Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southern Pines Nursing Center during CMS and state inspections, most recent first.
Failure to supervise a wandering resident resulted in two residents being found together in one resident’s bed while both were fully unclothed. The resident involved had severe dementia-related wandering and needed increased supervision, while the other resident had moderate cognitive impairment and a history of sexually inappropriate behaviors. Staff described frequent wandering, room entry, and attempts to get into other residents’ beds, and the DON and NHA confirmed they did not know who was supervising the residents at the time of the incident.
Medication administration errors exceeded the allowed rate after 2 errors were identified during 36 observed opportunities. An LPN pulled and gave the wrong medications and dosages to a resident, including Omeprazole instead of the ordered Pantoprazole and Guaifenesin 400 mg instead of the ordered Guaifenesin ER 600 mg. The DON was notified, and the facility policy required checking the label for the right resident, medication, dosage, time, and route before administration.
Kitchen sanitation requirements were not maintained. Observations found debris and dried residue on the hand washing sink, countertop, cabinet face, faucet, backsplash area, and wall behind the sink, along with black debris on pipes and light fixtures above the food prep area. The SCDM said daily cleaning and monthly deep cleaning were in place, but maintenance was not doing a very good job, and the NHA stated the kitchen was not clean enough for the standards.
Unsanitary dumpster area and improper refuse storage. Surveyors observed used plastic gloves scattered around the trash receptacles, a filled trash bag lying on the ground outside the designated container, and a dumpster lid left open. The CDM said the issue had been discussed in staff meetings because multiple departments use the area, and the NHA later stated the conditions were unacceptable, unsanitary, and could attract pests. The facility policy required food waste to be kept in containers and outside dumpsters to be kept closed and free of surrounding litter.
QAPI failed to sustain corrective actions for kitchen sanitation after prior F812 concerns. Surveyors observed debris, residue, and buildup on the handwashing sink area, pipes, light fixtures, and juice machine, along with staff beverages and a cell phone in the food prep area and unlabeled, undated drinks in a cooler. The CDM, SCDM, and NHA acknowledged the recurring sanitation issues and that similar concerns had been cited before.
The facility failed to keep current, correct advance directive/DNR documentation for two residents. One resident’s DNR in the EHR and binder was on white paper instead of the expected yellow form, and another resident’s DNR could not be located in the A wing nurses’ station binder even though staff stated they use the binder and EHR to verify code status. Staff interviews confirmed the binder is relied on by CNA staff, an LPN, the RNE, the RNC, and the DON for code status checks.
Inaccurate PASRR screening was identified for a resident with generalized anxiety disorder, depression, and bipolar disorder. The PASRR marked bipolar disorder and depressive disorder under the MI section, but did not mark anxiety disorder. The DON acknowledged the omission and stated the facility did not have a PASRR policy.
Failure to follow enteral feeding orders for a resident with dysphagia and a PEG tube. The resident was NPO and ordered Jevity 1.5 with water flushes, but the tube feeding pump repeatedly alarmed, the feeding bag was found hanging but not connected, and the feeding was not instilling during multiple observations. An LPN reported the resident had not been receiving tube feedings during her shift, and the DON acknowledged missing equipment and delayed feeding. The resident also had significant weight loss during the period reviewed.
Infection control practices were not followed for a resident with a PICC line, during an LPN medication pass and nebulizer treatment, and with a resident’s wheelchair that had large cracks exposing non-cleanable material. The PICC dressing was observed overdue based on the order, the LPN handled a pill with bare hands and performed resident care without gloves or hand hygiene, and the wheelchair was found in disrepair and unacceptable.
Surveyors found widespread uncleanliness and disrepair throughout all hallways and the dining room, including dirty treatment carts, stained and scuffed floors, unfinished wall patches, odorous and unsanitary bathrooms, and improperly maintained resident rooms. Bathrooms contained strong odors, soiled items, and uncleanable surfaces, while common areas had visible debris and stains. Despite the facility's cleaning policy, these conditions persisted, indicating a failure to provide a safe, clean, and homelike environment for residents.
A resident with significant medical issues and existing skin impairments did not receive ongoing skin assessments or documentation after the initial days following admission. Despite a care plan and facility policies requiring regular skin monitoring and documentation, these actions were not carried out, resulting in a deficiency related to inadequate treatment and care according to orders and resident needs.
The facility did not maintain required skilled nursing documentation for several residents receiving skilled services. For example, a resident with multiple medical conditions had no skilled nursing or progress notes during their skilled service period, and another resident had incomplete skilled documentation, with notes missing after the initial days and no documentation regarding skin condition. The DON confirmed the absence and incompleteness of these records.
A resident with moderate cognitive impairment and multiple medical conditions was moved to a different room without proper documentation or notification to their representative. While a later room change was documented and communicated, the initial move lacked required notification, contrary to facility policy.
An LPN failed to perform hand hygiene and did not clean a blood pressure cuff after use on a resident under contact precautions for candida auris, then used the same equipment and continued care activities for another resident without proper infection control practices. Facility policy and CDC guidelines require hand hygiene and cleaning of reusable equipment between residents, which was not followed.
Failure to Supervise a Wandering Resident Resulted in Two Residents Being Found Unclothed Together
Penalty
Summary
The facility failed to provide supervision to a known wandering resident, resulting in an incident involving two residents who were found together while both were fully unclothed. Resident #9 had severe cognitive impairment, dementia-related wandering, and required increased supervision per the care plan. Resident #8 had moderate cognitive impairment and a history of sexually inappropriate behaviors. On 05/30/2026, staff became aware that Resident #9 had entered Resident #8's bed, and the facility did not implement immediate protective measures consistent with its policy. Resident #8 stated that Resident #9 came into his room, removed her clothing, and got into his bed, and that both residents were fully unclothed and lying together for about half an hour before staff entered and removed Resident #9. Staff F stated she found Resident #8 and Resident #9 completely naked in Resident #8's bed, with Resident #9 lying flat on her back and her clothing placed on her wheelchair. Staff E reported that Resident #9 frequently entered other residents' beds and rooms, and Staff A, Staff B, Staff C, and Staff D all described Resident #9 as wandering frequently, entering rooms, and attempting to get into other residents' beds, with redirection sometimes ineffective. On 06/24/2026, survey observations showed Resident #9 self-propelling through the halls without staff present and approaching another resident's room. Staff interviews confirmed that supervision was provided generally by staff members rather than being directly assigned to specific residents, and Staff F stated she did not know who supervised her residents while she was on break. The DON and NHA confirmed they did not know who was supervising the residents at the time of the incident, that the investigation did not begin until 06/02/2026, and that documentation from 05/30/2026 did not reflect monitoring consistent with Resident #9's needs or facility policy. The facility policy defined neglect as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5.00% after 36 medication administration opportunities were observed and 2 errors were identified for one resident, resulting in a 5.56% medication error rate. During observation on 5/20/2026 at 9:00 AM, Staff G, LPN pulled Omeprazole 20 mg and Guaifenesin 400 mg for Resident #118. Record review showed the resident had current physician orders for Pantoprazole Sodium oral packet 40 mg by mouth two times a day for GERD and Guaifenesin ER 12 hour 600 mg by mouth two times a day for chest congestion for 10 days. At 9:30 AM, Staff G confirmed she gave one tablet of Omeprazole 20 mg and one tablet of Guaifenesin 400 mg, and she opened her assigned medication cart and presented each over-the-counter bottle to review the milligrams and medications. At 4:30 PM, the DON was interviewed and notified of the medication error rate. The facility policy stated medications are to be ordered and administered safely and as prescribed, and the administering individual checks the label to verify the right resident, right medication, right dosage, right time, and right route before giving the medication.
Kitchen Sanitation Deficiencies
Penalty
Summary
Kitchen sanitation requirements were not maintained in the facility kitchen. During an observation of the kitchen hand washing sink, debris was seen on the face of the cabinet, countertop, faucet, and the area where the backsplash met the wall behind the sink. A pink dried liquid was present on the left rear side of the countertop, the cabinet door face had a dried brown substance streak, buildup surrounded the faucet fixture, paper trash was sitting on the fixture, and debris was built up on the wall behind the sink. During a later tour of the kitchen, the food preparation area in the middle of the kitchen had black debris on the pipes and light fixtures above it. The Senior Certified Dietary Manager stated the staff had a daily cleaning schedule with monthly deep cleanings and said maintenance was not doing a very good job. The Certified Dietary Manager stated there was not enough room to store chemicals properly. The Nursing Home Administrator stated the debris buildup in various areas of the kitchen should have been identified sooner and stated the kitchen was not clean enough for the standards. The administrator also stated kitchen staff were responsible for cleaning the outside mop bucket area, the kitchen hand washing sink, and the area above the food preparation table.
Unsanitary Dumpster Area and Improper Refuse Storage
Penalty
Summary
The facility failed to maintain the garbage storage area in a sanitary manner. During a tour of the garbage storage area immediately following the kitchen tour, surveyors observed approximately 14 used plastic gloves scattered around the trash receptacles, a clear trash bag filled with trash lying on the ground outside the designated container, and one dumpster lid left open. When these conditions were observed, the CDM stated, in reference to the gloves on the ground around the dumpster, "I'll get on it now, I'll pick that stuff up," and the Senior CDM stated the items would be picked up and discarded. The CDM also stated the concern had been discussed in staff meetings because multiple departments use the dumpster area, and that administrators were aware of the concern. The NHA later reviewed the photographic evidence and stated the conditions in the dumpster area were unacceptable, unsanitary, and could attract pests. The facility policy titled Food-Related Garbage and Refuse Disposal stated that food waste shall be kept in containers and that outside dumpsters will be kept closed and free of surrounding litter.
QAPI Failed to Sustain Kitchen Sanitation Corrections
Penalty
Summary
The facility failed to ensure its QAPI program effectively identified, monitored, and sustained corrective actions related to food storage, food preparation, and sanitary practices. The facility had previously completed a Plan of Correction for F812 that included cleaning the kitchen, educating dietary staff, performing routine sanitation audits, and reporting findings through QAPI until compliance was achieved, but similar sanitation concerns were later observed again in the kitchen. During observations, the kitchen handwashing sink area had debris on the cabinet face, countertop, faucet, and wall backsplash, including pink dried liquid, brown residue, and paper trash on the faucet fixture, with visible brown buildup on the wall behind the sink. Later observations found debris on pipes and light fixtures above the food preparation area. During a subsequent kitchen tour, dust and debris were again seen on pipes and light fixtures above the food preparation station, the juice machine had visible buildup and residue, staff beverages were present on and around the food preparation area, a staff cell phone was on the rack where cups were stored, and cups with clear and colored liquids in a cooler were unlabeled and undated without prepared-on or use-by dates. The CDM and SCDM acknowledged the sanitation concerns, and the NHA stated the facility had previously been cited for similar issues and was not aware the concerns had reoccurred until they were brought to her attention.
Advance Directive and DNR Documentation Not Current or Correct
Penalty
Summary
The facility failed to ensure that current and correct copies of residents’ advance directives were maintained in the medical record for two residents. For one resident, the Regional Nurse Educator stated that the DNR form in the A wing nurses’ station binder should have been on yellow paper, but the binder contained a DNR on white paper. Review of that resident’s EHR showed the advance directive consent was signed, the DNR order was entered, and the DNR was signed, but the DNR in both the EHR and the binder was on white paper rather than the expected yellow form. For another resident, the DNR was not found in the A wing nurses’ station DNR binder during observation, and the Regional Nurse Educator and Regional Nurse Consultant stated the form was supposed to be in the binder but could not locate it. The resident’s EHR showed an advance directive discussion document was signed and a DNR order was entered by the medical director. Staff interviews showed CNA staff and an LPN relied on the binder and/or EHR to determine code status during an emergency, and the DON stated code status is checked in both the binder and EHR. A facility order listing report identified 34 residents labeled as DNRs, including the two residents whose records were corrected.
Inaccurate PASRR Mental Illness Screening
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was inaccurate for one resident. The resident had an admission record showing an initial admission date of 1/08/25 and an admission date of 3/08/25, with diagnoses including generalized anxiety disorder, depression unspecified, and bipolar disorder, current episode depressed, mild. Review of the resident’s PASRR dated 2/03/26 showed bipolar disorder and depressive disorder marked under Section A for Mental Illness or Suspected Mental Illness, but anxiety disorder was not marked. During interview, the DON stated the admissions department is responsible for ensuring a PASRR is in place at admission, that a new PASRR is submitted if a resident has a new MI diagnosis or change of condition, and that Level 2 PASRRs are triggered by a major mental illness. The DON reviewed the chart and acknowledged anxiety was not marked under Section A and stated the PASRR would be resubmitted to include anxiety. She also stated the facility did not have a PASRR policy.
Failure to Follow Enteral Feeding Orders
Penalty
Summary
Physician orders for Resident #39’s enteral nutrition were not followed. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, gastrostomy status, muscle weakness, and dysphagia, and was NPO with tube feeding for nutritional support. The record showed a continuous order for Jevity 1.5 at 75 ml/hr with water flushes, but the resident was observed multiple times with the tube feeding pump alarming, the feeding bag hung but not connected, or the pump not instilling nutrition. On 5/17/2026, the resident’s enteral pump was alarming and nutrition was not infusing, and the resident could not state when the alarm started. On 5/18/2026, the feeding bag was observed hanging on the pole but not connected to the resident, and later that day the pump was again observed alarming for downstream occlusion and continued to alarm during repeated observations. On 5/19/2026, the room was observed without enteral feedings or tubing hanging from the pole, and later the tube feeding was observed instilling, then alarming again. Staff interviews confirmed concerns about the resident not receiving tube feedings as ordered. An LPN stated she had discussed with the DON that the resident was not having tube feedings instilling during her shift and that this was not the first time. The DON stated she was notified that the night shift nurse was missing the appropriate equipment to hang the enteral feedings and acknowledged the resident’s feeding went up after 8:30 AM. The RD stated the resident had been changed from continuous tube feedings to a total volume over 20 hours to allow participation in therapy or activities, and acknowledged concern that the resident had not received the ordered enteral nutrition over the increased time intervals. The resident’s weights declined from 203.0 pounds on 4/06/2026 to 184.0 pounds on 4/20/2026 and 181.1 pounds on 5/07/2026.
Infection Control and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to ensure infection prevention and control practices were followed for a resident with a PICC line. On 5/17/2026, Resident #80 was observed with a PICC dressing dated 5-7-26. The resident stated she was receiving antibiotics for an infection. The physician order required the PICC dressing to be changed within 24 hours of admission, insertion, or reinsertion and every 7 days thereafter using sterile technique, along with daily measurement of arm circumference and external catheter length every 7 days. The facility also failed to ensure proper hand hygiene and infection control during medication administration for Resident #118. During morning medication pass on 5/20/2026, an LPN handed the resident a medication cup, then picked up a pill the resident had removed from the cup with bare hands and returned it to the cup. The resident later began coughing during medication administration, and the LPN handled the resident’s nasal cannula, picked up an item from the floor to reach the oxygen concentrator, and administered and cleaned a nebulizer treatment without donning gloves or performing hand hygiene. The DON stated she was aware of the lack of gloves/hand hygiene and the potential for cross-contamination. The facility also failed to maintain resident equipment with a cleanable surface for Resident #65’s wheelchair. On 5/18/2026 and 5/19/2026, the wheelchair was observed with two large cracks in the sitting area, exposing the inside fabric and foam material, and the surface was no longer cleanable. The resident had diagnoses including Parkinson’s disease, dementia, and dysphagia. Interviews with the DOR, Maintenance Director, and NHA confirmed the wheelchair was in disrepair and unacceptable.
Failure to Maintain Clean, Sanitary, and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, sanitary, and homelike environment across all four hallways and the dining room, as evidenced by multiple observations of uncleanliness, disrepair, and unsanitary conditions. Surveyors observed an empty, unlocked, and visibly dirty treatment cart parked in the dining room, with crumbs, stains, and debris on and around it. The dining room floor and surrounding areas were also noted to be unclean and scuffed. In several resident rooms, closet doors were off their tracks or not properly installed, walls had unfinished or unpainted patches, and floors were stained or had uncleanable surfaces. In one room, a resident identified a stained and unmovable doorstop and bolt on the floor, while another room had piles of black dirt under the window sill with multiple potted plants above. Shared bathrooms between resident rooms were found to be odorous of urine or bowel, with strong smells detected even before entering. Observations included gaps between flooring and toilets filled with cracked silicone, stained and dirty floors, towels with brown substances, and unlabeled wash basins left on the floor. In some bathrooms, trash cans contained soiled incontinent briefs, and toilets were found with yellow or brown liquids and splattered seats. Items such as plungers and containers were left on the floor or on the back of toilets, and privacy curtains were not fully hooked. Residents reported using these bathrooms with staff assistance, and in one case, a resident believed only a subset of assigned residents used a particularly odorous bathroom. Common areas and additional resident rooms also exhibited deficiencies, such as black stains on lobby floors, overturned medication cups, and unprotected personal hygiene items left on dressers. Housekeepers were present in the dining room during some observations, but issues persisted throughout the day, including the continued presence of debris and stains. The facility's environmental policy outlined daily and weekly cleaning tasks, infection control protocols, and staff responsibilities, but the observed conditions indicated these procedures were not consistently followed, resulting in an environment that did not meet regulatory standards for cleanliness and homelikeness.
Failure to Perform Ongoing Skin Assessments and Documentation
Penalty
Summary
A resident with multiple complex medical conditions, including metabolic encephalopathy, dementia, and a history of falls, was admitted with existing skin impairments such as a scalp scab and bilateral upper extremity bruises. Initial assessments and skilled documentation noted these skin issues for several days following admission. However, after a certain date, there were no further skilled notes or documentation regarding the resident's skin condition, and no weekly skin checks were performed as required. The resident's care plan identified a risk for skin impairment and included interventions such as monitoring and observing the skin during routine care and notifying a nurse of any concerns. Despite these interventions, the facility failed to continue regular skin assessments and documentation after the initial period. The facility's own policies required ongoing skin monitoring, documentation of changes, and communication among the care team, but these procedures were not followed for this resident.
Failure to Maintain Required Skilled Nursing Documentation
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards for residents receiving skilled services. For one resident admitted with multiple diagnoses including a femur fracture, history of falls, hypertension, anemia, urine retention, and weakness, there were no skilled nursing notes or skilled progress notes documented during the period skilled services were provided. The Director of Nursing (DON) confirmed that there should have been daily skilled nursing documentation for each day the resident received skilled services, but none were found in the assessment or progress notes sections of the medical record. Another resident, admitted with diagnoses such as metabolic encephalopathy, scalp contusion, history of falls, necrotizing enterocolitis, dementia with mood disturbance, and other conditions, also lacked complete skilled documentation. Skilled notes were only present for the first four days of skilled services, with no further skilled notes or documentation regarding skin condition for the remainder of the skilled service period. The DON acknowledged that the documentation was incomplete for the duration of the skilled services provided.
Failure to Notify Resident Representative of Room Change
Penalty
Summary
The facility failed to promptly notify the resident representative of a room change for one resident. The resident, who had a history of left femur fracture, falls, hypertension, anemia, urine retention, and weakness, was assessed as moderately cognitively impaired. On one occasion, the resident was moved from one room to another, but there was no documentation in the progress notes or on the Room Change Notification form regarding this move. The Social Services Director (SSD) confirmed that the room change was not documented and stated that if she did not perform the move, someone else may have done so without completing the required notification. Further review showed that while a subsequent room change was properly documented, including notification to the resident and their representative, the initial room change lacked any record of notification or documentation. The facility's policy requires advance notice and documentation of room changes for residents and their representatives, but this was not followed for the room change in question.
Failure to Follow Hand Hygiene and Equipment Cleaning Protocols
Penalty
Summary
A Licensed Practical Nurse (LPN) failed to follow standard infection control practices during the care of two residents, one of whom was under contact precautions for candida auris and the other for a urinary infection. The LPN entered a resident's room with contact precaution signage, used a blood pressure cuff on the resident, touched the bed's footboard, and then exited the room without performing hand hygiene or cleaning the blood pressure cuff. The blood pressure cuff was placed on the medication cart and later moved to another location without being disinfected. The LPN continued to interact with other staff, access the wound care cart, and begin medication administration for another resident, all without performing hand hygiene between tasks or after glove removal. Facility policy requires hand hygiene before and after direct resident contact, after glove removal, and after contact with resident care equipment. The LPN repeatedly failed to perform hand hygiene at required intervals, including before and after entering isolation rooms, after removing gloves, and after using shared equipment. Additionally, the blood pressure cuff, a non-critical reusable item, was not cleaned or disinfected between residents as required by facility policy and CDC guidelines. These actions were confirmed through observation, interview with the Director of Nursing, and review of facility policies.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near New Port Richey
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nursing & Rehabilitation Center Of New Port Richey | 0.3 mi | ★★★★★ | 3 | 0 |
| Madison Pointe Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Heather Hill Healthcare Center | 0.6 mi | ★★★★★ | 1 | 0 |
| Aspire At Ridge Haven | 1.2 mi | ★★★★★ | 12 | 0 |
| Life Care Center Of New Port Richey | 1.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.