ST JOSEPH OF THE PINES HEALTH CENTER

Nursing Home Inspector

103 GOSSMAN DRIVE
PINEHURST, NC 28374
Moore County
Phone: 910-246-1000
Provider Number: 345044
Last Inspection: 05/25/2017

About the Nursing Home

Number of Beds: 176
Number of Residents: 150
Beds Available: 26
Percent Occupancy: 85%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: Non profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

23

Facility
34

County
14

NC
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

23

2017
18

2016
7

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

5/25/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 6/21/2017
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Pattern : Minimal 4 6/22/2017
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 6/22/2017
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 6/22/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 6/22/2017
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 6/22/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Isolated : Minimal 3 6/22/2017
 

6/3/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 8/23/2016
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Isolated : Minimal 3 6/27/2016
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 6/27/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 6/27/2016
 
Failed To: Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. Isolated : Minimal 3 6/27/2016
 
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Isolated : Minimal 3 6/6/2016
 

8/19/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 9/3/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 9/3/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

2/21/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 3/13/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 3/13/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 3/13/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Isolated : Minimal 3 3/13/2017
 

1/20/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 2/21/2017
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NC State Avg
Number of Residents 150 87.29 84.96
Registered Nurses 0.50 0.55 0.72
Licensed Practical / Vocational Nurses 0.97 0.92 0.87
Certified Nursing Assistants 2.30 2.45 2.33
Total Staff Hours 3.77 3.92 3.91

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NC State Avg%
of high risk long-stay residents with pressure ulcers 3 7 7
of long-stay residents assessed and appropriately given the pneumococcal vaccine 98 97 93
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100 95 93
of long-stay residents experiencing one or more falls with major injury 4 3 3
of long-stay residents who have depressive symptoms 0 0 2
of long-stay residents who lose too much weight 18 11 8
of long-stay residents who received an antianxiety or hypnotic medication 30 29 29
of long-stay residents who received an antipsychotic medication 8 11 13
of long-stay residents who self-report moderate to severe pain 3 3 6
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 29 28 23
of long-stay residents whose need for help with daily activities has increased 30 26 18
of long-stay residents with a catheter inserted and left in their bladder 0 2 1
of long-stay residents with a urinary tract infection 1 3 4
of low risk long-stay residents who lose control of their bowels or bladder 65 53 55
of short-stay residents assessed and appropriately given the pneumococcal vaccine 99 91 83
of short-stay residents who had an outpatient emergency department visit 6 14 13
of short-stay residents who made improvements in function 62 67 64
of short-stay residents who newly received an antipsychotic medication 0 2 1
of short-stay residents who self-report moderate to severe pain 11 9 14
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 98 84 81
of short-stay residents who were rehospitalized after a nursing home admission 15 22 20
of short-stay residents who were successfully discharged to the community 76 56 55
of short-stay residents with pressure ulcers that are new or worsened 1 0 0