TREYBURN REHABILITATION CENTER

Nursing Home Inspector

2059 TORREDGE ROAD
DURHAM, NC 27712
Durham County
Phone: 919-477-4474
Provider Number: 345458
Last Inspection: 03/30/2017

About the Nursing Home

Number of Beds: 132
Number of Residents: 104
Beds Available: 28
Percent Occupancy: 79%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

18

Facility
11

County
14

NC
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

18

2017
6

2016
0

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

3/30/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Reasonably accommodate the needs and preferences of each resident. Isolated : Minimal 3 4/27/2017
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 4/27/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 4/27/2017
 
Failed To: Give each resident enough fluids to keep them healthy and prevent dehydration. Isolated : Minimal 3 4/27/2017
 
Failed To: Make sure that special or therapeutic diets are ordered by the attending doctor. Isolated : Minimal 3 4/27/2017
 
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Isolated : Minimal 3 4/27/2017
 

4/14/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 5/11/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 5/11/2016
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

7/26/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Isolated : Minimal 3 8/9/2017
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 8/9/2017
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 8/9/2017
 

3/30/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Isolated : Minimal 3 4/27/2017
 

2/16/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 3/16/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 3/16/2017
 

2/1/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 3/1/2017
 
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 3/1/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Isolated : Minimal 3 3/1/2017
 

5/21/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Pattern : Minimal 4 6/18/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NC State Avg
Number of Residents 104 90.33 84.96
Registered Nurses 0.83 0.56 0.72
Licensed Practical / Vocational Nurses 0.75 0.83 0.87
Certified Nursing Assistants 2.13 1.91 2.33
Total Staff Hours 3.71 3.30 3.91

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NC State Avg%
of high risk long-stay residents with pressure ulcers 15 7 7
of long-stay residents assessed and appropriately given the pneumococcal vaccine 86 87 93
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 83 90 93
of long-stay residents experiencing one or more falls with major injury 1 2 3
of long-stay residents who have depressive symptoms 0 0 2
of long-stay residents who lose too much weight 3 7 8
of long-stay residents who received an antianxiety or hypnotic medication 16 16 29
of long-stay residents who received an antipsychotic medication 11 11 13
of long-stay residents who self-report moderate to severe pain 2 5 6
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 34 26 23
of long-stay residents whose need for help with daily activities has increased 24 18 18
of long-stay residents with a catheter inserted and left in their bladder 3 2 1
of long-stay residents with a urinary tract infection 0 1 4
of low risk long-stay residents who lose control of their bowels or bladder 86 66 55
of short-stay residents assessed and appropriately given the pneumococcal vaccine 61 72 83
of short-stay residents who had an outpatient emergency department visit 11 11 13
of short-stay residents who made improvements in function 61 61 64
of short-stay residents who newly received an antipsychotic medication 3 2 1
of short-stay residents who self-report moderate to severe pain 10 15 14
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 75 75 81
of short-stay residents who were rehospitalized after a nursing home admission 22 20 20
of short-stay residents who were successfully discharged to the community 58 58 55
of short-stay residents with pressure ulcers that are new or worsened 1 0 0