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 Treyburn Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of vascular dementia and urinary tract infection exhibited increased agitation and struck another resident with a reacher, causing a minor injury. Despite staff attempts to manage the situation, the resident's behavior escalated, leading to the altercation. The facility's investigation revealed the resident was experiencing distress related to military flashbacks.
A facility failed to notify a resident's responsible party when the resident's IV fluids infiltrated and were placed on hold, leading to a delay in treatment. The resident, who had multiple medical conditions and was experiencing new swallowing problems and nausea, was not sent to the hospital in a timely manner. As a result, the resident was later transferred to the hospital and admitted to the ICU with sepsis.
A resident with multiple medical conditions experienced a decline in health due to poor communication and inadequate assessment by LTC facility staff. Despite family concerns and requests for hospital transfer, the facility attempted in-house treatment, which was delayed and ineffective. The resident's condition worsened, resulting in emergency hospitalization for sepsis and acute organ dysfunction.
A resident with cognitive impairment and a history of falls experienced multiple falls resulting in injuries due to inadequate supervision and ineffective interventions. The facility failed to investigate the root cause of the falls, and there were inconsistencies in documentation and staff communication, leading to repeated incidents and hospital interventions.
A resident's medical records were found to be incomplete and inaccurate, with missing physician orders, incomplete meal intake records, and discrepancies in medication administration times. A nurse failed to document an order to hold IV fluids, and meal consumption sheets were not accurately filled. Additionally, medication administration times did not match the nurse's report, indicating a lack of accurate record-keeping.
The facility failed to discard expired food, label and date thickened liquids, and maintain kitchen equipment and utensils clean. Expired yogurt cups, unlabeled thickened liquids, and dirty kitchen equipment were found. Additionally, nourishment refrigerators contained expired and unlabeled food items. The Dietary Manager and DON acknowledged these deficiencies.
The facility failed to maintain proper food storage and sanitation practices, and did not involve residents or their representatives in the care planning process. Expired food was not discarded, and kitchen equipment was not kept clean. Additionally, care plan meetings were not conducted for a resident. The administrator was new and still learning procedures, while the Regional Director was providing ongoing training.
The facility failed to document the Advance Directives (code status) for a resident who was severely cognitively impaired. Despite procedures for entering this information into the EHR and hard copy chart, the resident's code status was not documented, as confirmed by staff interviews and record reviews.
The facility failed to conduct baseline care plan meetings within 72 hours of admission for two residents. One resident did not recall having a baseline care plan meeting or receiving a summary, and the meeting was only conducted upon readmission. Another resident reported not having any care plan meeting since admission, and the meeting was scheduled after the deficiency was identified. The President of Operations stated that such meetings should occur within 48 hours of admission, with a summary provided to the resident or their representative.
The facility failed to involve a resident and/or the resident's representative in the care planning process. A resident with severe cognitive impairment and multiple diagnoses did not have a comprehensive care plan meeting scheduled or conducted with their representative. Staff interviews revealed a misunderstanding of the requirement for comprehensive care plan meetings, leading to the deficiency.
The facility failed to thoroughly investigate an abuse allegation involving a resident with intact cognition. The investigation did not follow the required protocols, as written statements and comprehensive interviews were not conducted. The accused Nurse Aide was suspended and later terminated for poor customer service, not directly related to the abuse allegation.
Resident-to-Resident Altercation Due to Unmanaged Agitation
Penalty
Summary
The facility failed to protect a resident from abuse when another resident, who was experiencing increased agitation due to a urinary tract infection, hit him with a reacher. The incident involved Resident #3, who had a history of vascular dementia and was moderately cognitively impaired, and Resident #2, who was cognitively intact. On the day of the incident, Resident #3 exhibited aggressive behaviors and was observed attempting to strike others with his reacher. Despite staff attempts to de-escalate the situation, Resident #3's agitation continued, leading to the altercation with Resident #2. Resident #3's behavior was noted to have escalated throughout the day, with increased confusion and agitation. He was seen by both a PA and a Psychiatric PA, who noted his aggressive behaviors and ordered a urinalysis to check for a urinary tract infection. Despite these interventions, Resident #3's condition worsened, and he eventually struck Resident #2, causing a scratch on his ear. The facility's staff did not witness the incident but responded to the commotion and separated the residents. The facility's investigation revealed that Resident #3 had been experiencing flashbacks related to his military service, which contributed to his distress. Although Resident #3 had no prior history of hitting other residents, his acute confusion and agitation due to the urinary tract infection led to the incident. The facility's response included notifying the appropriate authorities and initiating an investigation, but the deficiency highlights a failure to adequately monitor and manage Resident #3's behavior before the incident occurred.
Failure to Notify Responsible Party of IV Infiltration and Delay
Penalty
Summary
The facility failed to immediately notify the responsible party when a resident's intravenous (IV) fluids infiltrated and were placed on hold. The resident, who had been experiencing new swallowing problems, nausea, and no food intake for multiple consecutive meals, was not sent to the hospital in a timely manner. The resident's family reported that they would have requested the resident be sent to the hospital if they had been informed about the delay with the IV fluids. As a result, the resident was transferred hours later to the hospital and admitted to the Intensive Care Unit with a principal diagnosis of sepsis. The resident had a history of multiple medical conditions, including an occipital stroke, Lewy body dementia, diabetes, hypothyroidism, hypertension, Parkinson's disease, depression, and a history of deep vein thrombosis/pulmonary embolism. On the morning of the incident, the resident's provider had given orders for IV fluids to be administered. However, the IV infiltrated, and there was a delay in restarting it due to the unavailability of the facility's IV team until later in the evening. Despite the change in the treatment plan, the responsible party was not notified of the delay. The failure to communicate the change in the resident's treatment plan resulted in a significant delay in the resident receiving necessary medical care. The resident's condition deteriorated, leading to an emergency transfer to the hospital, where she was intubated and treated for sepsis. The emergency department physician indicated that if the resident had been transferred to the hospital earlier, her condition might not have been as severe.
Removal Plan
- Education was initiated to licensed nursing staff by the Director of Nursing/designee on notification to provider and resident/responsible party for change in treatment during change of condition.
- Education was completed.
- Education was initiated to certified nursing assistants by the Director of Nursing/designee regarding the ability to identify a change in condition in residents and reporting those changes to the nurse that includes but not limited to having a decreased appetite, consistent refusal of therapeutic diet, nausea, decreased intake of fluids, and/or general malaise, etc.
- Education for licensed and unlicensed staff was completed.
- The Director of Nursing was responsible for ensuring all licensed and unlicensed staff received the education.
- Newly hired licensed, unlicensed and agency staff will receive this education during orientation.
- The Director of Nursing will be responsible for ensuring that this education is completed.
- The Administrator and Director of Nursing will be ultimately responsible for ensuring implementation of this immediate jeopardy removal for this alleged noncompliance.
- 100% licensed nursing staff education regarding notification to the provider and resident and/or responsible party (RP) for any changes of condition, as well as 100% unlicensed nursing staff education regarding reporting changes in resident condition to the nurse.
- Education was completed.
- 100% audit of resident medical records was completed to ensure that notification of changes in condition was completed in the past 30 days as applicable.
- The audits were ongoing.
Failure to Communicate and Assess Leads to Resident's Hospitalization
Penalty
Summary
The facility failed to effectively communicate among staff, medical providers, and the family of a resident who was showing signs of a change in condition. The resident, who had a history of multiple medical conditions including stroke, dementia, and diabetes, was initially requested by her family to be transferred to the hospital. However, the family agreed to facility treatment based on the understanding that the resident would receive appropriate evaluation and care at the nursing home. Despite this, the resident's condition deteriorated, and she was eventually transferred to the hospital where she was emergently intubated and admitted to the intensive care unit with sepsis and acute organ dysfunction. The deficiency was marked by poor communication over several shifts, which led to a failure to identify the seriousness of the resident's condition. The resident had been experiencing nausea and difficulty swallowing, but these symptoms were not adequately addressed. Orders for tests and treatments, such as IV fluids and lab work, were delayed or not executed properly. The resident's vital signs indicated a decline, but there was a lack of timely and effective response from the nursing staff and management. Interviews with staff revealed a lack of awareness and urgency regarding the resident's condition. The Director of Nursing and Unit Manager did not perform a hands-on assessment, and there was confusion about the orders for IV fluids. The resident's family was not informed of the IV infiltration or the delay in treatment, leading to a critical situation where the resident was found unresponsive and had to be sent to the hospital via emergency services.
Failure to Prevent Repeated Falls and Provide Adequate Supervision
Penalty
Summary
The facility failed to adequately investigate the root cause of repeated falls and provide necessary supervision to prevent further incidents for a resident with a history of falls and cognitive impairment. The resident, who had metabolic encephalopathy, osteoarthritis, intervertebral disc degeneration, and macular degeneration, experienced multiple falls within a short period, some resulting in significant injuries requiring hospital intervention. Despite these incidents, the facility did not implement effective interventions or update the care plan to address the resident's fall risk adequately. On several occasions, the resident was found on the floor after attempting to transfer or ambulate independently, despite requiring supervision. The facility's response to these falls was insufficient, as interventions such as frequent rounding and reminders to use the call bell were not effective in preventing further falls. Additionally, there was a lack of thorough documentation and incident reporting, as some falls were not recorded in the facility's incident list, and there were no nursing notes regarding the resident's return from the hospital. Interviews with staff revealed inconsistencies in supervision and communication regarding the resident's condition and needs. Some staff members were unaware of the resident's fall history or the interventions in place, and there was a lack of coordination in monitoring the resident's activities. The facility's failure to provide adequate supervision and investigate the root cause of the falls contributed to the resident's repeated injuries and eventual transfer to a memory care unit.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident, leading to several deficiencies. On one occasion, a nurse documented that intravenous (IV) fluids for the resident had infiltrated, and a Nurse Practitioner was notified, who ordered the IV fluids to be placed on hold. However, this order was not entered into the resident's electronic medical record, as confirmed by the regional clinical director. Additionally, the resident's meal consumption records were incomplete, with missing entries for several supper meals and inaccurate documentation of meal intake on another occasion. Furthermore, discrepancies were found in the medication administration records. A medication administration audit revealed that the documented times for administering medications did not match the times reported by the nurse who administered them. The nurse reported giving medications at the same time as a blood sugar check, but the records showed the medications were given over an hour later. This inconsistency in documentation was acknowledged by the nurse, who could not explain the discrepancy.
Failure to Discard Expired Food and Maintain Cleanliness in Kitchen
Penalty
Summary
The facility failed to discard expired food from the walk-in refrigerator, label and date thickened liquids in the reach-in refrigerator, and maintain the kitchen equipment and bin holding scoops and ladles clean. During an observation, ten 4-ounce cups of yogurt with an expiration date were found in the walk-in refrigerator. The Dietary Manager acknowledged that the expired yogurt cups were overlooked and would be discarded. Additionally, two opened 46 fluid ounce cartons of nectar thick water were found in the reach-in refrigerator without any labels indicating the open date or use by date. The Dietary Manager admitted that all opened food and nutrition supplements should be labeled with an open date, but these cartons may have been opened during the weekend and were not labeled accordingly. The facility also failed to maintain the cleanliness of kitchen equipment and utensils. The deep fryer had dried food crumbs on the top panel, light brown food particles floating in the oil, and a large brown greasy stain on the back splash. The Assistant Dietary Manager, responsible for cleaning the deep fryer, stated that the oil was not drained, and the equipment was not cleaned after the Friday meal. Additionally, a plastic bin containing scoops, ladles, and serving spoons was found to have dirt and dried food particles during a tray line observation. The Dietary Manager acknowledged that the bin was constantly used by staff and had some dried food particles on the base. Furthermore, the facility failed to label and date opened dietary supplements and thickened liquids and discard expired food from two nourishment refrigerators. In nourishment refrigerator #2, a white plastic bag containing takeout food, a wet brown bag with takeout containers, and a small opened snack tray with brown-colored fluid on apple slices were found. Four opened 32 fluid ounce nutritional supplements were also found without any labels indicating the open date or use by date. In nourishment refrigerator #1, a plastic bag containing takeout food and two opened 46 fluid ounce nectar thick water cartons without open dates were found. The Director of Nursing stated that nurses should label all opened nutritional supplements with an open date and discard perishable food brought by families within 72 hours if not consumed by the resident. The dietary department was responsible for ensuring these foods were discarded within 72 hours.
Deficiencies in Food Storage and Care Planning
Penalty
Summary
The facility failed to maintain proper food storage and sanitation practices, as well as involve residents or their representatives in the care planning process. Specifically, the facility did not discard expired food from the walk-in refrigerator, label and date thickened liquids in the reach-in refrigerator, or maintain kitchen equipment cleanliness. Additionally, the facility did not label and date opened dietary supplements and thickened liquids, failed to discard expired food, and did not maintain the nourishment refrigerators clean. These deficiencies were observed in both the walk-in and reach-in refrigerators, as well as in two nourishment refrigerators near nursing stations. The Dietary Manager also failed to change gloves and perform hand hygiene between tasks during meal preparation. The facility also failed to involve residents or their representatives in the care planning process. This was evidenced by the lack of care plan meetings for one of the sampled residents reviewed for care plans. Interviews with the administrator and the Regional Director revealed that the administrator was new to the position and still learning the procedures involved in the survey process. The Regional Director stated that training was ongoing and that the QAPI/QA Manual was being updated to improve performance outcomes. Despite these efforts, the facility's inability to sustain an effective QAPI program was evident during two federal surveys of record, showing a pattern of continued failure in maintaining implemented procedures and monitoring interventions.
Failure to Document Advance Directives for a Resident
Penalty
Summary
The facility failed to have Advance Directives (code status) documented in the records for a resident who was assessed as severely cognitively impaired. The resident was admitted to the facility, and the admission Minimum Data Set (MDS) indicated severe cognitive impairment. However, the comprehensive care plan and the physician's orders did not contain any information regarding the resident's code status or Advance Directives. This deficiency was confirmed through a review of the resident's electronic health record (EHR) and hard copy chart, which lacked any documentation of the code status. Interviews with various staff members, including a nurse, the Director of Nursing (DON), the Social Worker assistant, and a Nurse Practitioner, revealed that the facility's process for documenting code status was not followed. The Social Worker assistant explained that the code status should be discussed during the initial care plan meeting and entered into the EHR and hard copy chart. Despite these procedures, the resident's code status was not documented in any of the expected locations, including the EHR, hard copy chart, and the code status book. The Administrator confirmed that the resident's code status should have been entered at admission, but it was not, leading to the deficiency.
Failure to Conduct Timely Baseline Care Plan Meetings
Penalty
Summary
The facility failed to conduct a baseline care plan within 72 hours of admission for two residents, leading to a deficiency. Resident #91 was admitted to the facility and later readmitted after a hospital discharge. Despite being assessed as cognitively intact, the resident did not recall having a baseline care plan meeting or receiving a summary of the baseline care plan. The Social Worker confirmed that the baseline care plan meeting was missed during the initial admission and was only conducted upon readmission, four days after the resident returned from the hospital. The details of the meeting were documented in the resident's electronic medical record, but no summary was provided to the resident or their representative. Similarly, Resident #252, who was also assessed as cognitively intact, reported not having any care plan meeting since admission and did not receive a summary of the baseline care plan. The Social Worker and Admission Assistant acknowledged that the baseline care plan meeting was not scheduled within the required 72-hour timeframe. The meeting was eventually set up after the deficiency was identified. The President of Operations stated that baseline care plan meetings should be conducted within 48 hours of admission, and a summary should be signed and provided to the resident or their representative.
Failure to Involve Resident in Care Planning Process
Penalty
Summary
The facility failed to involve a resident and/or the resident's representative in the care planning process. Resident #41, who was readmitted with diagnoses including end-stage renal disease, dependence on renal dialysis, and dementia, was assessed as severely cognitively impaired and dependent on staff for most activities of daily living. The comprehensive care plan for Resident #41 was reviewed by staff, but there was no indication that the resident or the resident's representative participated in the care plan meeting or its development. Interviews revealed that the Social Worker and Social Worker assistant did not schedule comprehensive care plan meetings with residents and/or their representatives, as they believed the baseline care plan meeting conducted within 3 days of admission sufficed for detailed care planning discussions. The Social Worker assistant stated that she did not schedule the comprehensive care plan meeting for Resident #41 because it was not indicated in the monthly calendar provided by the MDS Nurse coordinator. The MDS Nurse coordinator confirmed that the calendar did not include the comprehensive assessment ARD, assuming that the Social Services department would schedule these meetings during the 72-hour care plan meeting. The President of Operations confirmed that the expectation was for care plan meetings and notifications to be sent to residents and/or their representatives per state and federal regulations, and that the care plan should be reviewed and revised by the interdisciplinary team after each assessment, including comprehensive assessments. However, this process was not followed for Resident #41, leading to the deficiency noted in the report.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to complete a thorough investigation for an allegation of physical abuse involving a resident with intact cognition. The facility's abuse neglect policy required a comprehensive investigation, including obtaining written statements from all involved parties and witnesses, as well as conducting interviews with other residents who may have had contact with the accused staff member. However, the investigation conducted by the Administrator and the former Director of Nursing did not adhere to these protocols. They only obtained oral statements from the resident and the accused Nurse Aide, without securing written statements or interviewing other potential witnesses and residents. This oversight was acknowledged by the Administrator during an interview. The incident report revealed that the resident had reported the abuse, but the investigation summary lacked evidence of a thorough review. The accused Nurse Aide was suspended and later terminated for poor customer service, not directly related to the abuse allegation. Interviews with the involved staff and the former Director of Nursing confirmed that the standard procedures for abuse investigations were not followed, as written statements and comprehensive interviews were not conducted. This failure to follow protocol resulted in an incomplete investigation of the abuse allegation.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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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) |
|---|---|---|---|---|
| Accordius Health At Rose Manor Llc | 4 mi | ★★★★★ | 1 | 0 |
| Carver Living Center | 4.2 mi | ★★★★★ | 1 | 0 |
| Croasdaile Village | 5.8 mi | ★★★★★ | 8 | 0 |
| Pettigrew Rehabilitation Center | 7 mi | ★★★★★ | 0 | 0 |
| Hillcrest Convalescent Center | 7 mi | ★★★★★ | 0 | 0 |
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