Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pruitthealth-raleigh during CMS and state inspections, most recent first.
A cognitively intact resident was unable to control an overhead light because the pull string was broken and the wall-mounted light was positioned behind the bed, out of reach. The resident reported the string had been broken since admission, slept with the light on, and had not filed grievances or informed staff. The Maintenance Director confirmed there was no way for the resident or staff to turn the light on or off and that no work orders existed for the issue, noting other lights on the hall had been replaced but not this one due to plans to convert the room to an office. The NA who typically worked the hall, the DON, and the Administrator all stated they were unaware of the problem, had received no complaints, and that the resident had not reported being unable to operate the light.
A resident with Parkinson’s disease, dementia, and weakness had a provider order for all medications to be given whole in applesauce, including delayed-release aspirin and bisacodyl. The MAR did not reflect this instruction, and nursing documentation showed that at times medications were given whole in applesauce and at other times were crushed in applesauce. Nurses reported crushing all of the resident’s medications, including extended-release drugs, based on their own discretion when the resident was slow to swallow, without evidence of actual swallowing difficulty, without notifying the provider, and without documenting a change in condition. The NP stated slowness in taking medications was not an indication to crush them and that no concerns had been communicated, while the DON stated nurses were expected to follow orders and seek provider input if whole medication administration was unsafe.
A resident with dementia and depression on a locked memory care unit, whose MDS documented severe cognitive impairment and specific activity preferences (reading, music, pets, news, groups, outdoor time, and religious services), had no activity-related goals or interventions in the care plan or Kardex and no documentation of participation in group, 1:1, or self-directed activities. Observations showed the resident sitting passively in common areas without engagement, while interviews revealed that Activities staff did not provide services on the memory care unit, there was no activity calendar, and nursing staff only occasionally offered non-individualized activities such as TV, music, or bingo without documentation. The Activity Director reported not completing activity assessments for memory care residents and being unaware they were required, and leadership acknowledged previously identified gaps in specialized activities, assessments, and documentation for the unit.
A controlled medication and its count sheet intended for return to the pharmacy went missing after a resident's discharge, due to incomplete return procedures and lapses in medication security. Nursing staff failed to follow established protocols for handling and documenting the return of discontinued controlled substances, leading to the loss of both the medication and its records.
A nurse failed to accurately document the administration of PRN Oxycodone HCL for a resident, as doses signed out on the narcotic count record were not recorded on the MAR. The nurse could not recall if documentation was completed, and the DON confirmed that accurate and prompt documentation was expected. This resulted in incomplete and inaccurate medical records for the resident.
A resident suffered a fall in a contracted transport van when their wheelchair flipped backwards, resulting in a head and back injury. The transport driver, unqualified to assess injuries, moved the resident without seeking medical evaluation and failed to notify facility staff of the incident. The resident later reported severe pain and was found to have a lumbar fracture, with care delayed due to the lack of timely reporting and assessment.
A contracted transport driver failed to secure a resident's wheelchair, resulting in a fall during transport. The driver moved the resident without a clinical assessment and did not notify nursing staff of the incident, leading to delayed recognition and treatment of a spinal fracture. The resident, who had multiple amputations and severe cognitive impairment, returned to the facility in severe pain and required hospital evaluation.
A contracted transport driver failed to secure a resident's wheelchair in a van, resulting in the wheelchair flipping backwards during transit and causing the resident to sustain a vertebral fracture and severe pain. The resident, who had significant mobility and cognitive impairments, was not properly restrained, and the incident was not immediately reported by the driver. Facility staff identified the injury upon the resident's return, and the deficiency was confirmed through interviews and medical record review.
The facility inaccurately coded the MDS for several residents, leading to deficiencies in documenting Gradual Dose Reduction, Discharge Location, and Restraints. A resident on antipsychotic medication had a GDR contraindication not documented, another had a non-antipsychotic medication incorrectly coded as a GDR attempt, a resident's discharge location was miscoded, and a restraint was inaccurately documented. Staff interviews confirmed these errors.
A resident with a urinary catheter was observed with the catheter bag resting on the floor, contrary to infection control protocols. Despite staff training, the deficiency was noted during observations, and staff interviews confirmed the correct procedure was not followed.
Two residents were not offered the opportunity to participate in their person-centered care planning due to staffing shortages in the MDS department. Both residents, who were cognitively intact and required assistance with daily activities, had not been included in care plan meetings, and their care plans had not been reviewed or revised in a timely manner.
The facility did not include the resident census in the daily staffing postings for four consecutive days. The Staffing Coordinator was unaware of how to access the census and often forgot to update it due to being busy with resident care. The Administrator was not aware of this omission.
A resident's medication and treatment records were found incomplete for both day and night shifts, with missing documentation for various treatments and medications. Interviews with staff revealed a lack of awareness and recollection regarding the incomplete records, and the facility's administration was unaware of the issue.
Failure to Ensure Resident Access to Operable Overhead Light Control
Penalty
Summary
The facility failed to reasonably accommodate a resident’s preference and ability to control her overhead light. The cognitively intact resident was observed in bed with the overhead light on, and there was no pull string attached to the wall-mounted light located behind her head, leaving her unable to operate it. The resident reported that the string had been broken since her admission in December, that she slept with the light on all night and could sleep fine that way, but that she would like the option to turn the light off. She stated she did not recall submitting any grievances, reporting the issue to staff, or asking staff to turn the light off. The Maintenance Director confirmed during a room observation that there was no way for the resident or staff to turn the overhead light on or off, including at night, and that there were no open work orders for that hall. He stated the light issue was a simple fix and noted he had replaced other lights on the hall but not this one because the room was planned to be converted to an office. The NA who typically worked the hall stated she routinely asked residents if they wanted the light on or off and would notify Maintenance if there was a problem, but she was not aware the resident lacked a string or a way to control the light and had not noticed the broken string; the resident had not informed her of the issue. The DON and Administrator both reported they were unaware of the problem, had received no complaints from the resident, and indicated that many residents sleep with a light on, so staff may not have immediately noticed that residents were unable to turn off their lights.
Failure to Follow Medication Administration Orders and Manufacturer Instructions
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to the physician’s orders and manufacturer’s instructions for one resident with Parkinson’s disease, dementia, and weakness. The resident was severely cognitively impaired and required substantial/maximal assistance with eating and oral hygiene. A physician’s order dated 12/25/2025 specified that the resident’s medications were to be given whole in applesauce. Active medication orders included delayed-release aspirin 81 mg once daily, carbidopa-levodopa 25-100 mg three times daily, and delayed-release bisacodyl 5 mg at bedtime. The January 2026 MAR did not include instructions to administer medications whole in applesauce. Manufacturer instructions for delayed-release aspirin and bisacodyl stated these medications must not be chewed, crushed, or broken because crushing destroys the enteric coating and may cause severe stomach irritation. Nursing documentation and interviews showed inconsistent and inappropriate medication administration practices. Nursing notes by one nurse on multiple dates in early January documented that the resident tolerated medications given whole in applesauce, while other notes by the same nurse and another nurse documented that medications were crushed in applesauce. One nurse documented crushing medications due to the resident’s “slow alertness,” and in an interview admitted she crushed all of the resident’s medications on a shift despite knowing the order required them to be given whole in applesauce and acknowledging that some were extended-release. Another nurse stated she crushed the resident’s medications on days when the resident was “slow” to swallow, even though the resident was not having difficulty swallowing, did not notify the provider, and did not document a change in condition, believing she could use nursing discretion. The NP stated that being slow to take medications was not an indication to crush them and that she had not received any communication about swallowing difficulties. The DON stated nurses were expected to administer medications as ordered and to notify the physician or request a swallowing evaluation if it was unsafe for a resident to take medications whole.
Failure to Provide Resident-Centered Activities Program on Memory Care Unit
Penalty
Summary
The facility failed to provide an ongoing, resident-centered activities program for a resident with dementia and depression residing on the locked memory care unit. The resident’s MDS annual assessment showed severe cognitive impairment and documented that it was important to her to have reading material, listen to music, be around pets, keep up with news, be around groups of people, go outside, and participate in religious services. Despite these identified preferences, her care plan last reviewed on 11/18/25 contained no goals or interventions related to activities, and her Kardex included no mention of activities. Record review showed no documentation of her participation in group activities, 1:1 sessions, or self-directed activities. Observations on two separate days found her sitting passively in common areas (hallway looking out the window and in the memory care common area) without engagement in meaningful activities, and she was not watching the television that was on in the unit. Staff interviews confirmed that the structured activities program did not extend to the memory care unit. Nurse #1 reported that Activities staff did not conduct activities on the memory care unit and that nursing staff only sometimes played music, turned on the television, or assisted residents with bingo, timed to minimize disruption to care routines. She stated that activities were not individualized according to residents’ MDS-identified preferences and were instead based on ad hoc resident requests, with no documentation of activities provided by nursing staff. The Activities Director stated he did not conduct activities or complete activity assessments for residents on the memory care unit, there was no activity calendar for that unit, and he was unaware that assessments for those residents were required. The Administrator and Corporate Nurse Consultant acknowledged previously identified issues with the memory care activities program, including lack of specialized activities, missing activity assessments, absence of 1:1 activity documentation, and the Activities Director’s lack of necessary certification at the time.
Failure to Secure and Return Controlled Medication Results in Diversion
Penalty
Summary
The facility failed to maintain effective systems for the return of controlled medications to the pharmacy, resulting in the diversion of a controlled substance for one resident. A resident was discharged from the facility, and 11 tablets of 5 mg oxycodone HCL remained to be returned to the pharmacy. The process for returning these medications was started by a nurse but not completed, and the medication, along with the narcotic count sheet, subsequently went missing from the medication cart. Multiple staff interviews confirmed that the medication and count sheet were present during the morning shift change but were discovered missing during the evening shift narcotic reconciliation. Nursing staff provided conflicting accounts regarding the handling and storage of the controlled medication and associated documentation. One nurse stated she believed she had returned the medication and count sheet to the narcotic drawer but was unsure if she may have inadvertently discarded them. Another nurse reported that the return process for the narcotics had been started but not completed, and that it was the responsibility of all nurses to ensure discontinued or discharged medications were returned to the pharmacy. The Director of Nursing confirmed that the process required completion of a return form, placement of the medication and count sheet in a bag, and transfer to a locked safe in the DON's office, but this process was not followed in this instance. The missing medication and documentation were reported to the Director of Nursing, and an internal investigation was initiated. The police were notified, but the missing items could not be located, and no charges were filed due to lack of evidence. The incident revealed lapses in medication security, incomplete documentation, and failure to follow established procedures for the return of controlled substances, resulting in the loss of a controlled medication and its associated records.
Failure to Accurately Document PRN Narcotic Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for a resident prescribed Oxycodone Hydrochloride (HCL), a controlled opioid medication. A physician's order specified that the resident was to receive Oxycodone HCL 5 mg every six hours as needed for moderate to severe pain. Review of the narcotic controlled substance count record showed that a nurse signed out doses of Oxycodone on multiple dates. However, corresponding entries were missing from the Medication Administration Record (MAR) for each of those instances, indicating that the medication was not documented as administered in the resident's medical record. During interviews, the nurse involved could not recall whether she had documented the administration of the medication on the MAR for the dates in question. The Director of Nursing (DON) confirmed that the expectation was for nursing staff to document medication administration accurately and promptly after giving the medication. The discrepancy between the narcotic count sheet and the MAR demonstrated a failure to maintain accurate and complete medical records in accordance with accepted professional standards.
Neglect Following Unreported Fall During Resident Transport
Penalty
Summary
A deficiency occurred when a contracted transport driver failed to protect a resident from neglect during transportation from a medical appointment. The resident's wheelchair flipped backwards in the transport van, causing the resident to fall and sustain a head and back injury. The driver, who was not qualified to assess injuries, asked the resident if she was okay, set the wheelchair upright, secured it, and continued the trip without seeking medical evaluation or notifying facility staff of the incident. Upon arrival at the facility, the driver only informed staff that the resident was not feeling well and wanted to go to bed, deliberately withholding information about the fall. The resident later reported severe pain in her neck, shoulders, and back, rating it as 10 out of 10, and staff observed her in significant distress. Despite administration of opioid pain medication, the resident's pain persisted, and she was subsequently transferred to the hospital, where she was diagnosed with a fracture at the superior endplate of the L1 vertebra. The contracted transport driver's actions, including moving the resident without a clinical assessment and failing to report the fall to facility staff, resulted in delayed care and prolonged suffering for the resident. The facility's initial report identified the driver as the accused individual in an allegation of neglect, and the incident was determined to constitute neglect due to the disregard for the resident's need for timely clinical assessment and appropriate care following the fall.
Removal Plan
- Ceased use of the vendor for the company that provided transportation for Resident #1.
- Completed an audit of all facility falls to verify that all residents were assessed by a licensed nurse for injury following a fall and that non-medical staff notified qualified staff to perform a clinical assessment prior to the resident being moved.
- Completed an investigation for any concerns identified during the audit and took appropriate follow-up action based upon the results.
- Provided training for all contract transport drivers from the new Transportation Vendor on notifying 911 to assess the resident for injury prior to moving the resident and the requirement to notify the facility of falls by calling the facility at the time of the fall after calling 911.
- Provided training for contract transport drivers on identifying and reporting neglect, including examples of what constitutes neglect, completed by Contract Transportation Vendor Supervisors.
- Required that all contract transport drivers for the Transportation Vendor complete this training prior to being assigned transportation trips for facility residents, with documentation provided to the Administrator.
- Required that newly hired contract transport drivers for this vendor receive this training prior to being assigned transportation trips for facility residents.
- Re-educated 100% of facility staff regarding the facility policy for Abuse Identification, including indicators of neglect and reporting neglect, with examples.
- Department Supervisors provided this education for their respective staff, and all staff who did not complete this training received it prior to working their next shift.
- Clinical Competency Coordinator responsible for tracking to ensure 100% of staff receive the training, including during general orientation for all newly hired staff.
- Re-educated 100% of facility staff regarding the facility policy not to move the resident after a fall until examined by a licensed nurse for possible injuries.
- Provided training to 100% of the facility's transport drivers related to ensuring the resident is assessed by a qualified professional in the event a fall occurs during transportation and prior to moving the resident, including calling 911 and notifying the facility.
- Required that newly hired facility transportation drivers receive this training prior to being assigned transportation trips for facility residents.
Failure to Ensure Clinical Assessment After Resident Fall During Transport
Penalty
Summary
A contracted transport driver failed to have a resident assessed for injury by a qualified professional prior to moving the resident after a fall in a transportation van. The driver also did not notify facility nursing staff of the fall, which delayed the clinical assessment and treatment of the resident. Upon return to the facility, the resident reported severe pain in the neck, shoulders, and back, and it was later determined that the resident had suffered a fracture at the superior endplate of the L1 vertebra. The resident involved had a history of left above-the-knee amputation, right below-the-knee amputation, and was dependent on dialysis. The resident was severely cognitively impaired, dependent on staff for transfers, and used a wheelchair for mobility. The incident occurred when the resident's wheelchair flipped backwards in the van due to the driver failing to secure it. The driver lifted the resident and the wheelchair back upright without a clinical assessment and returned the resident to the facility, only reporting that the resident was in pain and wanted to go to bed, without disclosing the fall. Facility staff became aware of the incident only after the resident reported the fall and her pain. The nurse on duty assessed the resident, administered pain medication, and contacted the physician, who ordered the resident to be sent to the emergency department. The contracted transport driver did not follow required procedures for reporting and responding to the fall, and the lack of immediate clinical assessment posed a high likelihood of further injury and delayed necessary treatment.
Removal Plan
- The Director of Nursing (DON) will review all facility falls to verify that all residents were assessed by a licensed nurse for injury following a fall and non-medical staff notified staff who were qualified to perform clinical assessments prior to the resident being moved. The facility will complete an investigation for any concerns that are identified and take appropriate follow-up action based upon the results of the investigation. The Administrator will assume responsibility to ensure the investigation and follow-up are completed.
- The Contracted Transportation Company Owner will provide training for all contract transport drivers who transport residents from the facility. Training will be provided by the Contract Transportation Vendor Supervisors and will include notifying 911 to assess the resident for injury prior to moving the resident and the requirement to notify the facility of falls by calling the facility at the time of the fall after calling 911. All contracted transport drivers this Transportation Vendor sends to the facility will have this training completed prior to being assigned transportation trips for the facility residents. Training documentation will be provided to the Administrator by the Contracted Transportation Company Owner or Designee to be maintained at the facility. Newly hired contract transport drivers for this vendor will be provided this training by the Contracted Transportation Company Owner or Designee prior to being assigned transportation trips for the facility residents.
- Facility staff will receive re-education provided by the Administrator regarding the facility policy not to move the resident after a fall until he/she has been examined by a licensed nurse for possible injuries. Department Supervisors will provide this education for their respective staff. All staff who did not complete this training will have the training provided prior to working their next shift, provided by their respective Department Supervisor. The Clinical Competency Coordinator will be responsible for tracking to ensure that 100% of staff receive the training. This training will be provided during general orientation for all newly hired staff.
- Facility's transport drivers will receive training related to ensuring the resident is assessed by a qualified professional in the event the fall occurs during transportation and prior to moving the resident. Per the policy, they should move to the side of the road and call 911 for resident assessment by a qualified professional. Per policy, the facility transport driver will notify the facility of any fall that occurs during transport. The facility's Transport Driver training was provided by the facility Maintenance Director.
- Newly hired facility transportation drivers will be provided training related to ensuring the resident is assessed by a qualified professional in the event the fall occurs during transportation and prior to moving the resident. Per the policy, they should move to the side of the road and call 911 for resident assessment by a qualified professional. Per policy, the facility transport driver will notify the facility of any fall that occurs during transport provided by the Maintenance Director.
Failure to Secure Wheelchair in Transport Van Results in Resident Injury
Penalty
Summary
A deficiency occurred when a contracted transport driver failed to secure a resident's wheelchair in accordance with the manufacturer's instructions prior to departing from a dialysis clinic. The wheelchair was not attached to the van's floor securement system, which resulted in the wheelchair flipping backwards during transit. The resident, who remained in the wheelchair, struck her head and back on the van floor, leading to immediate and severe pain. The resident involved had a history of left above-the-knee and right below-the-knee amputations, was dependent on dialysis, and had severe cognitive impairment, requiring staff assistance for transfers and wheelchair mobility. Prior to the incident, the resident's pain was managed with PRN ibuprofen and tramadol, and she was not coded for pain or opioid use on her most recent assessment. On the day of the incident, the resident returned from dialysis reporting severe pain, and staff observed her moaning, crying out, and unable to sit upright in her wheelchair. She was subsequently transferred to the hospital, where imaging revealed a fracture at the superior endplate of the L1 vertebra. Interviews and documentation confirmed that the contracted transport driver was distracted while loading the resident, failed to secure the wheelchair, and did not report the incident to facility staff. The driver admitted to the error after being contacted by the transportation company. Facility staff, including nurses and nurse aides, noted the resident's distress and pain upon her return, and the incident was reported to the facility's DON and administrator. The event was substantiated through interviews with the resident, staff, and the contracted transportation company, as well as review of medical records and pain assessments.
Removal Plan
- Ceased use of the outside vendor responsible for transportation of Resident #1.
- Identified all residents transported by all transportation providers using the facility transportation calendar.
- Social Worker identified alert and oriented residents on this list using the Brief Interview for Mental Status (BIMS) score of 10 and above.
- Social Services interviewed alert and oriented residents to identify any incident where the transport driver failed to safely secure the wheelchair in the transportation van.
- Facility licensed nurses completed a Skin Note and Pain Assessment for all residents with a BIMS of less than 10 who had transportation to identify potential injury.
- Facility completed investigations and appropriate follow-up action for any concerns identified during interviews and assessments.
- Administrator assumed responsibility to ensure investigations and follow-up were completed.
- Administrator spoke with the Contracted Transportation Company Owner regarding the need for education and documentation.
- Contracted Transportation Vendor provided competency training for all contract transport drivers who transport residents from the facility, including a return demonstration of safely securing a wheelchair.
- Training for contracted transport drivers included the manufacturer's instructional Training Video and return demonstration.
- Training documentation for contracted transport drivers to be provided to the Administrator by the Contracted Transportation Company Owner or Designee and maintained at the facility.
- Newly hired contract transport drivers for this vendor will be provided this training prior to being assigned transportation trips for the facility residents, including a return demonstration.
- Facility's transport drivers received competency training related to securing wheelchairs in the van.
- Facility's transport driver training was provided by the facility Maintenance Director using the manufacturer's instructions and included a return demonstration.
- Newly hired facility transportation drivers will be provided this training and include a return demonstration prior to being scheduled to provide transportation trips, provided by the Maintenance Director.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for several residents, leading to deficiencies in the areas of Gradual Dose Reduction (GDR), Discharge Location, and Restraints. Resident #74, diagnosed with tactile hallucination and delusion, was receiving quetiapine, an antipsychotic medication. Despite psychiatry notes indicating that a GDR was not recommended, the MDS assessment did not document this contraindication. Similarly, Resident #15, who was on risperidone for major depressive disorder, had her MDS incorrectly coded to reflect a GDR attempt on a non-antipsychotic medication, divalproex. The MDS Nurse acknowledged these errors, attributing them to oversight and misinterpretation of the records. Additionally, Resident #146's discharge MDS was inaccurately coded as discharged to a short-term general hospital, while nursing notes indicated the resident was discharged home with family. Furthermore, Resident #44's MDS inaccurately documented the use of a trunk restraint, despite no physician orders or progress notes supporting its use. Interviews with the nursing staff confirmed these coding errors, highlighting a lack of accuracy in the MDS assessments. The facility's Administrator expressed an expectation for accurate MDS assessments, underscoring the importance of precise documentation.
Improper Urinary Catheter Bag Positioning
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident with a urinary catheter. Resident #5, who was admitted with conditions including end-stage renal disease, obstructive and reflux uropathy, and a urinary tract infection, was observed with a urinary catheter bag resting on the floor. This was noted during two separate observations on consecutive days. The resident's care plan specifically included interventions to prevent the catheter bag from touching the floor to reduce infection risk. Interviews with staff, including a nurse and a nurse aide, confirmed that the catheter bag should be kept below the bladder and off the floor. The Infection Preventionist acknowledged the concern and indicated plans for staff re-education. The Director of Nursing also confirmed that staff had been trained on proper catheter care, emphasizing the importance of keeping the catheter bag off the floor. Despite this training, the deficiency was observed, indicating a lapse in adherence to established protocols.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to offer two residents the right to participate in the development and implementation of their person-centered care plans. Resident #96, who was admitted with diagnoses including heart failure, diabetes, and depression, was cognitively intact and required substantial assistance with activities of daily living. Despite this, there was no indication that care plan meetings had been conducted for her. Her family member, who had participated in an initial care plan meeting, reported not being invited to subsequent meetings and expressed a desire to be involved in her care planning. The MDS Nurse confirmed that the department was short-staffed and had fallen behind on care plan meetings, which had not included Resident #96. Similarly, Resident #21, admitted with conditions such as cerebrovascular accident, heart failure, diabetes, and depression, was also cognitively intact and required varying levels of assistance with daily activities. He did not recall being invited to participate in his care planning. The MDS Nurse acknowledged the backlog in care plan meetings due to staffing shortages, and the Administrator confirmed that the facility was working to address the issue. Both residents' care plans had not been reviewed or revised in a timely manner, indicating a systemic issue in the facility's care planning process.
Failure to Include Resident Census in Daily Staffing Posting
Penalty
Summary
The facility failed to complete the daily staff posting sheet for four consecutive days, from November 12 to November 15, 2024. Observations on each of these days revealed that the daily staffing posting at the front desk did not include the resident census. The Staffing Coordinator, interviewed on November 15, 2024, admitted to not knowing how to access the daily census and would instead make rounds to gather accurate information. However, she often became busy assisting residents and forgot to update the census on the staffing posting. The Administrator, also interviewed on November 15, 2024, was unaware that the census had not been posted but acknowledged that it should have been included.
Incomplete Medication and Treatment Records
Penalty
Summary
The facility failed to maintain a complete and accurate medication and treatment administration record for a resident, identified as Resident #399, during a review for medical record accuracy. Resident #399 was admitted with multiple diagnoses, including chronic pain syndrome, high cholesterol, yeast infection of skin and nails, and a non-pressure chronic ulcer of the right lower leg. Physician orders for the resident included various medications and treatments, such as atorvastatin for high cholesterol, miconazole nitrate for yeast infection, and oxycodone for pain management, among others. However, on January 18, 2024, documentation for several treatments and medications, including wound care, miconazole nitrate application, COVID-19 monitoring, pain evaluation, and behavior monitoring, was missing for the day shift. Additionally, the night shift on the same day also lacked documentation for the placement of a plastic eye shield, administration of acetaminophen, atorvastatin, and oxycodone. Interviews with the nursing staff revealed that Nurse #6, who worked the day shift, could not recall why the documentation was incomplete, and attempts to interview Nurse #7, who worked the night shift, were unsuccessful. The Director of Nursing and the Administrator were unaware of the documentation gaps but acknowledged the expectation for complete and accurate records.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Raleigh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Raleigh Rehabilitation Center | 3.6 mi | ★★★★★ | 8 | 0 |
| The Laurels Of Forest Glenn | 3.9 mi | ★★★★★ | 0 | 0 |
| Bloomsbury At Hayes Barton Place | 4.5 mi | — | 0 | 0 |
| Rex Rehab & Nursing Care Center | 4.9 mi | ★★★★★ | 0 | 0 |
| Highfield Nursing And Rehabilitation | 5.2 mi | ★★★★★ | 15 | 0 |
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