Inspection Reports for
Pinehurst Senior Community

.305.03 Resident Health Status: the facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status, including multiple falls and episodes of diarrhea and respiratory symptoms.

.320.01 Use of NSA: residents' negotiated service agreements did not clearly reflect the resident's needs nor describe the services to be provided, missing instructions for emergency evacuation, night needs, and money management.

.330.04.a Resident Care Records: facility staff documentation was not completed by the staff making observations; medication technicians charted for caregivers who lacked computer access.

.330.14 As Worked Schedules: the facility's as-worked schedule did not document the dates and exact times the administrator nor the facility's nurse were at the facility.

.335.02 Standard Precautions: a medication technician handled residents' oral medications with bare hands without hand hygiene between passes, dropped a tablet on the floor and retrieved it without hand hygiene; the facility nurse was made aware.

.403 Fire and life safety standards: the facility lacked fire suppression protection of combustible overhangs, a previously cited deficiency from 2/29/2024 and 10/10/2024, and the administrator stated they were waiting for an estimate.

.600.04.a. Sufficient personnel: the facility did not schedule sufficient staff during all hours, including night shifts without medication-certified staff and inadequate staffing for residents requiring two-person transfers.

.403 Fire and life safety standards for existing buildings: the facility was identified as not having fire suppression protection of combustible overhangs, previously cited on 05/25/2022 and still present as of 03/30/2024.

.215.08.f. Notification to Licensing Agency within One Business Day: the facility did not notify Licensing and Certification within one business day when multiple residents had falls requiring hospital or outside assessments; the administrator was unaware these incidents needed reporting.

.216.02. Written Agreement: four of seven residents did not have new admission agreements in place between the residents and current ownership following a change in ownership.

.305.02.a. Current Medication Orders and Treatment Orders: medication container labels did not match providers’ orders, including conflicting acetaminophen orders, unlabeled milk of magnesia, and olanzapine dosing changes not reflected on labels; the facility nurse was unsure why labels were incorrect.

.403. Fire and life safety standards for existing buildings licensed for three through sixteen residents: the facility had combustible overhangs without fire suppression, missing 5-year sensitivity test documentation for smoke detectors, attic access panel not properly seated, no 5-year assessment documentation for sprinkler piping, inadequate smoking area signage, missing oxygen precaution signs in resident rooms, and missing delayed egress signage on exit doors (previously cited 12/17/2021).

.405.01.a. Electrical installations and equipment: the facility used a non-grounded extension cord at building one and a grounded extension cord at building two to power decorative lights on front patios.

.405.04. Fuel-fired heating: the facility had two gas fireplaces and a central boiler but could not produce documentation of inspection within the past 12 months.