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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tower Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with chronic atrial fibrillation and full code status was found unresponsive, not breathing, and pulseless. Nursing staff initiated a Code Blue, called EMS, moved the resident to the floor, and provided CPR with chest compressions and ventilations via Ambu bag with oxygen. Although facility policy required deployment of an AED with the crash cart during cardiopulmonary arrest, and an AED was mounted above the crash cart on the hall, the responding RN and another nurse did not bring or apply the AED, focusing only on manual CPR until EMS arrived. Interviews showed the RN was unaware she was expected to use the AED, while another nurse described that the expected procedure included AED application and following its prompts. The facility also lacked documentation of current, valid CPR certification for the RN who led the response, despite policy requiring staff to maintain CPR certification.
A deficiency was cited when a nurse aide failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy during indwelling urinary catheter care for a resident with a urinary catheter. The facility’s policy and a sign on the resident’s door required use of both gown and gloves for high-contact device care, and PPE was available at the room entrance. The aide performed hand hygiene, entered without a gown, donned only gloves, and began catheter care before being stopped by surveyors. In interviews, the aide acknowledged knowing the EBP requirements and stated she forgot to wear a gown, while the DON and Administrator confirmed that both gown and gloves were required for this care to prevent spread of infections.
The facility failed to maintain accurate medical records for two residents. A resident's medication was documented as administered despite blood pressure parameters not being met, due to clerical errors by several nurses. Another resident's wound vac therapy was incorrectly documented as functioning, despite being off, due to lack of verification and communication among staff.
A facility failed to involve a cognitively intact resident in their care planning process. Despite the resident's interest in attending meetings to discuss medications and concerns, no care plan meetings were documented or offered from the time of admission until nearly a year later. The Social Worker, who started months after the resident's admission, was not provided with a list of due meetings, and the MDS Nurse did not facilitate this process, leading to the deficiency.
A resident with type I diabetes was denied the use of an insulin pump, her preferred method for managing her condition, due to the facility's lack of policy on such devices. Despite her history of brittle diabetes and previous use of an insulin pump, the facility did not accommodate her request, leading to poorly controlled blood sugars and hospitalizations for DKA. The facility staff were aware of her preference but faced challenges in obtaining and implementing the device.
A resident reported concerns about staff language and a roommate issue, but the facility failed to provide a written grievance resolution. The DON did not complete the grievance form or communicate effectively with the Social Worker, leaving the resident unaware of any resolution. The previous Administrator, responsible for the grievance resolution, did not receive the completed form from the DON.
A facility failed to evaluate a resident with hearing difficulties for treatment and services. Despite the resident's diagnosis of sensorineural hearing loss and severe cognitive impairment, no audiology consultations were scheduled. The MDS Nurse did not communicate the resident's hearing needs to the Social Worker, who was unaware of the issue and did not arrange for an audiology consult. The Administrator acknowledged the communication lapse.
The facility failed to remove expired lidocaine 4% pain relief patches from the medication storage room, as observed during a survey. Twenty-two expired patches were found alongside unexpired ones, and the Director of Nursing (DON) confirmed the oversight. Interviews revealed no designated person was responsible for removing expired medications, and the Administrator stated that the DON and nursing team were responsible for this task.
The facility failed to implement its infection prevention program when a Wound Treatment Nurse did not wear a gown during wound care for two residents on Enhanced Barrier Precautions (EBP). Despite signage and available PPE, the nurse performed care without a gown, contrary to the facility's EBP policy. The nurse admitted to forgetting the gown, and both the DON and Administrator confirmed the requirement for gown use during such care.
Failure to Use Available AED During CPR and Lack of Documented CPR Certification
Penalty
Summary
The deficiency involves the facility’s failure to utilize an available Automatic External Defibrillator (AED) during CPR for a resident who was a full code, and the lack of documentation of current CPR certification for the nurse leading the response. Facility policy stated that the HeartSaver level of CPR, as defined by the American Heart Association (AHA), would be provided and that CPR would be initiated immediately for residents following cardiopulmonary arrest unless a DNR order or obvious signs of clinical death were present. The AED policy authorized any licensed nurse trained in AED use to deploy the device in emergencies, specified that staff would maintain CPR certification, and directed that the AED be used in tandem with CPR during a Code Blue, with the crash cart and AED to be immediately deployed to the location of the unresponsive individual. The resident involved had chronic atrial fibrillation and was admitted with a physician’s order and care plan indicating full code status. She was cognitively intact on admission and was not receiving anticoagulant medication. On the night of the event, Nurse #1 reported that the resident had been her usual self and had spoken to her around 2:30 AM. Sometime after 5:00 AM, Nurse #1 found the resident unresponsive, not breathing, and without a pulse, though still warm. Nurse #1 called a Code Blue, 911 was called, and the crash cart was brought to the room. Nurse #1 and Nurse #2 moved the resident to the floor; Nurse #2 performed chest compressions while Nurse #1 provided ventilations with an Ambu bag connected to 15 liters of oxygen. EMS records confirmed that upon their arrival, CPR was already in progress and that EMS personnel placed the monitor in AED mode, with no shock advised, and the resident remained in asystole despite advanced life support. Despite facility policy and the presence of an AED mounted on the wall above the crash cart on the 100 Hall, Nurse #1 did not bring or apply the AED during the Code Blue. She stated that everything happened quickly and she did not think to bring the AED, and that although she recalled AED instruction during CPR training, she was not aware it was something she had to use, so she and Nurse #2 focused solely on CPR until EMS arrived. Nurse #2 similarly reported that he did not recall an AED being present and that in prior Code Blues he had not used an AED, concentrating instead on CPR. Another nurse (Nurse #3), who arrived after CPR had begun, described the facility’s expected procedure as including bringing and applying the AED and following its prompts, indicating that staff understanding of AED use was inconsistent. The Central Supply Clerk confirmed that the AED on the 100 Hall was functional and checked monthly. Additionally, the Administrator acknowledged that the facility did not have a copy of Nurse #1’s current CPR certification on file at the time, even though facility policy required staff to maintain CPR certification, resulting in a failure to maintain documentation of current, valid CPR certification for Nurse #1.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to failure to follow Enhanced Barrier Precautions (EBP) during indwelling urinary catheter care. The facility’s EBP policy dated 4/2023 required the use of both gowns and gloves, in conjunction with Standard Precautions, for high-contact resident care activities, including device care for indwelling urinary catheters. The policy specified that EBP applied to residents with indwelling medical devices, such as indwelling urinary catheters, for the duration of the resident’s stay or until the device was discontinued. A sign posted on the resident’s door instructed that all healthcare personnel must wear gloves and a gown for urinary catheter care, and gowns and gloves were available at the room entrance. On the survey date, a continuous observation of catheter care was conducted for Resident #4, who had an indwelling urinary catheter. Nurse Aide (NA) #1 performed hand hygiene and entered the room without wearing a gown, despite the posted EBP sign and available PPE. She explained the procedure, set up supplies, performed hand hygiene again, and donned gloves before assisting with positioning and opening the incontinence brief. As she prepared to clean the urinary catheter at the insertion site, the observation was stopped and she was asked to leave the room. In an interview immediately afterward, NA #1 acknowledged that the resident was on EBP, stated she had been educated on EBP, and correctly described that EBP required both gown and gloves for catheter care to prevent the spread of germs, but reported she had been nervous and forgot to wear a gown on this occasion. The DON and Administrator both confirmed that a gown and gloves should have been used for indwelling urinary catheter care under EBP.
Inaccurate Medical Records and Wound Care Documentation
Penalty
Summary
The facility failed to ensure accurate medical records regarding medication administration for two residents. Resident #29, who was cognitively intact, had a physician's order for Midodrine to be held if the systolic blood pressure was greater than 120. However, the medication administration record (MAR) indicated that the medication was documented as administered on multiple occasions despite the blood pressure being above the specified threshold. Interviews with several nurses revealed that the medication was not actually administered, and the incorrect documentation was attributed to clerical errors and misunderstanding of the electronic medical record system. Resident #7, who had a stage 3 pressure ulcer, was supposed to have a wound vac therapy in place, as per physician orders. Observations revealed that the wound vac machine was off, and the drainage canister was empty, indicating the therapy was not functioning as required. Despite this, the MAR showed that the wound vac was validated as functioning with proper settings by several nurses. Interviews indicated that the nurses did not verify the wound vac's status before documenting, and there was a lack of communication regarding the removal of the wound vac therapy. The Director of Nursing acknowledged that the nurses should have chosen the correct documentation codes and verified the status of the wound vac therapy before recording it as functioning. The Administrator also confirmed that the documentation errors were not in line with the facility's procedures. These deficiencies highlight a failure in maintaining accurate medical records and ensuring proper communication among staff regarding resident care.
Failure to Involve Resident in Care Planning
Penalty
Summary
The facility failed to honor a resident's right to participate in the development and implementation of their person-centered plan of care. Resident #34, who was cognitively intact, was admitted to the facility and had a care plan meeting documented on 4/30/24. However, there was no further documentation of any care plan meetings or invitations for Resident #34 to participate in such meetings from that date until 3/17/25. During an interview, Resident #34 expressed interest in attending a care plan meeting to discuss medications and other concerns but stated that it had not been offered. The Social Worker, who began working at the facility in August 2024, confirmed that no care plan meeting had been held for Resident #34 during her tenure. She noted that care plan meetings should occur every three months or more frequently if requested, but she was not provided with a list of due meetings. The MDS Nurse stated it was not her practice to provide such a list to the Social Worker and that she did not participate in care plan meetings. The Administrator acknowledged that the MDS Nurse should have provided the necessary list to the Social Worker to ensure meetings were scheduled appropriately.
Facility Fails to Honor Resident's Choice for Insulin Pump
Penalty
Summary
The facility failed to honor a resident's choice to use an insulin pump, which was a preferred method for managing her type I diabetes. The resident, who was cognitively intact and had a history of brittle diabetes, had previously used an insulin pump before her admission to the facility. Despite her requests and the involvement of her endocrinologist, the facility did not allow her to use the insulin pump due to a lack of policy on such medical devices. The resident had been hospitalized twice in the past year for diabetic ketoacidosis (DKA), and her blood sugars were not well-controlled with the insulin regimen provided by the facility. The Medical Director and other facility staff were aware of the resident's preference for an insulin pump and had discussed it with her endocrinologist. However, the facility's corporate office had not given permission for the use of the insulin pump, and the Regional President indicated that the absence of a policy meant the facility did not allow the device. The resident had been waiting for the insulin pump to arrive and had expressed her ability to manage it independently, having used it for five years prior to her admission. Interviews with facility staff, including the Medical Director, Regional AVP of Health Services, and the Director of Nursing, revealed a lack of clarity and communication regarding the process for obtaining and implementing the insulin pump. The facility's pharmacy did not provide insulin pumps, and there was uncertainty about how to acquire the device and provide necessary education to the resident and staff. The resident's preference for the insulin pump was not fulfilled in a timely manner, despite her medical history and the recommendation from her endocrinologist.
Failure to Provide Written Grievance Resolution
Penalty
Summary
The facility failed to provide a written grievance decision to a resident who was cognitively intact and had reported concerns about staff language in the hallways and issues with a roommate. The resident had submitted a grievance form to the Social Worker, which was then assigned to the Director of Nursing (DON) for investigation. The DON noted actions taken, such as speaking with the resident and staff, but did not complete the grievance resolution section or return the form to the Administrator, who was the grievance officer responsible for providing the written resolution. Interviews revealed that the resident was unaware of the outcome of her grievance, as she remained in the same room and the staff continued to be loud. The Social Worker did not recall a specific request for a room change, and the DON assumed the Social Worker was aware of the resident's request. The previous Administrator, who was responsible for completing the grievance resolution, stated that several grievance forms, including the resident's, were not returned by the DON before her departure from the facility. This lack of communication and follow-up resulted in the resident not receiving a written resolution to her grievance.
Failure to Evaluate Resident's Hearing Needs
Penalty
Summary
The facility failed to ensure that a resident with reported hearing difficulties was evaluated for treatment and services to maintain his hearing ability. The resident, who was admitted with a diagnosis of unspecified sensorineural hearing loss, was not scheduled for any audiology consultations despite having severe cognitive impairment and moderate hearing difficulty. The resident's care plan included interventions for auditory alteration, but there was no documentation of audiology consultations in the electronic health record. Interviews with staff revealed a lack of communication and follow-up regarding the resident's hearing needs. The MDS Nurse, who completed the resident's assessment, did not discuss the need for an audiology consult with the Social Worker, assuming the hearing loss was chronic and baseline. The Social Worker was unaware of the resident's hearing impairment and did not schedule an audiology consult. The facility's Administrator acknowledged that the MDS Nurse should have communicated the hearing impairment findings to the Social Worker to facilitate the necessary consultation.
Expired Medications Not Removed from Storage Room
Penalty
Summary
The facility failed to remove expired medications from the medication storage room, as observed during a survey. Specifically, twenty-two lidocaine 4% pain relief patches with an expiration date of 2/25/25 were found in a bin on the counter alongside unexpired patches. This was confirmed by the Director of Nursing (DON) during an observation on 3/19/25. The facility's process for returning expired medications to the pharmacy was not followed, as the expired patches were not placed in the pharmacy tote for return during the daily delivery. Interviews with the DON and the Pharmacist revealed that there was no designated person responsible for ensuring the removal of expired medications from the storage room. The DON admitted to not noticing the expired patches and acknowledged that they might have been overlooked for return to the pharmacy. The Administrator confirmed that the responsibility for removing expired medications lay with the DON and the nursing team, indicating a lapse in the facility's medication management procedures.
Failure to Implement Infection Prevention Program
Penalty
Summary
The facility failed to implement its infection prevention and control program policies and procedures when the Wound Treatment Nurse did not apply personal protective equipment (PPE) during wound care for residents on Enhanced Barrier Precautions (EBP). Specifically, the Wound Treatment Nurse was observed performing wound care for two residents with stage 3 pressure ulcers without wearing a gown, as required by the facility's EBP policy. The policy mandates the use of gloves and gowns during high-contact care activities, such as wound care, to prevent the transmission of infections. Resident #7 and Resident #22 both had signage indicating they were on EBP, and PPE, including disposable gowns, was available in the hallway. Despite this, the Wound Treatment Nurse conducted wound care for both residents without donning a gown. During interviews, the Wound Treatment Nurse acknowledged the oversight, stating she normally wore a gown but forgot on these occasions. The Director of Nursing confirmed the requirement for gown use during wound care and noted the absence of an Infection Preventionist at the facility. The Administrator also acknowledged that the Wound Treatment Nurse should have adhered to the EBP guidelines.
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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) |
|---|---|---|---|---|
| Sunnybrook Rehabilitation Center | 1.2 mi | ★★★★★ | 7 | 1 |
| Capital Nursing And Rehabilitation Center | 1.2 mi | ★★★★★ | 6 | 0 |
| The Cardinal At North Hills | 3.7 mi | ★★★★★ | 2 | 0 |
| Raleigh Rehabilitation Center | 3.8 mi | ★★★★★ | 8 | 0 |
| Bloomsbury At Hayes Barton Place | 4.2 mi | — | 0 | 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.