D+
53/100Southpoint Rehabilitation and Healthcare Center Inspection Report, Violations & Safety Grade (Durham, North Carolina)
6000 Fayetteville Road, Durham, North Carolina 27713
Phone: 9195449021
CMS Overall:2/5
Overview & Bed Count
Certified Beds
140
Avg Residents/Day
125.1
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Durham
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall2/5
Health2/5
Staffing2/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | North Carolina Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.54 | 0.62 | -0.08 |
| Total Nurse Hours per Resident per Day | 3.28 | 3.87 | -0.59 |
| CMS Staffing Rating | 2/5 | 2.7/5 | - |
| Nursing Staff Turnover | 55.4% | 48.7% | - |
Health Citation History
29 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-04-10 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | E – Moderate Harm Potential |
| 2025-04-10 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from the wrongful use of the resident's belongings or money. | D – Moderate Harm Potential |
| 2025-04-10 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2025-04-10 | 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 |
| 2025-04-10 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2025-04-10 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2025-04-10 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2025-04-10 | 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. | D – Moderate Harm Potential |
| 2024-11-19 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2024-05-24 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E – Moderate Harm Potential |
| 2024-04-05 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J – Immediate Jeopardy |
| 2024-04-05 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | J – Immediate Jeopardy |
| 2024-04-05 | Nursing and Physician Services Deficiencies | 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. | J – Immediate Jeopardy |
| 2024-04-05 | 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 |
| 2024-04-05 | 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. | E – Moderate Harm Potential |
| 2024-04-05 | 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 |
| 2024-04-05 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2024-04-05 | 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 |
| 2024-04-05 | Resident Rights Deficiencies | Allow residents to self-administer drugs if determined clinically appropriate. | D – Moderate Harm Potential |
| 2024-04-05 | 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 |
| 2024-04-05 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2024-04-05 | Resident Rights Deficiencies | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | D – Moderate Harm Potential |
| 2024-04-05 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2024-04-05 | Resident Assessment and Care Planning Deficiencies | Plan the resident's discharge to meet the resident's goals and needs. | D – Moderate Harm Potential |
| 2024-04-05 | Resident Assessment and Care Planning Deficiencies | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | D – Moderate Harm Potential |
| 2024-04-05 | Quality of Life and Care Deficiencies | Provide activities to meet all resident's needs. | D – Moderate Harm Potential |
| 2024-04-05 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D – Moderate Harm Potential |
| 2023-11-20 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | E – Moderate Harm Potential |
| 2023-11-20 | Quality of Life and Care Deficiencies | Provide medically-related social services to help each resident achieve the highest possible quality of life. | D – Moderate Harm Potential |
Fire Safety Citation History
18 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-04-10 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | F – Moderate Harm Potential |
| 2025-04-10 | Smoke Deficiencies | Install a fire alarm system that can be heard throughout the facility. | D – Moderate Harm Potential |
| 2025-04-10 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | D – Moderate Harm Potential |
| 2024-04-05 | Construction Deficiencies | Use approved construction type or materials. | D – Moderate Harm Potential |
| 2024-04-05 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D – Moderate Harm Potential |
| 2024-04-05 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
| 2024-04-05 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | D – Moderate Harm Potential |
| 2024-04-05 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | D – Moderate Harm Potential |
| 2023-01-10 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2023-01-10 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2023-01-10 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D – Moderate Harm Potential |
| 2023-01-10 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | D – Moderate Harm Potential |
| 2023-01-10 | Smoke Deficiencies | Provide properly protected cooking facilities. | D – Moderate Harm Potential |
| 2023-01-10 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2023-01-10 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | D – Moderate Harm Potential |
| 2023-01-10 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | D – Moderate Harm Potential |
| 2023-01-10 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | D – Moderate Harm Potential |
| 2023-01-10 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the installation and maintenance of electrical systems. | D – Moderate Harm Potential |
Total Penalties & Fines
$48,523
Total Fine Amount (CMS)
1
Number of Fines
2
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2024-04-05 | Fine | $48,523 | - |
| 2024-04-05 | Payment Denial | - | 34 days starting 2024-05-04 |
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3-Year Complete Report ($19)
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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.
Find Safe, Vetted Facilities Near Durham
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.