Pinehurst, NC

Saint Joseph of the Pines Health Center

5-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

103 Gossman Road, Pinehurst, NC

(910) 246-1000

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

176

Certified beds

Average residents

66

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Trinity Health

Operator or chain grouping

Approved since

1968-01-29

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

20 facilities

Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.87

Registered nurse staffing · state 0.59 · national 0.68

LPN hours / resident day

1.03

Licensed practical nurse staffing · state 0.87 · national 0.87

Aide hours / resident day

2.56

Nurse aide staffing · state 2.33 · national 2.35

Total nurse hours

4.46

All reported nurse hours · state 3.78 · national 3.89

Licensed hours

1.90

RN + LPN hours · state 1.45 · national 1.54

Weekend hours

4.00

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.49

Weekend registered nurse coverage · state 0.38 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.96

CMS adjusted RN staffing hours

Adjusted total hours

4.92

CMS adjusted total nurse staffing hours

Case-mix index

1.24

Higher values indicate more complex resident acuity

RN turnover

33%

Annual RN turnover · state 48% · national 45%

Total nurse turnover

35%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

3,437

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

44.33

Composite VBP score used to determine payment impact.

Payment multiplier

0.9974

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

6.45

Baseline 20.07% · Performance 18.44% · Measure score 6.45 · Achievement 6.45 · Improvement 4.85

Healthcare-associated infections

2.14

Baseline 7.41% · Performance 7.19% · Measure score 2.14 · Achievement 2.14 · Improvement 0.40

Total nurse turnover

5.85

Baseline 42.65% · Performance 39.76% · Measure score 5.85 · Achievement 5.85 · Improvement 1.12

Adjusted total nurse staffing

3.29

Baseline 4.21 hours · Performance 4.01 hours · Measure score 3.29 · Achievement 3.29 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.33%	10.72% 0.6 pts worse	No Different than the National Rate · Eligible stays 385 · Observed rate 10.13% · Lower 95% interval 8.79%
Discharge to community	67.17%	50.57% 16.6 pts better	Better than the National Rate · Eligible stays 401 · Observed rate 62.84% · Lower 95% interval 61.39%
Medicare spending per beneficiary	0.86	1.02 0.2 pts better
Drug regimen review with follow-up	99.63%	95.27% 4.4 pts better	Numerator 268 · Denominator 269
Falls with major injury	0.37%	0.77% 0.4 pts better	Numerator 1 · Denominator 269
Discharge self-care score	44.5%	53.69% 9.2 pts worse	Numerator 97 · Denominator 218
Discharge mobility score	35.78%	50.94% 15.2 pts worse	Numerator 78 · Denominator 218
Pressure ulcers or injuries, new or worsened	2.23%	2.29% 0.1 pts better	Numerator 6 · Denominator 269 · Adjusted rate 2.53%
Healthcare-associated infections requiring hospitalization	7.19%	7.12% 0.1 pts worse	No Different than the National Rate · Eligible stays 239 · Observed rate 5.86% · Lower 95% interval 4.55%
Staff COVID-19 vaccination coverage	6.45%	8.2% 1.7 pts worse	Numerator 8 · Denominator 124
Staff flu vaccination coverage	18.42%	42% 23.6 pts worse	Numerator 28 · Denominator 152
Discharge function score	39.91%	56.45% 16.5 pts worse	Numerator 87 · Denominator 218
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 220 · Denominator 220
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 27 · Denominator 27
Resident COVID-19 vaccinations up to date	18.75%	25.2% 6.4 pts worse	Numerator 27 · Denominator 144

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.0	1.8 0.8 pts better	1.9 0.9 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.7 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.1	1.8 0.7 pts better	1.8 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.4%	91.5% 7.9 pts better	93.4% 6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.6% · 4Q avg 99.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	94.1% 5.9 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	1.9%	3.6% 1.7 pts better	3.3% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	4.8% 4.8 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	11.9%	7.2% 4.7 pts worse	5.4% 6.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 13.3% · Q3 6.2% · Q4 17.1% · 4Q avg 11.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	16.5%	21.6% 5.1 pts better	19.6% 3.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 16.7% · Q3 12.5% · Q4 17.1% · 4Q avg 16.5%
Percentage of long-stay residents who received an antipsychotic medication	8.0%	15.0% 7 pts better	16.7% 8.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 11.5% · Q3 10.0% · Q4 6.5% · 4Q avg 8.0% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose need for help with daily activities has increased	8.5%	16.8% 8.3 pts better	14.9% 6.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 17.9% · Q3 10.3% · Q4 3.0% · 4Q avg 8.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	0.9% 0.5 pts better	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.6%	2.6% About the same	1.7% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 7.3% · 4Q avg 2.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	30.0%	21.2% 8.8 pts worse	19.8% 10.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 34.1% · Q3 30.6% · Q4 32.5% · 4Q avg 30.0%
Percentage of long-stay residents with pressure ulcers	2.9%	6.0% 3.1 pts better	5.1% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.7% · Q3 5.4% · Q4 2.0% · 4Q avg 2.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	98.5%	79.9% 18.6 pts better	81.7% 16.8 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.7% · Q3 97.6% · Q4 96.3% · 4Q avg 98.5%
Percentage of short-stay residents who had an outpatient emergency department visit	15.9%	13.2% 2.7 pts worse	12.0% 3.9 pts worse	Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 13.7% · Expected 9.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.3%	1.5% 1.2 pts better	1.6% 1.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.6% · Q4 0.7% · 4Q avg 0.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	98.6%	78.1% 20.5 pts better	79.7% 18.9 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 98.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.1%	22.9% 0.2 pts worse	23.9% 0.8 pts better	Short Stay · 20240701-20250630 · Adjusted 23.1% · Observed 18.1% · Expected 18.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-31 · Fire 2024-07-11

2 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2024-07-11 · Fire 2023-04-05

3 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

8 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Cycle 3 Health 2023-04-05 · Fire 2021-07-14

2 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2024-07-11

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-07-11

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-07-11

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-07-11

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-07-11

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2024-10-18

F · Potential for more than minimal harm 2023-04-05

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-08-18

F · Potential for more than minimal harm 2023-04-05

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-08-18

E · Potential for more than minimal harm 2023-04-05

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-08-18

D · Potential for more than minimal harm 2023-04-05

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2023-08-18

D · Potential for more than minimal harm 2023-04-05

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-08-18

D · Potential for more than minimal harm 2023-04-05

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-08-18

D · Potential for more than minimal harm 2023-04-05

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-08-18

D · Potential for more than minimal harm 2023-04-05

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-08-18

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-07-31

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2025-08-08

B · Minimal harm 2025-07-31

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2025-08-08

E · Potential for more than minimal harm 2024-07-11

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-08-02

D · Potential for more than minimal harm 2024-07-11

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2024-08-02

C · Minimal harm 2024-07-11

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-08-02

D · Potential for more than minimal harm 2023-04-05

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2023-04-28

D · Potential for more than minimal harm 2023-04-05

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2023-04-28

Penalties and ownership

What sits behind the stars

Ownership

Trinity Continuing Care Services

5% Or Greater Direct Ownership Interest · Organization

100% 11 facilities 2013-05-01

Buist, Timothy

Operational/Managerial Control · Individual

0% 1 facilities 2019-04-29

Canfield, Brian