Sunrise at Pinehurst

A relicensure survey with complaints #CO40625, #CO41505, and #CO41552 was completed on 2/18/26. Deficiencies were cited. Based on observations and interviews, the residence failed to have a locked medication cart to store medications when unattended by qualified medication administration persons (QMAP) or other licensed staff, affecting 13 current residents residing in a secured environment. (Cross-reference U1542)Findings include:1. ObservationsOn 2/17/26 at 9:10 a.m., a medication cart, located in a secured environment, was observed unlocked and unattended while residents wandered the halls. Residence staff were not observed near the medication cart.On 2/18/26 at approximat.. Based on record review and interview, the residence failed to ensure the qualified medication administration person (QMAP) supervisor conducted a competency assessment with direct observation of all medication administration tasks that the QMAP will be assigned to perform, before the initial assignment for four of eight sample staff (#1, #4, #5, #8) who were scheduled as QMAPs for 17 of 31 days in January 2026, affecting 60 current residents. (Cross-reference U1568 and U1632)Findings Include:1. Residence PolicyAn undated residence Medication Administration/Assistance Tr.. Based on record review and interview, the residence failed to ensure there was at least one staff member on-site at all times with current cardiopulmonary resuscitation (CPR) and obstructed airway techniques certification from a nationally recognized organization, affecting 60 current residents.Findings include:The residence' s February 2026 schedule revealed the following shifts did not have at least one staff member onsite who had current CPR certification and obstructed airway techniques from a nationally recognized organization: 2/6-2/7, 2/12, 2/19-2/20, and 2/22/26.. Based on record review and interview, the residence failed to ensure there was at least one staff member on-site at all times with current certification in first aid from a nationally recognized organization, affecting 60 current residents.Findings include:Review of the residence' s February 2026 schedule revealed the following shifts did not have at least one staff member onsite who had current certification in first aid from a nationally recognized organization: 2/6-2/7, 2/12, 2/19-2/20, and 2/26/26. On 2/18/26 at approximately 10:58 a.m., the resident care coordinator ack.. Based on record review and interviews, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting two of eight sample residents (#3, #6), and one former resident (#8). (Cross-reference U1542)Specifically, the residence failed to comply with authorized practitioner orders to administer Torsemide, a diuretic. The residence was directed to administer Torsemide 40 mg every morning to Former Resident #8; however, the January 2026 medication administration record (MAR) revealed that the residence failed to adminis.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised that it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record(MAR) which contains the name and date of birth of the resident, the resident ' s room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner.(..

A revisit survey was completed on 8/15/23 for all previous deficiencies cited on 1/13/23. The agency is in compliance with all regulations surveyed. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

9999THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 2.2.10.5 The licensee shall provide, upon request, access to or copies of the following to the Department for the performance of its regulatory oversight responsibilities: (A) Individual client records. (B) Reports and information required by the Department including but not limited to, staffing reports, census data, statistical information, and other records, as determined by the Department. A relicensure survey was completed on 1/13/23. Deficiencies were cited. A change of ownership occurred on 1/16/2020. Based on observation and interview, the residence failed to ensure rooms occupied by smokers had fire resistant wastebaskets, affecting two of two residents who smoked cigarettes (#4, #5).Findings include: On 1/13/23 at approximately 4:00 p.m., an environmental tour of resident #4 and #5' s rooms revealed the waste baskets in the residents' rooms were not fire resistant. Both of these room had a small white plastic wastebasket.On 1/13/23 at 4:00 p.m., Resident #4 stated he was aware of the smoking area and stated he only smoked in the designated location. On 1/13/23 at approximately 4:20 p.m., Resident #5 stated she only smoked outdoors in the designated smoking area. On 1/13/23 at approximately 5:00 p.m., the resident care director confirmed Resident #4 and #5 smoked. The resident .. Based on observation, record review, and interview, the residence failed to ensure a list of all staff who had current certification in first aid and/or cardiopulmonary resuscitation (CPR) was placed in a visible location, affecting 54 current residents. Findings include:1. ObservationOn 1/13/23, during the onsite visit, a list of staff members that were certified in first aid and CPR was not posted in a visible location within the building.2. Record ReviewReview of staffs' personnel files revealed Staff #1-#3 were certified in CPR and first aid on 4/28/22, 1/4/23, and 4/27/21 respectively.3. InterviewOn 1/13/23 at 12:30 p.m., the resident care director confirmed that a list of first aid/CPR certified staff was not posted anywhere in the residence. The resident care director stated that she was unaware tha.. Based on record review and interview, the residence failed to ensure the resident roster contained a residence diagram that showed room locations, affecting 54 residents.Findings include:On 1/13/23 at approximately 9:00 a.m., the resident care director was asked to provide a copy of the current resident roster. On 1/13/23 at approximately 11:00 a.m., the resident care director provided an updated resident roster and an emergency contact list.On 1/13/23 at approximately 11:00 a.m., the resident care director stated that she had provided the current resident roster. She stated the residence did not have a diagram that showed room locations. The resident care director stated she was unaware the roster was required to contain a residence diagram.