Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Pinehurst Healthcare & Rehabilitation Center
Pinehurst, NC · 144 certified beds · Last Life Safety survey January 24, 2025
CMS Certification Number 345370 · first certified May 1991
Ownership
Operated by LIBERTY SENIOR LIVING · For profit - Corporation
- Ownership changed February 1, 2020 (change of ownership)to PINEHURST HEALTHCARE AND REHABILITATION CENTER from PINEHURST NURSING CENTER, INC.
Position within NC
22 citations — more than 92% of the 419 certified nursing homes in NC. Compared within NC rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 6 citations; the earlier surveys in the window averaged 8. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (March 2026 to May 2026), and past the point by which nine in ten NC facilities have been surveyed. This facility’s last Life Safety survey was January 2025. Facilities in NC are typically surveyed 14–16 months after the last one (median 15), measured over 412 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 22 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in NC, and nationally. Surveyors differ markedly between states, so the NC figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 22 |
| Median facility in NC | 9 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 26, 2022 | 8 |
| September 13, 2023 | 8 |
| January 24, 2025 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2025-01-24 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 3 | 2025-01-24 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 3 | 2025-01-24 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 2 | 2023-09-13 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2025-01-24 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2023-09-13 |
| K-0111 | Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | 1 | 2022-05-26 |
| K-0222 | 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. | 1 | 2022-05-26 |
What the citations cover
- Smoke Deficiencies 10
- Services Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Egress Deficiencies 3
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Services Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Egress Deficiencies | 3 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 24, 2025 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (January 8, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (January 8, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (January 8, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (January 8, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (January 8, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 8, 2025) |
September 13, 2023 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 21, 2023) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (December 21, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (December 21, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 21, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (December 21, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (December 21, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (December 21, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 21, 2023) |
May 26, 2022 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0111 | Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Deficient, Provider has date of correction (September 1, 2022) |
| K-0222 | 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. | Deficient, Provider has date of correction (September 1, 2022) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (September 1, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (September 1, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 1, 2022) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (September 1, 2022) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (September 1, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 1, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.