Provider Name: RALEIGH REHABILITATION CENTER
Address: 616 WADE AVENUE, RALEIGH, NC 27605
Phone: (919) 828-6251
County: Wake (910)
Ownership Type: For profit - Limited Liability company
Certified Beds: 157
Average Residents Per Day: 121. ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: RALEIGH REHABILITATION CENTER LLC
First Approved Date: October 1, 1972
Affiliated Entity: SOVEREIGN HEALTHCARE HOLDINGS (482)
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: None
Sprinkler System Status: Yes
Overall Rating: 1 ()
Health Inspection Rating: 1 ()
QM Rating: 4 ()
Long Stay QM Rating: 3 ()
Short Stay QM Rating: 4 ()
Staffing Rating: 2 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 2.31272, LPN Staff Hours Per Day: 1.0737, RN Staff Hours Per Day: 0.2685, Licensed Staff Hours Per Day: 1.3422
Total Nurse Staff Hours Per Day, per resident: 3.65500
Weekend Nurse Staff Hours: 3.23971, Weekend RN Staff Hours: 0.2119
PT Staff Hours Per Day, per resident: 0.1386
Nurse Staff Turnover: 65.3, Nurse Turnover Note:
RN Turnover: 84.6, RN Turnover Note:
Admin Left Number: 1, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 1.9948, Case Mix LPN Hours Per Day: 0.7736, Case Mix RN Hours Per Day: 0.3784
Adjusted Nurse Aide Hours Per Day, per resident: 2.36184, Adjusted LPN Hours Per Day: 1.0241, Adjusted RN Hours Per Day: 0.2673
Total Adjusted Nurse Hours Per Day, per resident: 3.66080
Adjusted Weekend Nurse Hours Per Day, per resident: 3.24486
Health Survey Dates and Scores: Cycle 1: 2023-10-12 (Score: 144), Cycle 2: 2022-06-23 (Score: 64), Cycle 3: 2021-07-16 (Score: 52)
Total Weighted Health Score: 102.00
Reported Incidents: 0, Substantiated Complaints: 10
Infection Control Citations:
Fines and Penalties: Number of Fines: 4, Total Fines in Dollars: 127858.25, Payment Denials Number: 1, Total Penalties Number: 5
Location and GPS: 616 WADE AVENUE,RALEIGH,NC,27605 (35.7965, -78.650)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Past Non-Compliance on 2023-07-15
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Past Non-Compliance on 2023-03-17
Type: Health, Deficiency: Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-07
Type: Health, Deficiency: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-07
Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-07
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-07
Type: Health, Deficiency: Provide activities to meet all resident's needs.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-07
Type: Health, Deficiency: Post nurse staffing information every day.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2023-11-07
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-07
Type: Health, Deficiency: Dispose of garbage and refuse properly.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-07
Type: Health, Deficiency: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-07
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-07
Type: Health, Deficiency: Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-11-07
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Past Non-Compliance on 2023-07-26
Type: Health, Deficiency: Ensure each resident receives an accurate assessment.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-25
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-25
Type: Health, Deficiency: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-25
Type: Health, Deficiency: Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-25
Type: Health, Deficiency: Provide safe and appropriate respiratory care for a resident when needed.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-25
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-25
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-25
Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2022-07-15
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-08-25
Type: Health, Deficiency: Allow residents to self-administer drugs if determined clinically appropriate.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-04
Type: Health, Deficiency: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity: B - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has plan of correction on 2021-08-04
Type: Health, Deficiency: Ensure each resident receives an accurate assessment.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-04
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Past Non-Compliance on 2021-07-06
Type: Health, Deficiency: Ensure medication error rates are not 5 percent or greater.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-04
Type: Health, Deficiency: 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.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-04
Type: Health, Deficiency: Keep all essential equipment working safely.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-04
Type: Health, Deficiency: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-04
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0231, Version: New
Description: Provide large enough exits.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-12-22
Type: Fire Safety, Tag: 0341, Version: New
Description: Install a fire alarm system that can be heard throughout the facility.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-12-22
Type: Fire Safety, Tag: 0374, Version: New
Description: Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-12-22
Type: Fire Safety, Tag: 0521, Version: New
Description: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-12-22
Type: Fire Safety, Tag: 0911, Version: New
Description: Meet requirements for the installation and maintenance of electrical systems.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-12-22
Type: Fire Safety, Tag: 0914, Version: New
Description: Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-12-22
Type: Fire Safety, Tag: 0918, Version: New
Description: Have generator or other power source capable of supplying service within 10 seconds.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-12-22
Type: Fire Safety, Tag: 0321, Version: New
Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-07-22
Type: Fire Safety, Tag: 0521, Version: New
Description: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-07-22