Southern Pines Nursing Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide supervision to a known wandering resident resulting in an incident of potential sexual abuse for two residents (#8 and #9) out of three residents sampled. On 05/30/2026, facility staff became aware that Resident #9, who was cognitively impaired, had entered Resident #8's bed while both residents were fully unclothed. The facility did not implement immediate protective measures consistent with their policy.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure kitchen sanitation requirements were maintained, for one of one kitchen. Findings Included: On 05/17/2026 at 09:31AM, during a tour of the kitchen, an observation was made of the kitchen hand washing sink. The kitchen sink was white with debris in various areas to include the face of the cabinet, countertop, faucet, and the area where the backsplash of the countertop made contact with the wall behind it. There was a pink dried liquid, on the left rear side of the countertop. The cabinet door face had a dried brown substance streak from the middle for about two inches. [NAME] buildup surrounded the faucet fixture and paper trash was sitting on the fixture. [NAME] buildup of debris on the wall behind the sink. [...]

Inspectors wroteBased on observations, interviews, and review of facility policy, the facility failed to maintain the garbage storage area in a sanitary manner creating unsanitary conditions and increasing the risk of attracting pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program effectively identified, monitored, and sustained corrective actions related to food storage, food preparation, and sanitary practices. This failure resulted in the recurrence of previously identified sanitation concerns in one of one kitchen observed.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that a current/correct copy of a resident's advance directive was in the resident's medical record for two residents (#2 and #80) of two residents sampled for advanced directives.

Inspectors wroteBased on interview and record review, the facility did not ensure Preadmission Screening and Resident Review (PASRR) was accurate for one (Resident #51) out of six residents reviewed. Review of Resident #51's admission record revealed an admission date of 3/08/25, with an initial admission date of 1/08/25, with diagnosis to include but not limited to: generalized anxiety disorder (onset 1/08/25), depression unspecified (3/08/25), and bipolar disorder, current episode depressed, mild (onset 3/08/25). Review of Resident #51's Preadmission Screening and Resident Review (PASRR) dated 2/03/26 revealed bipolar disorder and depressive disorder were marked under Section A. Mental Illness or Suspected Mental Illness (MI). Anxiety disorder was not marked. On 5/20/26 at 1:16 PM, an interview was conducted with the Director of Nursing (DON). [...]

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure physician orders were followed for enteral nutrition for one resident (#39) out of one resident reviewed. On 5/17/2026 at 9:18 AM., an observation was made of Resident #39 in his room. Resident #39's enteral (tube feeding) pump was alarming and enteral nutrition was not instilling nutrition. Resident #39 could not state when the alarm started. On 5/18/2026 at 11:05 AM, an observation was made of Resident #39's tube feeding bag hung on a pole but not connected to the resident to instill nutrition. On 5/18/2026 at 3:04 PM, an observation was made of Resident #39's tube feeding bag hung on a pole but not connected to the resident to instill nutrition. [...]

Inspectors wroteBased on observations, interviews and review of facility's policy, the facility did not ensure proper infection control practices and standards of care were followed related to 1. a (peripherally inserted central catheter) PICC dressing was not changed per standard of care for one resident (#80) of one resident reviewed for central catheters; 2. proper hand hygiene during a medication administration for one resident (#118) of seven residents observed for medication administrations; and 3. failed to ensure resident daily reusable equipment was maintained with cleanable surface for one resident's (#65) wheelchair out of 3 wheelchairs observed.

Inspectors wroteBased on observations and interviews, the facility failed to provide a clean, comfortable, sanitary, and homelike environment in four halls (A, B, C, D) of four hallways and one of one dining room.

Inspectors wroteBased on interview and record review the facility failed to provide treatment and care in accordance with professional standards of practice related to performing weekly skin checks for four residents (#1, #3, #5, #6) out of five sampled residents.

Inspectors wrote3. Review of Resident #3's admission Record revealed the resident was admitted on [DATE] from an acute care hospital. The record included diagnoses not limited to other idiopathic peripheral autonomic neuropathy, unspecified chronic obstructive pulmonary disease, unspecified cord compression, and generalized muscle weakness. The resident discharged to a private home on 3/13/25. An interview was conducted on 6/11/25 at 1:57 p.m. with the Director of Rehab (DOR). The DOR stated all new admissions are evaluated or screened by therapy. The DOR reported remembering Resident #3 did participate in physical and occupational therapies. A review of the therapy notes for both disciplines revealed the resident did not miss any scheduled visits. Review of Resident #3's assessments did not reveal any Daily Skilled Nursing notes were completed for the resident. [...]

Inspectors wroteBased on interview and record review the facility failed to promptly notify the resident representative of a room change for one resident (#4) of three sampled residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow standard infection control practices related to hand hygiene and cleaning of resident care multi-use equipment.

Inspectors wroteBased on interviews and record review, the facility failed to make prompt efforts to resolve grievances and progress toward a resolution for concerns expressed in Resident Council Meetings by three residents (#63, #52, and #23) of 36 sampled residents.

Inspectors wrote3. A review of the admission Record for Resident #33 showed an admission date of 12/20/2019 with diagnoses of cerebrovascular disease (Stroke), peripheral vascular disease, muscle weakness and other co-morbidities. A review of Resident #33's MDS with an Assessment Reference Date (ARD) of 8/14/2023 revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of eleven out of fifteen which revealed the resident was moderately cognitively intact. Section E Behaviors showed the resident had no behaviors, did not reject care or evaluation of care. Section G Functional Status was marked for no impairment of the upper or lower extremities. Further review of the MDS revealed no documentation that Resident #33 had functional impairments at admission. On 10/16/2023 at 10:00 a.m. and 1:41 p.m. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure 1) medications on one medication cart (A-wing cart) were secured while unattended, 2) insulin pens and vials were dated in one medication cart (B-wing cart), 3) bottles of ophthalmic solutions were dated and internal/external medications were not stored in the same compartments on one medication cart (C-wing cart) of four medication carts observed.

Inspectors wrote2. During an observation of medication administration on 10/18/23 at 8:21 a.m. with Staff G, LPN the following medications were dispensed for Resident #37: -Buspirone 10 milligram (mg) tablet -Folic Acid 1 mg tablet -Diltiazem 120 mg tablet -Montelukast 10 mg tablet -Spirolactone 50 mg tablet -Xifaxan 550 mg tablet -Potassium 20 milliequivalents (meq) Extended Release (ER) tablet -Omeprazole 20 mg over the counter (otc) tablet -Iron 325 mg otc tablet -Magnesium oxide 400 mg tablet otc. Staff G, LPN placed the tablets in a medication cup while dispensing and when asked to confirm there were 10 tablets, Staff G poured the tablets out of the cup and onto an 8x11 piece of paper lying on the medication cup. Staff G put the tablets back into the cup with bare hands including a couple that had rolled off the paper and onto the top of the medication cart. [...]

Inspectors wroteBased on interview and record review, the facility failed to honor a resident preference to have medication administered at a later time in the morning for one resident (#75) of five residents sampled.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to develop and implement a care plan related to: 1. smoking for one resident (#82), 2. lack of range of motion for one resident (#33), and 3. related to the changes in one resident's (#78) mood, behavior and new medications for depression and anxiety out of thirty-three sampled residents.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure one resident (#33) of two sampled residents received treatment and services to prevent further decrease in range of motion.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure respiratory equipment was changed and maintained in a sanitary manner for one resident (#60) out of one resident sampled for receiving respiratory therapy.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide psychological and behavioral health care services to maintain the highest practicable mental and psychosocial well-being for one resident (#60) out of three residents sampled for emotional and mood behaviors.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-four medication administration opportunities were observed and three errors were identified for three residents (#240, #33, #64) of seven residents observed. These errors constituted a 8.82% medication error rate.

Inspectors wroteBased 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).

Inspectors wroteBased on observations and staff interviews the facility failed to ensure one of one outside courtyard area was maintained in a safe, clean, and sanitary manner during four of four days observed (8/31/2021, 9/1/2021, 9/2/2021, and 9/3/2021).

Inspectors wroteBased on observations, interviews and medical record review, the facility failed to implement interventions for a fall care plan for one (#16) of four residents sampled for accidents out of a total resident sample of 39.

Inspectors wroteBased on observations, interviews, medical record review and policy review, the facility failed to ensure the safety and supervision for one (#36) of four residents sampled for accidents related to Resident #36 self propelling through a busy parking area, positioning himself off of the facility property with no orders for leave of absence, and smoking cigarettes unsupervised in an area with high vehicle traffic.

Inspectors wroteBased on record review and interview the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for one (#73) of one resident sampled for dialysis out of 3 facility residents receiving dialysis.