Below 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 Pinehurst Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
Improperly Stored Leftover Food: Surveyors found undated, unsealed, and unlabeled leftover food in the walk-in refrigerator, walk-in freezer, and reach-in refrigerator, including whipped topping, biscuits, hash browns, turkey lunchmeat, and multiple zipper-sealed bags of food labeled dialysis ready. Dietary staff could not state when several items had been opened or prepared, and the DM and DON confirmed foods should be covered, sealed, dated, and labeled when opened or prepared.
A cognitively intact, fully dependent resident became upset about not receiving morning medications and used profanity toward an RN, who initially attempted to remain professional but then told the resident she would give him the same energy he was giving her and called him a “crippled motherf****r” in front of others in the room. The resident reported feeling shocked, angry, hurt, and embarrassed by being called crippled, while a NA present in the room corroborated the exchange. The NP and DON both received reports of the incident, and the RN later acknowledged using the derogatory term, demonstrating a failure to maintain the resident’s dignity and right to respectful communication.
A housekeeping staff member mopped the full width of a section of the 300 hallway, leaving an approximately 4-foot by 10-foot area completely wet and requiring residents, staff, and visitors to walk on the wet floor to pass. Only one wet floor sign was placed at the end of the hallway. In interviews, the housekeeper reported this was her usual method and believed the single sign was adequate, later acknowledging she should have left a dry walking area. The Director of Housekeeping, floor technician, and DON all stated that only half the hallway should be cleaned at a time so a dry path remains available and that floor technicians normally handle full hallway floor cleaning.
Inaccurate and Incomplete MDS Coding: The facility failed to accurately code MDS assessments for a resident receiving hospice services and another resident whose medication section incorrectly showed anticoagulant and anticonvulsant use despite no corresponding orders or MAR entries. The facility also left the Preferences for Customary Routine and Activities section unassessed for a third resident, with staff describing missed responsibilities, assumptions about who would complete the section, and an MDS nurse entering dashes instead of completing the assessment.
Late Medication Administration for Two Residents: Two residents had scheduled meds given well outside the expected timeframe after an agency RN fell behind during morning med pass and did not request help. One resident with HTN received Hydralazine and Metoprolol late, and another resident with neuropathic pain received Neurontin late. The NP confirmed both residents had no ill effects and remained clinically unaffected.
Oxygen Flow Rates Not Delivered as Ordered: Three residents with orders for continuous oxygen at 3 lpm were found with concentrator settings that did not match the prescribed rate. One resident’s oxygen was set too low, one was set too high, and one was also set too low during observations. Nurses documented oxygen administration on the MAR, but interviews showed staff sometimes checked the concentrator while standing over it rather than at eye level, leading to incorrect verification of the flow setting.
Failure to Hold BP Meds per Ordered Parameters: Two residents received BP-related meds despite SBP being below ordered hold limits. One resident with paroxysmal AF received metoprolol multiple times when SBP was under the prescribed threshold, and another resident with HTN, CHD, and edema received Cozaar, acetazolamide, and Cardizem CD when SBP was below the hold parameters. Nurses described the administrations as oversights, and the NP and DON stated staff were expected to follow the orders as written.
A resident with severe cognitive impairment and a history of wandering exited the facility unsupervised and was found outside without her assigned wanderguard. Staff failed to verify the presence and function of the wanderguard as ordered, and the main entrance was not monitored at the time, allowing the resident to leave undetected.
A resident with severe cognitive impairment and hemiplegia experienced two falls during personal care due to inadequate supervision. The care plan required two-person assistance, but staff failed to adhere to this, resulting in injuries requiring emergency treatment.
A facility failed to accurately code the MDS assessment for a resident with a stage 3 pressure ulcer, omitting the presence of a pressure reducing device for her wheelchair. Despite the resident's care plan including interventions for pressure ulcer prevention, the MDS Coordinator acknowledged the oversight, and the Administrator confirmed the need for accurate coding.
A resident with vascular dementia and dependent on staff for ADLs did not receive necessary nail care, resulting in jagged and dirty nails. Despite being on hospice and having a care plan requiring assistance, there were no specific interventions for nail care. Nursing assistants were inconsistent in providing nail care, and the DON confirmed that nails should be groomed during showers and as needed.
Improperly Stored Leftover Food
Penalty
Summary
The facility failed to label, date, and seal leftover food stored for use in the walk-in refrigerator, walk-in freezer, and reach-in refrigerator. During observation with Dietary Aide #1, an undated piping bag partially filled with whipped topping was found on a shelf in the walk-in refrigerator, and the aide stated it was likely used on desserts from the previous day. In the walk-in freezer, surveyors observed one undated, open-to-air bag of twenty biscuits and one undated partially used bag of hash browns, and the aide was unable to state when either package had been opened. In the reach-in refrigerator, surveyors observed one opened and undated bag of turkey lunchmeat and seven undated zipper-sealed bags of food containing a sandwich, marshmallow pie, oatmeal pie, and peanut butter crackers labeled dialysis ready. Dietary Aide #1 was unable to state when the lunchmeat had been opened or when the bags had been prepared. During interviews, Dietary Aide #1 stated all foods should have been wrapped and sealed, dated, and labeled with their contents. The dietary manager stated she was responsible for monitoring the freezer and refrigerators to ensure food items were properly dated and labeled, and the DON stated all foods should be covered and stored correctly and dated if they were opened.
Derogatory Language Toward Dependent Resident Violates Dignity and Respect
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to dignity and respectful communication when a nurse spoke to a resident in a derogatory and demeaning manner. The resident, who was cognitively intact per a quarterly MDS and completely dependent on others for care, had refused to respond to the nurse’s earlier attempts to administer morning medications and obtain a blood sugar reading, as documented in a nursing progress note. The note described the nurse bumping the resident’s bed several times, calling his name, and then later telling him that if he chose not to respond, she could only move on and would not leave medications at the bedside. During this interaction, the resident used profanity toward the nurse, calling her a liar and other offensive names. According to the resident’s interview, during a subsequent encounter in February, the nurse argued with him about whether she had attempted to give his morning medications and ultimately called him a “crippled motherf****r” before walking out of his room and slamming the door. The resident reported feeling shocked at first, then angry and hurt, and stated that it was particularly upsetting because he is completely dependent on others for his care. He also reported feeling embarrassed because other people were in the room and heard the nurse use the term “crippled” toward him. The resident further stated that the nurse told him she was going to “feed him the same energy he fed her” and again called him a “crippled motherf****r.” A nurse aide who was present during the incident corroborated that the resident was upset about not receiving his morning medications and was cursing at the nurse, and that the nurse initially tried to be professional and asked him to stop. The aide stated that after the resident called the nurse a particularly derogatory name, the nurse told him she was about to give him the same energy he was giving her and then called him a “crippled motherf****r” before leaving the room. The nurse practitioner reported that the resident told him about the phrase the nurse used, and he relayed this to the DON. In a subsequent interview, the nurse involved stated she had never been cursed at so badly by a resident, became enraged, and could neither confirm nor deny that she used a derogatory term. The DON reported that both the aide and the resident described the nurse calling the resident a “crippled motherf****r,” and that the nurse later admitted to using that term, stating she had her back to the resident and did not think he could hear her.
Unsafe Hallway Mopping Created Wet-Floor Hazard
Penalty
Summary
The deficiency involves a failure to maintain a safe environment free from accident hazards in the 300 hallway, specifically the lower end serving rooms 304 through 312. During a continuous observation, a housekeeper was seen mopping the entire length and width of an approximately 4-foot by 10-foot section of the hallway floor, leaving the entire area completely wet across the hall. A wet floor sign was placed only at the end of the hallway near one room, while the mopping practice required residents, staff, and visitors to walk on the wet floor if they needed to pass through that section. In an interview, the housekeeper stated she usually mopped across the entire floor and then followed with a dry mop, and believed that placing a wet floor sign at the end of the hallway was sufficient to warn others. She acknowledged she should have left a dry area for others to walk on. The Director of Housekeeping confirmed that the housekeeper should have mopped only one side of the hallway to leave a dry path and that a caution sign should have been placed at the end of the wet area to direct others to use the dry side. The floor technician explained that he normally cleans hallways with a machine that scrubs and dries the floor, working on one half of the floor at a time to keep a dry walking path, and that housekeeping would only mop for minor spills. The DON also stated the housekeeper should have left a dry, clear path and only mopped one half of the hallway at a time.
Inaccurate and Incomplete MDS Coding
Penalty
Summary
The facility failed to code the MDS accurately for Resident #4, who was admitted with Alzheimer’s disease and had an active physician order for hospice services related to that diagnosis. A Significant Change in Status MDS assessment indicated the resident had Alzheimer’s disease and a prognosis of less than six months, but hospice care was not marked on the assessment. MDS Nurse #1 confirmed the resident was receiving hospice services and stated the omission was an oversight by MDS Nurse #2, who completed that section. The DON stated it was her expectation that the MDS be coded accurately. The facility also inaccurately coded the MDS for Resident #2 and left the Preferences for Customary Routine and Activities section incomplete for Resident #101. Resident #2’s quarterly MDS showed intact cognition but incorrectly indicated routine anticoagulant and anticonvulsant use despite January 2026 physician orders and the MAR showing no such medications. MDS Nurse #2 verified the medication coding was incorrect and said it was an oversight. For Resident #101, the admission MDS had dashes entered for the Preferences for Customary Routine and Daily Activities section, indicating it was not assessed. The Activities Director stated she normally completed that section but was on vacation, while MDS Nurse #1 said she was working alone, did not have time to complete it, and entered dashes, assuming the Activity Assistant would do it; the Activity Assistant stated she had not been trained or asked to complete MDS assessments.
Late Medication Administration for Two Residents
Penalty
Summary
The facility failed to administer medications at the scheduled time for 2 of 6 residents reviewed for medication administration. Resident #102 had physician orders for Hydralazine 100 mg three times daily for hypertension and Metoprolol Tartrate 25 mg twice daily for hypertension, both scheduled for 9:00 AM. The April 2026 MAR and audit report showed Hydralazine was administered at 11:17 AM and Metoprolol Tartrate at 11:18 AM on 4/28/26. Nurse #1, an agency nurse, stated she fell behind on morning medication administration and did not give Resident #102’s scheduled morning medications until 11:00 AM, and she did not request assistance to ensure the medications were given on time. Resident #92 had an order for Neurontin 300 mg twice daily for neuropathic pain, scheduled for 9:00 AM. The April 2026 MAR and audit report showed the medication was administered at 12:06 PM on 4/28/26. Nurse #1 stated she fell behind on morning medication administration and did not administer Resident #92’s scheduled morning medications until 12:00 PM, and she did not request assistance. The NP reviewed both residents’ records and confirmed neither experienced ill effects from the late administration, with vital signs remaining within normal limits and both appearing clinically unaffected. The DON stated the medications were expected to be administered on time, especially when ordered more than once a day, and said agency staff had been instructed to request assistance if they fell behind.
Oxygen Flow Rates Not Delivered as Ordered
Penalty
Summary
The facility failed to ensure supplemental oxygen was delivered at the prescribed rate for 3 residents who were ordered continuous oxygen at 3 liters per minute via nasal cannula. Resident #44 had diagnoses of unspecified asthma and dependence on supplemental oxygen, and her care plan and active orders required oxygen at 3 lpm continuous. On two separate observations, her oxygen concentrator was found set at 1.5 lpm while she was resting in bed with oxygen on and without signs of respiratory distress. The MAR showed oxygen was documented as given each shift, and Nurse #1 later stated she had checked the concentrator during medication pass but, when viewing it at eye level, found it was set at 1.5 lpm and adjusted it to 3 lpm. Resident #84 had diagnoses of emphysema, COPD, and acute and chronic respiratory failure with hypoxia, with an active order for oxygen at 3 lpm continuous by nasal cannula. On two observations, the concentrator was set at 3.5 lpm while she was resting in bed with oxygen on and without apparent respiratory distress. The MAR reflected oxygen administration documentation for each shift, and Nurse #1 stated she had verified the concentrator during morning medication pass but, when viewing it at eye level, found it was set between 3 and 4 lpm and adjusted it to 3 lpm. The NP reviewed the record and noted the resident’s oxygen saturation levels were within her expected range. Resident #123 had diagnoses including acute and chronic respiratory failure, COPD, and dependence on supplemental oxygen, with an order for oxygen at 3 liters continuous via nasal cannula. On two observations, the oxygen regulator was set at 2 liters when viewed at eye level while the resident was sitting up using oxygen. Nurse #4 stated she had glanced at the concentrator during morning medication pass but had not yet signed the MAR, and acknowledged she should have checked the setting at eye level rather than standing over the machine. The DON stated it was her expectation that oxygen be delivered at the ordered rate and that staff should observe the concentrator at eye level to verify the flow rate.
Failure to Hold BP Medications per Ordered Parameters
Penalty
Summary
The facility failed to ensure that residents’ drug regimens were free from unnecessary drugs by not holding blood pressure medications according to the physician-ordered parameters for 2 of 7 residents reviewed. Resident #44 had diagnoses including paroxysmal atrial fibrillation and an active order for metoprolol tartrate 25 mg, half a tablet twice daily, with instructions to hold for heart rate less than 60 or systolic blood pressure (SBP) less than 120. Review of the March and April 2026 MARs showed multiple administrations of metoprolol tartrate when the resident’s SBP was below 120, including readings of 102, 110, 98, 112, 118, 101, 106, 105, and 119, with the medication given by several nurses despite the hold parameter. Interviews with the nurses who administered the medication indicated they were aware of the hold parameter and stated the doses should have been held. Each nurse described the administrations as an oversight, mistake, or error when the MAR entries were reviewed with them. The Nurse Practitioner stated he did not feel Resident #44 suffered serious harm from receiving metoprolol tartrate outside the ordered hold parameter, but he expected staff to follow the order as written. The DON also stated she expected nurses to follow physician orders, including blood pressure medications with hold parameters. Resident #123 had diagnoses including localized edema, coronary heart disease, and hypertension, and had active orders for Cozaar 25 mg daily for hypertension with a hold parameter for SBP less than 120, acetazolamide 250 mg daily for edema with a hold parameter for SBP less than 110, and Cardizem CD 360 mg daily for coronary heart disease with a hold parameter for SBP less than 110. The MARs showed Cozaar was administered when SBP was 111, 108, 115, 100, and 118, and on one occasion acetazolamide, Cardizem CD, and Cozaar were all given when SBP was 102. A nurse interviewed about one of the administrations stated the medication should have been held per the ordered parameter and described it as an oversight. The Nurse Practitioner again stated he did not feel the resident suffered serious harm, but expected staff to follow the hold parameters as written, and the DON stated nurses were expected to follow physician orders including blood pressure medication hold parameters.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with diagnoses including dementia, anxiety disorder, and brain cancer, and who was assessed as high risk for elopement, was able to leave the facility unsupervised through the main entrance. The resident, who was non-ambulatory and used a wheelchair, was found outside in the parking lot by a nurse aide, approximately twenty minutes after leaving the building. At the time of discovery, the resident was not wearing her assigned wanderguard bracelet, which was intended to prevent such incidents. Staff interviews and record reviews revealed that the resident's care plan included interventions such as placement of a wanderguard, redirection from exits, and notification of the DON for exit-seeking behaviors. However, on the day of the incident, the nurse assigned to the resident did not check for the presence of the wanderguard at the start of her shift, as required by physician orders. The nurse aide who last provided care to the resident could not recall if the wanderguard was in place, and the receptionist responsible for monitoring the main entrance was not present, as the incident occurred on a weekend when no receptionist was scheduled for that time. Facility staff, including the maintenance director and receptionist, described the wanderguard system and monitoring procedures, noting that the main entrance is typically monitored by a receptionist during certain hours and that the system is designed to alarm and lock if a resident with a wanderguard approaches. Despite these measures, the resident was able to exit undetected, and staff only became aware of the incident when the resident was found outside without her wanderguard. The event highlighted lapses in supervision and failure to ensure the effectiveness of elopement prevention interventions for a high-risk resident.
Failure to Provide Adequate Supervision Leads to Resident Falls
Penalty
Summary
The facility failed to provide care in a safe manner for a resident who was reviewed for falls. The resident, who was severely cognitively impaired and dependent on staff for activities of daily living due to a stroke with left hemiplegia, experienced two falls while receiving care. On one occasion, the resident slid out of bed while a nurse aide was providing personal care, resulting in a cut and swelling to the left eyelid. The resident required emergency department evaluation and received sutures for the injury. In another incident, the resident was placed on his side during incontinence care by a nurse aide and fell off the bed, hitting his head on a side table. This resulted in a laceration on the left upper eyelid, requiring further emergency department treatment and sutures. Both incidents occurred because the resident's care plan required assistance from two staff members for bed mobility and personal care, but this was not adhered to by the staff involved. The facility's care plan and Kardex for the resident clearly indicated the need for two-person assistance for personal care and bed mobility. However, the staff involved in the incidents either misunderstood or did not follow these instructions, leading to the resident's falls and subsequent injuries. The facility's failure to ensure adherence to the care plan and proper supervision during care contributed to the deficient practice.
Inaccurate MDS Coding for Skin Treatments
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of skin treatments. The resident, who was admitted with a stage 3 pressure ulcer, had a quarterly MDS assessment that did not reflect the presence of a pressure reducing device for her wheelchair, despite having one since admission. The resident's care plan included interventions for pressure ulcer prevention, such as a pressure reducing mattress and encouragement to shift weight when sitting. During an observation and interview, the resident confirmed the presence of a pressure reducing cushion in her wheelchair. The MDS Coordinator acknowledged the oversight in coding, and the Administrator confirmed that the MDS assessment should be accurately coded in all care areas.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary nail care assistance to a resident who was dependent on staff for activities of daily living (ADL). The resident, diagnosed with vascular dementia and receiving hospice services, was observed with medium-length fingernails that were jagged and had a brown substance under some nails. Despite being dependent on staff for personal hygiene, there were no specific interventions for nail care in the resident's care plan. Nursing progress notes did not document any refusals of nail care, and the resident's shower schedule showed refusals on two occasions. Interviews with nursing assistants revealed inconsistencies in the provision of nail care. One nursing assistant could not recall the last time she provided nail care to the resident, while another stated that nail care was typically done on shower days. The Director of Nursing confirmed that nails should be groomed during showers and as needed, indicating that the resident's nail condition should have been addressed. Observations and interviews highlighted that the resident's nail care needs were overlooked, leading to the deficiency identified by surveyors.
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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) |
|---|---|---|---|---|
| Inn At Quail Haven Village | 0.1 mi | ★★★★★ | 0 | 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 | 4.6 mi | ★★★★★ | 3 | 0 |
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