hard chart showing education was provided to the resident or RP about the benefits and potential side effects of the influenza vaccine, and no documentation showing the resident received or refused the vaccine. The RP stated they could not recall whether the facility provided education or an opportunity for the resident to receive the vaccine. Similar findings were documented for Resident #56, who was cognitively intact, and Residents #71, #77, and #121, all of whom had severely impaired cognition. For each of these residents, the MDS showed the influenza vaccine was not received because it was not offered, the medical record lacked documentation of education or consent/refusal, and the resident or RP could not recall being provided education or an opportunity to receive the vaccine. The Infection Preventionist stated that influenza education and consents were to be reviewed yearly with residents and/or RPs. She reported that one batch of influenza vaccines had to be discarded because it was not refrigerated when received, and that there was a delay in obtaining additional vaccine. She also stated that she used the Preventative Health tab in the EMR to track who had and had not received the vaccine and must have overlooked the referenced residents. The Pharmacist confirmed the facility received 60 doses of influenza vaccine and later requested 40 more, but only 27 additional doses were available. The DON stated she was unaware that the six residents did not receive education or the opportunity to receive the influenza vaccine during the most recent influenza season and expected yearly education, administration after consent, and documentation in the medical record.
Failure to Offer and Document COVID-19 Booster Vaccinations
Penalty
Summary
The facility failed to assess residents for eligibility and ensure they were offered the COVID-19 booster vaccination for 6 of 7 residents reviewed for COVID-19 booster immunizations. The facility policy stated that residents without medical contraindications would be offered the updated COVID-19 vaccine per CDC recommendations and would be provided information about the risks and benefits of vaccination. CDC guidance reviewed by surveyors indicated a 2025 to 2026 COVID-19 vaccine was recommended for individuals age 65 and older, those at high risk for severe COVID-19, or those who had never received a COVID-19 vaccine. Resident #38, #39, #56, #71, #77, and #121 each had significant medical diagnoses, including diabetes, COPD, CHF, dementia, chronic kidney disease, chronic respiratory failure, anemia, and chronic fatigue syndrome. MDS assessments showed several of these residents had severely impaired cognition, one had moderately impaired cognition, and one was cognitively intact. Their immunization records showed each had received a COVID-19 booster at the facility in 2024, but there was no documentation that they were offered, given, or refused additional doses of the COVID-19 vaccination. For each resident, the MDS COVID-19 item indicated they were not up to date with the vaccine. Interviews supported that the residents and/or responsible parties could not recall receiving education or an opportunity for a recent booster. The Infection Preventionist stated every resident should be offered the opportunity to receive the COVID-19 booster based on CDC guidance, but she used the EMR Preventative Health tab rather than a log and said she must have overlooked the six residents. She also stated she needed to develop a system so immunizations were not overlooked. The Infection Control nurse said she had been pulled to work on medication carts frequently and had not been able to dedicate the time needed to ensure residents received immunizations in a timely manner. The DON stated she was unaware these residents did not receive education or the opportunity for an updated COVID-19 booster and expected vaccine education, administration after consent, and documentation in the medical record.
Undignified Communication With Resident During Call Bell Interaction
Penalty
Summary
The facility failed to maintain a resident's dignity when staff spoke to her in an undignified manner. Resident #69 was admitted with hemiplegia and hemiparesis following a CVA affecting her left non-dominant side, and a quarterly MDS indicated she was moderately cognitively impaired and required substantial assistance with turning in bed and was dependent. During an observation on 6/11/26, her call bell was seen draped across the foot of the bed and lying on the floor, and the resident stated staff had put it there when assisting her earlier. During an observation and interview with NA #1, the call bell was again observed draped across the bottom of the bed and lying on the floor. NA #1 stated she had forgotten to return the call bell after changing the resident's clothes and handed it to the resident. As the resident began rubbing the side of the call bell, NA #1 stated in a stern voice, "Don't you hit that call bell, I'm standing right here. What do you need?" Resident #69 looked away and did not respond. The resident later stated the way NA #1 spoke to her upset her. Nurse #4 stated the resident should not have been discouraged from using her call bell or spoken to disrespectfully, and the DON stated NA #1 spoke inappropriately and that it was the resident's right to be spoken to in a dignified manner.
Failure to Assess Resident Self-Administration of Medication
Penalty
Summary
The facility failed to assess whether Resident #135 could safely self-administer medications. The resident was admitted with diagnoses of bipolar disorder and major depressive disorder, single episode, with psychotic features, and the annual MDS indicated she was cognitively intact without behavioral concerns. An active order was in place for Cipro 500 mg twice daily for a UTI, but the resident refused the facility’s doses on multiple occasions and stated she had her own antibiotics from an urgent care visit that she was taking herself. Nursing documentation showed the DON noted the resident was refusing blood work and refusing to give staff her own antibiotics or take the facility’s antibiotics. The MAR reflected repeated refusals of the ordered Cipro by multiple nurses over several days. A nurse later documented that the resident showed her a bottle of ciprofloxacin from Walgreens, said she had obtained it from urgent care, and stated she had taken a dose from her own supply while refusing the facility medication packet. The resident also showed a notebook in which she had written the dates she believed she should take the medicine. During interview, the resident stated she was in her right mind, capable of taking her own medication, and denied being formally assessed for independent medication administration. Nurses and the UM stated the resident refused to surrender the medication for storage and that staff did not observe her taking the medication. The DON stated she asked the MDS nurse to observe the resident self-administer the antibiotic, but the MDS nurse stated she had not been asked to monitor any resident self-administering medications and had not observed Resident #135 take the antibiotic.
Failure to Honor Residents’ Requests to Get Out of Bed
Penalty
Summary
The facility failed to honor residents’ choices to get out of bed for two residents reviewed for self-determination. One resident was cognitively intact, dependent on staff for bed mobility and ADLs, used a wheelchair, and had diagnoses including incomplete quadriplegia, traumatic brain injury, muscle weakness, and spastic hemiplegia. During lunch observation, the resident asked a nursing assistant to get him into his wheelchair after the meal, but the nursing assistant walked away without responding. The resident later stated no one returned to assist him, and the nursing assistant acknowledged forgetting to follow up because she became busy passing meal trays. The resident was not assisted out of bed until later in the day after staff were questioned about the request. The second resident had diagnoses of hemiplegia and hemiparesis following a CVA and was assessed as moderately cognitively impaired and dependent for turning in bed. She told surveyors she had asked multiple staff members over the prior week to get her out of bed, but they told her no, and she had not been out of bed for several days. A nursing assistant assigned to her stated staff did not get her up because when she was up, she complained and wanted to go back to bed. The DON stated staff should get the resident out of bed when she asked, even if she wanted to return to bed shortly afterward.
Delayed Refund of Resident Funds After Discharge
Penalty
Summary
The facility failed to distribute a resident’s funds within 30 days of discharge for 1 of 3 residents reviewed for refund of deposit, Resident #127. Resident #127 was admitted to the facility and later had a planned discharge to another facility documented on the discharge tracking MDS. The HCPOA stated that Resident #127 was discharged to another skilled nursing facility and was owed a refund of approximately $1000. During an interview, the Business Office Manager stated she received an email from the accepting facility in April 2026 indicating they had not received Resident #127’s funds, and she initiated the refund on approximately 04/18/26. She stated the funds were sent to the accepting facility on 04/21/26, which was more than 30 days after the resident’s discharge on 03/07/26. She also stated no one communicated to her that Resident #127 had been discharged to the other facility, although she saw the transfer discussed in morning meeting and noted on the census report. The Administrator stated the refund of funds for Resident #127’s account should have occurred per the regulation.
Failure to Develop Care Plans for Behavioral Symptoms, Psychotropic Use, and Dental Problems
Penalty
Summary
The facility failed to develop individualized and comprehensive care plans for a resident with a history of behavioral symptoms and psychotropic medication use. Resident #35 was admitted with diagnoses including traumatic brain injury, mood disorder, dementia with other behavioral disturbance, anxiety disorder, and depression. Nursing progress notes documented episodes of disrobing in the hallway and propelling the wheelchair to other residents’ rooms. The admission MDS showed severe cognitive impairment, wandering behavior, and use of antipsychotic and antidepressant medications. The CAA summary triggered dementia, behavioral symptoms, and psychotropic drug use for care planning, but the active care plan initiated afterward did not address the resident’s behavioral symptoms or psychotropic medication use. The facility also failed to develop a care plan for a resident’s dental concerns. Resident #62’s nursing admission assessment identified obvious or likely cavities or broken natural teeth, but the annual MDS did not identify any dental problems and the active care plan did not address dental issues. An observation showed missing upper and lower teeth, with the remaining teeth in poor condition and evidence of breakage and black decay. The resident stated he had experienced dental problems for years and wanted his remaining teeth extracted, with a dental appointment scheduled later that month.
Failure to Complete Smoking Care Plan After Admission Assessment
Penalty
Summary
The facility failed to complete a comprehensive care plan within 7 days of the admission MDS assessment for Resident #104, who was admitted on 4/6/26. A smoking assessment identified the resident as a safe smoker, and the admission MDS noted the resident was cognitively intact and coded for current tobacco use. However, review of the medical record on 6/8/26 found no care plan addressing smoking. During an interview on 6/11/26, the DON stated she was not certain why the smoking care plan was not in place, said the nurse completing the admission assessment should have initiated it, and expected all smokers to have smoking addressed in a care plan on admission.
Insulin Not Given Per Ordered Blood Glucose Parameters
Penalty
Summary
The facility failed to administer insulin lispro according to the physician’s ordered parameters for a resident with diabetes mellitus. The resident had active orders for insulin lispro 10 units subcutaneously once daily with breakfast and 8 units subcutaneously twice daily at 12:00 PM and 5:00 PM, with instructions to hold the dose if blood glucose was less than 90, give half the dose if blood glucose was less than 120, and not administer if the resident was not eating. Review of the May 2026 and June 2026 MARs showed multiple instances in which the resident received half doses even though the documented blood glucose values were above 120, including several administrations of 5 units instead of 10 units and 4 units instead of 8 units. Nurse #2 acknowledged that on one occasion she administered 5 units when the resident’s blood glucose was above 120 and stated she should have given 10 units. Nurse #3 confirmed multiple additional instances in which the resident received 5 units or 4 units despite blood glucose levels above the threshold for a half dose, and she stated the discrepancies were mistakes that may have been influenced by concerns about the resident’s meal intake. She also stated the resident had a continued history of poor meal intake, but she did not document whether the insulin dosage was adjusted in response to reduced food consumption. The Medical Director and DON both stated that staff were expected to follow physician orders as written.
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care according to physician orders for a resident who was readmitted with diagnoses including hypertension, diabetes, and an unspecified open wound. The physician ordered wound care for a skin tear on the lower right leg to include cleansing with antiseptic wound cleanser, application of medi-honey, placement of a silicone bordered foam dressing, and dressing changes every 3 days and as needed. A skin care assessment noted the skin tear with an intact dressing and wound care ordered, and the resident was cognitively intact and did not reject care. The Treatment Administration Record documented wound care as completed on two dates, but later observations showed the dressing on the right lower leg remained dated several days earlier. The resident reported the dressing had not been changed since that date and did not know why. During interviews, the Wound Nurse stated she was not aware of the wound and knew nothing about the ordered care, while the ADON was uncertain whether the wound had been communicated to her. The nurse whose initials appeared on the TAR denied completing the wound care and did not know why her initials were recorded. The DON and Administrator were also unable to explain why the wound care was not completed as ordered or why the Wound Nurse had not been notified.
Failure to Apply Ordered Palmar Guard Orthosis
Penalty
Summary
The facility failed to apply a right hand palmar guard orthosis as outlined in the care plan for a resident with hemiplegia and hemiparesis following a cerebral infarction, along with a right wrist contracture and right hand contracture. The resident’s OT discharge summary stated the resident had plateaued at maximum producible end-range PROM and tolerated the right palmar guard orthosis for 3-4 continuous hours without adverse signs. The care plan required preparatory PROM followed by application of the right palmar guard orthosis for up to 4 continuous hours daily, up to 7 days per week. Review of the MDS showed the resident had cognitive impairment, was dependent on staff for ADLs, and was not receiving therapy services. The care plan, last updated 5/22/26, required splint/brace assistance to the RUE up to 7 days per week due to hypertonicity and right hand contracture, with interventions including PROM from shoulder to hand, monitoring for pain, applying the right palmar guard orthosis after PROM, and monitoring skin integrity. However, Point of Care documentation from 5/11/26 through 6/10/26 was inconsistent and incomplete for both PROM and splint/brace assistance, with entries marked unavailable, refused, combative, no information/not observed, or missing entirely on multiple dates. Observations on 6/8/26, 6/9/26, and 6/10/26 showed the resident in bed without a palmar guard in place, and no splints were seen on the bedside table or in the immediate area. During interviews, Nurse #7 stated staff were trained on splint application but was unaware of the location of the resident’s splints. The OT later found two palmar guards in the bottom drawer under personal items and stated staff had not looked for them after the resident returned from the hospital. The DON acknowledged the resident was not wearing a palmar guard and stated the resident should have been wearing one; the Physician stated that if OT had written an order or the care plan indicated palmar guard use, the splints should be applied as directed.
Failure to Process Ordered UA for Resident With UTI Symptoms
Penalty
Summary
The facility failed to implement an active order for a urinalysis with culture and sensitivity for a resident who reported dysuria and requested testing for a possible UTI. Resident #135 was admitted with diagnoses of cognitive communication deficit and prediabetes, and the annual MDS indicated she was cognitively intact. A Nurse Practitioner progress note dated 5/29/26 documented that the resident endorsed burning or discomfort with urination and wanted a UA with culture and sensitivity ordered, and the order was listed in the note. However, review of the May 2026 physician orders did not show an order for the UA with culture and sensitivity, and lab results for May and June 2026 did not show that the test had been completed or was pending. The resident stated she asked the NP to order a urine test because she believed she had a UTI, but the facility never obtained a urine sample, so she went to an urgent care clinic where she was tested on 6/2/26, diagnosed with a UTI, and prescribed antibiotics. Staff interviews indicated the NP did not have access to enter orders into the computer system and had emailed the order to the DON, but the DON and UM did not recall receiving or seeing the order, and the UM stated the progress note had been uploaded under resident documents instead of progress notes.
Missing Blood Glucose Monitoring Order on Admission
Penalty
Summary
The facility failed to transcribe blood glucose monitoring orders on admission for a resident with type 2 diabetes who was receiving Metformin 500 mg daily with breakfast. The resident’s hospital discharge medication list included an order for blood glucose monitoring three times a day, but the September 2025 facility physician orders did not include that monitoring order even though the Metformin order was entered. The resident’s admission MDS indicated moderately impaired cognition and use of a hypoglycemic medication. During interview, the admitting nurse confirmed he entered the hospital discharge orders on admission but acknowledged the blood glucose monitoring order was not transcribed and said it was an oversight. The NP reviewed the discharge summary and facility orders and stated the monitoring order should have been transcribed so blood glucose results would be available to assess whether Metformin needed adjustment or whether monitoring should be adjusted or discontinued. The DON stated she normally completed a second check for new admissions to ensure medications were transcribed correctly, but was unsure whether that review was completed for this resident.
Unsecured Medications Found at Bedside
Penalty
Summary
The facility failed to secure prescribed medications stored at bedside for 2 of 6 residents reviewed. Resident #84 was admitted with seborrheic dermatitis and had severe cognitive impairment on the quarterly MDS. The physician ordered Triamcinolone Acetonide Cream 0.025% for daily application to affected areas, but the resident had not been assessed for self-administration of medication. Observations on two separate occasions showed three containers of the cream sitting on top of the nightstand beside the resident’s bed. During interview, the Unit Manager stated the cream should have been kept in the locked treatment cart and removed the containers from the room, and staff including a nurse, a nurse aide, and the DON stated they were not aware the cream was in the room and that it should have been secured in the medication cart. Resident #104, who was cognitively intact and admitted earlier in the year, had no diagnosis for toenail fungus, no physician order for ciclopirox topical nail lacquer, and no order to self-administer medications. A self-administration assessment documented that the resident did not want to self-administer medications and would not self-administer them. During observation, a package of ciclopirox topical nail lacquer was found on the desk inside the resident’s room. The resident stated another physician prescribed it and that he used it on his toenails, while also saying he forgot to apply it on a schedule. A nurse confirmed the lacquer should not have been in the room, the DON stated she was not aware it was there, and the physician stated residents should not have medication in their room.
Failure to Follow Documented Food Preferences
Penalty
Summary
The facility failed to accommodate Resident #56’s food preferences by serving meals that did not match the resident’s documented dislikes and vegetarian preference. Resident #56 was cognitively intact and able to eat independently. Records included a Diet History/Food Preference List that identified dislikes including beef, pork, chicken, turkey, fish, and other foods, and the meal ticket also identified the resident as a vegetarian who liked fish and did not eat beef or pork. During a lunch observation, Resident #56’s tray contained Mech Soft Beef Stir Fry, and the resident had pushed the brown, ground-up meat to the side. The resident stated she had regularly received pork, beef, and other meats for meals and had reported the issue to nurse aides, nursing staff, and dietary staff, but continued to receive food she disliked. Staff interviews confirmed the meal ticket indicated the resident should not have received beef, and the Dietary Manager stated the beef was served because of a server error. Staff also stated meal tickets and trays were expected to be checked for accuracy before delivery, but Resident #56 continued to receive meals that did not reflect the documented preferences.
Hand Hygiene Not Performed During Wound Care
Penalty
Summary
The facility failed to implement its infection control policy regarding hand hygiene during wound care for Resident #17. During an observation of wound care, the wound care nurse performed hand hygiene, donned a gown and gloves, removed soiled dressings from the resident’s left buttocks, doffed gloves, and performed hand hygiene. She then donned clean gloves and used a single piece of gauze wet with Dakin’s solution to wipe the upper and lower wounds on the left buttocks. After doffing gloves, she put on a clean pair of gloves without performing hand hygiene and placed separate pieces of calcium alginate over each wound, then covered both wounds with a single bordered foam dressing. The wound care nurse again doffed her gloves and applied a clean pair of gloves without performing hand hygiene before applying skin protective ointment to the excoriation on the resident’s scrotal area. The resident’s wounds were described by the PA as being close together in the same area and labeled as a cluster, and the PA stated the wounds did not show signs of infection. The wound care nurse stated she should have performed hand hygiene with each glove change and between each separate wound care area, and that she should have used separate gauze to clean both wounds. The DON also stated the nurse should have performed hand hygiene with each glove change and used separate gauze for each wound.
Failed Privacy Curtain During Bed Bath
Penalty
Summary
The facility failed to provide a working privacy curtain that allowed full visual privacy for a resident during ADL care while bathing. During an observation of care for one resident, the resident was receiving a bed bath with the door closed and the privacy curtain pulled between the resident and a roommate who was resting in bed. While the resident’s bare bottom was exposed during washing, a nurse knocked on and opened the room door, and the resident remained visible from the hallway. The privacy curtain next to the door could not be closed because multiple hooks were missing, leaving an approximately 2-foot span that prevented the curtain from moving properly. The NA providing care stated the curtain would not pull all the way around, so privacy could not be given to the resident, and said housekeeping was responsible for replacing privacy curtains when needed. Housekeeping staff stated curtains were changed when dirty and that maintenance was responsible for installing hooks when needed. The Housekeeping Director stated nurses were responsible for entering a work order in the TELS system when the curtain was not working, but no work order for this resident’s curtain was found. The DON stated housekeeping should have checked the curtain and changed it if defective, and the Administrator stated the curtain should have been maintained in functional order and a work order should have been entered in TELS.
Inaccurate Daily Nurse Staffing Sheets
Penalty
Summary
The facility failed to accurately document the actual working hours of licensed nursing staff on 6 of 6 daily nurse staffing sheets reviewed. Review of the posted staffing sheets for 5/6/26, 5/15/26, 5/17/26, 6/1/26, 6/2/26, and 6/6/26 showed that the hours posted for RNs and LPNs did not match the hours of care reflected in the schedules for the day, afternoon, and night shifts. In each instance, the posted staffing sheets listed totals that differed from the hours that should have been recorded based on the schedule review. During interview, the Staffing Coordinator stated she was responsible for updating the posted daily nurse staffing sheet Monday through Friday, while the charge nurse updated it on weekends. She reported that licensed nursing staff worked 12-hour shifts and that she counted the number of RNs and LPNs in the building and multiplied that number by 12 to determine total hours worked for each shift. She stated she had not been instructed to count the actual hours worked by each nurse for the total hours worked each shift, and she acknowledged that the posted nurse staffing sheet should be accurate to reflect the current staffing in the facility. The Administrator stated he was not aware the Staffing Coordinator was reporting inaccurate hours on the daily posted nurse staffing sheet and expected the sheet to accurately reflect current staffing.
Failure to Notify Provider and Family of Change in Condition After Resident Fall
Penalty
Summary
The facility failed to notify the provider of a change in condition and x-ray results after a fall for one resident who was receiving hospice services and had a history of cerebral vascular accident, hemiplegia, hemiparesis, and lung cancer. The resident experienced a fall while attempting to go to the bathroom, after which staff did not document the incident, assess the resident thoroughly, or notify the physician or family. The nurse on duty was preoccupied with other tasks and did not complete the required documentation or notifications, and the fall was not entered into the electronic medical record. The resident's responsible party learned of the fall from a nurse aide the following day and observed that the resident was in pain and unable to bear weight, which was a change from her baseline. Despite these observations and being informed by the responsible party, the nurse did not perform an assessment or notify the physician. The lack of documentation and communication persisted, and the resident continued to experience pain and functional decline without appropriate medical intervention or notification to the provider or family. It was not until two days after the fall, when the hospice nurse was notified by the responsible party, that an assessment was performed and a STAT x-ray was ordered, revealing an acute impacted left femoral neck fracture. The x-ray results were received at the facility but were not promptly communicated to the provider, with the on-call provider only being notified after hours. The delay in notification and lack of timely assessment and documentation resulted in a significant delay in appropriate care for the resident.
Failure to Assess and Communicate Change in Condition After Fall
Penalty
Summary
The facility failed to provide ongoing assessments and appropriate medical intervention following a resident's fall. After the fall, staff did not identify or respond to significant changes in the resident's condition, including pain, inability to bear weight, one leg appearing shorter than the other, and external rotation of the leg. These signs, which required medical evaluation and treatment, were not recognized or communicated effectively among staff. Additionally, the facility did not notify the provider of the resident's change in condition or the results of an x-ray that revealed an acute impacted left femoral neck fracture until after hours, delaying necessary medical attention. Record review and interviews with staff, responsible party, hospice nurse, physician, and medical director confirmed these failures. The lack of timely assessment, inadequate communication, and failure to notify the provider of critical changes and diagnostic results contributed to the delay in treatment for the resident's fracture. These deficiencies were identified for one of three residents reviewed for abuse, neglect, and post-fall assessment.
Failure to Assess and Communicate After Resident Fall Resulting in Delayed Fracture Diagnosis
Penalty
Summary
A deficiency occurred when facility staff failed to provide ongoing assessments and appropriate medical evaluation and treatment following a resident's fall. After the resident, who had a history of cerebral vascular accident, hemiplegia, hemiparesis, and lung cancer, fell while attempting to go to the bathroom, the assigned nurse and nurse aide assisted her back to bed but did not document the incident, notify the physician or family, or conduct thorough post-fall assessments. The nurse reported being too busy to document or notify anyone, and there was no record of the fall or subsequent assessments in the electronic medical record for that shift. The resident experienced pain and a significant change in her ability to bear weight and participate in activities of daily living following the fall. Despite these changes, staff across multiple shifts were not informed of the fall, and the resident's pain was not adequately assessed or managed. Communication failures between shifts and lack of documentation led to delays in recognizing the severity of the resident's condition. The family and hospice nurse were the first to escalate concerns after observing the resident's increased pain and inability to bear weight, which prompted further assessment and a physician-ordered x-ray. The x-ray revealed an acute impacted left femoral neck fracture, but this diagnosis and the need for medical intervention were not promptly communicated to the family or acted upon by facility staff. The resident continued to experience pain and functional decline until the fracture was identified and she was transferred to the hospital for surgical repair. Throughout this period, there were repeated failures in assessment, documentation, communication, and timely notification of changes in the resident's condition.
Failure to Document Falls and Medication Administration in Resident Records
Penalty
Summary
The facility failed to maintain accurate and complete documentation in the electronic medical record for two residents who experienced accidental falls. In the case of one resident, there was no initial documentation of the fall, no record of physical assessments, and no documentation of pain medication administration by multiple nurses. Additionally, there was incorrect documentation regarding the administration of pain medication, with discrepancies between the controlled drug record and the Medication Administration Record (MAR). Nurses involved admitted to being too busy or forgetting to document these critical events and interventions, despite having performed assessments and administered medications. For another resident who experienced a fall, the nursing progress notes lacked documentation of vital signs and range of motion assessments following the incident. Although the nurse reported having performed these assessments, they were not recorded in the electronic medical record. The nurse also failed to complete the required SBAR form for the incident. The nurse attributed the lack of documentation to unfamiliarity with the electronic medical record system. Interviews with the Director of Nursing confirmed that staff were expected to follow established protocols for documentation after falls, including recording assessments, vital signs, and medication administration. However, the required documentation was not completed as expected, resulting in incomplete medical records for the residents involved.
Failure to Immediately Report Resident Abuse Allegation to Administrator
Penalty
Summary
The facility failed to immediately notify the Administrator of an abuse allegation made by a resident, as required by its own policy. A resident with diagnoses including schizophrenia, depression, dementia, and bipolar disorder, who was cognitively intact, reported to staff that a nurse aide had made inappropriate actions of a sexual nature and an inappropriate comment during incontinent care. The resident stated she informed a nurse and another nurse aide about the incident, but neither could recall the exact day this occurred. The nurse denied being directly told of the allegation but was aware of rumors, and the nurse aide only became aware of the allegation after overhearing a conversation between the resident and the Activity Director. The Activity Director was told of the abuse allegation by the resident but became distracted and failed to immediately report it to the Administrator, only remembering to do so the following day. Meanwhile, the nurse aide, realizing at the end of her shift that no action had been taken, reported the allegation to a corporate consultant, who instructed her to immediately inform the Administrator. The Administrator was ultimately notified at the end of the nurse aide's shift, resulting in a delay in reporting the abuse allegation as required by facility policy.
Missed Glaucoma Medication Doses Due to Staff Miscommunication and Storage Oversight
Penalty
Summary
A resident with a diagnosis of glaucoma was admitted to the facility and had a physician's order for timolol maleate 0.5% eyedrops to be administered twice daily. Over the course of February and March, the resident missed 11 doses of the prescribed eyedrops. Nursing staff documented on the Medication Administration Record (MAR) that the medication was unavailable and that they were awaiting delivery from the pharmacy. Multiple nurses reported that the eyedrops were not on the medication cart and believed the medication had not been delivered, relying on information from other staff or their own assumptions. However, the pharmacy consultant confirmed that the medication had been delivered as scheduled with no gaps in delivery, and the medication was found stored in the medication refrigerator, where it was supposed to be kept. The resident, who was cognitively intact and had impaired vision due to glaucoma, reported to surveyors that she was not given her eyedrops and was told by nurses that the medication was being reordered. Interviews with nursing staff revealed a lack of awareness regarding the storage location of the medication, leading to repeated missed doses. The Assistant Director of Health Services confirmed that complaints were received from the resident and her family about missed doses, and upon investigation, the medication was located in the refrigerator where it had been delivered and stored.
Failure to Ensure Proper Food Service Hygiene and Equipment Cleaning
Penalty
Summary
A dietary staff member was observed in the kitchen without a facial hair covering while taking temperatures of lunch meal items at the steam table. The staff member acknowledged not wearing the covering because he was about to go on break, but also stated he should have had his beard and mustache covered while in the kitchen. The Dietary Manager confirmed that all dietary staff had recently been trained on the requirement to cover facial hair at all times in the kitchen, and that the staff member should have completed food temperature checks before going on break. The Administrator also confirmed that the staff member should have been wearing a facial hair covering while in the kitchen. Additionally, the convection oven doors in the kitchen were observed to be covered with a brown substance, and the deep fryer contained food particles in the oil and along the sides. The convection oven had last been cleaned over a week prior, and the deep fryer had not been cleaned since several days before the observation, despite being used the previous day. The Dietary Manager stated that both the oven and fryer should be cleaned after each use, and acknowledged that the equipment had not been cleaned as required. The Administrator confirmed that a daily cleaning schedule should have been in place for both pieces of equipment.
Failure to Apply Prescribed Hand Splint for Resident with Contractures
Penalty
Summary
A resident with a history of hemiplegia, contractures, and other significant medical conditions was admitted to the facility and received occupational therapy (OT) services, including the use of a left-hand splint to address contractures. Upon discharge from OT, recommendations were made for the continued daily application of the orthosis for up to six hours, with regular monitoring. However, subsequent observations revealed that the resident was not wearing the splint, and both the resident and staff reported that the splint had not been applied. Multiple staff interviews indicated a lack of awareness of any current orders for the splint, and the splint itself could not be located in the resident's room. Further review showed that there was no documentation or in-service training provided to nursing staff regarding the splint application after OT discharge. The electronic health record did not contain active orders for the splint, and staff were unclear about the process for continuing splint use after therapy ended. The breakdown in communication between therapy and nursing staff resulted in the resident not receiving the recommended intervention to maintain or improve range of motion, as prescribed by OT.
Failure to Properly Label and Shake Tube Feeding Formula
Penalty
Summary
A deficiency occurred when staff failed to properly label and shake a new tube feeding formula bottle before administration to a resident with a history of stroke, dysphagia, and gastrostomy status, who was severely cognitively impaired and dependent on tube feeding for all nutrition and hydration. Facility policy required that tube feeding formula containers be shaken to ensure proper mixing and labeled with the type of formula, strength, amount, rate of administration, date, time, and initials of the nurse. During observation, the tube feeding bottle in use was found to lack date, time, and initials, and had visible sediment at the top, indicating it had not been shaken prior to hanging. Interviews with nursing staff revealed that the nurse responsible for hanging the bottle did not shake the formula and failed to label the bottle as required, citing being in a hurry at the end of her shift. Other staff confirmed the bottle was already hanging at the start of their shift and acknowledged the lack of labeling and shaking. The Director of Healthcare Services and the Administrator both confirmed that the bottle should have been shaken and labeled according to facility policy.
Failure to Date and Remove Expired Insulin Pens from Medication Carts
Penalty
Summary
Surveyors found that the facility failed to properly date opened multi-dose insulin pen injectors and failed to remove expired insulin pens from medication carts in two of five medication administration carts. Specifically, on the 100 hall medication cart, an opened and undated Lantus insulin pen was observed. Manufacturer instructions require that Lantus insulin multi-dose vials be discarded 28 days after opening. On the 200 hall medication cart, an opened and undated Glargine insulin pen and an Admelog Solostar insulin pen, which had been opened on 3/2/25 and expired on 3/30/25, were found. These deficiencies were identified during observations with two nurses, both of whom acknowledged that nurses are responsible for dating and discarding multi-dose vials per facility training and competency requirements. Interviews with the nurses revealed that they had not checked the dates of opening on insulin vials in their medication carts at the beginning of their shifts, although they stated they had not administered expired medication during those shifts. The Director of Nursing and the Administrator both confirmed that it is the responsibility of all nurses to check for and remove expired medications from the carts every shift, and that no expired items should remain in the medication carts.
Significant Medication Error with Morphine Administration
Penalty
Summary
The facility failed to prevent a significant medication error when a nurse administered 40 mg of liquid morphine instead of the prescribed 5 mg to a resident. The resident, who had a history of schizophrenia, dysphagia, depression, chronic pain, muscle spasm, and gastrostomy status, was admitted to the facility and had been discharged from hospice services. The physician's order specified administering 0.25 mL (5 mg) of morphine through a gastric tube every six hours as needed for pain or air hunger. However, Nurse #1, during a late evening shift, administered 2.25 mL of morphine, which equates to 40 mg, due to a misinterpretation of the medication label, which she described as blurry. Nurse #1 was distracted and unfamiliar with the resident, contributing to the error. Upon realizing the mistake during a narcotic count with Nurse #2, Nurse #1 reported the error, and both nurses checked on the resident, who was stable with normal vital signs and responsive to touch and voice. Nurse #2 notified the on-call medical doctor about the overdose. The Director of Nursing was informed of the incident and completed a medication error report. The morphine bottle was observed to have 28.0 cc remaining, confirming the administration of 2.25 mL instead of the ordered 0.25 mL.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 143 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | 0.7 mi | ★★★★★ | 21 | 0 |
| Pettigrew Rehabilitation Center | 1.7 mi | ★★★★★ | 3 | 0 |
| Hillcrest Convalescent Center | 1.8 mi | ★★★★★ | 0 | 0 |
| The Forest At Duke Inc | 2 mi | ★★★★★ | 9 | 0 |
| Croasdaile Village | 2.6 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 October 2026) and official state health department websites.