Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pinehurst Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
A cognitively intact, fully dependent resident became upset about not receiving morning medications and used profanity toward an RN, who initially attempted to remain professional but then told the resident she would give him the same energy he was giving her and called him a “crippled motherf****r” in front of others in the room. The resident reported feeling shocked, angry, hurt, and embarrassed by being called crippled, while a NA present in the room corroborated the exchange. The NP and DON both received reports of the incident, and the RN later acknowledged using the derogatory term, demonstrating a failure to maintain the resident’s dignity and right to respectful communication.
A housekeeping staff member mopped the full width of a section of the 300 hallway, leaving an approximately 4-foot by 10-foot area completely wet and requiring residents, staff, and visitors to walk on the wet floor to pass. Only one wet floor sign was placed at the end of the hallway. In interviews, the housekeeper reported this was her usual method and believed the single sign was adequate, later acknowledging she should have left a dry walking area. The Director of Housekeeping, floor technician, and DON all stated that only half the hallway should be cleaned at a time so a dry path remains available and that floor technicians normally handle full hallway floor cleaning.
A resident with severe cognitive impairment and a history of wandering exited the facility unsupervised and was found outside without her assigned wanderguard. Staff failed to verify the presence and function of the wanderguard as ordered, and the main entrance was not monitored at the time, allowing the resident to leave undetected.
A resident with severe cognitive impairment and hemiplegia experienced two falls during personal care due to inadequate supervision. The care plan required two-person assistance, but staff failed to adhere to this, resulting in injuries requiring emergency treatment.
A facility failed to accurately code the MDS assessment for a resident with a stage 3 pressure ulcer, omitting the presence of a pressure reducing device for her wheelchair. Despite the resident's care plan including interventions for pressure ulcer prevention, the MDS Coordinator acknowledged the oversight, and the Administrator confirmed the need for accurate coding.
A resident with vascular dementia and dependent on staff for ADLs did not receive necessary nail care, resulting in jagged and dirty nails. Despite being on hospice and having a care plan requiring assistance, there were no specific interventions for nail care. Nursing assistants were inconsistent in providing nail care, and the DON confirmed that nails should be groomed during showers and as needed.
Derogatory Language Toward Dependent Resident Violates Dignity and Respect
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to dignity and respectful communication when a nurse spoke to a resident in a derogatory and demeaning manner. The resident, who was cognitively intact per a quarterly MDS and completely dependent on others for care, had refused to respond to the nurse’s earlier attempts to administer morning medications and obtain a blood sugar reading, as documented in a nursing progress note. The note described the nurse bumping the resident’s bed several times, calling his name, and then later telling him that if he chose not to respond, she could only move on and would not leave medications at the bedside. During this interaction, the resident used profanity toward the nurse, calling her a liar and other offensive names. According to the resident’s interview, during a subsequent encounter in February, the nurse argued with him about whether she had attempted to give his morning medications and ultimately called him a “crippled motherf****r” before walking out of his room and slamming the door. The resident reported feeling shocked at first, then angry and hurt, and stated that it was particularly upsetting because he is completely dependent on others for his care. He also reported feeling embarrassed because other people were in the room and heard the nurse use the term “crippled” toward him. The resident further stated that the nurse told him she was going to “feed him the same energy he fed her” and again called him a “crippled motherf****r.” A nurse aide who was present during the incident corroborated that the resident was upset about not receiving his morning medications and was cursing at the nurse, and that the nurse initially tried to be professional and asked him to stop. The aide stated that after the resident called the nurse a particularly derogatory name, the nurse told him she was about to give him the same energy he was giving her and then called him a “crippled motherf****r” before leaving the room. The nurse practitioner reported that the resident told him about the phrase the nurse used, and he relayed this to the DON. In a subsequent interview, the nurse involved stated she had never been cursed at so badly by a resident, became enraged, and could neither confirm nor deny that she used a derogatory term. The DON reported that both the aide and the resident described the nurse calling the resident a “crippled motherf****r,” and that the nurse later admitted to using that term, stating she had her back to the resident and did not think he could hear her.
Unsafe Hallway Mopping Created Wet-Floor Hazard
Penalty
Summary
The deficiency involves a failure to maintain a safe environment free from accident hazards in the 300 hallway, specifically the lower end serving rooms 304 through 312. During a continuous observation, a housekeeper was seen mopping the entire length and width of an approximately 4-foot by 10-foot section of the hallway floor, leaving the entire area completely wet across the hall. A wet floor sign was placed only at the end of the hallway near one room, while the mopping practice required residents, staff, and visitors to walk on the wet floor if they needed to pass through that section. In an interview, the housekeeper stated she usually mopped across the entire floor and then followed with a dry mop, and believed that placing a wet floor sign at the end of the hallway was sufficient to warn others. She acknowledged she should have left a dry area for others to walk on. The Director of Housekeeping confirmed that the housekeeper should have mopped only one side of the hallway to leave a dry path and that a caution sign should have been placed at the end of the wet area to direct others to use the dry side. The floor technician explained that he normally cleans hallways with a machine that scrubs and dries the floor, working on one half of the floor at a time to keep a dry walking path, and that housekeeping would only mop for minor spills. The DON also stated the housekeeper should have left a dry, clear path and only mopped one half of the hallway at a time.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with diagnoses including dementia, anxiety disorder, and brain cancer, and who was assessed as high risk for elopement, was able to leave the facility unsupervised through the main entrance. The resident, who was non-ambulatory and used a wheelchair, was found outside in the parking lot by a nurse aide, approximately twenty minutes after leaving the building. At the time of discovery, the resident was not wearing her assigned wanderguard bracelet, which was intended to prevent such incidents. Staff interviews and record reviews revealed that the resident's care plan included interventions such as placement of a wanderguard, redirection from exits, and notification of the DON for exit-seeking behaviors. However, on the day of the incident, the nurse assigned to the resident did not check for the presence of the wanderguard at the start of her shift, as required by physician orders. The nurse aide who last provided care to the resident could not recall if the wanderguard was in place, and the receptionist responsible for monitoring the main entrance was not present, as the incident occurred on a weekend when no receptionist was scheduled for that time. Facility staff, including the maintenance director and receptionist, described the wanderguard system and monitoring procedures, noting that the main entrance is typically monitored by a receptionist during certain hours and that the system is designed to alarm and lock if a resident with a wanderguard approaches. Despite these measures, the resident was able to exit undetected, and staff only became aware of the incident when the resident was found outside without her wanderguard. The event highlighted lapses in supervision and failure to ensure the effectiveness of elopement prevention interventions for a high-risk resident.
Failure to Provide Adequate Supervision Leads to Resident Falls
Penalty
Summary
The facility failed to provide care in a safe manner for a resident who was reviewed for falls. The resident, who was severely cognitively impaired and dependent on staff for activities of daily living due to a stroke with left hemiplegia, experienced two falls while receiving care. On one occasion, the resident slid out of bed while a nurse aide was providing personal care, resulting in a cut and swelling to the left eyelid. The resident required emergency department evaluation and received sutures for the injury. In another incident, the resident was placed on his side during incontinence care by a nurse aide and fell off the bed, hitting his head on a side table. This resulted in a laceration on the left upper eyelid, requiring further emergency department treatment and sutures. Both incidents occurred because the resident's care plan required assistance from two staff members for bed mobility and personal care, but this was not adhered to by the staff involved. The facility's care plan and Kardex for the resident clearly indicated the need for two-person assistance for personal care and bed mobility. However, the staff involved in the incidents either misunderstood or did not follow these instructions, leading to the resident's falls and subsequent injuries. The facility's failure to ensure adherence to the care plan and proper supervision during care contributed to the deficient practice.
Inaccurate MDS Coding for Skin Treatments
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of skin treatments. The resident, who was admitted with a stage 3 pressure ulcer, had a quarterly MDS assessment that did not reflect the presence of a pressure reducing device for her wheelchair, despite having one since admission. The resident's care plan included interventions for pressure ulcer prevention, such as a pressure reducing mattress and encouragement to shift weight when sitting. During an observation and interview, the resident confirmed the presence of a pressure reducing cushion in her wheelchair. The MDS Coordinator acknowledged the oversight in coding, and the Administrator confirmed that the MDS assessment should be accurately coded in all care areas.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary nail care assistance to a resident who was dependent on staff for activities of daily living (ADL). The resident, diagnosed with vascular dementia and receiving hospice services, was observed with medium-length fingernails that were jagged and had a brown substance under some nails. Despite being dependent on staff for personal hygiene, there were no specific interventions for nail care in the resident's care plan. Nursing progress notes did not document any refusals of nail care, and the resident's shower schedule showed refusals on two occasions. Interviews with nursing assistants revealed inconsistencies in the provision of nail care. One nursing assistant could not recall the last time she provided nail care to the resident, while another stated that nail care was typically done on shower days. The Director of Nursing confirmed that nails should be groomed during showers and as needed, indicating that the resident's nail condition should have been addressed. Observations and interviews highlighted that the resident's nail care needs were overlooked, leading to the deficiency identified by surveyors.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 32 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pinehurst
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Inn At Quail Haven Village | 0.1 mi | — | 0 | 0 |
| Saint Joseph Of The Pines Health Center | 1.1 mi | — | 0 | 0 |
| The Greens At Pinehurst Rehabilitation & Living Ce | 2.4 mi | — | 9 | 0 |
| Dahlia Gardens Center For Nursing And Rehabilitati | 4.1 mi | — | 6 | 0 |
| Penick Village | 4.6 mi | — | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pinehurst Healthcare & Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.