Southern Pines Nursing Center

In the surveyor’s words

From the most serious findings on record at Southern Pines Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 18, 2023

  Based on record review, interviews, hospital record review, hospice record review, facility documentation and policy review, the facility failed to ensure one (Resident #1) of five residents reviewed for insulin administration was free from neglect as evidenced by neglecting to give insulin per physician orders, neglecting to notify the provider immediately after an insulin overdose, and neglecting to monitor the resident after a medication error. Resident #1 had Diabetes Mellitus Type II and had physician orders for Levemir U-100 (long-acting) insulin, 5 units (u) to be given one time daily at 9:00 a.m. He also had orders for Novolog 100 unit (u)/milliliter (ml) (short-acting) insulin to be given per a sliding scale (based on blood glucose measurement) before each meal and at bedtime. […]

• Immediate jeopardy, isolatedF726Apr 18, 2023

  Based on record review, interviews, hospital record review, hospice record review, facility documentation and policy review, the facility failed to provide competent staff, which ensured residents reviewed for insulin administration received medication as ordered and follow-up monitoring occurred after a medication error. The facility failed to ensure one (Resident #1) of five residents were assessed and monitored for approximately five hours following identification of an insulin medication error and failed to notify the provider of a medication error in a timely manner as evidenced by a lapse of approximately two hours after the medication error occurred. […]

• Immediate jeopardy, isolatedF760Apr 18, 2023

  Based on record review, interviews, hospital record review, hospice record review, facility documentation and policy review the facility failed to ensure one (Resident #1) of five residents reviewed for insulin administration was free from a significant medication error as evidenced by the wrong dose and wrong type of insulin being administered a diabetic resident. This failure created a situation that resulted in a worsened condition and death to Resident #1 and resulted in the determination of Immediate Jeopardy beginning on 3/12/23. […]

• No harm, potential for more than minimal, widespreadF925Sep 3, 2021

  Based on observations, interviews and facility record review, the facility failed to ensure it had an effective pest control program with regards to flying insects observed in resident spaces to include one of one main dining room, hallways, and one of one kitchen, during four of four days observed, (8/31/2021, 9/1/2021, 9/2/2021, and 9/3/2021). Findings included: On 8/31/ at 11:00 a.m., the main dining room was observed for the lunch meal service. The dining room was a very large open area located in between both the 100/200 and 300/400 unit stations. Further, the middle of the dining room was observed with double doors that led to the smoking area/courtyard. The dining room was observed with ten tables with thirty residents seated throughout the area. […]

• No harm, potential for more than minimal, patternF759May 20, 2026

  Based on observations, interviews and record review, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-six medication administration opportunities were observed and two errors were identified for one resident (#118) out of seven residents observed. These errors constituted a 5.56% medication error rate.Findings included:On 5/20/2026 at 9:00 AM, an observation was made of Staff G, Licensed Practical Nurse (LPN) pull the following medication for Resident #118:Omeprazole 20 mg (milligrams) one tabletGuaifenesin 400 mg one tabletA record review of Resident #118's current physician orders showed the following:Pantoprazole Sodium oral packet 40 mg , give 40 mg by mouth two times a day for GERD (Gastroesophageal reflux disease), ordered 5/13/2026Guaifenesin ER… […]