Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Southpoint Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Multiple residents with respiratory conditions did not receive supplemental oxygen as prescribed, lacked required physician orders for respiratory devices, and did not have oxygen/no smoking signage posted outside their rooms. Staff interviews confirmed that these actions were expected but not consistently performed.
A resident with heart failure and hypertension, who was prescribed and administered a daily diuretic, was not accurately coded on the MDS assessment for receiving diuretics. The MDS Coordinator and MDS nurse confirmed the oversight, and the Administrator acknowledged the assessment should have reflected the diuretic use.
A resident did not have care plan meetings conducted or documented after multiple quarterly and significant change MDS assessments. The resident, who was cognitively intact and their own responsible party, and their emergency contact both reported not receiving invitations or participating in care plan meetings. Staff interviews revealed that care plan meetings were not scheduled or documented as required, with responsibility shifting between several social workers and the administrator.
A facility failed to maintain a secure medication cart and accurate controlled medication records when a narcotic count sheet for oxycodone was found missing during a shift change count. A nurse admitted to leaving narcotic keys unattended on the cart during breaks, and the missing count sheet could not be located despite an audit. Staff interviews confirmed that medication carts and narcotic drawers were expected to be locked and keys kept with nursing staff at all times.
A resident's medical record was found to be incomplete and inaccurate when multiple nurses documented cholecystostomy dressing changes that were not performed. One nurse recorded care she did not provide, another documented a dressing change by the Wound Nurse without proper verification, and the Wound Nurse relied on unverified information from a nurse aide to document care. This resulted in discrepancies between the MAR, TAR, and actual care provided.
A resident's card of oxycodone was discovered missing during a narcotic count, after a nurse left narcotic keys unattended on a medication cart while sharing the cart with another nurse. This breach of protocol led to the misappropriation of the resident's medication, and the nurse involved was later charged with felony larceny.
A nurse failed to observe a resident take prescribed medications and left them at the bedside, despite the resident not being authorized for self-administration. The nurse later acknowledged this was not in accordance with facility policy, and the DON confirmed there was no order or assessment for self-administration.
A resident with a biliary drain did not receive cholecystostomy dressing changes as ordered by the physician. Nursing staff documented dressing changes that were not performed, with one nurse assuming the wound nurse had completed the task and the wound nurse not present that day. Further inconsistencies were found in documentation and communication among staff, resulting in missed dressing changes for the resident.
A nurse failed to perform hand hygiene between glove changes during wound care for a resident, contrary to the facility's infection control policy. The nurse acknowledged the oversight, and the DON emphasized the importance of hand hygiene to prevent infection spread.
The facility failed to ensure timely administration of antibiotics for two residents, resulting in delays of over 24 hours. The delays were due to issues with the pharmacy's delivery schedule and the facility's follow-up procedures.
Failure to Administer Oxygen as Prescribed and Post Required Oxygen Signage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for multiple residents by not administering supplemental oxygen as prescribed, not obtaining required physician orders for respiratory devices, and not posting required oxygen/no smoking signage. In one case, a resident with COPD, CHF, and chronic respiratory failure was observed receiving oxygen at a higher flow rate than ordered by the physician, and there was no signage indicating oxygen use or no smoking outside the resident's room. Nursing staff interviews revealed inconsistent monitoring of the oxygen concentrator settings and a lack of awareness regarding the absence of required signage. Another resident with acute and chronic respiratory failure, pleural effusion, COPD, and pneumonia had a prescription for a bilevel positive airway pressure machine from the hospital, but no corresponding physician order was entered into the facility's medical record. The resident's room also lacked the required oxygen in use signage. Staff confirmed that the order should have been entered upon admission and that the signage was missing. Additional residents with diagnoses including COPD, lung cancer, and acute respiratory failure were observed receiving supplemental oxygen without the required signage posted outside their rooms. Staff interviews consistently indicated that signage should be placed upon admission for any resident receiving oxygen, but this was not done for these residents. The Director of Nursing confirmed that it was the facility's expectation for both physician orders and signage to be in place for residents using oxygen or respiratory devices.
Failure to Accurately Code MDS Assessment for Diuretic Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident in the area of medications. The resident, who had diagnoses including hypertension and heart failure, was admitted with a care plan that included diuretic therapy and had a physician's order for daily Bumetanide, a diuretic, for edema. Medication Administration Records confirmed that the diuretic was administered daily during the relevant period, and the MDS Coordinator acknowledged that the resident received the medication during the seven-day look-back period for the quarterly MDS assessment. However, the MDS assessment was not coded to reflect the resident's receipt of diuretics, which was attributed to an oversight by the MDS nurse. The Administrator also confirmed that the MDS should have been coded accurately for diuretic use.
Failure to Conduct and Document Care Plan Meetings After MDS Assessments
Penalty
Summary
The facility failed to conduct and document care plan meetings following the completion of quarterly and significant change Minimum Data Set (MDS) assessments for one resident. The resident was admitted to the facility and had multiple MDS assessments completed over the course of a year, including quarterly and significant change assessments. Despite these assessments, the last documented care plan meeting in the resident's medical record was over a year prior to the most recent assessment. The resident was cognitively intact and listed as their own responsible party, yet did not recall receiving invitations or participating in care plan meetings with the interdisciplinary team. Interviews with the resident's emergency contact confirmed that no invitations or notifications for care plan meetings had been received since an initial meeting over a year ago. Staff interviews revealed that the process for scheduling care plan meetings after MDS assessments was not followed, with responsibility for these meetings shifting between multiple social workers and, more recently, the administrator. There was no documentation of care plan meetings for the resident after the initial meeting, and the administrator acknowledged that meetings had not been conducted as required.
Failure to Secure Medication Cart and Maintain Accurate Narcotic Records
Penalty
Summary
The facility failed to maintain a secure medication cart and accurate controlled medication records for a resident who was admitted and later discharged. During a routine narcotic reconciliation on one of the facility's halls, it was discovered that a narcotic count sheet for oxycodone HCL was missing from the medication cart. The incident was identified during a shift change narcotic count conducted by two nurses, one of whom admitted to leaving the narcotic keys on top of the cart during her breaks and could not recall the name or description of the nurse she shared the cart with. The missing count sheet could not be located despite an audit of all medication carts. Interviews with staff revealed that the facility's expectation was for narcotic drawers and medication carts to remain locked at all times when not in use, and for nurses to keep the medication cart keys on their person. The process for receiving and storing narcotics was described, including verification and secure storage, but the missing count sheet indicated a lapse in these procedures. The pharmacy consultant confirmed that she was notified of the incident and had not observed similar issues before or after this event. The facility's draft plan of correction was not substantiated due to a lack of defined auditing and monitoring related to narcotic count sheets and key security.
Inaccurate Documentation of Cholecystostomy Dressing Changes
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident receiving cholecystostomy care. Documentation on the Medication Administration Record (MAR) indicated that two nurses had changed the resident's cholecystostomy dressing at scheduled times, but both nurses later confirmed they had not performed the dressing change. One nurse documented the care as completed despite not providing it, while the other nurse recorded that the dressing was changed by the Wound Nurse, but was unsure how to properly document care provided by another nurse and could not recall the Wound Nurse's name. Additionally, the Treatment Administration Record (TAR) showed the Wound Nurse had documented dressing changes on subsequent days, but the Wound Nurse admitted to recording the care as completed based on information from a nurse aide, without verifying that the dressing change had actually occurred. Further investigation revealed that the nurse aide had assumed the dressing was changed after hearing a nurse mention taking care of the sutures, but the nurse only inspected the site and did not perform a dressing change. The Wound Nurse did not confirm with the nurse or check the dressing before documenting the care. The Director of Nursing confirmed that documentation should only reflect care that was actually provided and that staff should not record care they did not perform. These actions resulted in inaccurate and incomplete medical records for the resident's cholecystostomy care.
Failure to Secure Controlled Substances Resulting in Misappropriation
Penalty
Summary
A deficiency occurred when a resident's controlled medication, specifically a card of oxycodone HCL 5 mg tablets, went missing from a medication cart. The medication was prescribed for the resident to be taken as needed, and the prescription was filled with 18 tablets, with one tablet administered and 17 remaining. During a routine narcotic count at shift change, it was discovered that the entire card of 17 tablets was missing. The incident was reported, and an investigation was initiated. The investigation revealed that during the night shift, two nurses shared a medication cart and only had one set of keys. One of the nurses admitted to leaving the narcotic keys on top of the medication cart during her breaks, rather than keeping them on her person or handing them to another nurse, as required by facility policy. This practice was contrary to the facility's expectations and created an opportunity for the medication to be taken without authorization. Interviews with staff confirmed that the keys should always be kept with a nurse and never left unattended on the cart. Attempts to interview all staff involved were not fully successful, but available witness statements and interviews confirmed the improper handling of narcotic keys. The missing medication was not recovered, and the incident was reported to the appropriate authorities, including the local police and the DEA. The nurse involved was later charged with felony larceny by an employee. The facility failed to protect the resident's property by not ensuring proper security of controlled substances.
Medications Left at Bedside Without Supervision
Penalty
Summary
A nurse entered the room of a resident with multiple active diagnoses, including osteoarthritis, muscle weakness, lymphedema, major depressive disorder, hypertension, and other chronic conditions. The resident was assessed as cognitively intact. During medication administration, the nurse brought a cup containing several medications, water, and eyedrops to the resident's bedside. Instead of observing the resident take the medications as required, the nurse left the medications at the bedside and told the resident she would return later to check on her. The resident did not take the medications during this time and left them on her bedside table. Record review revealed there was no physician's order or assessment for the resident to self-administer medications. During interviews, the nurse acknowledged that the resident was not permitted to self-administer medications and stated she should have removed the medications from the room when the resident was not ready to take them. The DON confirmed that the resident was not ordered to self-administer medications and that the nurse should not have left the medications at the bedside.
Failure to Provide Cholecystostomy Dressing Changes as Ordered
Penalty
Summary
The facility failed to provide cholecystostomy dressing changes as ordered by the physician for a resident with a biliary drain. The resident, who was severely cognitively impaired and had a history of chronic cholecystitis managed with a percutaneous cholecystostomy tube, had physician orders for dressing changes every twelve hours. Documentation on the Medication Administration Record indicated that the dressing was changed on a specific date by two nurses, but both nurses later stated in interviews that they did not perform the dressing change as ordered. One nurse documented the dressing change based on the assumption that a wound nurse had completed the task, but the wound nurse was not present in the facility that day and could not identify who was responsible for wound care on that date. The Director of Nursing was also unable to identify the nurse assigned to wound care on the relevant date. Further review of the Treatment Administration Record and direct observation revealed additional inconsistencies. The wound nurse documented dressing changes on subsequent days, but during an observation, the dressing was found to be dated two days prior, indicating it had not been changed as recorded. The wound nurse explained that she relied on information from a nurse aide, who had assumed another nurse had changed the dressing after hearing a comment about the sutures. However, the nurse in question confirmed she only inspected the site and did not change the dressing. The Director of Nursing confirmed that the dressing should have been changed daily per physician orders by either the wound nurse or the assigned nurse.
Infection Control Lapse During Wound Care
Penalty
Summary
The facility failed to adhere to its infection control policy during a wound care procedure. Specifically, Nurse #1 did not perform hand hygiene between the removal of soiled gloves and the application of clean gloves while treating a resident's sacral wound. This lapse was observed during a wound care session involving Treatment Nurse #1 and Treatment Nurse #2. The facility's policy, revised in 2023, mandates hand hygiene after glove removal to prevent infection spread. During an interview, Nurse #1 acknowledged forgetting to perform hand hygiene, and the Director of Nursing confirmed the necessity of this practice to minimize infection risks. The Wound Care Physician also noted the protocol but expressed a belief that it might be excessive.
Delay in Antibiotic Administration
Penalty
Summary
The facility failed to ensure antibiotics were available for timely administration, resulting in a delay of over 24 hours in initiating antibiotic therapy for two residents. Resident #6, who was admitted with an infection of her left prosthetic knee joint, was ordered to receive cefazolin intravenously every eight hours. Despite the order being placed in the electronic medical record on the day of admission, the antibiotic was not administered until nearly 11:00 PM the following day. The delay was due to the pharmacy not delivering the medication as scheduled, and the facility's failure to promptly follow up on the missing delivery. Resident #5, who had been residing at the facility, was prescribed ofloxacin otic solution for otitis media. The order was entered into the electronic record, but the medication was not administered until two days later. The delay occurred despite the pharmacy's records indicating that the medication had been delivered to the facility. The facility's system for checking and verifying medication deliveries failed to ensure that the medication was available for administration. Interviews with staff, residents, and pharmacists revealed that the facility's processes for obtaining and verifying medication deliveries were inadequate. The pharmacy's delivery schedule and the facility's follow-up procedures contributed to the delays in administering the necessary antibiotics. Both residents expressed concerns about the delays, and the facility's staff confirmed the issues with the pharmacy and delivery processes.
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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 Durham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Forest At Duke Inc | 4.1 mi | ★★★★★ | 0 | 0 |
| The Cedars Of Chapel Hill | 4.3 mi | ★★★★★ | 0 | 0 |
| Parkview Health And Rehabilitation Center | 4.7 mi | ★★★★★ | 3 | 0 |
| Signature Healthcare Of Chapel Hill | 5.7 mi | ★★★★★ | 0 | 0 |
| Hillcrest Convalescent Center | 6.1 mi | ★★★★★ | 0 | 0 |
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