Inspection Report
Annual Inspection
Deficiencies: 2
Sep 17, 2025
Visit Reason
The Adult Care Licensure section conducted an annual and follow-up survey on September 16 to 17, 2025 to assess compliance with resident assessment and care plan requirements.
Findings
The facility failed to ensure that one of three sampled residents had an assessment completed within 30 days of admission and failed to revise a care plan as needed based on a significant change in care for another resident. Deficiencies were related to incomplete resident assessments and care plans.
Deficiencies (2)
| Description |
|---|
| Failure to complete an assessment for Resident #3 within 30 days of admission. |
| Failure to revise the care plan for Resident #2 based on a significant change in care related to a Stage IV pressure wound. |
Report Facts
Sampled residents: 3
Pressure wound measurement: 2
Pressure wound measurement: 1
Pressure wound measurement: 1
Pressure wound tunneling: 3.5
Pressure wound undermining: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator | Interviewed regarding care plan responsibilities and facility processes |
| Executive Director | Executive Director | Interviewed regarding oversight of care plan completion and facility responsibilities |
| Clinical Director of Operations | Clinical Director of Operations | Interviewed regarding oversight of care plan completion and facility staff responsibilities |
| Health and Wellness Director | Health and Wellness Director | Former employee responsible for completing resident care plans |
| Personal Care Aide | Personal Care Aide | Interviewed regarding resident care and documentation |
| Medication Aide | Medication Aide | Interviewed regarding medication assistance for Resident #2 |
Inspection Report
Annual Inspection
Deficiencies: 3
Jan 12, 2024
Visit Reason
The Adult Care Licensure section and Moore County Department of Social Services conducted an annual and follow-up survey on January 11 to 12, 2024.
Findings
The facility failed to ensure medications were administered as ordered for one resident, with errors involving medications for depression and Alzheimer's disease. Additionally, the facility failed to notify the North Carolina Health Care Personnel Registry and the county Department of Social Services of injuries of unknown cause and injuries requiring emergency treatment for one resident.
Deficiencies (3)
| Description |
|---|
| Failed to ensure medications were administered as ordered for Resident #4, including missed doses of citalopram, memantine, and levothyroxine due to medication not being available. |
| Failed to notify the North Carolina Health Care Personnel Registry of injuries of unknown cause for Resident #1. |
| Failed to notify the county Department of Social Services of injuries requiring emergency medical evaluation and injuries of unknown cause for Resident #1. |
Report Facts
Medication error rate: 8
Number of residents observed with medication errors: 1
Number of residents with unreported injuries: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident #4 | N/A | Resident with medication administration deficiencies |
| Resident #1 | N/A | Resident with unreported injuries to HCPR and DSS |
| Medication Aide | Medication Aide (MA) | Interviewed regarding medication administration and injury observations |
| Executive Director | Executive Director | Interviewed regarding medication administration policies and procedures |
| Registered Nurse | Registered Nurse (RN) | Interviewed regarding medication administration and resident care |
| Pharmacist | Facility's contracted pharmacist | Interviewed regarding medication dispensing and resident medication profiles |
| Primary Care Provider | Resident #4's primary care provider (PCP) | Interviewed regarding medication administration and resident care |
| Personal Care Aide | Personal Care Aide (PCA) | Interviewed regarding observations of resident injuries |
| Clinical Service Specialist | Clinical Service Specialist (CSS) | Interviewed regarding injury reporting and resident safety |
| Cooperate Area Nurse Manager | Cooperate Area Nurse Manager | Interviewed regarding injury reporting and fall management |
| Administrator | Administrator | Interviewed regarding injury reporting responsibilities and procedures |
| County Adult Home Specialist | County Adult Home Specialist (AHS) | Interviewed regarding reporting requirements for injuries and incidents |
Inspection Report
Follow-Up
Deficiencies: 3
May 12, 2022
Visit Reason
A follow-up survey was conducted by the Adult Care Licensure Section on May 12-13, 2022 to verify correction of previous deficiencies related to medication administration and physician order implementation.
Findings
The facility failed to ensure physician orders for weekly weights were implemented for one resident and failed to administer medications as ordered for two residents, including a blood pressure medication omission and late pain medication administration. Additionally, two of three medication aides had not completed required medication aide training and competency evaluations prior to administering medications.
Deficiencies (3)
| Description |
|---|
| Failed to ensure physician orders for weekly weights were implemented for 1 of 5 sampled residents. |
| Failed to administer medications as ordered for 2 of 6 residents observed during medication pass, including omission of blood pressure medication and late administration of pain medications. |
| Failed to ensure 2 of 3 medication aides completed required medication aide training and competency evaluation before administering medications. |
Report Facts
Medication error rate: 9
Sampled residents with medication errors: 2
Sampled residents with order implementation failure: 1
Medication aides without completed training: 2
Medication administration opportunities observed: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Medication Aide | Failed to complete clinical skills checklist before administering medications |
| Staff C | Medication Aide | Did not complete 5, 10, or 15 hour medication aide training course and clinical skills checklist before administering medications |
| Health and Wellness Coordinator | Interviewed regarding weekly weight orders and medication administration responsibilities | |
| Administrator | Interviewed regarding medication administration responsibilities and staff training oversight | |
| Business Office Manager | Responsible for giving medication aide staff records to Health and Wellness Director and tracking training compliance |
Inspection Report
Follow-Up
Census: 33
Capacity: 76
Deficiencies: 7
Feb 18, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey to verify correction of previous deficiencies related to housekeeping, personal care, supervision, medication administration, and staff training.
Findings
The facility failed to ensure safe storage of oxygen tanks, proper supervision of residents with a history of falls, timely notification of primary care providers regarding resident health issues, accurate medication administration, and adequate staff training specific to the Special Care Unit population.
Severity Breakdown
Type B Violation: 5
Type A2 Violation: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure safe storage of oxygen tanks on the Assisted Living Unit and failed to ensure the facility was free of hazards accessible to residents on the Special Care Unit. | Type B Violation |
| Failed to provide supervision to a resident with a history of falls resulting in two falls within one week causing injuries requiring emergency department visits. | Type B Violation |
| Failed to notify primary care providers timely regarding rectal bleeding and falls for two residents. | Type B Violation |
| Failed to ensure implementation of physician orders for labs, x-rays, vital signs, and oxygen saturation monitoring, resulting in delayed treatment and hospitalization. | Type A2 Violation |
| Failed to clarify and accurately document medication orders for multiple residents, including duplicate orders and improper medication crushing. | Type B Violation |
| Failed to ensure medication administration was in accordance with orders, including crushing extended-release medications and omission of medications. | Type B Violation |
| Failed to ensure Special Care Unit staff completed required orientation and training within the first week of employment. | — |
Report Facts
Oxygen tanks unsecured: 15
Oxygen tanks total: 17
Residents on SCU: 11
Residents on AL unit: 22
Medication errors: 6
Medication pass opportunities: 27
Medication error rate: 22
Staff orientation hours: 4.75
Staff orientation hours: 5.25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Did not complete required 6 hours of SCU specific orientation within first week of employment. |
| Staff B | Personal Care Aide | Did not complete required 6 hours of SCU specific orientation within first week of employment. |
| Staff E | Medication Aide | Did not complete required 6 hours of SCU specific orientation within first week of employment. |
| Staff D | Medication Aide | No documentation of completing required medication administration training course. |
| Staff F | Medication Aide | No documentation of completing required medication administration training course or clinical skills evaluation. |
| Lead Medication Aide | Responsible for entering medication orders and medication cart audits. | |
| Health and Wellness Director | Responsible for reviewing medication orders and ensuring implementation. | |
| Business Office Manager | Responsible for ensuring staff training and maintaining documentation. | |
| Administrator | Responsible for oversight of staff training and clinical team responsibilities. |
Inspection Report
Annual Inspection
Capacity: 19
Deficiencies: 9
Nov 15, 2021
Visit Reason
The adult care licensure section conducted an annual and follow-up survey between 11/09/21 and 11/15/21 to assess compliance with state regulations for Brookdale Pinehurst.
Findings
The facility had multiple deficiencies including failure to ensure tuberculosis testing for staff, incomplete implementation of physician orders for residents, lack of licensed health professional support evaluations, medication order clarifications, medication administration errors, missing special care unit disclosures, incomplete care plans signed by physicians, and inadequate dementia-specific training for staff.
Severity Breakdown
Type B: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 5 sampled staff had tuberculosis testing upon hire. | — |
| Failed to ensure implementation of physician orders for oxygen saturation and weights for 2 of 6 sampled residents. | Type B |
| Failed to ensure licensed health professional provided onsite health evaluation for 1 of 5 sampled residents with oxygen order. | Type B |
| Failed to ensure a signed special care unit disclosure was present for 2 of 2 sampled residents prior to admission. | — |
| Failed to ensure care plans were completed within 30 days of admission and signed by a physician for 2 of 2 sampled residents in the special care unit. | Type B |
| Failed to ensure special care unit staff completed required dementia-specific training hours within 6 months of hire and annually for 2 of 2 sampled staff. | — |
| Failed to ensure 3 of 3 sampled medication aides completed required medication aide training and clinical skills evaluation. | — |
| Failed to clarify medication orders with primary care provider for 2 of 4 residents related to vitamin and eye medication orders. | — |
| Failed to ensure medications were administered as ordered for 4 of 5 residents including probiotic, dementia medication, vitamin supplements, and eye drops. | — |
Report Facts
Medication error rate: 3
Special Care Unit capacity: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Personal Care Aide | No documentation of 20 hours dementia training within first 6 months of hire. |
| Staff E | Personal Care Aide | No documentation of 20 hours dementia training within first 6 months of hire or any dementia training in 2021. |
| Staff B | Medication Aide | Completed 15 hour MA training and passed exam but no documentation of clinical skills evaluation. |
| Staff C | Medication Aide | No documentation of 5, 10 or 15 hour MA training but passed exam and completed clinical skills evaluation. |
| Staff D | Medication Aide | No documentation of 5, 10 or 15 hour MA training but passed exam and completed clinical skills evaluation. |
Inspection Report
Follow-Up
Deficiencies: 2
Jul 18, 2019
Visit Reason
Biennial Follow Up Construction Survey to verify correction of previously cited deficiencies from the Biennial Construction Survey.
Findings
The facility was found to have deficiencies related to housekeeping and furnishings, specifically excessive accumulation of dust/lint in ventilation systems in multiple areas, and lack of mechanical exhaust ventilation in the Laundry Room/SCU.
Deficiencies (2)
| Description |
|---|
| Building mechanical systems are not kept clean and in good repair, with excessive accumulation of dust/lint in ventilation systems in Employee Rest room, Resident Laundry Closet, and MCU Public Restroom. |
| No mechanical exhaust ventilation provided in the Laundry Room/SCU as required. |
Inspection Report
Capacity: 76
Deficiencies: 19
Jun 4, 2019
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1996 (1998 Revision) Edition of the North Carolina Building Code(s), Institutional Occupancy, and the 1996 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure.
Findings
Multiple deficiencies were cited related to physical plant, fire safety, housekeeping, building equipment, and ventilation. Issues included missing signage on delayed egress doors, lack of current fire and sprinkler inspection reports, corridor obstructions, poor housekeeping with dust accumulation, failure to document fire safety rehearsals, malfunctioning emergency lighting, fire doors not latching properly, fire sprinkler system deficiencies, electrical hazards, and non-functioning exhaust ventilation in the bulk laundry.
Deficiencies (19)
| Description |
|---|
| Delayed egress locked doors missing required signage. |
| Facility failed to maintain current annual sprinkler system inspection report. |
| Corridors obstructed by equipment and vegetation, reducing required clearance. |
| Outside grounds not maintained in a clean and safe condition with tripping hazards. |
| Excessive dust/lint accumulation on ventilation systems in multiple locations. |
| Ice machine drain line improperly installed, contacting floor receptor. |
| Facility failed to document fire safety rehearsals with descriptions of activities. |
| Smoke barrier doors did not close completely or latch, some held open by equipment. |
| Commercial kitchen hood fire suppression system lacked required inspections and documentation. |
| Emergency lights failed to illuminate on backup power during testing. |
| Corridor doors did not positively latch or resist passage of smoke/fire. |
| Fire safety compromised by gaps in fire collars and holes in fire-resistance-rated walls. |
| Fire alarm smoke detector dangling from ceiling by wires. |
| Electrical hazards including use of extension cords for permanent wiring and blocked electrical panels. |
| Exterior light fixture missing globe, reducing illumination. |
| Fire rated doors held open by furniture or devices preventing proper closure and latching. |
| Fire sprinkler escutcheon plates dropped down exposing openings allowing spread of smoke and heat. |
| Fire sprinkler heads obstructed with lint and debris, potentially delaying fire response. |
| Exhaust ventilation system in bulk laundry not functioning. |
Report Facts
Licensed capacity: 76
Special Care Unit beds: 19
Inspection Report
Annual Inspection
Deficiencies: 6
May 8, 2017
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Brookdale Pinehurst on May 4, 5, and 8, 2017 to assess compliance with state regulations.
Findings
The facility was found deficient in multiple areas including hot water temperature regulation, tuberculosis testing for staff and residents, failure to serve water at breakfast in the special care unit, medication administration errors, and inadequate special care unit staff training.
Deficiencies (6)
| Description |
|---|
| Facility failed to maintain hot water temperatures between 100°F and 116°F for 19 of 20 fixtures used by residents. |
| One of six sampled staff (Staff F) was not tested upon hire for tuberculosis with the required two-step skin test. |
| Three of five sampled residents (#3, #4, #5) were not tested upon admission for tuberculosis disease in compliance with control measures. |
| Facility failed to serve water to residents in the special care unit during breakfast meals. |
| Medication administration errors observed for 2 of 7 residents including crushing an extended release medication (Diltiazem ER) and improper timing of vitamin supplement administration. |
| Three of three sampled special care unit staff (Staff D, E, F) did not receive 6 hours of orientation training within the first week of employment and did not complete 20 hours of special care unit training within 6 months of employment. |
Report Facts
Medication error rate: 7
Number of fixtures with hot water temperature out of range: 19
Number of sampled staff missing TB testing: 1
Number of sampled residents missing TB testing: 3
Number of sampled special care unit staff missing required training: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Personal Care Aide/Resident Assistant | Named in tuberculosis testing deficiency for missing second step TB skin test |
| Staff D | Resident Assistant | Named in special care unit training deficiency for missing required orientation and training |
| Staff E | Resident Assistant | Named in special care unit training deficiency for missing required orientation and training |
| Health and Wellness Director | Interviewed regarding TB testing, medication administration, and staff training deficiencies | |
| Business Office Manager | Interviewed regarding staff file organization and training documentation | |
| Executive Director | Interviewed regarding facility compliance and corrective actions | |
| Medication Aide | Observed and interviewed regarding medication administration errors |
Inspection Report
Capacity: 76
Deficiencies: 10
May 3, 2017
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1996 (1998 Revision) Edition of the North Carolina Building Code(s), Institutional Occupancy, and the 1996 Rules for Licensing of Adult Care Homes of Seven or More Beds in effect at the time of initial licensure during a Construction Section Biennial Survey.
Findings
Multiple deficiencies were identified related to physical plant and safety including bathrooms used for storage, doors swinging into corridors, exit door locks not operable by single hand motion, chronic unpleasant odors, damaged flooring and walls, hazards obstructing emergency egress, fire safety equipment and components not maintained in safe operating condition, gaps in fire resistant rated ceilings and doors, and plumbing equipment not maintained safely.
Deficiencies (10)
| Description |
|---|
| Bathrooms shall not be utilized for storage; community bath taken out of service and used as storage. |
| Doors to spaces other than reach-in closets shall not swing into the corridor; screen door swings into corridor. |
| Exit door locks shall be operable by single hand motion; front entrance exit door has deadbolt lock with twist lock. |
| Facility not free from chronic unpleasant odors; strong urine odor in room 102 detected in corridor. |
| Flooring not kept in good repair; broken/missing tile in kitchen dry storage, vinyl flooring curled in shower room. |
| Walls not kept in good repair; door damaged by torn bolt lock, holes in walls, missing wall base. |
| Facility not maintained free from hazards; items stored in exit vestibule, obstructed electrical panels, detached porch board with exposed nails. |
| Failure to maintain fire safety equipment in safe operating condition; gaps in resident room doors, overdue fire extinguisher inspection, items stored too close to sprinkler heads, door closers removed, gaps in fire resistant walls and ceilings, doors propped open with wedges. |
| Doors that open to corridors do not close completely and latch; door in small dining room hits door frame and cannot latch. |
| Plumbing equipment not maintained safely; hand washing sink in kitchen detaching from wall and extremely loose. |
Report Facts
Licensed beds: 76
Special Care Unit beds: 19
Inspection Report
Annual Inspection
Deficiencies: 4
Nov 25, 2015
Visit Reason
The Adult Care Licensure Section conducted an annual survey on 11/24/15 and 11/25/15 to assess compliance with state regulations for the adult care home.
Findings
The facility was found deficient in multiple areas including failure to ensure staff qualifications regarding Health Care Personnel Registry checks prior to hire, improper medication administration for two residents involving insulin and antipsychotic medications, failure to conduct thorough medication regimen reviews, and lack of annual infection control training for medication aides.
Severity Breakdown
TYPE A2 VIOLATION: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 6 staff had no substantiated findings on the North Carolina Health Care Personnel Registry prior to hire. | — |
| Medications (Lantus and Humalog insulin, Seroquel) were not administered as ordered by a licensed prescribing practitioner for 2 of 6 sampled residents. | TYPE A2 VIOLATION |
| Facility failed to ensure the on-site medication review included review of medication administration records to determine medications were administered as prescribed for 2 of 6 sampled residents. | — |
| Facility failed to assure all medication aides received annual in-service training for infection control for 2 of 2 sampled staff. | — |
Report Facts
Days worked by Staff D as Medication Aide: 25
FSBS range for Resident #1: 547
Number of occasions Novolog insulin was withheld or not documented: 36
Number of occasions Lantus insulin was withheld or not documented: 9
Seroquel 100 mg tablets dispensed: 60
Number of residents reviewed in Medication Regimen Review: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Medication Aide | Failed to have substantiated findings check on Health Care Personnel Registry prior to hire; worked 25 days as Medication Aide during review period. |
| Business Office Manager | Interviewed regarding Health Care Personnel Registry checks and infection control training records. | |
| Interim Health and Wellness Director | Health and Wellness Director | Conducted diabetic training; noted issues with medication administration and monitoring. |
| Resident #1's Physician | Physician | Provided orders and clarified insulin administration parameters. |
| Resident #7's Neurologist Nurse | Nurse | Provided information on medication dosage changes and resident condition. |
| Pharmacist | Consulting Pharmacist | Completed Medication Regimen Review and did not identify medication administration discrepancies. |
| Executive Director | Executive Director | Interviewed regarding pharmacy reviews and follow-up on medication discrepancies. |
| Staff C | Medication Aide | Lacked documentation of annual infection control training. |
| Staff E | Medication Aide | Lacked documentation of annual infection control training. |
| Pro tem Nurse | Nurse | Interviewed about infection control training requirements and record keeping. |
| Administrator | Administrator | Interviewed about infection control training compliance and staff education. |
Inspection Report
Follow-Up
Deficiencies: 4
Jun 25, 2015
Visit Reason
Follow-up construction survey to verify correction of deficiencies cited during the February 4, 2015 Biennial Construction Survey.
Findings
The building was found not to be maintained in a safe and operating condition due to issues such as corridor doors not resisting smoke passage, breaches in fire-resistance-rated construction, deteriorating door components, and improperly functioning delayed egress systems. These deficiencies could affect all residents, staff, and visitors.
Deficiencies (4)
| Description |
|---|
| Corridor doors did not resist passage of smoke due to door leafs not fitting into their frames with acceptable gaps. |
| Breaches through fire-resistance-rated construction invalidated its integrity, including gaps around cables and unapproved firestop materials. |
| Time Clock Room exterior door had a 3/4 inch gap between threshold and door bottom and was delaminating/rotting. |
| Delayed egress doors lacked required signage indicating alarm and door opening time. |
Report Facts
Gap measurement: 0.25
Gap measurement: 0.75
Inspection Report
Census: 76
Capacity: 76
Deficiencies: 16
Feb 4, 2015
Visit Reason
Biennial Construction Survey conducted to assess compliance with the 1996 and applicable portions of the 2005 Rules for Licensing of Adult Care Homes and the 1996 (1998 Revision) North Carolina State Building Code(s), Section 409 - Institutional Occupancy.
Findings
Multiple physical plant deficiencies were identified including excessive dust accumulation on HVAC components, lack of ground fault protection on electrical outlets near wet areas, unsafe building egress conditions, obstructed fire sprinkler heads, non-functioning exit signs, blocked electrical panels, smoke barrier door issues, breaches in fire-resistance-rated construction, gaps in exterior doors, non-functioning emergency lighting, improperly working delayed egress systems, prohibited portable electric heaters, unsecured cooking ranges, and inadequate ventilation in certain areas.
Deficiencies (16)
| Description |
|---|
| Excessive accumulation of dust/lint on return HVAC grilles and radiation dampers. |
| Electrical power receptacles near wet areas lacked ground fault protection. |
| Egress from some areas required keys, tools, or special knowledge; barrel bolt on porch door. |
| Obstructed fire sprinkler heads with large boxes placed against them. |
| Exit signs did not work on backup power and had inappropriate directional graphics. |
| Items stored in front of electrical panels encroaching on required clear working space. |
| Corridor doors did not resist passage of smoke due to gaps and improper latching. |
| Breaches through fire-resistance-rated construction compromising integrity. |
| Exterior doors had significant gaps and some door components were rotting or broken. |
| Emergency lighting did not work properly or was absent in some egress pathways. |
| Delayed egress doors lacked required signage. |
| Corridor doors held open by devices preventing rapid closing and latching. |
| Portable electric heater found in Sales Manager's Office, prohibited by rule. |
| Range in 200 Hall Lounge was powered on without staff supervision and power switch was not locked. |
| Ventilation equipment/components not maintained in good working order; excessive dust/lint on exhaust fans and dampers. |
| No ventilation in housekeeping closet on 200 Hall and SCU Hopper Sink Room. |
Report Facts
Residents served: 76
Special care unit residents: 19
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