01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-04-16 | 8 | 2026-04-16 | 13 |
| Cycle 2 | 2025-01-16 | 13 | 2025-01-16 | 8 |
| Cycle 3 | 2023-09-14 | 16 | 2023-09-14 | 10 |
CMS CCN 3450702026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
University Health And Rehabilitation Center
411 S Lasalle Street · Durham, NC 27705 · Durham County
Certified beds126CMS provider file
Recent citation rows68current CMS citation release
Penalty rows3current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
68 rows in the current release
5 rows carry G–L scope/severity codes; 2 carry J–L. 15 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-04-16 · HEALTHF0561Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Correction field: Deficient, Provider has date of correction · 2026-05-14 · complaint2026-04-16 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-05-14 · complaint2026-04-16 · HEALTHF0679Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Correction field: Deficient, Provider has date of correction · 2026-05-142026-04-16 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2026-05-14 · complaint2026-04-16 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2026-05-14 · complaint2026-04-16 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-05-142026-04-16 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-05-142026-04-16 · HEALTHF0925Severity E · pattern; potential for more than minimal harm
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Correction field: Deficient, Provider has date of correction · 2026-05-14 · complaint2026-04-16 · FIREK0100Severity D · isolated; potential for more than minimal harm
Construction Deficiencies
Meet other general requirements.
Correction field: Deficient, Provider has no plan of correction2026-04-16 · FIREK0211Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has no plan of correction2026-04-16 · FIREK0222Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Correction field: Deficient, Provider has no plan of correction2026-04-16 · FIREK0293Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has no plan of correction2026-04-16 · FIREK0321Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has no plan of correction2026-04-16 · FIREK0363Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has no plan of correction2026-04-16 · FIREK0372Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has no plan of correction2026-04-16 · FIREK0374Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Correction field: Deficient, Provider has no plan of correction2026-04-16 · FIREK0511Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has no plan of correction2026-04-16 · FIREK0521Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has no plan of correction2026-04-16 · FIREK0741Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has no plan of correction2026-04-16 · FIREK0914Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has no plan of correction2026-04-16 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has no plan of correction2025-01-16 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2025-02-022025-01-16 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2025-02-022025-01-16 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-02-0203 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-11-05 | Fine | $86,473 | 0 |
| 2024-05-09 | Fine | $10,033 | 0 |
| 2024-03-06 | Fine | $33,248 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- LBS CAPITAL HOLDINGS LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST20% · since 04/03/2022
- NC ROYAL HEALTHCARE LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST50% · since 01/01/2020
- BORNSTEIN, YISROELIndividual · 5% OR GREATER DIRECT OWNERSHIP INTEREST20% · since 09/21/2016
- HIRSCH, NISSONIndividual · 5% OR GREATER DIRECT OWNERSHIP INTEREST10% · since 09/21/2016
- BORNSTEIN, YISROELIndividual · CORPORATE OFFICERNOT APPLICABLE · since 09/21/2016
- HIRSCH, NISSONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 09/21/2016
- MCNEILL, STACEYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/28/2025
- LBS CAPITAL HOLDINGS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/03/2022
- NC ROYAL HEALTHCARE LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 01/01/2020
- BORNSTEIN, YISROELIndividual · ADP OF THE SNFNOT APPLICABLE · since 01/01/2020
- MCNEILL, STACEYIndividual · ADP OF THE SNFNOT APPLICABLE · since 09/24/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.31per resident day
RN hours0.51per resident day
Weekend nurse hours2.78per resident day
Staff turnover62.2%CMS reported field
06 / LOCAL RECORDS
Open the Durham ledger →Other published facilities nearby
Accordius Health At Rose Manor Llc111 beds · CMS overall 2/559 citation rowsCarver Living Center232 beds · CMS overall 1/567 citation rowsCroasdaile Village102 beds · CMS overall 4/512 citation rowsHillcrest Convalescent Center86 beds · CMS overall 5/515 citation rowsPettigrew Rehabilitation Center96 beds · CMS overall 4/525 citation rowsPruitthealth-Carolina Point138 beds · CMS overall 1/538 citation rowsPruitthealth-Durham125 beds · CMS overall 1/576 citation rowsSouthpoint Rehabilitation And Healthcare Center140 beds · CMS overall 1/556 citation rows