Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Penick Village during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and an indwelling urinary catheter was repeatedly observed in common areas with her urine collection bag uncovered and visible to others, despite her family’s statement that she would want it concealed. An NA and a medication aide, both trained in catheter care and resident dignity, were involved in transferring and emptying the bag; the medication aide admitted she overlooked replacing the dignity cover after emptying it. Facility leadership, including the DON and Administrator, confirmed that dignity covers were required and available for residents with urine collection bags but could not explain why a cover was not in place for this resident.
A resident who remained in the facility after Medicare Part A skilled services ended did not receive the required CMS-10055 SNF-ABN, even though a CMS-10123 NOMNC was issued and signed via telephone consent by the responsible party. The Care Navigator confirmed that only the NOMNC was provided and stated she was unaware that a SNF-ABN was required for residents who continue to stay after Part A coverage ends, while the Administrator confirmed that facility procedures require both forms to be completed and given in such situations.
Surveyors found that clean dishware in the dietary department was stacked and stored while still wet, resulting in wet nesting of multiple metal serving pans that were ready for use. The Dietary Manager acknowledged that dishware should be thoroughly dried and stored facing down to prevent wet nesting and that such moisture could allow bacteria to grow, but could not identify which dietary staff member had improperly stored the pans. The Administrator also confirmed that items should not be stored wet due to the potential for bacterial growth.
A resident's MDS assessment was inaccurately coded, failing to reflect that the resident received Lantus insulin injections on all seven days of the look-back period. The MDS Nurse acknowledged the oversight, and the DON confirmed the discrepancy, emphasizing the need for accurate documentation of medication administration.
A facility failed to maintain an active hospice order for a resident receiving hospice care. The order was mistakenly discontinued by a nurse, but the resident continued to receive hospice services without interruption. Staff interviews confirmed the absence of an active order in the medical record, despite ongoing hospice care.
Failure to Maintain Dignity by Leaving Urine Collection Bag Uncovered
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s dignity by not ensuring her urinary catheter collection bag was covered while she was in common areas. The resident, who was severely cognitively impaired and had an indwelling urinary catheter related to urinary retention and neuromuscular bladder dysfunction, was observed multiple times on the same day in various public locations within the facility with her urine collection bag exposed. Surveyors observed her in the activity room with other residents and staff, during an activity with the chaplain, and later in a small dining area near the nurse’s station, each time with the urine collection bag uncovered and yellow urine visible. The bag was visible not only to those in the room but also through glass windows and from the hallway, where other residents, staff, hospice staff, and visitors were passing by. The resident’s family member stated that the resident would absolutely want her urine collection bag concealed when out of her room and in activities. The nurse aide assigned to the resident reported she was agency staff, had received training on urinary catheter care and maintaining dignity, and was responsible for transferring the urine collection bag between the bed and wheelchair, but she did not recall whether a cover was in place and stated she did not know where the covers were located. A medication aide, who also reported receiving training that included ensuring urine collection bags had covers or dignity bags, acknowledged that she emptied the resident’s urine collection bag that afternoon and normally would ensure a cover was in place afterward, but admitted she overlooked applying the cover on this occasion. The DON and the Administrator both confirmed that residents with urine collection bags should have dignity covers in place and that covers were available, but they were unable to explain why this resident did not have a cover in place.
Failure to Provide Required SNF-ABN Notice When Medicare Part A Services Ended
Penalty
Summary
The deficiency involves the facility’s failure to provide a CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) to a resident who remained in the facility after Medicare Part A skilled services ended. Record review showed that the resident was readmitted on an identified date and received a CMS-10123 Notice of Medicare Non-Coverage (NOMNC), which informed the resident that Medicare Part A coverage for skilled nursing and therapy services would end on 3/26/26. The NOMNC was reviewed and signed by the Care Navigator via telephone consent from the resident’s responsible party on 3/24/26. During the survey period from 4/13/26 to 4/16/26, the resident continued to reside in the facility. Further review of the resident’s medical record revealed that a CMS-10055 SNF-ABN form was not provided to the resident or the responsible party. In an interview on 4/16/26 at 3:02 PM, the Care Navigator confirmed that only the CMS-10123 NOMNC was issued when Medicare Part A services were ending and acknowledged that the CMS-10055 SNF-ABN was not provided. The Care Navigator stated she was unaware that residents who remain in the facility after Medicare Part A coverage ends should receive a SNF-ABN, and also communicated that the resident had 37 days of Medicare Part A coverage left. In a separate interview on 4/16/26 at 3:35 PM, the Administrator stated that the facility’s process required both a NOMNC and SNF-ABN to be accurately completed and provided to residents who remain in the facility, and confirmed that this resident should have received the SNF-ABN.
Improper Storage of Wet Dishware Leading to Wet Nesting in Dietary Department
Penalty
Summary
Surveyors observed that the facility failed to ensure clean dishware was thoroughly dried before being stacked and stored, resulting in wet nesting of items that were ready for use. During an initial kitchen tour with the Dietary Manager and Director of Dietary, surveyors noted that clean metal serving pans in the dishware storage area were stacked upside down while still visibly wet, with pooled water on the sides and around the rims, including three metal 1/3 serving pans and two metal half serving pans. The Dietary Manager stated that dishware should be cleaned, dried thoroughly, and stored facing down to prevent wet nesting, and acknowledged that wet nesting could cause bacteria to grow, but was unable to identify which dietary staff member had stacked the pans while wet. In a separate interview, the Administrator confirmed that items should not be stored wet because retained moisture could promote bacterial growth. No specific residents were identified in the report, and no resident conditions or medical histories were described in relation to this deficiency.
Inaccurate MDS Assessment for Insulin Administration
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of medications. The resident, who was admitted to the facility, had a physician's order for Lantus insulin, a long-acting injectable medication to control blood sugar, to be administered daily at bedtime. A review of the resident's Medication Administration Record (MAR) for December 2024 showed that the resident received the insulin injections on all seven days of the look-back period for the MDS assessment. However, the MDS assessment inaccurately documented that the resident received insulin injections on only four of the seven days. The MDS Nurse, who completed the medication section of the assessment, acknowledged the oversight during an interview, stating that she missed the documentation on the MAR. The Director of Nursing confirmed the resident received insulin injections on all seven days of the look-back period, and the MDS assessment should have accurately reflected this information. The Administrator also indicated that MDS assessments should accurately reflect the medication a resident received.
Failure to Maintain Active Hospice Order for Resident
Penalty
Summary
The facility failed to maintain an active hospice order for a resident who was receiving hospice care. Resident #3 was admitted to the facility and had a hospice consult and care order initiated on January 10, 2024. However, this order was mistakenly discontinued by Nurse #3 on August 8, 2024. Despite the discontinuation of the order, Resident #3 continued to receive hospice care without interruption. The lack of an active hospice order was identified during a review of the resident's medical records and confirmed through staff interviews. Interviews with the nursing staff, including Nurse #2 and the Director of Nursing, revealed that there was no active hospice order in the resident's medical record, although the resident was still receiving hospice services. The Director of Nursing acknowledged that the floor nurse was responsible for entering the hospice order, which could not be found. The Administrator also confirmed that an active hospice order should be present for any resident admitted to hospice. The deficiency was identified as a failure to maintain proper documentation of hospice orders, despite the continuous provision of hospice care.
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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 Southern Pines
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dahlia Gardens Center For Nursing And Rehabilitati | 3.6 mi | ★★★★★ | 6 | 0 |
| Pinehurst Healthcare & Rehabilitation Center | 4.6 mi | ★★★★★ | 7 | 0 |
| Inn At Quail Haven Village | 4.7 mi | ★★★★★ | 0 | 0 |
| Saint Joseph Of The Pines Health Center | 4.8 mi | ★★★★★ | 9 | 0 |
| The Greens At Pinehurst Rehabilitation & Living Ce | 5.1 mi | ★★★★★ | 11 | 0 |
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