Pruitthealth-Durham

Inspectors wroteBased on observation, record review, resident and staff interviews, the facility failed to maintain personal privacy and dignity for 3 of 5 residents reviewed for resident rights. The facility failed to ensure privacy when a Resident #17 was left naked with his genitals exposed and visible to the public. Resident #17 stated he felt angry, embarrassed, and as though he was on display as a result of the incident. The facility also failed to treat Resident #57 in a dignified manner when staff did not provide privacy during activities of daily living, exposing Resident #57's buttocks and private areas during bathing and wound care. Additionally, the facility failed to protect the dignity and privacy of Resident #80 by failing to provide a privacy cover while Resident #80 was dressed only in an adult incontinence brief and visible to the public. [...]

Inspectors wroteBased on record review, observations, staff and provider interviews, the facility failed to ensure 1 of 5 residents (Resident # 17) received ongoing assessments of a stage 4 pressure ulcer. The facility failed to recognize the pressure ulcer was not improving and involve a wound provider. On admission, 4/20/26, the wound measurements were 2.5 centimeters (cm) in length, 1.5 cm in width, and 0.5 cm in depth. When the wound provider assessed the pressure ulcer on 5/21/26 the wound measured 10 cm in length, 2.5 cm in width, and 1 cm in depth. Findings Included: [...]

Inspectors wroteBased on record review, observations, staff and provider interviews, the facility failed to ensure adequate staffing to ensure 1 of 5 residents (Resident # 17) received ongoing assessments of a stage 4 pressure ulcer and were able to recognize the pressure ulcer was not improving and involve a wound provider. On admission, 4/20/26, the wound measurements were 2.5 centimeters (cm) in length, 1.5 cm in width, and 0.5 cm in depth. When the wound provider assessed the pressure ulcer on 5/21/26 the wound measured 10 cm in length, 2.5 cm in width, and 1 cm in depth. Cross refer to F686 Based on record review, observations, staff and provider interviews, the facility failed to ensure 1 of 5 residents (Resident # 17) received ongoing assessments of a stage 4 pressure ulcer. The facility failed to recognize the pressure ulcer was not improving and involve a wound provider. [...]

Inspectors wroteBased on staff interviews, the facility failed to employ a qualified food and nutrition services manager with the competencies and skills required to carry out food and nutrition services for 115 of 116 residents who received meal trays.

Inspectors wroteBased on observation, record review, and interviews with residents, resident representative and staff, the facility failed to ensure residents' menus and/or individual food plans met their nutritional needs, prescribed diet consistencies, and documented food preferences for 2 of 9 residents reviewed for food plans (Residents #89 and #116). The facility failed to follow standard recipes and failed to serve the indicated serving size during the lunch meal for 1 of 1 tray line observation. This practice had the potential to affect food served to residents.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to keep the floors and walls behind the deep fryer and stove clean and free of dirt and oil. Staff failed to keep the oven, stove, deep fryer, and steam table backsplash clean and free of burnt food and food stains. Staff failed to label food stored for use in 1 of 1 reach in refrigerator and ensured that dry food with a scoop inside it was covered and labeled with the correct name. In addition, the facility failed to keep trash containers in the kitchen covered, failed to store cleaning equipment away from clean dishes, and failed to discard chipped plates and remove cups with dried food on them from the tray line. Dietary staff with facial hair failed to use facial hair covers to cover their facial hair for 2 of 2 staff observed. The facility also failed to maintain the ceiling to prevent peeling paint. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to keep the dumpster area free of accumulated trash and debris for 3 of 3 dumpsters observed. This practice had the potential to attract pests and rodents.

Inspectors wroteBased on a review of the Resident Council meeting minutes and interviews with Resident Council members, the facility failed to resolve concerns voiced by the Resident Council members during 4 of the 7 previous Resident Council meetings (Resident Council meetings held on 3/30/26, 4/23/26, 5/20/26, and 5/27/26).

Inspectors wroteBased on observations, resident and staff interviews the facility failed to ensure 2 urinals (Resident #5 and #88) and 6 bath basins (Resident #5, #88, #21, #38, #65, and #85) were labeled for each resident and stored in a sanitary manner. The facility failed to ensure a privacy curtain was clean and was free from coming into contact with the floor (Resident #116). The facility also failed to ensure resident rooms were clean as evidenced by soiled and sticky floors (Resident #89 and #116), a sticky floor (Resident #6), failed to keep a Packaged Terminal Air Conditioner (PTAC) unit from dust and debris (Resident #57), and failed to keep a resident's room wall surface smooth and intact as evidenced by damaged sheetrock and missing paint (Resident #91). [...]

Inspectors wroteBased on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for the use of tobacco, indwelling urinary catheter, insulin and dental status for 4 of 20 residents (Resident #100, Resident #62, Resident #76, and Resident #6 ) reviewed for MDS accuracy.

Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility failed to complete a smoking assessment (Resident #100) and complete a quarterly smoking assessment (Resident #100 and Resident #62). The facility failed to secure smoking material (cigarettes and ignition material) for 3 of 3 residents (Resident #100, Resident #62, and Resident #104) reviewed for safe smoking. The facility also failed to secure one oxygen cylinder stored in a resident's room for 1 of 1 resident (Resident #99) reviewed for accidents.

Inspectors wroteBased on record review, Pharmacist, Medical Director and staff interviews, the facility failed to prevent a significant medication error when lacosamide and zonisamide (anticonvulsant medications used to treat epilepsy) were transcribed and administered to Resident #127 incorrectly. This was for 1 of 10 residents (Resident #127) whose medications were reviewed.

Inspectors wroteBased on record review and interviews with the Registered Dietitian, staff and 5 of 5 residents present in the Resident Council Group Meeting (Resident #17, Resident #4, Resident #85, Resident #91 and Resident #92) the facility failed to serve a nourishing snack to residents at bedtime.

Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility failed to maintain complete and accurate medical records for wound care (Resident #4, Resident #17, and Resident #76) for 3 of 6 residents reviewed for wound care. Findings Included: 1a. Review of the April 2026 Medication Administration Record (MAR) revealed treatment for the pressure ulcer to the left ischium was documented by Nurse #6 on 04/20/26, 04/21/26, 04/25/26, 04/26/26, and 04/27/26. Review of the May 2026 Medication Administration Record (MAR) revealed treatment for the Stage 4 pressure ulcer to the left buttock/ischium was documented by Nurse #6 on 05/26/26, 05/27/26, 05/28/26, and 05/29/26. [...]

Inspectors wroteBased on record review, Pharmacist, resident, responsible party (RP) and staff interviews, the facility failed to provide education regarding the benefits and potential side effects of the influenza immunization with documentation in the medical record and failed to offer the influenza immunization during the influenza season (October to March) for 6 of 7 residents reviewed for influenza immunization (Residents #38, #39, #56, #71, #77 and #121).

Inspectors wroteBased on record reviews, resident, responsible party (RP) and staff interviews, the facility failed to assess residents for the eligibility and ensure residents were offered the COVID-19 booster vaccination for 6 of 7 residents reviewed for COVID-19 booster immunizations (Residents #38, #39, #56, #71, #77 and #121).

Inspectors wroteBased on observation, record review, resident and staff interviews the facility failed to maintain a resident's dignity when staff spoke to a resident in an undignified manner. The resident stated she was upset by the way the staff member spoke to her when the staff told her not to hit her call bell (Resident #69). This deficient practice affected 1 of 5 residents reviewed for dignity and respect.

Inspectors wroteBased on observation, record review, resident, staff and Nurse Practitioner interviews, the facility failed to assess the ability of a resident to safely self-administer medications for 1 of 1 resident reviewed for self-administering medications (Resident #135).

Inspectors wroteBased on observation, record review, and interviews with Resident and staff, the facility failed to honor residents' choices of getting out of bed for 2 of 11 residents reviewed for self determination (Residents #116 and #69).

Inspectors wroteBased on record reviews, staff and Health Care Power of Attorney interviews, the facility failed to distribute the funds within 30 days of discharge for 1 of 3 residents reviewed for refund of deposit (Resident #127).

Inspectors wroteBased on record reviews, observations, and staff interviews, the facility failed to develop an individualized and comprehensive care plan for the potential for or history of behavioral symptoms as well as the use of psychotropic medications (Resident #35) and dental concerns (Resident #62). This deficient practice affected 2 of 10 residents reviewed for dementia and dental concerns.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a comprehensive care plan within 7 days of the admission Minimum Data Set assessment for 1 of 3 residents (Resident # 104) reviewed for smoking.

Inspectors wroteBased on record review, Medical Director, and staff interviews, the facility failed to administer insulin per the parameters in the physician order (Resident #62) for 1of 1 resident reviewed for well-being.

Inspectors wroteBased on observation, record review, physician, and staff interviews, the facility failed to provide wound care for a non-pressure wound as order by the physician for 1 of 6 residents reviewed for wound care (Resident #76).

Inspectors wroteBased on observations, record review, staff, and Physician interviews, the facility failed to apply a right hand palmar guard orthosis (type of hand splint designed to protect the palm of the hand from injury caused by severe finger flexion contractures, also called palm protectors) as outlined in the care plan for 1 of 1 resident (Resident #8) reviewed for contractures and range of motion (ROM).

Inspectors wroteBased on record review and interviews with the Nurse Practitioner, resident, and staff, the facility failed to implement an active order to obtain a urinalysis with culture and sensitivity for a resident who exhibited symptoms of a urinary tract infection. This deficient practice resulted in missed diagnostic evaluation and affected 1 of 6 residents reviewed for urinary care management (Resident #135).

Inspectors wroteBased on record review, Nurse Practitioner and staff interviews, the facility failed to transcribe blood glucose monitoring orders on admission to monitor the use of an oral diabetic medication for 1 of 10 residents whose medications were reviewed (Resident #130).

Inspectors wroteBased on record review, observations, and interviews with the resident, Physician, and staff, the facility failed to secure prescribed medications stored at bedside for 2 of 6 residents reviewed for medication storage (Resident #84 and Resident #104).

Inspectors wroteBased on record reviews, observation, resident and staff interviews, the facility failed to accommodate food preferences for 1 of 1 resident reviewed for food preferences (Resident #56). The finding Included:Resident #56 was admitted to the facility on [DATE]. A review of Resident #56's records revealed a form titled Diet History/Food Preference List, completed by the Former Dietary Manager. The form indicated Resident #56 disliked foods such as bacon, beef liver, beef, veal, bologna, chicken liver, chicken, chili, enchiladas, fish, ham, lasagna, pork, sausage, shrimp, tuna, turkey, and other. The form was undated. The Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #56 was cognitively intact and able to eat independently. A dining observation of Resident #56's lunch tray occurred on 06/09/2026 at 1:30 PM. [...]

Inspectors wroteBased on observations, record review, physician, Physician Assistant, and staff interviews, the facility failed to implement their infection control policy regarding hand hygiene when a staff member failed to perform hand hygiene while performing wound care (Resident #17). This deficient practice occurred for 1 of 28 staff observed for infection control (Wound care nurse).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to provide a working privacy curtain that allowed for full visual privacy to protect a resident from view of others during activities of daily living care while bathing. This deficient practice affected 1 of 3 residents reviewed for privacy curtains (Resident #57).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately document actual working hours of licensed staff for 6 of 6 daily nurse staffing sheets reviewed (5/6/26, 5/15/26, 5/17/26, 6/1/26, 6/2/26, and 6/6/26).

Inspectors wroteBased on record review, and staff, responsible party (RP), Hospice Nurse, and Physician interviews, the facility failed to notify the provider of a change in condition and x-ray results after a fall for one (Resident #1) of three residents reviewed for notification of falls. Resident #1 fell on 5/17/2025 and the facility failed to notify the provider of pain and a new inability to bear weight. X-ray results obtained midday on 5/19/2025 were not relayed to the on-call provider until after hours on 5/19/2025. Resident #1 sustained an acute impacted left femoral neck fracture (an acute impacted left femoral neck fracture is a break in the upper part of the thigh bone (femur), specifically at the neck, where it connects to the ball of the hip joint).

Inspectors wroteBased on record review, and staff, resident, responsible party (RP), Hospice Nurse, Physician, and Medical Director interviews, the facility failed to provide ongoing assessments after a fall; failed to identify a change in condition that required medical evaluation and treatment; failed to notify a provider of a change in condition; failed to identify one leg shorter than the other and external leg rotation required medical evaluation and treatment; failed to communicate effectively to provide treatment; and failed to notify a provider of fracture x-ray fax results upon receipt for one (Resident #1) of three residents reviewed for abuse and/or neglect. Resident #1 sustained an acute impacted left femoral neck fracture. [...]

Inspectors wroteBased on record review, and staff, responsible party (RP), resident, Hospice Nurse, Physician, and Medical Director interviews the facility failed to provide ongoing assessments after a fall; failed to identify the change in condition required medical evaluation and treatment; failed to identify one leg shorter than the other and external leg rotation required medical evaluation and treatment; and failed to communicate effectively to provide treatment for one (Resident #1) of three residents reviewed for assessment after a fall. Resident #1 sustained an acute impacted left femoral neck fracture (an acute impacted left femoral neck fracture is a break in the upper part of the thigh bone (femur), specifically at the neck, where it connects to the ball of the hip joint).

Inspectors wroteBased on record review and staff interviews, the facility failed to effectively document in the electronic medical record for conveyance of medical information for two (Resident #1 and Resident #5) of three residents reviewed for accidental falls. Resident #1 lacked initial documentation of a fall by Nurse #4, initial physical assessments by Nurse #4, and administration of pain medication by Nurse #2 and Nurse #3. Resident #1 had incorrect documentation of the administration of pain medication by Nurse #5. Resident #5 lacked documentation of a nursing physical assessment after a fall.

Inspectors wroteBased on record review, and staff and a resident interview, the facility failed to immediately notify the Administrator of an abuse allegation made by a resident for one (Resident #2) of three residents reviewed for abuse investigations.

Inspectors wroteBased on record reviews and interviews with staff, resident, and the Pharmacist, the facility failed to administer medications as ordered for 1 of 6 residents (Resident #64). Staff did not remove medication from the refrigerator believing the medication had not been received by the pharmacy, resulting in 11 missed doses of eyedrops for glaucoma.

Inspectors wroteBased on observation and staff interviews, the facility failed to cover facial hair during food service for 1 of 2 dietary staff (Cook #1) observed and clean the convection oven and the deep fryer. These practices had the potential to affect food served to residents.

Inspectors wroteBased on observations, records review, and resident and staff interviews, the facility failed to apply a left-hand splint for 1 of 3 residents (Resident #31) reviewed for contractures.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to label and shake a new tube feeding formula bottle before hanging for 1 of 3 residents (Resident #307).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to date opened multi-dose pen injectors of insulin medication in 2 of 5 medication administration carts (100 hall and 200 hall), failed to remove expired multi-dose pen injectors of insulin from the medication cart drawer for 1 of 5 medication administration carts (200 hall).

Inspectors wroteBased on record review, and staff interviews, the facility failed to prevent a significant medication when a nurse administered 40 mg of liquid morphine when the physician order was for 5mg to 1 of 3 sampled residents (Resident #1) reviewed for medication administration.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to maintain the ice scoop holder clean, failed to have deep fryer cleaned and free of food crumbs, failed to maintain the walk-in freezer clean, failed to discard expired food from reach-in refrigerator, failed to label, and date food placed in 2 of 2 nourishment refrigerator. Failed to ensure dietary staff covered their facial hair. These practices had the potential to affect food served to residents.

Inspectors wroteBased on record review and staff interviews the facility failed to ensure advanced directive information was accurate throughout resident's electronic and paper medical records for 1 of 1 resident (Resident #97) reviewed for advanced directives.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment to reflect a resident's admission to Hospice for 1 of 2 residents (Resident #13) reviewed who had received Hospice services.

Inspectors wroteBased on observations, interviews with staff, and record reviews, the facility failed to: 1) Label a medication stored on 1 of 2 medication (med) carts (300 Long Hall Med Cart) with the minimum information required, including the resident's name; 2) Store medications in accordance with the manufacturer's storage instructions on 1 of 2 med carts (300 Long Hall Med Cart); and 3) Maintain clean and sanitary conditions for the storage of medications on 1 of 2 medication carts observed (200 Short Hall Med Cart).

Inspectors wroteBased on staff interviews and record review, the facility's quality assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the recertification surveys dated 10/27/22 in order to achieve and sustain compliance. These were for recited deficiencies cited during a recertification survey on 1/12/24. The deficiencies were in the following areas: comprehensive assessment, quarterly assessment, and encoding. The continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective quality assurance program.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to complete a Discharge Minimum Data Set (MDS) assessment within the required time frame for 2 of 3 residents (Resident # 93, and Resident # 99) selected for Resident Assessments and for 1 of 9 residents whose closed records were reviewed (Resident #13).