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Health Inspection

College Pines Health And Rehabilitation

April 29, 2026 · Connelly Springs, NC · 95 Locust Street
Citations 2
CMS Rating 5/5
Beds 100
Provider ID 345446
Healthcare Facility
College Pines Health And Rehabilitation
Connelly Springs, NC  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

College Pines Health and Rehabilitation in Connelly Springs, NC — inspection on April 29, 2026.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0584
Resident Rights Deficiencies

Findings included:Observations of the window screen in room [ROOM NUMBER] on 04/27/2026 at 1:45 PM and 04/28/2026 at 11:32 AM revealed the window screen's metal frame was out of the track at the bottom of the window frame.

The unsecured screen would make it possible for flying insects to enter if the window was open. On 4/29/26 a walking tour of the outside of the facility was conducted with the Maintenance Director from 2:00 to 2:50 PM and revealed the following 18 window screens that needed repair:room [ROOM NUMBER] showed the window screen's metal frame was bent and out of the track.room [ROOM NUMBER] did not have a window screen in place.room [ROOM NUMBER] showed the window screen to have a tear approximately 2 inches by 3 inches.room [ROOM NUMBER] had a tear approximately 4 inches by 2inches in the bottom of the window screen.Rooms #206, #210, #302, and #416 revealed the window screen's metal frame was out of the metal track.room [ROOM NUMBER] revealed a tear approximately 4 inches by 3 inches in the window screen.room [ROOM NUMBER] showed the window screen's metal frame was out of the metal track and revealed a tear approximately 2 inches by 2 inches in the bottom of the screen.room [ROOM NUMBER] showed the window screen to have a tear approximately 3 inches by 3 inches.room [ROOM NUMBER] showed the window screen's metal frame was out of the track at the bottom of the window frame.room [ROOM NUMBER] showed the screen missing from the window. room [ROOM NUMBER] showed a tear approximately 1 inch by 7 inches in the window screen. room [ROOM NUMBER] revealed a tear approximately 1 inch by 3 inches in the window screen. room [ROOM NUMBER] had a tear approximately 3 inches by 6 inches in the window screen.room [ROOM NUMBER] revealed no window screen on the window.room [ROOM NUMBER] revealed a tear approximately 4 inches by 2 inches in the window screen. An interview with Resident #14 in room [ROOM NUMBER] on 4/29/26 at 1:25 PM indicated he had no concerns with the window screen and had not opened his window since his admission. An interview with the Maintenance Director on 4/29/26 at 2:30 PM revealed he had only been employed with the facility for about two and a half months and had not yet established a good monitoring program of the windows. He reported he was aware of only two window screens that needed replacement and they were both in his office awaiting the new screen for the frames. He indicated all staff members could put in a work order if they noticed something in the building that required his attention, but he had not received any work orders for screen repairs. An interview with the Administrator on 4/29/26 at 3:18 PM revealed she expected all staff to alert maintenance staff to any issue and to fill out work orders for the concern.

She reported that she was unaware there were that many screens that needed repairing.

She stated the previous Maintenance Director had done an assessment of the window screens in early fall of 2025 and had repaired any that were damaged at the time.

assessment accurately in the area of medications for 1 of 5 sampled residents (Resident #6).

The

type 2 diabetes mellitus with hyperglycemia (high blood sugar).A review of Resident #6's physician admission orders dated 02/16/26 revealed an order for Lantus Solostar U-100 insulin (long-acting insulin and hypoglycemic medication used to manage blood glucose levels) 100 units per milliliter.

Inject 10 units subcutaneously (under the skin) daily in the morning for diabetes.A review of Resident #6's February 2026 Medication Administration Record (MAR) revealed Resident #6 received insulin injections daily as ordered. Resident #6's quarterly Minimum Data Set (MDS) dated [DATE] was reviewed and did not indicate insulin injections or hypoglycemic medications had been received. An interview with the MDS Coordinator was conducted on 04/28/26 at 11:56 AM.

The MDS Coordinator confirmed she completed the 02/20/26 MDS for Resident #6.

The MDS Coordinator stated Resident #6 received insulin daily and the MDS assessment should have included both insulin injections and the use of hypoglycemic medication.

She stated the insulin injections and hypoglycemic medication had been overlooked and the MDS had been coded incorrectly.An interview with the Corporate MDS Coordinator was conducted on 04/28/26 at 11:44 AM.

The Corporate MDS Coordinator stated that all MDS assessments should be coded correctly for relevant medications.An interview conducted with the Director of Nursing on 04/29/26 at 2:35 PM revealed Resident #6 had received daily insulin injections and the MDS should be coded correctly for relevant medications.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

345446 04/29/2026

College Pines Health and Rehabilitation 95 Locust Street Connelly Springs, NC 28612

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Connelly Springs, NC, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from College Pines Health and Rehabilitation or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.