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Deficiency Records for Pinehurst Healthcare and Rehabilitation Center
A list of the most recent deficiencies for Pinehurst Healthcare and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Pinehurst Healthcare and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-27 | 2024-04-18 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-10-11 | 2023-12-21 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-10-11 | 2023-12-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-10-11 | 2023-12-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-11 | 2023-12-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-10-11 | 2023-12-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-11 | 2023-12-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-11 | 2023-12-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-11 | 2023-12-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-13 | 2023-09-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-13 | 2023-09-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-13 | 2023-09-29 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-09-13 | 2023-09-29 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-13 | 2023-09-29 | Y |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2022-06-28 | 2022-09-01 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-06-28 | 2022-09-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-06-28 | 2022-09-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-06-28 | 2022-09-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-28 | 2022-09-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-28 | 2022-09-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-28 | 2022-09-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-28 | 2022-09-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-05-26 | 2022-06-27 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-05-26 | 2022-06-27 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-05-26 | 2022-06-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-26 | 2022-06-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-26 | 2022-06-27 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-05-26 | 2022-06-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-26 | 2022-06-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-26 | 2022-06-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-26 | 2022-06-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-26 | 2022-06-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-26 | 2022-06-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-26 | 2022-06-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-26 | 2022-06-27 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-05-26 | 2022-06-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-05-26 | 2022-06-27 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-05-26 | 2022-06-27 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-05-26 | 2022-06-27 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-13 | 2021-10-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-13 | 2021-10-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-13 | 2021-10-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-13 | 2021-10-28 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-13 | 2021-10-26 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-10-13 | 2021-10-25 | Y |
| Use approved construction type or materials. | Fire Safety | 2020-02-19 | 2020-03-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-02-19 | 2020-03-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-19 | 2020-03-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-19 | 2020-03-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-19 | 2020-03-28 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-01-09 | 2020-02-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-01-09 | 2020-02-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-01-09 | 2020-02-06 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-01-09 | 2020-02-06 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-01-09 | 2020-02-06 | N |
| Assess the resident when there is a significant change in condition | Health | 2020-01-09 | 2020-02-06 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2020-01-09 | 2020-02-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-09 | 2020-02-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-01-09 | 2020-02-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-09 | 2020-02-06 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-01-09 | 2020-02-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-01-09 | 2020-02-06 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-01-09 | 2020-02-06 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-01-09 | 2020-02-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-01-09 | 2020-02-06 | N |
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