Cycle 1
Health 2025-03-07 · Fire 2025-03-07
6 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Durham, NC
Pettigrew Rehabilitation Center
2-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1515 W Pettigrew Street, Durham, NC
(919) 286-0751
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
96
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sovereign Healthcare Holdings
Operator or chain grouping
Approved since
1969-01-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
43 facilities
Chain averages 4 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
0.54
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.48
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.30
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
87%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
72%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,392
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.30
Baseline 18.81% · Performance 20.37% · Measure score 2.30 · Achievement 2.30 · Improvement 0
Healthcare-associated infections
3.79
Baseline 5.85% · Performance 6.70% · Measure score 3.79 · Achievement 3.79 · Improvement 0
Total nurse turnover
0.86
Baseline 73.68% · Performance 67.05% · Measure score 0.86 · Achievement 0 · Improvement 0.86
Adjusted total nurse staffing
1.27
Baseline 3.87 hours · Performance 3.44 hours · Measure score 1.27 · Achievement 1.27 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.29% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 111 · Observed rate 10.81% · Lower 95% interval 7.67% |
| Discharge to community | 51.27% |
50.57%
0.7 pts better
|
No Different than the National Rate · Eligible stays 102 · Observed rate 40.2% · Lower 95% interval 41.64% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 96 · Denominator 96 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 96 |
| Discharge self-care score | 66.1% |
53.69%
12.4 pts better
|
Numerator 39 · Denominator 59 |
| Discharge mobility score | 64.41% |
50.94%
13.5 pts better
|
Numerator 38 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 9.38% |
2.29%
7.1 pts worse
|
Numerator 9 · Denominator 96 · Adjusted rate 7.02% |
| Healthcare-associated infections requiring hospitalization | 6.7% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 74 · Observed rate 6.76% · Lower 95% interval 4.18% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 117 |
| Staff flu vaccination coverage | 22.34% |
42%
19.7 pts worse
|
Numerator 42 · Denominator 188 |
| Discharge function score | 66.1% |
56.45%
9.6 pts better
|
Numerator 39 · Denominator 59 |
| Transfer of health information to provider | 98.28% |
95.95%
2.3 pts better
|
Numerator 57 · Denominator 58 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 36.36% |
25.2%
11.2 pts better
|
Numerator 16 · Denominator 44 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.2 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
91.5%
6.7 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.0% · Q3 97.3% · Q4 98.6% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.6%
1.1 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.5% · Q3 2.7% · Q4 2.8% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.5% |
4.8%
0.7 pts worse
|
11.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 8.2% · Q3 7.4% · Q4 4.3% · 4Q avg 5.5% |
| Percentage of long-stay residents who lose too much weight | 2.0% |
7.2%
5.2 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 1.7% · Q3 1.5% · Q4 1.7% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.7% |
21.6%
16.9 pts better
|
19.6%
14.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.3% · Q3 4.5% · Q4 6.2% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.3% |
15.0%
2.7 pts better
|
16.7%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 10.0% · Q3 13.3% · Q4 14.8% · 4Q avg 12.3% · 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 | 26.3% |
21.5%
4.8 pts worse
|
16.3%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.8% |
16.8%
About the same
|
14.9%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 13.5% · Q3 23.2% · Q4 15.5% · 4Q avg 16.8% · 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 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 with a urinary tract infection | 1.5% |
2.6%
1.1 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 1.4% · Q4 1.5% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.6% |
21.2%
4.6 pts better
|
19.8%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 24.3% · Q3 19.5% · Q4 6.9% · 4Q avg 16.6% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
6.0%
0.2 pts better
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 7.8% · Q3 5.2% · Q4 4.8% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.6% |
79.9%
11.7 pts better
|
81.7%
9.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.1% · Q2 99.0% · Q3 93.5% · Q4 80.9% · 4Q avg 91.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
13.2%
4 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 10.6% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.4% · Q3 1.5% · Q4 1.6% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.3% |
78.1%
15.2 pts better
|
79.7%
13.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.2% |
22.9%
9.7 pts better
|
23.9%
10.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.2% · Observed 15.2% · Expected 27.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-18 · Fire 2024-04-18
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Cycle 3
Health 2023-02-09 · Fire 2023-02-09
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-03-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-07
F · Potential for more than minimal harm
2024-04-18
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-04-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-04-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-05
F · Potential for more than minimal harm
2023-02-09
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-04-21
F · Potential for more than minimal harm
2023-02-09
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 2023-04-21
F · Potential for more than minimal harm
2023-02-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-21
F · Potential for more than minimal harm
2023-02-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-02-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-04-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-07
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 2025-04-01
E · Potential for more than minimal harm
2025-03-07
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 2025-04-01
D · Potential for more than minimal harm
2025-03-07
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 2025-02-22
D · Potential for more than minimal harm
2025-03-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-01
D · Potential for more than minimal harm
2025-03-07
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 2025-04-01
B · Minimal harm
2025-03-07
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-04-01
E · Potential for more than minimal harm
2024-04-18
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-05-16
E · Potential for more than minimal harm
2024-04-18
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-05-16
D · Potential for more than minimal harm
2024-04-18
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 2024-05-16
D · Potential for more than minimal harm
2024-04-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-16
D · Potential for more than minimal harm
2024-04-18
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-05-16
D · Potential for more than minimal harm
2024-04-18
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 2024-05-16
E · Potential for more than minimal harm
2023-05-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-23
F · Potential for more than minimal harm
2023-02-09
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 2023-05-05
E · Potential for more than minimal harm
2023-02-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-02-09
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-05-05
Penalties and ownership
What sits behind the stars
Ownership
Burke, Rachael
Operational/Managerial Control · Individual
Cronquist, Royce
Operational/Managerial Control · Individual
Mangine, John
Operational/Managerial Control · Individual
Melton, Donald
Operational/Managerial Control · Individual
O Brien, Patrick
Operational/Managerial Control · Individual
Southern Healthcare Management LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
#2
Durham Nursing & Rehabilitation Center
Durham, NC
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
#3
Pruitthealth-Durham
Durham, NC
2-star overall rating with 2-star inspections with abuse icon flag with $30,303 in total fines with 10 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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