Cycle 1
Health 2025-01-16 · Fire 2025-01-16
4 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
8 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Durham, NC
Durham Nursing & Rehabilitation Center
2-star overall rating with 1-star inspections with $129,754 in total fines with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
411 S Lasalle Street, Durham, NC
(919) 383-5521
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
126
Certified beds
Average residents
80
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Maximus Healthcare Group
Operator or chain grouping
Approved since
1973-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.45
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.43
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.98
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.65
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,228
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.40% · Performance 22.30% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.53
Baseline 6.74% · Performance 7.67% · Measure score 0.53 · Achievement 0.53 · Improvement 0
Total nurse turnover
0.69
Baseline 53.45% · Performance 60.87% · Measure score 0.69 · Achievement 0.69 · Improvement 0
Adjusted total nurse staffing
1.72
Baseline 2.66 hours · Performance 3.35 hours · Measure score 1.72 · Achievement 0.97 · Improvement 1.72
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.49% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 11.43% · Lower 95% interval 7.24% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 31 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 31 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.68% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 12.2% · Lower 95% interval 4.74% |
| Staff COVID-19 vaccination coverage | 21.69% |
8.2%
13.5 pts better
|
Numerator 18 · Denominator 83 |
| Staff flu vaccination coverage | 19.66% |
42%
22.3 pts worse
|
Numerator 23 · Denominator 117 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.8
0.6 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.5 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.8
0.8 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.6 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.5% |
91.5%
1 pts better
|
93.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 78.0% · Q2 94.0% · Q3 100.0% · Q4 98.7% · 4Q avg 92.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.9% |
94.1%
4.2 pts worse
|
95.5%
5.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.3% |
3.6%
3.3 pts better
|
3.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
4.8%
4.1 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 11.0% |
7.2%
3.8 pts worse
|
5.4%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 6.7% · Q3 11.3% · Q4 13.6% · 4Q avg 11.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.1% |
21.6%
3.5 pts better
|
19.6%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 15.6% · Q3 18.1% · Q4 19.4% · 4Q avg 18.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.8% |
15.0%
8.2 pts better
|
16.7%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 6.0% · Q3 8.7% · Q4 4.3% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.4% |
21.5%
17.1 pts better
|
16.3%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 5.3% · Q4 10.4% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.8% |
16.8%
3 pts better
|
14.9%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 8.8% · Q3 9.2% · Q4 22.1% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
2.6%
2 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 1.3% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.8% |
21.2%
2.4 pts better
|
19.8%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 18.5% · Q3 11.1% · Q4 34.9% · 4Q avg 18.8% |
| Percentage of long-stay residents with pressure ulcers | 9.8% |
6.0%
3.8 pts worse
|
5.1%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 10.6% · Q3 9.5% · Q4 9.2% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.5% |
79.9%
2.6 pts better
|
81.7%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 66.7% · Q2 82.8% · Q3 96.8% · Q4 80.0% · 4Q avg 82.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.3% |
13.2%
3.9 pts better
|
12.0%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 11.5% · Expected 13.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.9% |
78.1%
2.2 pts worse
|
79.7%
3.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.1% |
22.9%
5.8 pts better
|
23.9%
6.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 23.1% · Expected 32.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-14 · Fire 2023-09-14
25 health deficiencies
Top issue: Resident Rights (5 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-08-18 · Fire 2022-08-18
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-16
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-03-10
F · Potential for more than minimal harm
2025-01-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-10
F · Potential for more than minimal harm
2025-01-16
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-16
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-01-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-10
E · Potential for more than minimal harm
2023-09-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-09-14
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-09-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-09-14
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-09-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-09-14
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-09-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-09-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-09-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-06
D · Potential for more than minimal harm
2023-09-14
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-11-06
F · Potential for more than minimal harm
2022-08-18
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-12-12
F · Potential for more than minimal harm
2022-08-18
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-12-12
F · Potential for more than minimal harm
2022-08-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-12
F · Potential for more than minimal harm
2022-08-18
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-12-12
F · Potential for more than minimal harm
2022-08-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-12
F · Potential for more than minimal harm
2022-08-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-12-12
F · Potential for more than minimal harm
2022-08-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-12-12
F · Potential for more than minimal harm
2022-08-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-12
F · Potential for more than minimal harm
2022-08-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-12-12
D · Potential for more than minimal harm
2022-08-18
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-12-12
D · Potential for more than minimal harm
2022-08-18
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-12-12
D · Potential for more than minimal harm
2022-08-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-12-12
D · Potential for more than minimal harm
2022-08-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-12
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-02-02
D · Potential for more than minimal harm
2025-01-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-02
D · Potential for more than minimal harm
2025-01-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-02
D · Potential for more than minimal harm
2025-01-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-02
J · Immediate jeopardy
2024-11-05
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-11-22
J · Immediate jeopardy
2024-11-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-11-05
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-11-05
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-11-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-11-05
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-11-05
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-11-05
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-11-05
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-07-31
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-31
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-16
G · Actual harm
2024-05-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-05-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-05-23
G · Actual harm
2024-03-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-27
G · Actual harm
2024-03-06
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-03-06
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-03-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-03-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-27
E · Potential for more than minimal harm
2023-09-14
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-10-05
E · Potential for more than minimal harm
2023-09-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-05
E · Potential for more than minimal harm
2023-09-14
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-09-14
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-09-14
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-09-14
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-10-05
B · Minimal harm
2023-09-14
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-10-05
G · Actual harm
2023-04-13
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-04-14
E · Potential for more than minimal harm
2023-04-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-04-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-04-13
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-04-14
E · Potential for more than minimal harm
2022-08-18
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-09-13
E · Potential for more than minimal harm
2022-08-18
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-09-13
D · Potential for more than minimal harm
2022-08-18
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-09-13
D · Potential for more than minimal harm
2022-08-18
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-09-13
D · Potential for more than minimal harm
2022-08-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-09-13
Penalties and ownership
What sits behind the stars
$86,473
2024-11-05
Fine
Fine · fine $86,473
Fine
$10,033
2024-05-09
Fine
Fine · fine $10,033
Fine
$33,248
2024-03-06
Fine
Fine · fine $33,248
Fine
Ownership
Nc Royal Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Bornstein, Yisroel
5% Or Greater Direct Ownership Interest · Individual
Lbs Capital Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Hirsch, Nisson
5% Or Greater Direct Ownership Interest · Individual
Bornstein, Yisroel
Corporate Officer · Individual
Hirsch, Nisson
Corporate Officer · Individual
Mcneill, Stacey
Operational/Managerial Control · Individual
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