C-
58/100Accordius Health at Rose Manor LLC Inspection Report, Violations & Safety Grade (Durham, North Carolina)
4230 North Roxboro Street, Durham, North Carolina 27704
Phone: 9194779805
CMS Overall:2/5
Overview & Bed Count
Certified Beds
111
Avg Residents/Day
78.8
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Durham
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall2/5
Health2/5
Staffing3/5
Quality2/5
Nurse Staffing Check
| Metric | This Facility | North Carolina Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.53 | 0.62 | -0.10 |
| Total Nurse Hours per Resident per Day | 3.65 | 3.87 | -0.22 |
| CMS Staffing Rating | 3/5 | 2.7/5 | - |
| Nursing Staff Turnover | 55.2% | 48.7% | - |
Health Citation History
30 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-08-27 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2026-08-27 | Resident Rights Deficiencies | 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. | E – Moderate Harm Potential |
| 2026-08-27 | Resident Rights Deficiencies | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | D – Moderate Harm Potential |
| 2026-08-27 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2025-12-15 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2025-05-08 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2025-05-08 | Environmental Deficiencies | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | F – Moderate Harm Potential |
| 2025-05-08 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | E – Moderate Harm Potential |
| 2025-05-08 | Nutrition and Dietary Deficiencies | Dispose of garbage and refuse properly. | E – Moderate Harm Potential |
| 2025-05-08 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2025-05-08 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D – Moderate Harm Potential |
| 2025-05-08 | Resident Assessment and Care Planning Deficiencies | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D – Moderate Harm Potential |
| 2025-05-08 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2025-05-08 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2025-05-08 | Quality of Life and Care Deficiencies | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | D – Moderate Harm Potential |
| 2025-05-08 | Resident Rights Deficiencies | 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. | B – Minimal Harm Potential |
| 2024-01-29 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2024-01-29 | Resident Rights Deficiencies | 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. | E – Moderate Harm Potential |
| 2024-01-29 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E – Moderate Harm Potential |
| 2024-01-29 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | E – Moderate Harm Potential |
| 2024-01-29 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | E – Moderate Harm Potential |
| 2024-01-29 | Pharmacy Service Deficiencies | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | E – Moderate Harm Potential |
| 2024-01-29 | Nutrition and Dietary Deficiencies | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | E – Moderate Harm Potential |
| 2024-01-29 | Administration Deficiencies | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | E – Moderate Harm Potential |
| 2024-01-29 | Resident Rights Deficiencies | Honor the resident's right to organize and participate in resident/family groups in the facility. | D – Moderate Harm Potential |
| 2024-01-29 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2024-01-29 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-01-29 | Resident Rights Deficiencies | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | B – Minimal Harm Potential |
| 2024-01-29 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | B – Minimal Harm Potential |
| 2024-01-29 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | B – Minimal Harm Potential |
Fire Safety Citation History
20 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-05-08 | Construction Deficiencies | Use approved construction type or materials. | E – Moderate Harm Potential |
| 2025-05-08 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | E – Moderate Harm Potential |
| 2025-05-08 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D – Moderate Harm Potential |
| 2025-05-08 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2025-05-08 | Smoke Deficiencies | Provide properly protected cooking facilities. | D – Moderate Harm Potential |
| 2025-05-08 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2025-05-08 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
| 2025-05-08 | Miscellaneous Deficiencies | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | D – Moderate Harm Potential |
| 2025-05-08 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | D – Moderate Harm Potential |
| 2025-05-08 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | D – Moderate Harm Potential |
| 2024-01-29 | Smoke Deficiencies | Install an approved automatic sprinkler system. | F – Moderate Harm Potential |
| 2024-01-29 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | F – Moderate Harm Potential |
| 2024-01-29 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure electrical receptacles or cover plates have distinctive color or marking. | F – Moderate Harm Potential |
| 2024-01-29 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2024-01-29 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | D – Moderate Harm Potential |
| 2022-09-16 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
| 2022-09-16 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2022-09-16 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | D – Moderate Harm Potential |
| 2022-09-16 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | D – Moderate Harm Potential |
| 2022-09-16 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | D – Moderate Harm Potential |
Total Penalties & Fines
$16,801
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2024-01-29 | Fine | $16,801 | - |
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Durham area at no cost.
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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.