Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Richmond Pines Healthcare And Rehabilitation Cente during CMS and state inspections, most recent first.
Pharmaceutical services failed to provide the correct Depakote dose and form for a resident with epilepsy. The physician’s order was for Depakote 125 mg sprinkle capsules, 2 capsules PO three times daily, but the pharmacy repeatedly dispensed 500 mg delayed-release tablets in Smartpass pouches labeled to give 2 capsules three times daily, not matching the ordered dose. Pharmacy records and packing slips confirmed multiple deliveries of the 500 mg tablets. Interviews revealed that a pharmacist entered the wrong dose into the Smartpass system, described as human error, and the automated system then packaged and sent the incorrect medication strength. Nursing documentation showed that a nurse was later notified by a pharmacist that the wrong dose had been sent, and the DON stated that, in addition to relying on the pharmacy, nurses are responsible for checking medications against active orders.
A resident with epilepsy and severely impaired cognition received an incorrect Depakote dose for several days when pharmacy-dispensed Smartpass pouches contained 500 mg capsules instead of the ordered 125 mg capsules, resulting in administration of a much higher dose than prescribed. The MAR continued to show the lower ordered dose while staff administered the higher-dose pouches. The previous DON and multiple nurses worked the med cart during this period; the previous DON acknowledged administering the incorrect dose without using the scanner or comparing the pouch to the MAR. Other nurses and a med aide reported their usual practice of scanning and comparing Smartpass pouches to the MAR but did not recall identifying the discrepancy at the time. The DON and the physician later stated that nursing staff should have read and compared the medication on hand with the active MAR order to detect the mismatch.
A resident who was cognitively intact and largely independent with personal care was found to be without privacy curtains in a shared bedroom for several months. Surveyors twice observed the room with no curtains, and the resident reported using curtains in the past for privacy from a roommate during visits and rest. Direct care staff and a medication aide who routinely worked with the resident had not noticed the missing curtains. The Environmental Services Manager stated that curtains are supposed to be replaced the same day they are removed for laundering and acknowledged that the curtains had been taken down due to a skin infection and not replaced. The Administrator reported that management conducted daily room rounds but had not identified the missing curtains.
A resident with heart failure, hypertension, and severe cognitive impairment was admitted with consent from the representative authorizing both influenza and pneumonia vaccines, with no prior vaccine dates documented. The admission MDS recorded that these immunizations were not given because they were not offered, and the medical record contained no evidence that either vaccine was administered or that consent was withdrawn. The representative later confirmed the vaccines were not given despite her expectation they would be, and the former IC nurse acknowledged being aware of the request from daily meetings but did not administer the vaccines and could not provide a reason.
A resident with heart failure and hypertension was admitted with a signed consent authorizing COVID-19 vaccination, and the admission MDS documented severe cognitive impairment and that the COVID-19 vaccine was not given because it was not offered. The medical record contained no documentation of COVID-19 vaccine administration, no indication that consent was withdrawn, and no evidence of recent vaccination. The resident’s representative confirmed the vaccine was not given and had not been communicated as administered, while the former IC nurse acknowledged knowing the resident requested the vaccine, discussed during morning meetings, but did not administer it and had no reason for the omission. The Administrator stated that new admissions and requested immunizations are discussed in daily meetings and that residents are expected to receive vaccines as requested.
The facility failed to post accurate staffing information, with discrepancies in RN coverage for 13 days and missing resident census for 54 days. The Unit Manager, an RN, was not counted on staffing sheets, and the Staff Scheduler was unaware of the requirement to include the resident census. The Administrator expected accurate postings.
Incorrect Depakote Dose Dispensed and Administered Due to Pharmacy Entry Error
Penalty
Summary
Pharmaceutical services failed to provide the correct dose and form of Depakote for a resident with unspecified convulsions/epilepsy. The resident had an active order dated 03/16/25 for Depakote Sprinkle Capsule 125 mg, 2 capsules by mouth three times a day. Instead, the pharmacy dispensed Depakote 500 mg delayed-release tablets, packaged and labeled in Smartpass pouches with instructions to give 2 capsules three times a day to equal 250 mg, which did not match the ordered dose or form. Pharmacy records and packing slips showed multiple deliveries of Depakote 500 mg tablets on three separate dates, each with quantities consistent with ongoing administration of the incorrect medication strength. According to interviews, a pharmacist entered the incorrect Depakote dose into the Smartpass system, and this error was described as human error and a failure by pharmacists to pay attention when entering the order. The incorrect entry then flowed through the automated packaging process, resulting in the wrong medication strength being dispensed and sent to the facility. Nursing notes documented that a nurse was notified by the pharmacist on 04/02/25 that the wrong Depakote dose had been sent. The DON, who was not employed at the time of the incident, stated that while she expected the pharmacy to send the correct medication, dose, and form, it was also the nurse’s responsibility to check all medications against active orders.
Failure to Prevent Significant Medication Error with Incorrect Depakote Dose
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when Depakote was administered at an incorrect dose over multiple days. The resident was admitted with unspecified convulsions/epilepsy and had an active order dated 03/16/25 for Depakote Sprinkle Capsules 125 mg, 2 capsules by mouth three times a day. The resident’s MDS indicated severely impaired cognition, no behaviors, and no rejection of care, and she received scheduled anticonvulsant medications during the review period. The March electronic MAR showed that she received Depakote 125 mg, 2 capsules three times daily from 03/17/25 through 03/31/25, with one documented refusal on 03/28/25 at 9:00 PM. A medication error was later identified when the pharmacy notified the facility that the wrong Depakote dose had been dispensed. The Medication Error Report completed by the previous DON documented that the pharmacy had dispensed Depakote 500 mg, 2 capsules three times a day, while the active order was for Depakote 125 mg, 2 capsules three times a day. The report stated that the resident received the incorrect dose for 6 days. The investigation summary indicated that weekly Smartpass medication rolls were delivered on 03/27/25, and on 04/02/25 the pharmacy notified the facility that the wrong dosage had been dispensed for this resident. The previous DON verified that the active Depakote order on the MAR and the order printed on the Smartpass pouch were not the same. Nursing staff actions and inactions contributed to the continuation of the incorrect dosing. The previous DON stated that the pharmacy believed the error was related to nursing staff not using the medication scanner when preparing medications, and she acknowledged that she herself worked the medication cart on two nights and administered the incorrect Depakote dose without using the scanner or comparing the Smartpass pouch to the MAR. Multiple nurses and a medication aide who worked during the period when the incorrect dose was administered either did not recall the medication error or only recalled receiving general education on using scanners. Several nurses described their usual practice as scanning each Smartpass pouch and comparing it to the MAR, reading and comparing orders, and stated that if the dose had been different from the MAR they would have noticed it, but they could not explain how the incorrect dose was missed at the time. The DON and the attending physician both stated that nursing staff should have read and compared the medication on hand, including the Smartpass pouch, with the active MAR order to detect the discrepancy, and the physician noted that staff did not report any signs or symptoms of Depakote toxicity and that the resident may have refused medications at times without this being consistently documented on the MAR.
Failure to Maintain Privacy Curtains in Shared Bedroom
Penalty
Summary
The deficiency involves the facility’s failure to provide required privacy curtains in a shared bedroom, preventing residents from having visual privacy when needed. Record review showed that one resident, cognitively intact and generally independent with personal care given set-up and supervision, had been without privacy curtains in her room for an extended period. Surveyor observations on two consecutive days confirmed that no privacy curtains were present in the resident’s room. The resident reported that the curtains had been missing for about seven to eight months and stated that, although she performed personal care in the bathroom, she previously used the privacy curtain for privacy from her roommate when visitors were present or when she was resting in bed. Staff interviews revealed that direct care staff and a medication aide who routinely provided care and medications to the resident had not noticed the absence of privacy curtains. Review of the medical record showed an order to wash all clothes, bed linens, coats, and blankets in hot water for a skin infection, and the Environmental Services Manager stated that when privacy curtains were removed for laundering, a fresh set should be put up the same day. He recalled that the resident’s privacy curtains had been removed for laundering due to a skin infection and admitted he forgot to have a new set installed. The Administrator, who had been in the facility for five weeks, stated she would have expected same-day replacement of curtains when removed for laundering and noted that daily room rounds were reportedly completed by multiple management team members, yet the missing curtains had not been identified.
Failure to Administer Authorized Influenza and Pneumonia Vaccines on Admission
Penalty
Summary
The facility failed to administer influenza and pneumonia vaccines on admission to a resident who had authorized these immunizations. The resident was admitted with diagnoses including heart failure and hypertension and was assessed on the admission MDS as severely cognitively impaired. On the admission consent form, the resident’s representative checked “yes” to authorize both the flu vaccine, to be given annually unless medically contraindicated, and the pneumonia vaccine, to be given on admission unless medically contraindicated. The spaces to document the dates of the last flu and pneumonia vaccines were left blank. The admission MDS documented that influenza and pneumonia immunizations were not given because they were not offered. Record review showed no documentation that the resident received either the flu or pneumonia vaccine after admission and no documentation that consent for immunizations had been withdrawn or that the vaccines had been given in the recent year. In a phone interview, the resident’s representative stated that the resident had not received flu or pneumonia vaccines on admission, that she had signed the consents, and that no one from the facility had communicated that the vaccines were administered. The former IC nurse confirmed she had not provided flu or pneumonia vaccines to this resident, despite being aware from daily morning meetings that the resident had requested them, and reported no reason for not administering them. The Administrator stated that new admissions and requested immunizations were discussed in daily morning meetings and that the representative was unsure if the resident had received vaccines prior to admission and was going to obtain that information, but the expectation was that residents would receive vaccines when requested.
Failure to Administer COVID-19 Vaccine After Documented Consent on Admission
Penalty
Summary
The deficiency involves the facility’s failure to administer a COVID-19 vaccine to a newly admitted resident despite documented consent and no contraindications or withdrawal of consent. The resident was admitted with diagnoses including heart failure and hypertension, and the admission consent form, signed by the resident’s representative and admissions staff, explicitly authorized administration of the COVID-19 vaccine annually unless medically contraindicated. The consent form indicated “yes” for COVID-19 vaccine authorization, and the space for the last date the COVID-19 vaccine was received was left blank. The admission MDS assessment documented the resident as severely cognitively impaired and recorded that the COVID-19 immunization was not given because the vaccine was not offered. Review of the medical record showed no documentation that a COVID-19 vaccine was administered and no documentation that consent for immunizations had been withdrawn or that the resident had received the COVID-19 vaccine in the recent year. Interviews further confirmed that the vaccine was not provided. The resident’s representative reported that the resident had not received COVID-19 vaccines on admission and that no one from the facility had communicated that the vaccine had been given. The former IC nurse stated that, prior to leaving her position, she had not provided a COVID-19 vaccine to this resident. She explained that new admissions were discussed during the morning meeting, that she was aware the resident had requested a COVID-19 vaccine, and that she had no reason for not administering it. The Administrator reported that new admissions and requested immunizations were discussed in daily morning meetings and that the resident’s representative was uncertain if the resident had received vaccines prior to admission and was going to obtain that information, but there was an expectation that residents receive vaccines as requested.
Inaccurate Staffing Information and Missing Resident Census
Penalty
Summary
The facility failed to post accurate staffing information as required, leading to discrepancies in the reported number of nursing staff. Specifically, for 13 out of 57 days reviewed, the daily nurse staffing sheets did not accurately reflect the presence of a Registered Nurse (RN) who was scheduled to work. The Unit Manager, who is an RN, was not counted as RN coverage on the daily staffing sheets, despite being scheduled to work the day shift on those days. This discrepancy was confirmed by the Staff Scheduler during an interview, who acknowledged the oversight and the Administrator expressed an expectation for accurate staff postings. Additionally, the facility did not include the resident census on the daily nurse staffing sheets for 54 out of 57 days reviewed. The absence of the resident census was noted for all shifts across the majority of the days in the review period. The Staff Scheduler admitted to being unaware of the requirement to include the resident census on the daily postings, and the Administrator confirmed that the resident census should have been present as required.
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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 Hamlet
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth-rockingham | 4.1 mi | ★★★★★ | 1 | 0 |
| Scottish Pines Rehabilitation And Nursing Center | 15.9 mi | ★★★★★ | 6 | 0 |
| Scotia Village - Snf | 16.1 mi | ★★★★★ | 0 | 0 |
| Rehab Center Of Cheraw | 18.9 mi | — | 8 | 0 |
| Cheraw Healthcare | 19.2 mi | ★★★★★ | 9 | 1 |
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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.