Deficiency Records for Durham Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Durham Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2023-10-18 | 2023-11-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-10-18 | 2023-11-06 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-10-18 | 2023-11-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-18 | 2023-11-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-18 | 2023-11-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-18 | 2023-11-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-18 | 2023-11-06 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-10-18 | 2023-11-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-10-18 | 2023-11-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-18 | 2023-11-06 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-09-14 | 2023-10-05 | N |
| 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. | Health | 2023-09-14 | 2023-10-05 | N |
| 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. | Health | 2023-09-14 | 2023-10-05 | N |
| Post nurse staffing information every day. | Health | 2023-09-14 | 2023-10-05 | N |
| 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. | Health | 2023-09-14 | 2023-10-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-14 | 2023-10-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-14 | 2023-10-05 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-04-13 | 2023-04-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-13 | 2023-04-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-13 | 2023-04-14 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-04-13 | 2023-04-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-16 | 2023-04-14 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-01-09 | 2023-03-16 | Y |
| Meet other general requirements. | Fire Safety | 2022-09-13 | 2022-12-12 | N |
| Meet other general requirements. | Fire Safety | 2022-09-13 | 2022-12-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-13 | 2022-12-12 | N |
| 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. | Fire Safety | 2022-09-13 | 2022-12-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-13 | 2022-12-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-13 | 2022-12-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-09-13 | 2022-12-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-13 | 2022-12-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-13 | 2022-12-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-09-13 | 2022-12-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-09-13 | 2022-12-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-13 | 2022-12-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-09-13 | 2022-12-12 | N |
| 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. | Health | 2022-08-18 | 2022-09-13 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-08-18 | 2022-09-13 | N |
| 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. | Health | 2022-08-18 | 2022-09-13 | N |
| 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. | Health | 2022-08-18 | 2022-09-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-18 | 2022-09-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-14 | 2022-02-03 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-01-14 | 2022-02-03 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-01-14 | 2022-02-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-14 | 2022-02-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-14 | 2022-02-03 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-14 | 2022-02-03 | Y |
| Meet other general requirements. | Fire Safety | 2021-07-29 | 2021-10-15 | N |
