Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Inn At Quail Haven Village during CMS and state inspections, most recent first.
Surveyors found that opened food items in a walk-in freezer, including chicken nuggets and tilapia, were not labeled with the date opened or use-by/expiration dates. Staff interviews confirmed that labeling was required but not performed, resulting in a deficiency related to food storage practices.
The facility did not attempt alternative interventions before installing side rails for two residents with severe cognitive and physical impairments following stroke. Documentation and staff interviews confirmed that alternatives were not considered or tried prior to side rail use, and staff were unaware of the requirement to do so.
Two nurses failed to follow infection control protocols: one did not perform hand hygiene before donning gloves for wound care on a resident with an open wound, and another did not properly disinfect a glucometer after a blood glucose check, using only one wipe for a short duration instead of following manufacturer instructions. Facility leadership confirmed these actions did not meet policy or manufacturer requirements.
A resident's supply of oxycodone was misappropriated when medication records showed a significant discrepancy between the number of tablets delivered and those documented as administered. The issue was discovered after a nurse attempted to reorder the medication and the pharmacy indicated there should still be tablets remaining. Staff interviews and record reviews confirmed that the resident did not receive the full amount of medication as ordered, and the responsible nurse could not be reached for clarification.
A resident's oxycodone/acetaminophen medication was misappropriated, with discrepancies in administration records and missing inventory sheets. Nurse #2 was implicated after surveillance footage showed she did not enter the resident's room at recorded administration times. The DON and Administrator confirmed the misappropriation, leading to the nurse's termination.
A facility failed to report the misappropriation of a resident's narcotic medication to the state regulatory agency and Law Enforcement within 24 hours, as required by their policy. The DON was informed of the missing medication and began an investigation, but uncertainty about whether it was a diversion of facility drugs delayed the report until confirmation was obtained through camera footage.
Failure to Label Opened Frozen Food Items
Penalty
Summary
Surveyors observed that opened food items stored in one of two walk-in freezers were not labeled with the date opened or use-by/expiration dates. Specifically, an opened bag of chicken nuggets was found on a shelf without any labeling, and a carton of tilapia was discovered with the inner plastic bag open and the fish exposed to air, also lacking any received on, opened, or use-by labels. Staff interviews confirmed that it was the cook's responsibility to label partially used frozen food items before returning them to the freezer, and both the Dietary Director and Executive Director acknowledged that labeling was expected but not done in these instances. No information was provided regarding specific residents affected, their medical history, or their condition at the time of the deficiency.
Failure to Attempt Alternatives Prior to Bed Rail Installation
Penalty
Summary
The facility failed to attempt alternative interventions prior to the installation of side rails for two residents who were assessed for side rail use. Both residents had a history of hemiplegia and hemiparesis following a stroke, resulting in significant physical impairment and severe cognitive impairment. Documentation for both residents included a Device and Bed Rail Review, but these assessments did not include any questions or evidence regarding the use of alternatives before side rails were implemented. Care plans for both residents focused on the use of quarter length side rails to enable bed mobility and noted the increased risk for complications, but did not document any trial of less restrictive measures. Observations confirmed that both residents were using side rails during the survey period. Interviews with the nurse responsible for the assessments, as well as with the DON and Administrator, revealed that alternative interventions were not attempted prior to the installation of side rails. Staff indicated they were unaware that trying alternatives was a requirement before implementing side rails for these residents.
Failure to Follow Infection Control Practices During Wound Care and Glucometer Disinfection
Penalty
Summary
Nurse #1 failed to follow the facility's infection control policy by not performing hand hygiene before donning gloves prior to assisting with wound care for a resident with an open, draining boil. During the observation, Nurse #1 walked past a hand sanitizer dispenser without using it, donned a gown and gloves inside the resident's room, and assisted with the dressing change without first cleaning her hands. After completing the wound care and removing her gloves and gown, Nurse #1 used hand sanitizer only after leaving the resident's room. Both the Nurse Supervisor and the facility's Director of Nursing confirmed that hand hygiene should have been performed before donning gloves and after removing them, as outlined in the facility's policy and infection control standards. In a separate incident, Nurse #3 did not properly clean and disinfect an individually assigned glucometer after performing a blood glucose check for a resident. The glucometer was stored in a labeled plastic bag outside the resident's room. After use, Nurse #3 used only one EPA-approved disinfectant wipe for 8 to 10 seconds, rather than the manufacturer's recommended two wipes and required wet contact time of two minutes. The glucometer was then returned to the plastic bag and stored in the medication cart drawer. Nurse #3 later acknowledged not following the correct disinfection procedure, despite having received prior training on the process. Interviews with the Administrator, Director of Nursing, and Medical Director confirmed that the observed practices by Nurse #1 and Nurse #3 did not align with the facility's infection prevention and control policies or the manufacturer's instructions for equipment disinfection. These lapses were identified during observations and staff interviews, and were confirmed through review of facility policies and manufacturer guidelines.
Failure to Prevent Misappropriation of Controlled Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of controlled medications, specifically oxycodone, as required by its own abuse identification policy. A review of medication records showed that 60 tablets of oxycodone were delivered for a resident, but only 25 administrations were documented in the Medication Administration Record (MAR) between the delivery date and the attempted reorder. However, the declining narcotic count sheet indicated that all 60 tablets had been used, with one nurse signing off on 41 administrations, resulting in a discrepancy of 35 tablets. The issue was discovered when a nurse attempted to reorder the medication and was informed by the pharmacy that there should still be a supply remaining, prompting notification of facility leadership. Interviews with staff, pharmacy personnel, and the medical director revealed that the nurse responsible for the majority of the documented administrations could not be reached for clarification. The facility's documentation and interviews confirmed that the resident did not receive the full amount of medication as ordered, and the discrepancy was not identified until after the medication was depleted. The lack of adequate controls and monitoring allowed for the misappropriation of the resident's controlled medication, violating the resident's right to be free from wrongful use of their property.
Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of a narcotic medication, specifically oxycodone/acetaminophen, prescribed for pain management. The resident, who was cognitively intact, was admitted with conditions including cellulitis, a urinary tract infection, and lymphedema. During the resident's stay, the medication was administered nine times, with Nurse #2 responsible for seven of these administrations. However, discrepancies arose when the medication card and declining inventory sheet went missing, and the medication was not found in the locked narcotic drawer upon the resident's discharge. An investigation was initiated after the discharging nurse, Nurse #1, reported the missing medication and inventory sheet. Nurse #2 claimed to have administered the last dose on a specific date but failed to sign the Medication Administration Record (MAR) at that time, later making a late entry. Surveillance footage revealed that Nurse #2 did not enter the resident's room at the times recorded for administering the medication on two occasions. Despite attempts to contact the involved nurses and the resident, further clarification on the discrepancies was not obtained. The Director of Nursing (DON) and the Administrator reviewed the situation, confirming the misappropriation of the narcotic medication. The investigation substantiated the allegations against Nurse #2, who was subsequently suspended and terminated. The facility's failure to maintain accurate records and secure the resident's medication led to the deficiency, highlighting lapses in the administration and monitoring of controlled substances.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to submit an initial report to the state regulatory agency and notify Law Enforcement within 24 hours of discovering the misappropriation of a resident's property, specifically narcotic medication. The facility's policy, revised in January 2023, mandates that any alleged violations involving misappropriation of resident property must be reported within 24 hours if they do not result in serious bodily injury. However, the Director of Nursing (DON) and the Administrator did not report the incident within the required timeframe because they were uncertain whether the situation involved a diversion of facility drugs. The incident involved a resident whose narcotic medication was missing from the locked narcotic box, and the inventory flow sheet was also absent. The DON was informed of the missing medication on November 14, 2023, and began an investigation. Despite starting the investigation promptly, the facility did not report the incident to the state regulatory agency or Law Enforcement until November 17, 2023, after reviewing camera footage and confirming the diversion. This delay in reporting constitutes a deficiency in adhering to the facility's abuse policy and regulatory requirements.
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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.
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Nursing homes near Pinehurst
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pinehurst Healthcare & Rehabilitation Center | 0.1 mi | ★★★★★ | 7 | 0 |
| Saint Joseph Of The Pines Health Center | 1.1 mi | ★★★★★ | 9 | 0 |
| The Greens At Pinehurst Rehabilitation & Living Ce | 2.4 mi | ★★★★★ | 11 | 0 |
| Dahlia Gardens Center For Nursing And Rehabilitati | 4.1 mi | ★★★★★ | 6 | 0 |
| Penick Village | 4.7 mi | ★★★★★ | 3 | 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 July 2026) and official state health department websites.