Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pruitthealth-neuse during CMS and state inspections, most recent first.
A resident with hemiplegia and hemiparesis, moderate cognitive impairment, and documented nutrition/hydration risk had a physician order and care plan specifying use of a spouted cup with handle at all meals, but was repeatedly served beverages in regular cups with lids and straws. Observations showed that staff delivering meal trays did not properly check diet slips against tray contents, and one NA admitted she did not verify accuracy and would leave incorrect trays as they were, despite training. The resident reported spilling drinks with regular cups and finding the spouted cup easier to use, while the DON and Dietary Manager confirmed that staff were expected to verify trays and that appropriate adaptive cups were available in stock.
A moderately cognitively impaired resident with multiple comorbidities was found with a half-full 40-ounce bottle of multipurpose cleaner on the bedside table, which the resident had ordered and used for cleaning spills. The product’s label warned of eye, skin, and respiratory irritation and adverse effects if ingested. Direct care staff and a nurse reported they were unaware the cleaner was in the room and stated it should have been removed if seen. The DON and Administrator acknowledged the resident’s pattern of ordering items to the room and stated hazardous products should not be kept at the bedside and should be removed and reported when observed.
A resident's Responsible Party, who held Power of Attorney, repeatedly requested medical records from the Medical Records Director over several months but did not receive them within the required 2 working days. The records were eventually mailed after legal intervention, with the delay attributed to the Medical Records Director's misunderstanding of the release timeframe following the resident's discharge and death.
A resident with a history of bipolar disorder and documented tobacco use was incorrectly coded as a non-smoker on the MDS assessment, despite care plan and observation records indicating otherwise. Staff interviews confirmed the resident's smoking status and attributed the error to oversight during the assessment process.
A resident with a history of bipolar disorder and assessed as a safe, independent smoker was observed lighting and smoking a cigarette inside the facility lobby, contrary to the facility's no-smoking policy. Staff intervened by escorting the resident outside and attempting to secure her smoking materials, resulting in a combative incident and police involvement. The resident had previously been permitted to keep smoking materials in a lock box in her room due to a grandfathered policy.
A resident with diabetes experienced elevated blood sugar levels exceeding 500 mg/dL on multiple nights. Despite physician orders to notify the MD for levels over 400 mg/dL, the responsible party was not informed until the resident was hospitalized. The nurse involved did not notify the RP due to the time of night and perceived non-life-threatening nature, although the Director of Nursing acknowledged the RP should have been informed.
A resident with a history of UTI did not receive scheduled doses of ciprofloxacin due to a failure in verifying the physician's order. The order was not sent to the pharmacy or added to the MAR, leading to missed doses. Nursing staff were unaware or did not verify the order, and the facility's system for medication administration was not followed.
A resident with anxiety disorder did not receive 10 doses of prescribed lorazepam due to an error by the DON, who mistakenly discontinued the medication on the MAR. This led to increased anxiety for the resident, who was observed crying and asking for his medication. The error was compounded by confusion among nursing staff and a misunderstanding regarding the family's request, resulting in the resident not receiving either the scheduled or PRN lorazepam during this period.
A resident with respiratory failure and muscle weakness was transferred without a mechanical lift, despite being assessed as requiring one. The nursing assistants were unaware of this requirement due to a lack of communication between therapy and nursing staff. The resident experienced pain and shortness of breath during the transfer.
A facility failed to maintain a medication error rate below 5%, resulting in a 7.41% rate due to errors involving a resident's medication administration. A nurse crushed and administered medications in applesauce against orders, including an enteric-coated aspirin and Metoprolol Succinate extended-release, which were to be given whole. Interviews confirmed the errors and highlighted the risks of altering medication properties.
The facility failed to include estimated costs on SNF/ABN forms for two residents, as required. Medicare coverage ended for both residents, but the forms lacked the necessary cost information. Staff interviews revealed a lack of awareness about this requirement.
A facility failed to accurately code a significant change in status MDS for a resident who elected hospice care. The resident, with acute respiratory failure, acute pneumonitis, and Alzheimer's dementia, was admitted to hospice, but the MDS did not reflect this change. The MDS nurse was aware of the hospice admission but did not include it in the MDS, and the administrator confirmed this oversight.
A treatment cart was found unlocked and unattended in a hallway, with a resident nearby and staff and visitors passing by. The MDS Nurse locked the cart upon noticing it. Treatment Nurse #1, responsible for the cart, acknowledged it should be locked when unattended but had no explanation for the oversight. The cart contained various medications and ointments.
A nurse failed to perform hand hygiene before donning gloves and after glove removal during medication administration and a blood glucose test for a resident. Despite facility policies requiring hand hygiene at these times, the nurse did not comply, citing nervousness and a headache. The Infection Preventionist and DON confirmed the breach in protocol.
A facility failed to protect a resident's controlled medication, resulting in 30 Oxycodone 5mg pills being unaccounted for. The resident was unaware of the missing medication, and an internal investigation involving the DON, Administrator, and pharmacist could not locate the pills. The facility covered the cost to replace the medication.
The facility failed to report an incident of misappropriation of a resident's narcotic medication to the state regulatory agency, APS, and law enforcement in a timely manner. The DON and Administrator did not realize the incident was reportable, leading to delays and failures in required notifications.
The facility's QAA failed to maintain procedures and monitor interventions, leading to deficiencies in providing a homelike environment, reporting alleged violations, and infection control. Issues included strong urine smells in rooms, unreported misappropriation of resident property, and staff not wearing PPE during resident care.
The facility failed to implement enhanced barrier precautions when three nursing staff members did not wear PPE while providing care to a resident with chronic wounds, a urinary catheter, a gastrointestinal tube, and a tracheostomy. Despite training and infection control signage, the staff did not don gowns during high-contact care activities.
The facility failed to maintain a clean and homelike environment due to a strong urine odor in the 300 hallway and specific rooms. Despite multiple attempts to clean, residents' refusal to allow housekeeping contributed to the persistent smell. Staff and administration were aware of the issue, with suggestions to replace floor tiles to address the odor.
Failure to Provide Ordered Adaptive Drinking Equipment and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed adaptive drinking equipment and to ensure staff verified diet slips against meal trays. A resident with hemiplegia and hemiparesis following a nontraumatic intracranial hemorrhage had a physician’s order, dated 7/31/25, for a spouted cup with handle with all meals. The resident’s care plan, last reviewed 9/25/25, identified nutrition/hydration risk and included an approach to provide adaptive equipment with meal trays as ordered, specifically a spouted cup with handle. The quarterly MDS documented moderate cognitive impairment, impairment of one upper and one lower extremity, and independence with eating after tray setup. On observation, the breakfast tray diet slip specified a spouted cup with handle, but the tray contained only regular cups with lids and straws, and the beverages appeared untouched. Later observation of the lunch meal showed a nurse aide delivering the tray, placing it on the overbed table, removing the plate lid, and attempting to leave without checking the diet slip. When questioned, the aide initially stated she had not checked the diet slip and that they “didn’t really say anything,” then, after looking, failed to notice the spouted cup order and incorrectly stated the resident was not supposed to have one before correcting herself. She acknowledged that when a tray does not match the diet slip, she “just leaves it and hopes for the best,” despite having been trained on tray passing at hire. The resident reported sometimes spilling drinks when using a regular cup with lid and straw and that the spouted cup with handle was easier to use. The DON stated that staff passing trays were responsible for checking diet slips and returning incorrect trays to Dietary, and the Dietary Manager reported that multiple staff checked trays before carting and that there was adequate stock of spouted cups, yet the resident still received breakfast and lunch without the ordered assistive device.
Hazardous Cleaning Product Left at Resident Bedside
Penalty
Summary
The facility failed to maintain an environment free of hazards when a moderately cognitively impaired resident with diagnoses including diabetes, depression, and chronic kidney disease was observed with a 40-ounce bottle of multipurpose cleaner, approximately half full, on her bedside table. The cleaner’s warning label stated it could cause moderate to serious eye irritation, skin irritation, and respiratory tract irritation from vapors, and that ingestion could cause stomach distress, nausea, and vomiting. The resident reported she used the cleaner to clean spills in her room and had ordered it from a local retailer that delivered it directly to her room. The resident’s roommate was described as non-ambulatory, not self-propelling in a wheelchair, and severely cognitively impaired. Staff interviews revealed that direct care staff and nursing staff were unaware that the resident had the multipurpose cleaner in her room. A nurse aide stated she did not know the cleaner was present and acknowledged the resident should not have had it because it could cause harm if consumed or if splatter got into the eyes. A nurse reported she did not recall seeing the cleaner and stated that if aides, housekeepers, or nurses had seen it, they should have removed it immediately. The DON and Administrator both stated the resident should not have had the cleaner at the bedside, acknowledged the resident’s history of ordering items for delivery to her room, and indicated that any staff member who observed such a product should remove it and report it to leadership. North Carolina Poison Control confirmed that ingestion or eye contact with the cleaner could cause adverse effects, and the Medical Director stated she had no concerns about the resident’s exposure because she did not believe the resident would ingest it, but would call poison control if ingestion occurred.
Failure to Timely Provide Medical Records to Resident's Responsible Party
Penalty
Summary
The facility failed to provide copies of a resident's medical records to the resident's Responsible Party (RP) within 2 working days after a formal request was made. The RP, who was also the Power of Attorney, began requesting the records from the Medical Records Director several months prior to the resident's death, but the records were not provided despite repeated assurances. The RP eventually engaged legal assistance and submitted a signed consent for the records, but the Medical Records Director delayed mailing the records, believing that a 90-day timeframe applied since the resident was no longer at the facility. Interviews with facility staff, including the Medical Records Director, prior Administrator, and current Administrator, confirmed that the request was received and not fulfilled within the required 2 working days. The Senior Nurse Consultant acknowledged that not providing the records within this timeframe was a problem. The deficiency was identified for one resident who had expired, and the delay in providing records was attributed to a misunderstanding of the required timeframe for record release after discharge or death.
Inaccurate MDS Coding for Tobacco Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of tobacco use. The resident, who had a diagnosis of bipolar disorder with manic delusions, was admitted to the facility and was documented in the care plan and observation records as a smoker who understood and followed the facility's smoking policy. However, the annual MDS assessment incorrectly indicated that the resident did not use tobacco. Staff interviews revealed that the MDS was completed by a nurse from the corporate office during the regular coordinator's absence, and both the Case Mix Coordinator and the DON confirmed that the resident was a smoker and should have been coded as such. The error was attributed to oversight during the assessment process.
Resident Smoked Indoors in Violation of Facility Policy
Penalty
Summary
A deficiency occurred when a resident with a diagnosis including bipolar disorder with manic delusions was observed smoking a cigarette inside the facility lobby, in violation of the facility's smoking policy that prohibits smoking indoors at any time. The resident had been assessed as cognitively intact, able to self-propel in a wheelchair, and was care planned as a safe, independent smoker who could keep smoking materials in a lock box in her room. Staff interviews confirmed that the resident had previously understood and agreed to the smoking policy, and there were no prior incidents of indoor smoking reported for this resident. On the day of the incident, the resident was seen lighting and smoking a cigarette in the lobby area, away from other residents with oxygen. Staff intervened by escorting the resident outside and attempting to retrieve her smoking materials, which led to the resident becoming combative and the police being called. The resident was subsequently sent to the emergency room for evaluation due to escalating behaviors and later returned to the facility under one-to-one supervision. The facility's policy allowed certain residents, grandfathered in from a previous administration, to retain smoking materials in their rooms if assessed as safe smokers, which applied to this resident prior to the incident.
Failure to Notify Responsible Party of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's change in condition when the resident's fingerstick blood sugar (FSBS) levels exceeded 500 milligrams per deciliter on multiple occasions. The resident, who was admitted with diagnoses including diabetes, dementia, and a femur fracture, had a physician order for insulin lispro to be administered according to a sliding scale. Despite the elevated FSBS levels recorded on 10/01/24, 10/02/24, and 10/03/24, there was no documentation that the RP was informed of these critical changes. Nurse #3, who was responsible for monitoring the resident's FSBS levels, did not notify the RP of the elevated readings, citing the time of night and the non-life-threatening nature of the situation as reasons. The nurse did notify the on-call provider and administered additional insulin as instructed, which temporarily reduced the blood sugar levels. However, the RP was only informed of the elevated levels when the resident was transferred to the hospital on 10/05/24, after becoming unresponsive. The Director of Nursing confirmed that the RP should have been notified of the elevated blood glucose levels.
Missed Antibiotic Doses Due to Unverified Physician Order
Penalty
Summary
The facility failed to administer scheduled antibiotic medication to a resident, resulting in three missed doses. The resident, who had a history of urinary tract infection (UTI), was admitted to the facility with a discharge diagnosis that included a UTI. However, it was unclear if the resident had been treated for the UTI during a prior hospital stay. A physician order for ciprofloxacin, an antibiotic, was written to treat the UTI, but the medication was not administered as scheduled. The deficiency occurred because the physician order for ciprofloxacin was not verified by the nursing staff, which prevented the order from being sent to the pharmacy and appearing on the Medication Administration Record (MAR). Multiple nurses involved in the resident's care were unaware of the order or did not verify it in a timely manner. The order was eventually verified by a nurse, but not until after the scheduled doses had been missed. Interviews with the nursing staff and facility management revealed a lack of clarity and responsibility in verifying physician orders. The Director of Health Services stated that the nurses or the Unit Manager were responsible for verifying orders, but the order for ciprofloxacin was not verified, leading to the missed doses. The Medical Director and Nurse Practitioner were not informed of the missed doses, and the facility's system for verifying and administering medications was not followed, resulting in the deficiency.
Failure to Administer Prescribed Lorazepam Leads to Increased Anxiety
Penalty
Summary
The facility failed to administer prescribed medications to a resident, identified as Resident #45, who was diagnosed with hypertension, anxiety disorder, and asthma. The resident was prescribed lorazepam, an anti-anxiety medication, to be taken four times a day, as well as a PRN dose. However, due to an error by the Director of Nursing (DON), the scheduled lorazepam was erroneously discontinued on the Medication Administration Record (MAR) from 7/29/24 to 8/1/24, resulting in the resident missing 10 consecutive doses. This error led to the resident experiencing increased anxiety, as noted by the Nurse Practitioner (NP) on 8/1/24, who observed the resident crying and asking for his medication. The error occurred when the pharmacy sent an alert indicating that Resident #45 had two lorazepam orders. The DON mistakenly discontinued the scheduled lorazepam, believing it was a duplicate order. Despite the availability of PRN lorazepam, it was not administered during this period. Interviews with nursing staff revealed confusion and lack of clarity regarding the administration of the medication, with some nurses unaware of the discontinuation and others believing the family had requested the medication to be stopped. The resident's family member confirmed that they had only requested a single dose to be held for a visit and had not asked for the medication to be discontinued. The Psychiatric Nurse Practitioner and the Pharmacist both indicated that lorazepam should not have been abruptly stopped, as it could lead to increased anxiety and other withdrawal symptoms. The facility's Administrator acknowledged the error, attributing it to the medication re-order system setup, which led to the oversight in medication administration.
Failure to Use Mechanical Lift for Resident Transfer
Penalty
Summary
The facility failed to provide a safe transfer for a resident who required a mechanical lift, as assessed by a physical therapist. The resident, who was moderately cognitively impaired and dependent on staff for transfers, was transferred from bed to chair by two nursing assistants without the use of a mechanical lift. This occurred despite the resident's care plan indicating a risk for falls and the physical therapist's assessment that a mechanical lift was necessary due to the resident's inability to stand safely. The incident involved a resident with acute and chronic respiratory failure, anxiety, muscle weakness, and pneumonia, who was admitted to the facility with a need for supplemental oxygen. On the day of the incident, the resident informed the nursing assistants to use a mechanical lift, but they proceeded with a manual transfer, causing the resident to feel as though she was falling and resulting in pain and shortness of breath. The nursing assistants were unaware of the requirement for a mechanical lift, as the care card only indicated a two-person assist. Interviews with staff revealed a lack of a formal communication process between therapy and nursing staff regarding transfer methods. The physical therapist had verbally communicated the need for a mechanical lift to a nurse, but this information was not documented or relayed to the nursing assistants. The Director of Nursing acknowledged the absence of a set system for communicating transfer requirements, which led to the unsafe transfer of the resident.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a rate of 7.41% due to two medication errors involving a single resident. The errors were identified during an observation of medication administration by Nurse #1, who crushed and administered medications in applesauce contrary to the resident's orders. The resident was prescribed a 325 mg aspirin and a 50 mg Metoprolol Succinate extended-release tablet, both of which were to be given whole in puree. Nurse #1 admitted to crushing the medications because the resident had difficulty swallowing them whole, and she used an enteric-coated aspirin instead of a regular one due to availability in her cart. The errors were further confirmed through interviews with the nurse, pharmacist, Director of Nursing (DON), and the physician. The pharmacist and DON highlighted that crushing Metoprolol Succinate extended-release alters its release properties, potentially affecting the resident's blood pressure and pulse. The physician confirmed that the resident did not have an order for medications to be crushed and emphasized the risks associated with crushing enteric-coated aspirin. The facility's failure to adhere to the prescribed medication administration method led to these errors.
Failure to Include Estimated Costs on SNF/ABN Forms
Penalty
Summary
The facility failed to provide a complete Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF/ABN) by omitting the estimated cost of services for two residents. Resident #286 was admitted to the facility and began receiving Medicare Part A services on December 27, 2023. A Notice of Medicare Non-Coverage (NOMNC) was issued to Resident #286's representative on March 11, 2024, indicating that Medicare coverage would end on March 13, 2024. However, the SNF/ABN form dated March 11, 2024, did not include the estimated cost of services. Similarly, Resident #287, who began Medicare Part A services on June 14, 2024, received a NOMNC on August 12, 2024, stating that coverage would end on August 16, 2024. The SNF/ABN form for Resident #287, dated August 12, 2024, also lacked the estimated cost of services. Interviews with facility staff revealed a lack of awareness regarding the requirement to include estimated costs on the SNF/ABN forms. Nurse #2, responsible for completing the forms for both residents, stated she was unaware of the need to include estimated costs and would do so in the future. The Administrator in Training acknowledged that if estimated costs were required, they should have been included for both residents. The Administrator was also unaware that the estimated costs had not been completed for the residents and agreed that they should have been included.
Failure to Accurately Code Hospice Admission in MDS
Penalty
Summary
The facility failed to accurately code a significant change in status Minimum Data Set (MDS) assessment for a resident who elected hospice care. The resident, who was readmitted to the facility with acute respiratory failure, acute pneumonitis, and Alzheimer's dementia, was admitted to hospice on August 19, 2024. However, the MDS completed on the same day did not reflect this significant change. During an interview, the MDS nurse acknowledged awareness of the resident's hospice admission but was unsure how the information was omitted from the MDS. The facility's administrator also confirmed that the MDS should have captured the hospice admission.
Unattended and Unlocked Treatment Cart
Penalty
Summary
The facility failed to ensure that medications were securely stored in a locked treatment cart, as observed with Treatment Cart #1. On the specified date, the treatment cart was found unlocked and unattended in the 100 hall. During this time, a resident approached the cart and stopped approximately five feet away, while a nurse aide, a restorative aide, and a visitor walked past the unlocked cart. The MDS Nurse, upon noticing the cart was unlocked, proceeded to lock it. Interviews with staff revealed that the treatment cart was under the responsibility of Treatment Nurse #1, who acknowledged that the cart should be locked when unattended but could not provide a reason for it being left unlocked. The cart contained various medications and ointments, including calmoseptine ointment, triamcinolone acetonide cream, and nystatin ointment. The Director of Nursing confirmed that treatment carts are required to be locked when not in use.
Failure to Follow Hand Hygiene Protocols During Medication Administration
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies during medication administration, as observed with Nurse #1. The nurse did not perform hand hygiene before donning gloves and after glove removal while administering medications and conducting a blood glucose test for a resident. The facility's policy, dated 10/17/2023, clearly states that hand hygiene should be performed before and after glove use during medication administration. However, during an observation on 9/10/24, Nurse #1 was seen putting on gloves without prior hand hygiene and removing gloves without subsequent hand hygiene after completing the tasks. In interviews conducted on the same day, Nurse #1 acknowledged her failure to perform hand hygiene, attributing it to nervousness and a headache. The Infection Preventionist confirmed that hand hygiene should have been performed after glove removal. The Director of Nursing also stated that nurses receive infection control training upon hire and annually, and confirmed that Nurse #1 should have followed the hand hygiene protocol before and after glove use during the procedure.
Misappropriation of Controlled Medication
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of a controlled medication. Specifically, 30 Oxycodone 5mg pills prescribed for pain management were unaccounted for. The resident, who was moderately cognitively impaired, was unaware of the missing medication and did not recall any disruption in his pain management. The issue was discovered during a narcotic count at shift change, and the Director of Nursing (DON) was notified. The facility conducted an internal investigation, notified law enforcement and the pharmacy, and searched all medication carts and med rooms, but the medication was not found. Interviews with the DON revealed that the narcotics were kept double-locked, and both the nurse and an orientee working that night passed voluntary drug screening tests. The Administrator confirmed that the narcotic count sheet had been moved within the binder, and the medication cart was parked out of camera view for part of the shift. Despite these efforts, the missing medication was not recovered, and the facility covered the cost to replace it. The pharmacist also assisted in the investigation but was unable to locate the missing medication.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to submit an initial or investigation (5-day) report to the state regulatory agency and did not notify Adult Protective Services (APS) regarding an allegation of misappropriation of resident property. Specifically, the Director of Nursing (DON) received a phone call from a nurse on 9/7/23 reporting that a card of narcotic medication belonging to a resident was unaccounted for during a shift change medication count. The facility did not notify law enforcement until 9/13/23, and there was no indication that APS was notified at all. The DON admitted to not sending the required reports to the state regulatory agency and not notifying APS, as she did not realize the incident was reportable. The Administrator also failed to report the incident, thinking it was more of a diversion issue rather than misappropriation of resident property. The DON and the Administrator both acknowledged their failure to report the incident to the appropriate authorities. The DON spent five days searching for the missing medication before notifying law enforcement. The Administrator confirmed that no initial or 5-day investigation report was sent to the state regulatory agency and that APS was not notified. Both the DON and the Administrator did not categorize the missing medication as misappropriation, leading to delays and failures in reporting the incident as required by regulations.
Quality Assurance Failures in Multiple Areas
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor interventions that were previously put in place following recertification and complaint investigation surveys. This failure was evident in three recited deficiencies: Safe/Clean/Comfortable/Homelike Environment (F584), Reporting of Alleged Violations (F609), and Infection Control (F880). Specifically, the facility failed to provide a room free of a strong smell of urine, failed to report an allegation of misappropriation of resident property to the state regulatory agency and Adult Protective Services (APS), and failed to implement their policies and procedures for wearing Personal Protective Equipment (PPE) when providing care to a resident. These deficiencies were observed during multiple surveys, indicating a pattern of the facility's inability to sustain an effective Quality Assurance Program. In the case of F584, the facility was cited for failing to keep walls, resident furniture, and sinks in good condition, and for not addressing water damage, leaking plumbing, and black substances on walls. For F609, the facility did not report an allegation of misappropriation of resident property within the required time frame. For F880, nursing staff members were observed not wearing PPE when providing care to a resident, despite the facility's policies and procedures. The Administrator acknowledged these issues and mentioned that overcoming certain citations is difficult due to the need for corporate approval for funds to fix walls and replace resident furniture. Additionally, a citation for failure to report was attributed to a fax issue, which has since been resolved by using a different fax machine.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement their enhanced barrier precautions policies and procedures for wearing Personal Protective Equipment (PPE) when three nursing staff members were observed not wearing PPE while providing care to a resident. The resident had chronic wounds, a suprapubic urinary catheter, a gastrointestinal tube, and a tracheostomy, all of which required enhanced barrier precautions. Despite the infection control signage on the resident's door and the facility's guidelines, the staff did not don gowns during high-contact care activities such as wound care, catheter care, tube feeding, and tracheostomy care. Interviews with the nursing staff revealed that they had received enhanced barrier precautions training but failed to follow the protocols due to nervousness and falling out of practice. The Administrator and the Director of Nursing confirmed that the staff had been trained but were unsure why the protocols were not followed. The deficiency was observed during multiple instances of care provided to the resident, highlighting a lapse in adherence to infection control measures.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a room free of a strong smell of urine, which extended into the hallway. This issue was observed in two rooms on the 300 hall. During observations on multiple days, a strong urine odor was detected in the 300 hallway and specific rooms. Interviews with residents, staff, and the Housekeeping Director confirmed the persistent urine smell. The Housekeeping Director noted that the residents in the affected rooms refused to allow housekeeping to clean their rooms, and one resident was known to urinate in trashcans and on furniture. Nursing assistants and nurses working in the area corroborated the presence of the strong urine odor and the residents' resistance to care and room cleaning. The Maintenance Director suggested that the floor tiles might need replacement to eliminate the odor. The Administrator and Director of Nursing were aware of the issue, with the Administrator mentioning plans to retile the floor in one of the rooms. Despite multiple attempts by the facility to clean the rooms, the residents' refusal to permit cleaning contributed to the ongoing problem. The deficiency was evident in the strong urine odor that permeated the 300 hall and specific rooms, affecting the residents' right to a safe, clean, and homelike environment.
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 18 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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 New Bern
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth-trent | 0.2 mi | ★★★★★ | 6 | 2 |
| Bayview Nursing & Rehabilitation Center | 2.6 mi | ★★★★★ | 2 | 0 |
| Riverpoint Crest Nursing And Rehabilitation Center | 4.5 mi | ★★★★★ | 9 | 0 |
| Brook Stone Living Center | 11.8 mi | ★★★★★ | 0 | 0 |
| Grantsbrook Nursing And Rehabilitation Center | 14.1 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pruitthealth-neuse.
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 August 2026) and official state health department websites.