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

Staffing

Hours and turnover

RN hours / resident day

0.87

Registered nurse staffing

LPN hours / resident day

1.03

Licensed practical nurse staffing

Aide hours / resident day

2.56

Nurse aide staffing

Weekend hours

4.00

Weekend nurse staffing

RN turnover

33%

Annual RN turnover

Total nurse turnover

35%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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