Inspection Reports for Pinehurst Senior Community

The inspection was a health care licensure and follow-up survey to evaluate compliance with previously identified deficiencies and assess current facility operations.

The facility was found deficient in multiple areas including failure to conduct nursing assessments after resident health changes, incomplete and inaccurate resident care documentation, inadequate negotiated service agreements, improper medication handling without hand hygiene, incomplete as-worked schedules, and unresolved fire suppression system deficiencies previously cited.

The inspection was conducted as a health care complaint investigation to assess staffing sufficiency and compliance with medication technician requirements during night shifts.

The facility did not schedule sufficient staff during all hours, particularly on night shifts where there was no medication certified staff or delegated medication passers on multiple occasions. Residents requiring two-person assistance for transfers were at risk due to insufficient staffing.

The investigation was triggered by a complaint regarding insufficient staffing, specifically the absence of medication technicians on night shifts and inadequate staff to assist residents requiring two-person transfers.

The visit was a follow-up survey to verify correction of previously identified fire and life safety deficiencies related to fire suppression protection of combustible overhangs.

The facility was found to still lack fire suppression protection of combustible overhangs, a deficiency previously identified on March 30, 2024, and during a building evaluation on May 25, 2022. This deficiency remains uncorrected and is cited in accordance with NFPA 13 standards.

The inspection was conducted as an initial licensure survey for Pinehurst Senior Community.

The facility failed to notify Licensing and Certification within one business day of resident falls requiring hospital assessments, did not have updated admission agreements for four of seven residents after ownership change, and had discrepancies between medication orders and medication container labels for multiple residents.

The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with the 2018 edition of NFPA 101 Life Safety Code and related standards for existing residential board and care occupancies.

The facility did not maintain compliance with multiple fire and life safety standards including combustible overhangs without fire suppression, missing documentation for smoke detector sensitivity tests and sprinkler system assessments, inadequate smoking area signage, missing oxygen precaution signs in resident rooms, missing delayed egress signage on exit doors, use of non-grounded electrical extension cords, and lack of documentation for annual inspection of fuel-fired heating devices.