Inspection Reports for Croasdaile Village
2600 Croasdaile Farm Parkway Durham, NC 27705, Durham, NC, 27705
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
5.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Same as North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
NC DHSR Star Rating History
| Date | Rating | Score | Merits | Demerits | Type |
|---|---|---|---|---|---|
| Oct 21, 2025 | 104.5 | 4.5 | 0 | Annual Inspection | |
| Feb 26, 2024 | 102.5 | 2.5 | 0 | Annual Inspection | |
| Feb 6, 2023 | 97 | 5 | 4 | Follow-Up Inspection | |
| Nov 18, 2022 | 96 | 5.5 | 9.5 | Annual Inspection | |
| May 9, 2019 | 101.5 | 5.5 | 4 | Annual Inspection | |
| Jun 1, 2016 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Nov 21, 2013 | 103.5 | 5.5 | 2 | Annual Inspection | |
| Oct 13, 2011 | 101.5 | 3.5 | 2 | Annual Inspection | |
| Jul 14, 2010 | 105.5 | 5.5 | 0 | Annual Inspection | |
| Sep 15, 2009 | 105.5 | 5.5 | 0 | Annual Inspection |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Aug 14, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, specifically the completion and timely transmission of quarterly Minimum Data Set (MDS) assessments for residents.
Findings
The facility failed to complete a quarterly MDS assessment within the required timeframe for 1 of 7 residents reviewed and failed to transmit quarterly MDS assessments within the required timeframe for 2 of 7 residents. Issues were related to resident readmissions and transition to a new electronic medical records system.
Deficiencies (2)
Failed to complete a quarterly Minimum Data Set (MDS) assessment within the required timeframe for 1 of 7 residents.
Failed to transmit quarterly Minimum Data Set (MDS) assessments within the required timeframe for 2 of 7 residents.
Report Facts
Residents reviewed for assessments: 7
Residents affected: 1
Residents affected: 2
Days for quarterly MDS assessment completion: 92
Days for MDS transmission: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding missing and delayed MDS assessments and transmission issues | |
| Administrator | Interviewed regarding timely completion and transmission of MDS assessments |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 11, 2024
Visit Reason
The inspection was conducted to review the facility's compliance with timely transmission of Quarterly Minimum Data Set (MDS) assessments to the State.
Findings
The facility failed to transmit Quarterly MDS assessments within the required timeframe for 2 of 3 residents reviewed (Resident #16 and Resident #67). Both assessments were completed and signed on time but were not transmitted until nearly two months later due to a failure in triggering the transmission process.
Deficiencies (1)
Failure to transmit Quarterly Minimum Data Set (MDS) assessments within the required timeframe for Resident #16 and Resident #67.
Report Facts
Residents reviewed for MDS assessments: 3
Residents with late MDS transmission: 2
Days late for Resident #16 MDS transmission: 52
Days late for Resident #67 MDS transmission: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding delayed transmission of MDS assessments | |
| Administrator | Interviewed and stated expectation that all MDS assessments be completed and transmitted on time |
Inspection Report
Deficiencies: 1
Date: Feb 23, 2023
Visit Reason
The inspection was conducted to investigate medication administration practices following concerns about a significant medication error involving failure to administer an anticoagulant medication to a resident during his stay.
Findings
The facility failed to administer apixaban, an anticoagulant, to Resident #240 for a period of 10 days due to a medication order lapse caused by an inappropriate stop date in the hospital discharge medication list. Interviews with facility staff confirmed the error and acknowledged the need for physician oversight to prevent such occurrences.
Deficiencies (1)
Failure to administer an anticoagulant medication (apixaban) to a resident for 10 days during his stay.
Report Facts
Residents affected: 1
Medication lapse duration (days): 10
Medication order duration (days): 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #240's Medical Doctor | Medical Director | Authored progress notes and interviewed regarding medication lapse |
| Nurse Practitioner | Nurse Practitioner (NP) | Interviewed about medication administration and follow-up care |
| Interim Director of Nursing | Interim Director of Nursing (DON) | Interviewed regarding medication order lapse and facility procedures |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 21, 2023
Visit Reason
The inspection was conducted due to concerns regarding medication administration errors and lapses in medication orders for residents at the facility.
Complaint Details
The complaint investigation focused on medication administration errors for Resident #20 and a medication order lapse resulting in a 10-day discontinuation of apixaban for Resident #240. The medication errors were substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to maintain medication error rates below 5%, with specific errors involving incorrect medication administration and crushing of medications that should not be crushed for Resident #20. Additionally, the facility failed to administer an anticoagulant medication to Resident #240 for a period of 10 days during his stay, due to a medication order lapse.
Deficiencies (3)
Medication error rate of 10.7% due to missed immediate release carbidopa/levodopa tablets for Resident #20.
Crushing of potassium chloride Extended Release tablets and aspirin Delayed Release tablets which should not be crushed for Resident #20.
Failure to administer apixaban anticoagulant medication for 10 days to Resident #240 due to a medication order lapse.
Report Facts
Medication errors: 3
Medication error rate: 10.7
Days without medication: 10
Medication dose: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Agency Nurse | Observed preparing and administering medications, involved in medication errors for Resident #20 |
| Nurse #2 | Staff Nurse | Interviewed regarding medication discrepancies and administration for Resident #20 |
| Interim Director of Nursing | Interim Director of Nursing (DON) | Interviewed regarding medication administration concerns and facility expectations |
| Nurse Practitioner | Nurse Practitioner (NP) | Interviewed regarding medication order lapse for Resident #240 |
| Medical Doctor | Medical Doctor (MD) and Facility Medical Director | Interviewed regarding medication order lapse and facility medication issues |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jan 5, 2023
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on January 4-5, 2023 to verify correction of previous deficiencies related to resident assessments and medication self-administration.
Findings
The facility failed to ensure initial assessments were completed within 72 hours of admission for sampled residents #1 and #2. Additionally, the facility failed to ensure one of two residents sampled had a physician's order to self-administer vitamins, and there were documentation and medication storage issues related to Resident #4's self-administration of vitamins.
Deficiencies (3)
Facility failed to ensure an initial assessment of each resident was completed within 72 hours of admission using the Resident Register for 2 of 5 sampled residents (Resident #1 and Resident #2).
Facility failed to ensure 1 of 2 residents sampled (Resident #4) had a physician's order to self-administer vitamins.
Documentation and medication storage issues related to Resident #4's self-administration of vitamins, including lack of documentation of date bottle was opened and no self-administration order.
Report Facts
Residents sampled: 5
Residents sampled for self-administration: 2
Vitamin B dosage: 1000
Vitamin D dosage: 125
Vitamin B12 tablets: 16
Multi-vitamin tablets: 29
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Mar 8, 2019
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Croasdaile Village on March 7-8, 2019 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in tuberculosis testing documentation for one resident and in maintaining cleanliness and pest control in the assisted living kitchen, including issues with the plate warmer, floor under the dishwasher, and floor behind the refrigerator.
Deficiencies (2)
Failure to assure 1 of 3 residents sampled was tested upon admission for tuberculosis disease due to missing read date and results documentation for the second TB skin test.
The kitchen, dining and food storage areas were not kept clean and free from contamination, evidenced by debris and dead bugs including a cockroach inside the plate warmer, buildup of debris and dust under the dishwasher supported by a dishrack on the floor, and dead bugs and dust behind the reach-in refrigerator.
Report Facts
Inspection score: 96
Residents sampled for TB testing: 3
Residents with TB testing deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Clinical Supervisor | RNCS | Responsible for completion of the second step TB skin test for residents; interviewed regarding TB testing documentation |
| Administrator | Responsible for auditing TB tests for residents; interviewed regarding TB testing and kitchen cleanliness | |
| Assistant Dining Director | Interviewed regarding kitchen cleanliness and pest control observations | |
| Dinning Director | Interviewed regarding dishwasher support and kitchen cleaning practices | |
| Kitchen staff | Interviewed regarding cleaning practices of plate warmer, refrigerator, and dishwasher |
Inspection Report
Plan of Correction
Capacity: 30
Deficiencies: 5
Date: Feb 28, 2019
Visit Reason
Biennial Construction Survey conducted to assess conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the North Carolina Building Code and licensing rules.
Findings
The survey identified multiple deficiencies including failure to maintain outside premises in a clean and safe condition, furnishings and walls not kept in good repair, and building equipment including fire safety systems not maintained in a safe and operable condition.
Deficiencies (5)
Outside premises were not maintained in a clean and safe condition; insulation boards over exterior soffits were buckling, curling, and separating.
Furnishings were not kept in good repair, including chipped door veneer and doors dragging on frames.
Walls were not kept in good repair, with small holes in walls and fallen plastic housing for washer connections.
Failure to maintain building's fire safety systems in a safe condition; unsealed penetration in fire resistant ceiling.
Fire safety equipment not maintained in safe and operable condition; delayed egress door lacked required signage at time of observation.
Report Facts
Licensed capacity: 30
Inspection Report
Capacity: 30
Deficiencies: 9
Date: Mar 19, 2015
Visit Reason
This report is of a Biennial Construction Survey conducted to assess the facility's conformance with applicable adult care home licensing rules and state building codes.
Findings
Multiple deficiencies were identified including unsafe delayed egress doors, unprotected penetrations compromising fire-resistance ratings, plumbing issues risking contamination, non-illuminated exit signage, unsafe electrical outlet use, doors not closing properly to contain smoke and fire, loose toilets risking leaks, and a non-functioning exhaust fan in the kitchen mop room.
Deficiencies (9)
Delayed egress door at D201 Mechanical Room did not release upon alarm, restricting free egress in an emergency.
Unprotected penetrations in walls and ceilings compromising fire-resistance rating in multiple locations including mechanical rooms, kitchen mop room, and laundry wall.
Drain line on ice machine lacked required 2-inch air gap, risking contamination.
Exit sign at Dining Room exit door was not illuminated, reducing visibility in emergencies.
Residents were allowed to use electrical outlet expansion blocks, risking circuit overload.
Doors including Dining Room door and coordinated doors to Country Kitchen did not close properly to contain smoke and fire.
Toilets in rooms D109 and D104 were coming loose from the floor, risking leaks from broken wax seals.
Fire-resistance rated ceilings and walls penetrated by HVAC ducts and conduits in kitchen, corridor, mechanical rooms, and attic, compromising smoke and fire containment.
Exhaust fan in Kitchen Mop Room was not working, failing to maintain required ventilation.
Report Facts
Total licensed capacity: 30
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