Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Raleigh Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment had multiple grievances filed on their behalf by a responsible party regarding ADL care, missing personal items, hair grooming, and hand discoloration after a lab draw. The facility’s grievance forms for these concerns were largely incomplete, with missing entries for written decisions, notification methods, summaries of findings, corrective actions, and signatures. The responsible party reported not being offered or receiving any written grievance summaries or follow-up communication, and leadership staff confirmed that written grievance summaries were not provided despite facility policy requiring written conclusions to be communicated to the complainant.
A resident with bipolar disorder, dementia with behavioral disturbances, and anxiety disorder had a physician order for lamotrigine 25 mg PO BID, which was administered as ordered and documented on the MAR during the MDS 7-day lookback period. However, the quarterly MDS assessment completed by a per diem MDS nurse did not code the resident for anticonvulsant medication use. Subsequent review of the physician order and MAR by regional MDS leadership and interviews with staff confirmed that the resident’s anticonvulsant use should have been coded on the MDS and that the omission was an oversight.
A resident with a physician’s order for daily Lidocaine 4% patches to both shoulders for pain had multiple omissions in MAR documentation by an RN on several days. Record review showed the patches were not recorded as administered on four separate occasions over two months. In interviews, the unit manager and DON stated that nurses are expected to document all medications by the end of their shift, while the RN involved could not recall whether the patches were applied or why they were not documented. The administrator stated she expects staff to document medication administration when given, but the resident’s MAR was not accurately maintained.
The facility inaccurately coded MDS assessments for two residents, one with legal blindness and another with diabetes and elopement risk. The MDS assessments failed to reflect the residents' true conditions, including vision impairment and the use of a wander elopement alarm and hypoglycemic medication. The MDS Nurses acknowledged the errors, and the administrator confirmed their responsibility for accurate coding.
A resident with a tracheostomy did not receive appropriate care as the facility failed to change the disposable inner cannula according to the physician's order. Despite the order for tracheostomy care every shift, Nurse #1 did not change the inner cannula, believing it was not necessary daily. Interviews revealed inconsistencies in understanding the care protocol, with the DON confirming the inner cannula should be changed with each tracheostomy care session.
The facility failed to manage and store medications properly, with expired Zinc tablets found in a storage room, and loose, unidentified pills discovered in two medication carts. An opened bottle of Aspirin without an expiration date was also found. Nurses were unaware of these issues, highlighting lapses in the facility's medication management protocols.
Failure to Provide Required Written Grievance Summaries to Resident’s Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide written grievance summaries to a resident’s responsible party (RP) as required by facility policy and resident rights regulations. The facility’s grievance policy dated 08/2023 states that the Administrator is responsible for overseeing the grievance process, including receiving and tracking grievances, leading investigations, reaching conclusions, taking appropriate actions, and communicating the conclusion and corrective actions to the resident or the person acting on their behalf. The policy further states that the resident or their representative has the right to obtain a copy of the written conclusion. Despite this, multiple grievance forms related to one resident contained blank sections where written decisions, notification methods, summaries of findings, corrective actions, and signatures should have been documented. The resident involved was admitted and later readmitted to the facility, and an MDS assessment indicated the resident was severely cognitively impaired. The facility’s grievance log from January 2025 through March 2026 showed four grievances submitted by the resident’s RP. These grievances concerned ADL care with the resident being found wet and soiled, missing washable pads and a listening ear microphone, concerns about the resident’s hair appearance, and discoloration on the resident’s hands following a lab draw. For each of these grievances, the corresponding grievance forms lacked completion of key sections, including the date the written decision was issued, the method used to notify the resident or RP, the delivery method of the conclusion, whether the conclusion was accepted or declined, the summary of pertinent findings and conclusions, corrective actions taken, and the RP’s signature. Interviews confirmed that the RP did not receive written grievance summaries or follow-up notifications for any of the grievances filed. The RP reported submitting multiple verbal grievances to administrative staff, including the Administrator, and stated she was not asked if she wanted a written grievance summary and did not receive written or verbal updates or follow-up interviews regarding her concerns. The Administrator acknowledged that the RP did not receive written grievance summaries and stated she was not fully aware that written summaries were required for complainants or those filing grievances on the resident’s behalf, even when issues were resolved verbally. The Director of Clinical Services also confirmed that the RP did not receive verbal or written grievance summaries or follow-up notifications for the grievances she filed.
Failure to Accurately Code Anticonvulsant Use on MDS Assessment
Penalty
Summary
The facility failed to ensure an accurate MDS assessment by not coding the use of an anticonvulsant medication for one resident. The resident was admitted with diagnoses including bipolar disorder, dementia with behavioral disturbances, and anxiety disorder, and had a physician order for lamotrigine 25 mg by mouth twice daily for bipolar disorder. Review of the MAR for the relevant month showed the lamotrigine was administered as ordered during the 7-day lookback period for the quarterly MDS assessment. Despite this, the quarterly MDS, completed by a per diem MDS nurse, did not code the resident for anticonvulsant medication use. The Regional MDS Nurse, after reviewing the physician order and MAR, confirmed the assessment should have been coded for anticonvulsant use, and the MDS nurse who completed the assessment later stated that the omission was an oversight. Interviews with facility staff, including the Regional MDS Nurse and the Administrator, confirmed that the resident’s medical record contained the necessary documentation within the lookback period to support coding for anticonvulsant medication use, but this was not reflected in the MDS assessment.
Failure to Maintain Accurate MAR for Ordered Lidocaine Patches
Penalty
Summary
The facility failed to maintain an accurate Medication Administration Record (MAR) for one resident when ordered Lidocaine 4% topical patches were not consistently documented as administered. The resident was admitted on 4/9/25 with a physician’s order dated the same day for Lidocaine external patches to be applied to both shoulders each morning for pain. Review of the resident’s September 2025 MAR showed that the Lidocaine patches were not documented as given on 9/1/25 and 9/9/25 by Nurse #1, and review of the October 2025 MAR showed the patches were not documented as given on 10/6/25 and 10/20/25 by the same nurse. In interviews, the Unit Manager stated that all nurses should ensure medications are documented by the end of their shift, and the DON similarly stated that nursing staff should ensure all medication is documented accordingly at shift end. Nurse #1 reported she could not remember whether she applied the Lidocaine patches on the identified dates or why they were not documented, and the Administrator stated she expected nursing staff to document medication administration when the medication was given. These findings demonstrate that the resident’s medical record, specifically the MAR, was not maintained in accordance with accepted professional standards due to missing documentation of ordered pain medication on multiple dates by the responsible nurse.
Inaccurate MDS Coding for Vision and Medication Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the areas of vision and the use of a wander elopement alarm and hypoglycemic medication. Resident #69, who was admitted with diabetes and diabetic retinopathy, was legally blind as per a vision provider's note. However, the MDS significant change assessment inaccurately coded the resident as having adequate vision. Interviews with the resident and a nurse aide confirmed the resident's blindness, and the MDS Nurse acknowledged the coding error. Resident #74, admitted with anxiety, PTSD, and diabetes, was at risk for elopement and had a physician order for an alerting bracelet. Despite this, the MDS quarterly assessment did not code for the wander elopement alarm. Additionally, Resident #74 was on insulin therapy, but the MDS assessment failed to code for the use of hypoglycemic medication. The MDS Nurse responsible for the assessment admitted to missing these details during the coding process. The facility's administrator confirmed that the MDS Nurse was responsible for ensuring accurate resident assessments.
Failure to Change Tracheostomy Inner Cannula as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with a tracheostomy, specifically in changing the disposable inner cannula as required. The resident, who was admitted with chronic respiratory failure and a tracheostomy, had a physician's order for tracheostomy care to be performed every shift and as needed. During an observation of tracheostomy care, Nurse #1 did not change the disposable inner cannula, stating it did not need to be changed daily and was only changed as needed. However, the Staff Development Coordinator and the Director of Nursing later confirmed that the inner cannula should be replaced when tracheostomy care is completed, as per the physician's order. Interviews with the nursing staff revealed a lack of clarity and consistency in the understanding of the tracheostomy care protocol. Nurse #1 was unable to specify how often the inner cannula was changed, and there was a discrepancy between her actions and the facility's protocol as explained by the Staff Development Coordinator and the Director of Nursing. The Director of Nursing confirmed that the physician's order did not exclude the inner cannula change, indicating a failure to adhere to the prescribed care plan for the resident.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications in accordance with accepted professional principles. During an observation of the Unit 3 medication storage room, an unopened bottle of Zinc 50mg tablets was found to be expired. Additionally, in the 3A medication cart, three loose pills were discovered, which the attending nurse could not identify. Similarly, in the 4B medication cart, an opened bottle of Aspirin was found without an expiration date, and three loose pills were also present. The nurses responsible for these carts were unaware of the presence of the loose pills and acknowledged that they should be discarded. The Director of Nursing confirmed the absence of an expiration date on the Aspirin bottle and acknowledged the responsibility of unit managers and the management team to conduct daily checks of medication carts and storage rooms. However, the current process failed to identify and address these deficiencies, indicating a lapse in the facility's medication management and storage protocols.
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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) |
|---|---|---|---|---|
| Bloomsbury At Hayes Barton Place | 1.1 mi | — | 0 | 0 |
| The Cardinal At North Hills | 2.8 mi | ★★★★★ | 2 | 0 |
| Hillcrest Raleigh At Crabtree Valley | 3 mi | ★★★★★ | 2 | 0 |
| Rex Rehab & Nursing Care Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Pruitthealth-raleigh | 3.6 mi | ★★★★★ | 3 | 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.