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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
7D
4E
0F
Potential for minimal harm
0A
0B
5C
March 31, 2026Complaint inspection · 1 citation
- 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, and staff interview, it was determined that the facility failed to immediately report and investigate a resident's allegation, in response to allegations of abuse, neglect, exploitation, or mistreatment for one of eight residents (Resident R1). This was identified as past non-compliance.
December 2, 2025Standard inspection, Complaint inspection · 11 citations
- E
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, observations, and resident and staff interviews, it was determined that the facility failed to make accessible grievance boxes to residents on three of three locations, nursing units (Dogwood, Pinewood, and Specialty Care).
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of facility policy, documents, clinical record review, resident, and staff interviews, it was determined that the facility failed to make certain that necessary care and services were provided for thirteen of twenty-four residents (Resident R1, R6, R34, R50, R60, R123, R500, R501, R502, R503, R505, R506, and R507).
- E
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 medical supplies and medications were properly stored and/or disposed of in two of three medication rooms (Secure Care Unit and Dogwood Unit).
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of facility policies and documents, clinical record review, and staff interviews, it was determined that the facility failed to protect residents from neglect that resulted in the actual harm of a skin tear that required 17 sutures for one of three residents (Resident R3).
- D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on review of facility policy, documents clinical record and staff interviews, it was determined that the facility failed to make certain a resident was free from the use of physical restraints without a physical restraint order for one of eight residents reviewed (Resident R7).
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on clinical record review, facility policy, and staff interview, it was determined that the facility failed to ensure that resident's medication regime was free from unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medication for one of eight residents (Resident R7).
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of facility policies and documents, clinical record review, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a skin tear that required 17 sutures for one of three residents (Resident R3). This was identified as past non-compliance.
- C
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Inspectors wroteBased on observations and a staff interview, it was determined the facility failed to post information for Adult Protective Services (APS) as required in the building.
- C
Provide information about how to apply for and use Medicare and Medicaid benefits.
Inspectors wroteBased on observations and a staff interview, it was determined that the facility failed to display (for residents and/or their responsible person) written information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, in the building.
- C
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to revise/update care plans for two of eighteen residents to accurately reflect the current status of the resident (Resident R7 and R32).
- C
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Inspectors wroteBased on review of facility documents, personnel in-service training records, and staff interview, it was determined that the facility failed to provide documented training on the Quality Assurance and Performance Improvement (QAPI) Program for facility staff.
October 4, 2024Standard inspection · 2 citations
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for four of nine residents reviewed (Resident 40, R42, R61, and R63).
- C
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on a review of facility documents, information from the State Ombudsman Office and staff interviews it was determined that the facility failed to notify the State Ombudsman Office of resident transfers and discharges for four plus years ( 9/19 through 12/19. 1/20 through 12/20, 1/21 through 12/21, 1/22 through 12/22, 1/23 through 12/23 and 1/24 through 9/24) as required.
October 12, 2023Standard inspection · 2 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on review of facility policies, review of Centers for Disease Control (CDC) guidelines for Legionella (bacterium that causes Legionnaires Disease found in pipes and heating systems) Control, the facility's infection control tracking logs for water management and staff interviews, it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella within the facility.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of facility policy, clinical records, facility investigation reports, a progress note and staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards for residents who were at risk for falls for one of eight residents (Residents R58).
Fire safety inspections
10 fire safety citations on file: 4 on October 4, 2024, 4 on October 12, 2023, 2 on December 1, 2022.
Every fire safety citation10 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 4, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 4, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · October 4, 2024 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 4, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 12, 2023 · Corrected (the home has a date of correction)
- E
Meet requirements for the installation and maintenance of electrical systems.
K 911 · October 12, 2023 · Corrected (the home has a date of correction)
- C
Conduct testing and exercise requirements.
E 39 · October 12, 2023 · Corrected (the home has a date of correction)
- C
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 12, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 1, 2022 · Corrected (the home has a date of correction)
- C
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · December 1, 2022 · Corrected (the home has a date of correction)