College Pines Health and Rehab: MDS Coding Failure - NC
That is what inspectors found when they reviewed records at College Pines Health and Rehabilitation on 95 Locust Street during an April 2026 survey.
The resident, identified in inspection records only as Resident 6, was admitted to the facility in early 2026 with a diagnosis of type 2 diabetes with hyperglycemia. A physician order dated February 16, 2026 directed staff to inject 10 units of Lantus Solostar, a long-acting insulin, subcutaneously each morning. The facility's own Medication Administration Record for February confirmed the injections were given daily, as ordered.
The quarterly Minimum Data Set assessment completed on February 20, 2026 told a different story. It showed no insulin injections. It showed no hypoglycemic medications. The section that should have captured both was left uncoded.
The Minimum Data Set, known in the industry as the MDS, is the standardized federal assessment that nursing homes complete for every resident on a regular schedule. It drives care planning, staffing calculations, and Medicare reimbursement. When it is wrong, the consequences can ripple outward in ways that are not always visible from the outside.
The MDS Coordinator who completed the February 20 assessment acknowledged the error directly when inspectors interviewed her on April 28. She confirmed she had completed the assessment for Resident 6. She confirmed the resident was receiving insulin daily. She said both the insulin injections and the hypoglycemic medication classification should have been included. Then she said they had been overlooked.
"Overlooked" was the word she used.
A Corporate MDS Coordinator, also interviewed on April 28, said all assessments should be coded correctly for relevant medications. The Director of Nursing, interviewed the following day, confirmed the resident had received daily insulin injections and agreed the MDS should have reflected that.
Three people, all with direct knowledge of what the resident was receiving, confirmed the same thing: the record was wrong, and it had been wrong since February.
Inspectors cited the deficiency under federal standards governing the accuracy of resident assessments, noting the level of harm as minimal. One resident was affected.
What the inspection report does not describe is whether anyone caught the error before inspectors arrived, or whether it was corrected in the months between the February assessment and the April survey. The MDS Coordinator said the medications had been overlooked. Nobody in the report said when they noticed.
For a diabetic resident managing blood sugar with daily insulin, an accurate medication record is not an abstraction. Insulin dosing, hypoglycemia risk, interactions with other medications, care plan adjustments when blood sugar climbs or drops — all of it depends on the underlying record being correct. A record that omits insulin entirely is a record that cannot be trusted to support the care decisions built on top of it.
College Pines Health and Rehabilitation is a nursing and rehabilitation facility in Burke County, a rural stretch of western North Carolina about an hour east of Asheville. The April 29 inspection was a standard health survey.
The inspection report does not indicate whether the facility had filed a corrected assessment for Resident 6 by the time the survey concluded. It does not say how long the error went undetected internally, or whether anyone other than the MDS Coordinator reviewed the completed assessment before it was submitted.
Resident 6 was still receiving insulin every morning. The record, for a time, said otherwise.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for College Pines Health and Rehabilitation from 2026-04-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 7, 2026 · Our methodology
College Pines Health and Rehabilitation in Connelly Springs, NC was cited for violations during a health inspection on April 29, 2026.
That is what inspectors found when they reviewed records at College Pines Health and Rehabilitation on 95 Locust Street during an April 2026 survey.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.