Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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-rockingham during CMS and state inspections, most recent first.
Failure to respond appropriately to injury and wound care needs. One resident with a recent fracture fell while trying to transfer from bed to w/c and was moved despite c/o hip pain before being sent out and found to have a hip fx. Another resident had a skin tear to the arm/elbow that was dressed without a timely assessment or MD order, and staff interviews showed the wound was not promptly reported or documented.
The facility failed to maintain documentation of resolved grievances for nine months. The current administrator could not locate grievances from December 2023 to August 2024. The former administrator reportedly handed over the grievance log to the DON, who did not verify its contents. The Social Worker was not involved in the grievance process during the former administrator's tenure.
A nurse in an LTC facility misappropriated narcotic medications, affecting six residents. Discrepancies in medication records revealed that medications were signed out but not administered. The nurse left the facility mid-shift, leaving medication cups unattended. Staff discovered the issue, and the DON initiated an investigation, confirming the misappropriation. The incident was reported to authorities.
A nurse left her shift early, leaving pre-poured medications unsupervised on a cart, affecting multiple residents. This violated the facility's policy of preparing and administering medications one at a time. The incident was discovered by other staff, who then administered the medications. The facility lacked a process for ongoing monitoring to ensure compliance with professional standards.
A resident with dementia and impaired mobility was subjected to abuse by a nurse aide who tilted the resident's wheelchair and pushed it forcefully down the hall. Witnesses reported the incident, and the facility's investigation confirmed the abuse. The nurse aide was terminated, but the facility failed to provide a thorough plan of correction.
A facility failed to include a focus on anticoagulant therapy in a resident's care plan, despite the resident being prescribed Xarelto for atrial fibrillation. The omission was confirmed by the MDS nurse and the DON, who acknowledged that the care plan should have reflected the resident's medication regimen.
The facility failed to label and store insulin pens properly, as observed in two medication carts. An open Lantus Solostar insulin pen lacked a resident's name and prescribed dose, while unopened insulin pens were not refrigerated per manufacturer instructions. Additionally, an expired insulin pen was not discarded after 28 days. Staff interviews confirmed the need for proper labeling, storage, and disposal of insulin pens.
A resident with dementia and anxiety was denied their choice of coffee in the dining room, as a nurse aide removed them instead of fulfilling the request. The resident's preference for coffee, which helps manage anxiety, was not honored, leading to a deficiency in supporting resident self-determination.
A resident was readmitted to a facility with a sacral wound and heel redness, but the facility failed to obtain physician orders for treatment. Nursing staff applied treatments without orders, and the resident's wounds were later classified as a Stage 3 pressure ulcer and a deep tissue pressure injury. The DON confirmed the lack of orders and attributed it to new staff and the absence of a wound care nurse.
The facility failed to maintain accurate daily Posted Nurse Staffing sheets, with discrepancies found on three days between the posted sheets and the actual staff schedule. The NA/Staffing Scheduler confirmed the errors, citing a misunderstanding in counting staff splitting shifts. The Administrator was unaware of these inaccuracies.
Failure to respond appropriately to injury and wound care needs
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for two residents. One resident was admitted with a right tibia fracture and was later found on the floor after attempting to self-transfer from the bed to a wheelchair. Staff documented complaints of pain, but the resident was moved toward the wheelchair and then placed in bed when severe pain was reported. The resident was later sent to the hospital and diagnosed with a closed fracture of the left hip, with surgical repair performed the next day. Interviews with the Social Services Director and DON reflected that the resident had complained of hip pain and that leg length difference was observed, while the NP stated she had not been informed of pain or leg length difference and would have expected the resident to remain in place until EMS arrived if visible injury or pain was present. The facility also failed to assess and obtain treatment orders for a skin tear on another resident’s left arm/elbow. The resident had diagnoses including orthopedic aftercare following surgical amputation and required extensive assistance with ADLs. On observation, the resident had a dressing over the left arm/elbow area with drainage visible on the gauze, and the dressing had no date or writing. The resident stated the skin tear occurred a few days earlier during brief care when a NA turned him onto his side and he almost fell off the bed. At that time, there were no physician orders for treatment to the left arm/elbow area. Interviews showed that the wound was not promptly communicated or addressed by staff. The Hospice Nurse stated she was unaware of the skin tear and had not seen a bandage on the area during her last visit. The Wound Care Nurse stated she was not notified until later in the day, cleaned and bandaged the area, and did not initiate the treatment order or incident report that evening because she planned to do it the next day. The DON stated she was unaware of the skin tear, the missing incident report, and the lack of a treatment order when the dressing was applied, and said her expectation was that the nurse who found or was made aware of a new skin issue would initiate the treatment order, incident report, and notify the Wound Care Nurse.
Failure to Maintain Grievance Documentation
Penalty
Summary
The facility failed to maintain documentation of resolved grievances and evidence of the results of all grievances for nine out of thirteen months reviewed, from December 2023 to August 2024. During an interview, the current administrator, Administrator #1, stated that grievances from this period were not available for review as she did not have them. The Social Worker reported that the former administrator, Administrator #2, did not allow her to assist in the grievance process and was unaware of the location of the grievance log or copies of grievances. Administrator #2, when interviewed, claimed to have handed over the grievance log binder to the Director of Nursing (DON) in a box when she left the facility. The DON confirmed receiving a box from Administrator #2 in a parking lot but did not check its contents before placing it in Administrator #1's office. Administrator #1, who began working at the facility in August 2024, stated she had searched for the grievances and logs but was unable to find them. She was informed by the Social Worker that grievances were not recorded before her tenure. The facility provided Quality Assurance and Performance Improvement (QAPI) meeting minutes and a Performance Improvement Plan (PIP) dated August 2024, but these did not address the deficient practice, preventing the survey team from determining past noncompliance for grievances.
Misappropriation of Narcotic Medications by Nurse
Penalty
Summary
The facility failed to protect residents from the misappropriation of narcotic medications, specifically oxycodone and hydrocodone, affecting six residents. The issue was identified when discrepancies were found in the controlled drug forms and Medication Administration Records (MAR) for these residents. Nurse #6 was responsible for signing out the medications, but the actual pill counts did not match the documented counts, indicating that medications were signed out but not administered to the residents as recorded. Nurse #6 was observed to have left the facility mid-shift, leaving medication cups filled with pills on top of the medication cart, which was unattended. This was discovered by other staff members, including Nurse #3 and Nurse #7, who noted that the narcotic count was off and several medications were missing. The Director of Nursing (DON) was notified, and an investigation was initiated, revealing that Nurse #6 had not returned to the facility to account for the missing narcotics. Interviews with staff members, including Nurse #3 and Nurse #7, indicated that Nurse #6 had complained of a headache and expressed a temptation to take a resident's narcotic. Despite being advised against it, Nurse #6 left the facility without ensuring the narcotics were properly accounted for. The DON reviewed camera footage and confirmed that no other staff had accessed the medication cart until the discrepancies were discovered. The facility reported the incident to the appropriate authorities, including the local police department.
Medication Administration Deficiency Due to Nurse's Departure
Penalty
Summary
The facility failed to adhere to professional standards for medication administration, as evidenced by the actions of Nurse #6 during the 9:00 PM medication pass on D hall. Nurse #6 pre-poured medications into cups and left them unsupervised on top of the medication cart, affecting 13 residents. This practice was against the facility's policy, which mandates that medications be prepared and administered one resident at a time, and not pre-poured or left unattended. On the evening of the incident, Nurse #6 left the facility mid-shift to visit the emergency room for a migraine, leaving the medication cart unattended with pre-poured medication cups on top. Nurse #6 did not ensure the medications were administered or documented before leaving, nor did she secure the cart or its keys. This left the medications vulnerable and unaccounted for, as noted by other staff members who later discovered the situation. The Director of Nursing and other staff members, including Nurse #3 and Nurse #7, were involved in addressing the situation after it was discovered. They verified that the medication pass had not been completed and subsequently administered the medications to the affected residents. The facility's investigation did not reveal a process for ongoing monitoring to ensure compliance with professional standards, which was a critical oversight in preventing such deficiencies.
Failure to Protect Resident from Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when a nurse aide tilted a resident's wheelchair back, let it down, and then pushed the wheelchair forcefully down the hall. This incident involved a resident with dementia, anxiety disorder, aphasia, and lack of coordination, who was admitted to the facility with these diagnoses. The resident was known to have moderately impaired cognition and exhibited verbal behavioral symptoms, requiring assistance with activities of daily living due to impaired mobility and cognitive status. On the day of the incident, the resident was in the dining room and requested coffee after finishing his meal. The nurse aide, who was assisting other residents, attempted to move the resident by tilting his wheelchair back to lift his feet off the floor. The aide then pushed the wheelchair forcefully down the hall without ensuring the resident's safety. Witnesses, including a floor technician and a housekeeper, observed the incident and reported it to the staffing scheduler, who then informed the Director of Nursing. The facility's investigation confirmed the abuse, and the nurse aide was suspended and subsequently terminated. The Director of Nursing and Administrator reviewed video footage that corroborated the witnesses' accounts. Despite the resident's inability to recall the event, the facility substantiated the abuse allegation based on the evidence gathered. The facility did not provide a thorough plan of correction to address the failure to protect the resident from abuse, which was necessary for the survey team to evaluate eligibility for past non-compliance.
Failure to Include Anticoagulant Therapy in Care Plan
Penalty
Summary
The facility failed to develop an individualized and comprehensive care plan for a resident who was prescribed anticoagulant medication. The resident, who was admitted with diagnoses including congestive heart failure and atrial fibrillation, had an active medication order for Xarelto, an anticoagulant, to be taken daily. Despite this, the resident's care plan, updated in January 2025, did not include a focus on anticoagulant therapy. This oversight was confirmed during an interview with the MDS nurse, who acknowledged the missing focus on the care plan. The Director of Nursing also confirmed that the care plan should have accurately reflected the resident's anticoagulant medication regimen.
Improper Labeling and Storage of Insulin Pens
Penalty
Summary
The facility failed to properly label and store insulin pens in accordance with professional principles and manufacturer instructions. During an observation of the D hall medication cart, a Lantus Solostar insulin pen was found open and in use without a label indicating the resident's name or prescribed dose. Nurse #2 confirmed that insulin pens should be labeled with the resident's name and the date they were opened, and should be discarded 28 days after opening. The insulin pen was subsequently given to Nurse #2 for disposal. Additionally, an observation of the A hall medication cart revealed unopened insulin pens that were not stored in the refrigerator as required by the manufacturer's instructions. A Lantus Solostar insulin pen was also found open and available for use with a date of 12/12/24, indicating it was not discarded after 28 days as required. Nurse #5 acknowledged the need for proper storage and timely disposal of insulin pens. Interviews with the Director of Nursing and the Pharmacist confirmed the facility's procedures for insulin pen storage and labeling, and the Pharmacist noted a previous instance where an expired insulin pen was removed but later found back in the cart instead of being disposed of.
Failure to Honor Resident's Choice for Coffee
Penalty
Summary
The facility failed to honor a resident's choice to receive coffee, which was a preference expressed by a resident with dementia, anxiety disorder, and aphasia. On a specific date, a floor technician witnessed the resident requesting coffee in the dining room. Instead of fulfilling this request, Nurse Aide #1 removed the resident from the dining room, as she was occupied assisting another resident. This action was taken despite the resident's known preference for coffee, which was also used to help manage his anxiety and agitation. The resident, who had moderately impaired cognition and required setup assistance for eating, was unable to recall the incident when later observed. Interviews with the facility's Administrator and Director of Nursing confirmed that the resident should have been provided with coffee as requested. The failure to provide coffee as requested was seen as a failure to support the resident's self-determination and choice, which is a right that the facility is required to promote and facilitate.
Failure to Obtain Treatment Orders for Pressure Ulcers
Penalty
Summary
The facility failed to obtain treatment orders for pressure ulcers when a resident was readmitted from the hospital, leading to nursing staff providing treatments without a physician's order. This deficiency affected a resident who was readmitted to the facility after hospitalization for an acute stroke. Upon readmission, the resident had a wound to the sacral area and redness on the left heel, but no treatment orders were obtained from the physician for these conditions. Nursing staff applied barrier cream and dry dressings without proper orders, and the resident's care plan included interventions for wound care that were not followed due to the lack of physician orders. Interviews with nursing staff revealed a lack of recall regarding the resident's condition and the care provided upon readmission. The Wound Care Provider later evaluated the resident and classified the sacral wound as a Stage 3 pressure ulcer and the left heel as a deep tissue pressure injury, providing specific wound care orders. The Director of Nursing confirmed the absence of treatment orders and attributed the oversight to having many new nurses and the lack of a wound care nurse at the time. The deficiency highlights the facility's failure to ensure proper wound care management and documentation for the resident upon readmission.
Inaccurate Nurse Staffing Sheets
Penalty
Summary
The facility failed to ensure accurate daily Posted Nurse Staffing sheets for three specific days. A review of the daily Posted Nurse Staffing sheets compared to the Staff Schedule/Assignment sheets from January 18, 2025, through February 18, 2025, revealed discrepancies in the number of actual unlicensed Nursing Assistants (NAs) that worked. On January 24, 2025, during the first shift, the daily Posted Nurse Staffing sheet indicated that seven unlicensed staff worked, while the Staff Schedule/Assignment sheet showed only five. Similar discrepancies were found on January 27, 2025, and February 7, 2025, where the daily sheets showed more staff than the schedule sheets. During a phone interview, the NA/Staffing Scheduler confirmed the discrepancies and admitted to being unaware that two staff splitting a shift should be counted as one. The Administrator also stated she was unaware of the inaccuracies in the daily Posted Nurse Staffing sheets.
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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 Rockingham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Richmond Pines Healthcare And Rehabilitation Cente | 4.1 mi | ★★★★★ | 5 | 0 |
| Wadesboro Health & Rehab Center | 17.1 mi | ★★★★★ | 0 | 0 |
| Rehab Center Of Cheraw | 18.5 mi | — | 8 | 0 |
| Anson Health And Rehabilitation | 18.6 mi | ★★★★★ | 0 | 0 |
| Cheraw Healthcare | 19.1 mi | ★★★★★ | 9 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.