Pinehurst Healthcare & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Pinehurst Healthcare & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 24, 2025

  Based on record reviews, observations, and interviews with staff and the Nurse Practitioner, the facility failed to provide care in a safe manner for 1 of 7 residents reviewed for falls (Resident #72). On 8/26/24 Resident #72 slid out of the bed to the floor while care was being provided by Nurse Aide (NA) #9. The incident resulted in a cut and swelling to the left eyelid. Resident #72 was sent to the emergency department (ED) and required 3 dissolvable sutures to close the wound over his left eye. On 1/12/25 Resident #72 was placed on his side during incontinence care by NA #3 and fell off the bed hitting his head on the side table when the NA reached for cream. Resident #72 was sent to the ED and required sutures to repair a laceration on his left upper eyelid. […]

• Actual harm, isolatedF689May 26, 2022

  Based on observations, resident, staff and Medical Director (MD) interviews, the facility failed to provide wound care in a safe manner that resulted in a resident fall with injury. Resident #54 fell during wound care and sustained a distal femur fracture. In addition, the facility failed to complete an investigation for Resident #54's fall. The facility also failed to lift a non-ambulatory resident with a mechanical sling lift according to the manufacturer instructions resulting in a distal femur fracture (Resident #3). This was for 2 of 3 residents reviewed for accidents. The findings included: 1. Resident #54 was admitted on [DATE] with [CONDITION(S)] and a history of a left knee arthroplasty (knee replacement). […]

• Actual harm, isolatedF726May 26, 2022

  Based on staff interviews and record review, the facility failed to provide documented evidence 2 of 2 agency nursing assistants (NA's) (NA #9 and NA #10) were trained on the safe use of the facility's mechanical sling lift resulting in a distal femur fracture (Resident #3). This was for 2 of 3 residents reviewed for accidents. The findings included: The findings included: Resident #3 was admitted on [DATE]/20 with dementia and [CONDITION(S)]. Resident #3's quarterly Minimum Data Set, dated dated dated [DATE] indicated severe cognitive impairment, non-ambulatory and total staff assistance of 2 with transfers. Resident #3's revised care planned for a risk of falls dated 8/5/21 read she was a mechanical sling transfer with the assistance of 2 staff. […]

• No harm, potential for more than minimal, widespreadF812Mar 27, 2024

  Based on observations, record review, and staff interviews, the facility failed to maintain a walk-in cooler that was clean and in good repair for 1 of 1 walk-in cooler and failed to store food off the floor in the walk-in cooler. These practices had the potential to affect food served to 100 of 104 residents. The findings included: 1. An observation of the walk-in cooler on 3/26/24 at 11:31 am revealed a black and brown substance on the walls in the form of drip marks that appeared to be dry. There was also dust buildup on the ceiling of the walk-in cooler and to the vents in the walk-in cooler. A vent that contained 3 fans had dust build up. When the ceiling was touched the hanging dust was observed to fall to the cooler floor. […]

• No harm, potential for more than minimal, patternF812Apr 30, 2026

  Based on observations and staff interviews, the facility failed to label, date, and seal leftover food stored ready for use in 1 of 1 walk-in refrigerator, 1 of 1 walk-in freezer and 1 of 1 reach-in refrigerator. This practice had the potential to affect food served to residents.The findings included: a. Accompanied by Dietary Aide #1, an observation was made of the walk-in refrigerator on 4/27/26 at 6:30 AM. An undated piping bag, partially filled with whipped topping, was sitting on the shelf of the walk-in refrigerator. Dietary Aide #1 stated the whipped topping was likely used on desserts from the previous day. b. […]