Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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-trent during CMS and state inspections, most recent first.
Failure to provide ordered restorative ROM services: A resident with lumbar spinal stenosis, HTN, and DM was assessed as cognitively intact with no ROM impairment, yet therapy and the care plan required active and active-assisted ROM to both lower extremities 6x/week. Only two restorative sessions were documented, and the resident reported missed care because the restorative aide was pulled to the unit. The restorative aide confirmed she was reassigned as a CNA and did not complete the scheduled restorative program.
A resident with multiple comorbidities, including Type 2 DM, had a critically high blood glucose one week before a fatal decline, with only a one‑time insulin dose ordered and no ongoing BG monitoring documented afterward. Over the next several days, staff observed new respiratory symptoms, increasing sleepiness, markedly reduced oral intake, inability to drink through a straw, and decreased responsiveness, yet nursing staff notified the NP only of a cough and obtained an order for a CXR, without reporting the resident’s altered mental status, poor intake, or prior critical BG. Vital signs and BG checks were not consistently obtained despite these changes, and no additional provider consultation occurred until the resident was found extremely hot and in respiratory distress, prompting EMS transfer and subsequent death in the ED. Surveyors cited the facility for failing to notify the physician of all observed changes in condition and for not securing appropriate monitoring and treatment orders.
A resident with diabetes, CKD, intellectual disability, and multiple psychiatric and neurologic conditions had an elevated HgbA1C and later a critically high serum glucose, but providers did not initiate a diabetes treatment plan or order ongoing FSBS monitoring. After a one-time dose of SQ insulin for a glucose near 500 mg/dL, no further blood sugar checks or new orders were documented, and the care plan lacked specific diabetes interventions. Over subsequent days, staff noted the resident feeling like she had a cold, then becoming unusually sleepy, not eating three consecutive meals, developing a cough with coarse breath sounds, and losing the ability to drink through a straw, yet nurses did not obtain complete VS or FSBS despite these changes, focusing instead on ordering a chest x-ray. EMS later found the resident with a blood sugar reading of "high"; in the ED she was obtunded, severely hyperglycemic, febrile, and dehydrated, and she subsequently coded and died. Surveyors determined this constituted a failure to provide comprehensive assessment, monitoring, and treatment of diabetes and to perform acute monitoring and assessment when new respiratory symptoms developed.
A resident with diet-controlled diabetes had an elevated HgbA1C result, which was reviewed and signed by an NP without a corresponding progress note documenting a plan of care at that time. At the next regulatory visit, the NP referenced an older, lower HgbA1C value and documented that the diabetes remained diet controlled with a plan to continue a healthy diet, but did not address the more recent elevated HgbA1C result. In interview, the NP reported having discussed blood sugar monitoring and treatment options with the resident and the resident’s preference for diet control, but acknowledged that this discussion and plan were not documented in the medical record.
Surveyors found that the facility failed to maintain proper food storage and kitchen cleanliness, including unsealed cereal and grits in dry storage, grainy food particles on shelf liners, and multiple food items and debris on the dry storage floor, along with a span of dried grease under the oven. A dietary aide reported difficulty cleaning under the oven due to loose parts, while the Administrator noted that the former dietary manager had left abruptly and the current dietary manager worked only part time. The dietary supervisor stated staff were supposed to clean nightly but the conditions suggested this had not occurred, and the cleaning schedule in use did not include the dry storage area, despite the part-time dietary manager having previously created a schedule that did.
The facility failed to maintain effective kitchen sanitation and food storage practices and did not coordinate or communicate adequately with pest control technicians regarding pest-contributing factors in the main kitchen. Over multiple visits, pest control staff and a health department inspector documented roach activity, food and grease buildup under equipment, dirty and wet floors, dirty drains and strainers, structural issues such as holes and peeling wall covering, and repeated food debris throughout the kitchen. Surveyors later observed live and dead roaches, open and improperly sealed dry food items, food crumbs and miscellaneous items under shelving, dried grease under the oven, and peeling wall surfaces. Dietary staff cleaning routines did not cover the dry storage area per the corporate cleaning schedule, and facility leadership and maintenance did not consistently receive or act on detailed pest control reports describing sanitation and structural concerns.
A facility failed to include a resident's advanced directive in their medical record and did not honor the resident's DNR wishes. Despite the RP indicating the resident had a DNR order, the facility recorded the resident as full code. Staff interviews revealed a lack of follow-up to ensure the advanced directives were obtained and documented, leading to a discrepancy between the resident's wishes and the facility's records.
The facility failed to attempt alternatives before installing side rails for two residents, leading to a deficiency. One resident with a traumatic brain injury and another with hemiplegia had side rails installed without prior attempts at alternatives. Staff interviews revealed a lack of awareness about the requirement to try alternatives before using side rails, and observations confirmed the consistent use of side rails.
A resident with COPD was found with their inhaler at the bedside without a self-administration assessment or physician's order. The resident self-administered the medication, which was not documented as self-administered. Nurse #3 admitted to leaving the inhaler at the bedside inadvertently. The DON confirmed that medication should not be left at the bedside without proper assessment and orders.
A facility failed to accurately code the MDS assessment for a resident who experienced a fall. The resident's quarterly MDS assessment incorrectly indicated no falls since the prior assessment, despite documentation of a fall in nursing progress notes. The MDS Coordinator admitted the oversight, and both the DON and Administrator confirmed that MDS assessments should accurately reflect the resident's status.
A facility failed to follow infection control practices for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a hemodialysis catheter. Two nurse aides provided a bed bath without wearing gowns, despite signage indicating the requirement. Interviews revealed a misunderstanding of EBP requirements among staff, including the Director of Nursing and Unit Manager, who were unaware that a hemodialysis catheter necessitated EBP.
Failure to Provide Ordered Restorative ROM Services
Penalty
Summary
The facility failed to provide restorative services as outlined in the plan of care for a resident admitted with lumbar spinal stenosis with neurogenic claudication, hypertension, and diabetes mellitus. The resident’s MDS assessment showed he was cognitively intact and had no functional impairment of ROM to the upper or lower extremities and no contractures. Therapy documentation dated 4/28/26 indicated he required active ROM and active-assisted ROM to both lower extremities six days per week to reduce the likelihood of functional loss and prevent skin integrity issues, and the care plan dated 5/3/26 repeated that requirement and directed staff to place him in the restorative nursing program for ROM exercises. Restorative documentation showed the resident was scheduled to begin restorative programming on 4/29/26 and received only two documented 15-minute sessions, one on 4/29/26 and one on 5/5/26, with no further sessions documented. The resident stated he often did not receive restorative care because the aide was assigned to the unit and could not come to him, and later stated he had not received restorative care on the prior two days. The restorative aide stated she was the only restorative aide and could not complete sessions when reassigned as a nurse aide on 5/11/26 and 5/12/26, and she did not notify anyone when reassigned. The Therapy Director, Nurse Navigator, and Administrator all confirmed the resident should have received restorative services six times per week and that significantly more restorative intervention was expected than what was documented.
Failure to Notify Physician of Significant Change in Diabetic Resident’s Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of significant changes in a resident’s condition and to obtain appropriate medical orders for monitoring and treatment. The resident had a history of Type 2 diabetes, epilepsy, schizophrenia, schizoaffective disorder, hypertension, kidney disease, prior metabolic encephalopathy, feeding difficulties, and dysphagia, and was a full code. On 1/14/26, the resident’s blood glucose was critically elevated at 466–496, and the on‑call provider ordered a one‑time dose of Novolog insulin, a recheck in one hour, and placement in the acute book for PCP follow‑up with instructions to notify if glucose remained greater than 450. The recheck that evening was 386, but there were no further documented blood glucose checks or additional orders addressing blood sugars or abnormal labs from 1/14/26 through discharge. On 1/20/26, a nurse aide observed the resident sounding like she was getting a cold, with a deeper voice, dark circles and sunken eyes, and increased sleepiness, though the resident could still drink independently with a straw and assist with turning. On 1/21/26, a day‑shift nurse aide noted a significant change from the resident’s prior baseline: the resident remained sleepy all day, did not eat breakfast, lunch, or supper (only one bite at lunch), did not converse as usual, appeared darker in color, and could not pull fluid through a straw, requiring the aide to provide about one cup of fluids by sips. The aide reported to the nurse that the resident had not eaten breakfast or lunch and that she did not feel well. However, there was no documentation that the physician was notified of these changes, and no nursing progress notes on 1/21/26 reflected physician notification of a change in condition. On 1/21/26, the assigned nurse assessed the resident for a bad cough and coarse lung sounds, believed a respiratory issue was present, and contacted the NP only about the cough, obtaining an order for a chest x‑ray. The nurse did not obtain a blood glucose level, did not take full vital signs beyond a temperature of 98.5, and did not communicate the resident’s poor oral intake, altered responsiveness, or prior critical blood sugar to the provider. Subsequent nurses on the evening and night shifts were informed that the resident was not eating and that a chest x‑ray was ordered, but they did not obtain vital signs or blood glucose checks, and they did not notify or consult the physician about the resident’s diminished responsiveness and need for total assistance with turning. In the early morning hours of 1/22/26, a nurse aide found the resident extremely warm with labored breathing; the nurse then obtained abnormal vital signs, including a temperature of 104.6°F, hypotension, tachycardia, and low oxygen saturation, and EMS was called. EMS documented a blood sugar reading of “high,” and the hospital ED documented the resident as obtunded, severely dehydrated, with a blood glucose of 882 and multiple abnormal labs. The surveyors determined that the facility failed to notify the physician of all observed changes in condition on 1/21/26 and failed to consult regarding whether additional diagnostic tests, monitoring (including blood glucose, oxygen saturation, and vital signs), or treatment were needed, leading to the cited deficiency. Immediate jeopardy was determined to have begun on 1/21/26 when staff were aware that the resident had eaten only one bite in three consecutive meals, was not pulling up fluid through a straw, was not responding to staff per her baseline, and required total assistance to turn in bed and was no longer talking, without physician notification of these changes or consultation for further orders. The facility’s failure to notify the physician regarding all changes in condition and to obtain appropriate monitoring and treatment orders for the resident’s evolving symptoms on and after 1/21/26 constituted the core noncompliance identified by the surveyors.
Removal Plan
- Provide one-to-one education to NA #1 on the importance of communicating changes in condition timely to the charge nurse.
- Hold an ad hoc Quality Assurance Performance Improvement (QAPI) meeting including the Medical Director, Administrator, DON, Social Worker to address the breakdown in the nurse-to-provider notification process related to resident change in condition.
Failure to Monitor and Treat Diabetes and Acute Status Changes Leading to Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, monitor, and treat a resident’s diabetes and to provide acute monitoring and assessment when the resident later developed respiratory symptoms in the context of uncontrolled hyperglycemia. The resident had multiple diagnoses including type 2 diabetes, chronic kidney disease, intellectual disability, schizoaffective disorder, epilepsy, hypertension, and a history of feeding difficulties and dysphagia. A HgbA1C drawn on 10/14/25 was 8.1% (above the lab’s normal range of ≤5.7%), but there was no documented plan to address this elevated result. The consultant pharmacist notified the NP on 11/5/25, suggesting initiation of Metformin or Jardiance, but the NP initialed “no change” on 11/20/25 without documenting a rationale or creating a treatment plan, and no diabetic medications were ordered. The resident’s care plan, reviewed on 12/15/25, contained a problem related to diabetes-associated fatigue but did not include any interventions for blood sugar monitoring or diabetes management. On 12/18/25, the NP documented a regulatory visit and follow-up of chronic conditions, noting the resident’s diabetes as diet controlled based on an older HgbA1C of 6.5 from 9/1/24 and did not reference the elevated 10/14/25 HgbA1C of 8.1. On 1/5/26, a different NP saw the resident for chronic issues but addressed only hyperlipidemia, hypertension, and vitamin D deficiency, and did not review or plan for the resident’s diabetes, despite the elevated HgbA1C from October. A CMP drawn on 1/13/26 and reported on 1/14/26 showed a critically high serum glucose of 466, elevated creatinine, low potassium and chloride, high CO2, and a reduced estimated GFR. A nurse notified the on-call provider via the triage system, reporting the critical glucose, a finger-stick blood sugar (FSBS) of 496, stable vital signs, and the resident’s complaint of feeling sleepy all day, and requested insulin orders. The provider ordered a one-time dose of Novolog 10 units SQ, a recheck of glucose in one hour, and notification if the result remained above 450. The insulin was administered and a repeat FSBS was documented at 386, but no further blood sugar checks or additional orders addressing the abnormal labs were documented after 1/14/26. A progress note later received from the NP, dated for a service date of 1/15/26, stated that the resident was seen for an acute visit for elevated blood glucose, that labs were at baseline except for glucose, and that the resident was asymptomatic with no signs of infection or hyperglycemia. The NP documented that staff were encouraged to monitor for signs and symptoms of hyperglycemia and infection, to take FSBS, and to notify the PCP for status changes, and referenced risks such as diabetic ketoacidosis, hyperosmolar hyperglycemic state, blindness, kidney disease, heart attack, further decline, and rehospitalization if left untreated and unmonitored. However, no orders were actually written for FSBS monitoring or repeat HgbA1C, and no further blood sugar checks were documented from 1/14/26 through discharge. On 1/19/26, the resident received a COVID vaccine and had a recorded temperature of 97.6; this was the last documented vital sign before the acute decline. Over 1/19/26 and 1/20/26, nursing and NA staff reported the resident appeared at baseline. On the evening of 1/20/26, an NA noted the resident reported feeling like she was getting a cold, had a deeper voice, dark circles and sunken eyes, and was sleepy but still able to drink independently with a straw; the NA believed she informed a nurse but could not recall whom. On 1/21/26, multiple staff observed significant changes: the resident did not eat three consecutive meals (except for one bite at lunch), was unusually sleepy, did not converse at her baseline, and required assistance with drinking, with one NA unable to get her to pull fluid through a straw. A nurse caring for her that morning noted a bad cough and coarse breath sounds, difficulty administering medications in the morning due to somnolence, and only minimal intake at lunch. This nurse requested a chest x-ray from an NP, obtained an order, and verified it with the mobile x-ray company, but did not obtain a full set of vital signs or check the resident’s blood sugar, documenting only a temperature she recalled as 98.5 and citing a very busy day. Another nurse manager recalled being told the resident did not seem herself and knew a chest x-ray was ordered but did not perform an assessment. There were no nursing progress notes for 1/21/26 documenting vital signs or FSBS, and interviews with four nurses confirmed that no complete sets of vital signs or blood sugar levels were obtained despite the resident’s decreased intake, increased sleepiness, cough, and functional decline. In the early morning of 1/22/26, EMS was dispatched for the resident, and paramedics found a blood sugar reading of “high.” The resident was transported to the ED, where she was noted to be obtunded and dehydrated, with a glucose of 882, a temperature of 41.7°C (107.06°F), and other lab abnormalities. She coded at 6:53 AM and expired after unsuccessful resuscitation attempts. The survey identified that immediate jeopardy began on 1/15/26 when the facility failed to ensure ongoing monitoring and initiation of a treatment plan for the resident’s critically elevated blood glucose following the 1/14/26 lab result, in the context of a previously elevated HgbA1C and subsequent development of respiratory symptoms without appropriate acute monitoring, assessment, and treatment.
Failure to Document Diabetes Management Plan After Elevated HgbA1C Result
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the medical provider documented an appropriate plan of care for a resident’s diabetes during required regulatory visits. The resident was admitted with a diagnosis of diabetes, and during a regulatory visit in late September, the nurse practitioner (NP) documented that the diabetes was diet controlled. A Hemoglobin A1C (HgbA1C) lab ordered in mid-October showed an elevated result of 8.1%, significantly above the lab’s normal range of ≤5.7%. The electronic lab record showed the NP signed off on these results in early November, but there was no corresponding provider progress note on that date addressing the elevated HgbA1C. Following the September visit, the next documented regulatory visit by the NP occurred in mid-December. In that progress note, the NP documented that the resident’s Type 2 diabetes with chronic kidney disease was diet controlled, referenced an older HgbA1C of 6.5% from the previous year, and planned to continue a healthy diet. The NP did not reference or address the more recent elevated HgbA1C of 8.1% from October in this regulatory visit note. During interview, the NP stated she had discussed with the resident the option of more frequent blood sugar checks and treatment, and that the resident preferred diet control with reevaluation in three months, but she acknowledged that she had not documented this discussion or the diabetic plan in the regulatory progress note, and confirmed she should have done so.
Improper Food Storage and Inadequate Kitchen Cleaning Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s main kitchen related to improper food storage and inadequate cleaning practices. During observations in the dry storage room, an open bag of cereal was found in a container whose lid was on the floor under another shelving unit. A bag of grits on a metal shelf was not sealed, with the top only rolled up. Shelf liners on this and another shelf had visible fine grainy food particles. Underneath the shelving units in dry storage, surveyors observed multiple food items and debris, including loose dry cereal, a dried orange peel, closed packets of cookies, water bottles, condiment packets, a carbonated drink, a closed bag of Cheetos, a closed pudding cup, a loose cigarette, and a pair of sandal slides. Under the kitchen oven, there was about 12 inches of black, dried grease. Staff interviews further described the circumstances leading to the deficiency. A dietary aide stated they had to be careful when cleaning under the oven because part of the oven bottom would come off. The Administrator acknowledged seeing the unsealed food items and dirty dry storage floor and reported that the former Dietary Manager had left abruptly months earlier, and the current Dietary Manager was only present one to two days per week. The Dietary Supervisor stated she typically sealed opened food if staff forgot and that staff were supposed to sweep and clean nightly, but the condition of the dry storage area suggested this had not been done. She also provided a cleaning schedule that did not include dry storage. The part-time Dietary Manager reported that her own cleaning schedule, which included dry storage, had been replaced by a corporate schedule that did not address cleaning of the dry storage room, while also stating that staff had been instructed to clean and mop nightly and to ensure all food was sealed, covered, and dated.
Failure to Maintain Kitchen Sanitation and Coordinate Pest Control in Main Kitchen
Penalty
Summary
The deficiency involves the facility’s failure to maintain effective kitchen sanitation and food storage practices to deter pests, and failure to communicate effectively with contracted pest control technicians regarding contributing factors to pest activity in the main kitchen. Pest control records showed repeated findings of roaches and sanitation problems over several months. A pest control technician documented roaches in the kitchen and sanitation issues such as food and grease buildup under the cook/steam line and on the kitchen floor, with repeated notations to "please clean regularly." A local health department inspection of the main kitchen later identified a large number of roaches in an electrical box above the three-compartment sink, general floor cleaning deficiencies, lack of cleaning under food equipment and shelving in the walk-in cooler, walk-in freezer, and dry storage, as well as wall damage throughout the kitchen. Subsequent pest control invoices continued to note pest activity and sanitation problems in the kitchen, including cockroaches coming out of the trash disposal door and other areas, dirty floor drains, dirty strainers, and floors that were consistently wet. Technicians repeatedly documented that standing water and food debris were present during most services and that these conditions could cause pest problems, again instructing the facility to clean regularly and keep the kitchen as dry as possible. One technician later documented structural concerns that could cause pest problems, including holes and gaps throughout the kitchen and peeling wall covering, along with food debris throughout the kitchen. The facility could not produce documentation of all follow-up night services that technicians reported they intended to perform, and there was a gap in available pest control records for certain months. During on-site kitchen observations, surveyors found a dead roach behind the ice machine and a live roach in a kitchen corner, open and improperly sealed dry food items such as cereal and grits in dry storage, and food crumbs and miscellaneous items under shelving, including loose cereal, a dried orange peel, snack items, beverage containers, a loose cigarette, and shoes. There was a 12-inch span of dried black grease under the oven, and a portion of wall covering was peeling near the sink. Staff interviews revealed that dietary staff were expected to sweep and clean nightly, but the posted cleaning schedule did not include the dry storage area. The part-time Dietary Manager reported she had created a cleaning schedule that included dry storage but was told to use a corporate schedule that did not. Pest control technicians reported consistently seeing sanitation issues such as trash and food particles on the floor, wet floors around the ice machine, food left in the dishwasher food trap, and an unrinsed prep sink during their visits. Maintenance and administrative staff reported that pest control technicians did not routinely communicate structural or sanitation issues directly to them, and that the facility did not routinely receive or review detailed pest control invoices noting these problems.
Failure to Honor Resident's Advanced Directives
Penalty
Summary
The facility failed to ensure that a resident's advanced directive was included in their medical record and did not honor the resident's expressed wishes regarding their code status. The resident, who was admitted with a diagnosis of dementia, had a hospital discharge summary indicating a full code status. However, the resident's Responsible Party (RP) had completed admission paperwork indicating the resident had a DNR order and advanced directives, which were not included in the resident's record. Interviews with facility staff revealed a lack of follow-up to ensure the advanced directives were obtained and included in the resident's medical record. The Admissions Director and Unit Managers did not verify the presence of these documents, and the Social Worker did not clarify the discrepancy between the resident's code status in the medical record and the RP's expressed wishes. The RP was unaware that the resident's code status was recorded as full code in the facility, contrary to the resident's wishes. The Director of Nursing and the Administrator acknowledged the system in place to verify advanced directives on admission but admitted that the process was not followed through in this case. The failure to ensure the resident's advanced directives were documented and honored resulted in a discrepancy between the resident's expressed wishes and the facility's records.
Failure to Attempt Alternatives Before Installing Side Rails
Penalty
Summary
The facility failed to attempt alternatives before installing side rails for two residents, leading to a deficiency. Resident #18, who was admitted with a diagnosis of diffuse traumatic brain injury, had side rails installed without prior attempts at alternative interventions. The restraint-adaptive equipment use assessment for Resident #18 did not indicate whether alternatives had been tried, and staff interviews revealed a lack of awareness about the requirement to try alternatives before using side rails. Observations confirmed that side rails were consistently in the raised position for Resident #18. Similarly, Resident #98, who was admitted with hemiplegia and hemiparesis following a stroke, also had side rails installed without prior attempts at alternatives. The assessment for Resident #98 similarly lacked documentation of alternative interventions being tried. Staff interviews indicated a general lack of awareness about the necessity of attempting alternatives before implementing side rails, and observations showed that side rails were in use for Resident #98. Interviews with the nursing staff, including the Director of Nursing and the Administrator, revealed a systemic issue where side rails were routinely installed on beds without considering or attempting alternative interventions. The staff was unaware of the requirement to explore alternatives before using side rails, leading to the deficiency identified during the survey.
Medication Administration Deficiency
Penalty
Summary
The facility failed to assess whether self-administration of medication was clinically appropriate for a resident before leaving medication at the bedside. This deficiency was identified for a resident with chronic obstructive pulmonary disease (COPD), who was cognitively intact and admitted to the facility with a physician's order for Trelegy Ellipta, a medication for COPD. The resident's medical record did not contain a self-administration assessment or a physician's order to self-administer medication. Despite this, the resident was observed with the inhaler at her bedside and self-administered a dose, which was not documented as self-administered in the Medication Administration Record (MAR). Nurse #3, who was responsible for the resident's care, reported administering the inhaler at 9:00 AM but inadvertently left it at the bedside. The Director of Nursing confirmed that medication should not be left at the bedside without proper assessment and orders. The Nurse Practitioner indicated that taking an additional dose would not have harmed the resident, but the medication should not have been left at the bedside. The Administrator noted that leaving medication at the bedside was unusual for Nurse #3, suggesting it was a one-time mistake.
Inaccurate MDS Coding for Resident Fall
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of falls. The resident, who was admitted to the facility, experienced a fall from her bed, as documented in a nursing progress note. Despite this incident, the resident's quarterly MDS assessment incorrectly indicated that she had no falls since her prior assessment. The MDS Coordinator, responsible for coding the assessment, acknowledged the oversight, stating that she typically reviewed progress notes for such information. The fall occurred after the date of the resident's prior MDS assessment, and thus should have been included in the subsequent assessment. Interviews with the Director of Nursing and the Administrator confirmed that MDS assessments should accurately reflect the resident's status.
Failure to Implement Enhanced Barrier Precautions for Resident with Hemodialysis Catheter
Penalty
Summary
The facility failed to adhere to their infection control practices and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a hemodialysis catheter. Nurse Aide (NA) #1 and NA #2 were observed providing a bed bath and dressing to Resident #103 without wearing gowns, despite the presence of signage indicating the requirement for gowns and gloves for high contact care. The resident had a hemodialysis catheter inserted in the right upper chest area, which necessitated EBP according to the facility's policy. Interviews with NA #1 and NA #2 revealed a misunderstanding of the EBP requirements, as they believed the precautions were meant for the resident's roommate and did not recognize a hemodialysis catheter as a reason for EBP. The Infection Preventionist confirmed that all residents with indwelling medical devices, including hemodialysis catheters, require EBP for high contact care. The Director of Nursing and Unit Manager #2 also demonstrated a lack of awareness regarding the necessity of EBP for residents with hemodialysis catheters, indicating a gap in understanding and implementation of the facility's infection control policy.
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 14 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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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-neuse | 0.2 mi | ★★★★★ | 2 | 0 |
| Bayview Nursing & Rehabilitation Center | 2.8 mi | ★★★★★ | 2 | 0 |
| Riverpoint Crest Nursing And Rehabilitation Center | 4.3 mi | ★★★★★ | 9 | 0 |
| Brook Stone Living Center | 11.8 mi | ★★★★★ | 0 | 0 |
| Grantsbrook Nursing And Rehabilitation Center | 14 mi | ★★★★★ | 1 | 0 |
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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 August 2026) and official state health department websites.