Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pruitthealth-durham during CMS and state inspections, most recent first.
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 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 76 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 | ★★★★★ | 8 | 0 |
| Pettigrew Rehabilitation Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Hillcrest Convalescent Center | 1.8 mi | ★★★★★ | 0 | 0 |
| The Forest At Duke Inc | 2 mi | ★★★★★ | 0 | 0 |
| Croasdaile Village | 2.6 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pruitthealth-durham.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.