Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 32 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
17D
9E
4F
Potential for minimal harm
0A
1B
0C
August 6, 2026Standard inspection · 12 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent resident elopement that created an immediate jeopardy situation for one of fourteen residents that were identified as at risk for elopement and did not reside on a secured unit (Resident R84). Findings Include: Review of the facility policy, Wandering and Elopements dated 3/1/26, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Review of the clinical record revealed Resident R84 was admitted to the facility on [DATE]. [...]
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on review of facility policies, observations, and staff interview, it determined the facility failed to maintain sanitary conditions in the Main Kitchen, which created the potential for cross contamination and food borne illness.
- E
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, and resident and staff interviews, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for seven of twelve residents (Resident R19, R21, R22, R51, R58, R93, and R118).
- E
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on facility policy and clinical record review and staff interview, it was determined that the facility failed to complete a restorative nursing program for four of seven residents reviewed for ADLs (activities of daily living) concerns (Residents R23, R26, R91, and R99).
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of facility policy, clinical record review, resident observations, and staff interviews, it was determined that the facility failed to make certain that necessary care and services were provided for four of six residents (Resident R3, R62, R124, and R128).
- E
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Inspectors wroteBased on a review of facility policy, employment records and staff interviews, it was determined that the facility failed to maintain documentation that facility nursing personnel have current education and certification to provide basic life support, including CPR (cardiopulmonary resuscitation), to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 14 of 41 licensed nurses (Registered Nurse (RN) Employees E3, E4, E5, E6, and E7 and Licensed Practical Nurse (LPN) Employees E8, E9, E10, E11, E12, E13, E14, E15, and E16). Findings Include: [...]
- E
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain a monthly weight for one of six residents (Resident R6) and failed to identify and reassess residents for need for nutritional interventions for weight loss and/or skin issues for two of six residents. (Resident R97 and R9).
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on clinical record review and observation, it was determined that the facility failed to provide care and services to maintain a resident's dignity for one of 11 sampled residents. (Resident R23)
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on the review of facility policy and facility documents, observations and resident and staff interviews, it was determined that the facility failed to make certain grievance forms can be filed anonymously in one of four locations where grievance information is available. (Willow Unit).
- D
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed effectively manage the facility to protect residents from elopement. This failure resulted in a resident, who was a known elopement risk, exiting the resident's assigned nursing unit unsupervised (Resident R1). This failure created an Immediate Jeopardy situation for one of fourteen residents who were documented as elopement risks (Resident R1).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on review of facility documents, clinical records, and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for one of eight residents (Resident R84).
- B
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for four of eight residents reviewed for hospitalization (Resident R9, R58, R62, and R98). Findings Include: Review of federal regulation S483.15(d) Notice of Bed-Hold Policy, indicated, facilities must provide written information about these policies to residents prior to and upon transfer for such absences. This information must be provided to all facility residents, regardless of their payment source. These provisions require facilities to issue two notices related to bed-hold policies. The first notice could be given well in advance of any transfer, i.e., information provided in the admission packet. [...]
January 21, 2026Complaint inspection · 1 citation
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on a review of facility policy, observations, and staff interview, it was determined that the facility failed to make sure that medications were properly stored and/or disposed of in one of four medication rooms (Hickory Unit).
June 26, 2025Standard inspection · 10 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on review of facility policies, observations and staff interview, it determined the facility failed to maintain sanitary conditions to prevent the potential for cross contamination during lunch time tray line.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of the facility policy, observations, clinical record review, review of facility document and staff interviews, it was determined that the facility failed to provide an environment free from potential accident hazards due to uncovered electrical plugs, accessible potential hazardous materials, foods and sharps that had potential to cause injury and actual removal of a elopement bracelet for one resident (Resident R225) on one of four nursing units( Memory Care Unit).
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to report an allegation of neglect to the State Agency for one of four residents (Resident R325).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on review of facility clinical records, observations and staff interview, it was determined that the facility failed to make certain that resident assessments were accurate for one of five residents (Resident R71).
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for one of three residents (Resident R57).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels for three of nine residents reviewed (Residents R58, R64, and R111).
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on review of facility policies, observations, clinical records, and staff interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of an indwelling urinary catheter as required for two of four residents (Resident R51 and R331).
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure the pharmacy completed a Medication Regime Review (MRR) at least monthly for one of five residents (Resident R58).
- D
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Inspectors wroteBased on a review of facility documents and interviews with staff it was determined that the facility failed to provide the State Agency with access to facility information, causing a delay in the survey process.
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on a review of select facility policies and procedures, current Centers for Disease Control (CDC) guidelines, clinical record review, and staff interview, it was determined that the facility failed to document each resident was offered an influenza and/or pneumococcal immunization and the resident or resident's representative was provided education regarding the benefits and potential side effects of immunizations, for one of five residents reviewed for influenza and pneumococcal immunizations (Resident R53).
June 3, 2025Complaint inspection · 1 citation
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on review of facility policies, clinical records and staff interviews, it was determined that the facility failed to make certain medical records on each resident are complete and accurately documented for one of ten residents. (Resident R1).
July 17, 2024Standard inspection, Complaint inspection · 7 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility policies, facility infection control documentation, observations, and staff interviews, it was determined that the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility for 11 of 11 months. (September 2023 through July 2024).
- F
Implement a program that monitors antibiotic use.
Inspectors wroteBased on a review of the facility's antibiotic stewardship policy, infection control documentation and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program to include a system to monitor antibiotic use and conduct ongoing review of the treatment of infections (September 2023 through July 2024).
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of facility policy, clinical records, and resident and staff interviews, it was determined that the facility failed to make certain that showers were consistently provided for four of eight residents (Resident R7, R91, R110 and R111).
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose) and failed to follow physician orders for 3 of 6 residents receiving insulin (Residents R93, R7, and R58).
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations and staff interview it was determined that the facility failed to maintain an environment free of potential accident hazards on the secured Dementia nursing unit (Willow).
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on review of facility policy and clinical record, and staff interview, it was determined that the facility failed to make certain significant medications are administered as ordered by the physician for one of three residents (Resident R155).
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on review of facility policy, observation, and staff interviews, it was determined that the facility failed to properly secure one of four medications carts reviewed (Hickory Nursing Units back hall medication cart).
November 13, 2023Complaint inspection · 1 citation
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on review of facility policy, resident grievances for prior 60 days and resident and staff interviews, it was determined that the facility failed to effectively resolve and provide responses to residents and/or their responsible parties in a timely manner in relation to concerns documented via Grievance procedure and complete the reports in their entirety for four of nine grievances.
Fire safety inspections
19 fire safety citations on file: 7 on August 6, 2026, 6 on June 26, 2025, 6 on July 17, 2024.
Every fire safety citation19 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 6, 2026 · deficient, provider has
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · August 6, 2026 · deficient, provider has
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · August 6, 2026 · deficient, provider has
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · August 6, 2026 · deficient, provider has
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 6, 2026 · deficient, provider has
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · August 6, 2026 · deficient, provider has
- D
Have proper medical gas storage and administration areas.
K 923 · August 6, 2026 · deficient, provider has
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 26, 2025 · deficient, provider has
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · June 26, 2025 · deficient, provider has
- D
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · June 26, 2025 · deficient, provider has
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · June 26, 2025 · deficient, provider has
- D
Install corridor and hallway doors that block smoke.
K 363 · June 26, 2025 · deficient, provider has
- D
Ensure proper usage of power strips and extension cords.
K 920 · June 26, 2025 · deficient, provider has
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 17, 2024 · Corrected (the home has a date of correction)
- E
Meet requirements for sections of health care facilities separated by fire resistive construction.
K 131 · July 17, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 17, 2024 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · July 17, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · July 17, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · July 17, 2024 · Corrected (the home has a date of correction)