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 14 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
8D
2E
0F
Potential for minimal harm
0A
1B
0C
June 12, 2026Standard inspection · 2 citations
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to assess the ability of a resident to self-administer medications kept at bedside for 1 of 3 resident reviewed for self-administration (Resident #46).
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and staff interviews, the facility failed to submit a Level II Preadmission Screening and Resident Review (PASRR) evaluation request to North Carolina Medicaid Uniform Screening Tool (NC MUST-an internet-based application utilized to communicate and manage PASRR requests) for a resident diagnosed with a serious mental illness. This deficient practice affected 1 of 3 residents reviewed for coordination of PASRR assessments (Resident #10).
April 23, 2026Complaint inspection · 3 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and interviews with staff, the facility failed to protect a resident's right to be free from staff to resident physical abuse when Nurse Aide #2 hit a severely cognitive impaired resident with an open hand three times during care. Resident #1 did not have the cognitive capacity to express an adverse psychosocial outcome. A reasonable person would have experienced feelings such as fear, anxiety, helplessness, and dehumanization from being abused by their caregiver. This deficient practice affected 1 of 3 residents reviewed for abuse (Resident #1).
- G
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on record review and interviews with staff, the facility failed to protect the resident's right to be free from physical restraints when Nurse Aide #2 was witnessed by another staff member (Nurse Aide #1) to hold Resident #1's hands down against her chest to restrict her arm movements during care when the resident became combative. Resident #1 did not have the cognitive capacity to express an adverse psychosocial outcome. A reasonable person would have experienced feelings such as panic, distress, anger, and fear from being physically restrained by their caregiver. This deficient practice affected 1 of 1 resident reviewed for physical restraints (Resident #1).
- G
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review and interviews with staff, the facility failed to implement their policy and procedure in the areas of protection, prevention and reporting abuse for 1 of 3 residents reviewed for abuse (Resident #1). NA # 2 witnessed NA # 1 strike a cognitively impaired resident (Resident #1) and did not effectively intervene or immediately report to nursing or administration; this resulted in NA # 2 striking the resident two more times. A reasonable person would expect a witness to remove a cognitively impaired, vulnerable resident from an abusive situation and protect them from further abuse. A reasonable person would feel very dehumanized and helpless from repeated physical abuse.
May 7, 2025Standard inspection, Complaint inspection · 4 citations
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on record review, Responsible Party, Medical Director, and staff interviews, the facility failed to ensure a safe and orderly discharge when the facility failed to remove a midline catheter (a long peripheral intravenous catheter, typically 6-15 centimeters in length, that is inserted into a large vein in the upper arm or forearm) before discharging a resident home for 1 of 3 residents reviewed for discharge (Resident #229).
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and staff interviews the facility failed to complete a Preadmission Screening and Resident Review (PASRR) level II for a resident with a level II PASRR that expired prior to admission to the facility. This deficient practice occurred for 1 of 2 residents reviewed for PASRR (Resident #43).
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on record review, resident and staff interviews, the facility failed to provide a bagged meal or snack for 1 of 1 resident reviewed for dialysis (Resident #83).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to follow their Hand Hygiene policy when the Treatment Nurse did not perform hand hygiene before each donning of clean gloves while providing wound care to Resident #53. This deficient practice occurred for 1 of 4 staff members observed for infection control practices (Treatment Nurse).
October 2, 2024Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to implement their policy for Enhanced Barrier Precautions (EBP) when the Wound Nurse failed to don a gown before entering residents' room to provide care for Resident #1 who was under transmission-based precautions. The deficient practice occurred for 1 of 2 staff members observed for infection control practices.
January 25, 2024Standard inspection · 4 citations
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on record reviews and staff interviews, the facility failed to remove expired food items, date open and perishable foods stored in 1 of 1 reach-in cooler and 1 of 1 walk-in freezer and ensure steamer pans were not stacked wet for 1 of 2 kitchen observations. These practices had the potential to affect food served to residents.
- E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on observations, staff interviews and record review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented and effective procedures and monitor the interventions that the committee put into place following a recertification and complaint investigation dated 6/09/22 for one deficiency in the area of dietary services F 812. Also, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented and effective procedures and monitor the interventions that the committee put into place following the complaint survey date 4/10/23 for one deficiency in the area of accurate medical records F 842. These deficiencies were cited during a recertification and complaint survey dated 1/25/24. [...]
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observations, a resident interview, staff interviews and record review, the facility failed to honor food preferences for 1 of 3 sampled residents reviewed for food preferences (Resident #281).
- B
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on a resident interview, staff interviews and record review, the facility failed to accurately document an allergy (Resident #281) and the amount of nutritional supplement provided during medication administration (Resident #2). This failure occurred for 2 of 2 sampled residents reviewed for accuracy of the medical record.
Fire safety inspections
6 fire safety citations on file: 2 on June 12, 2026, 2 on May 7, 2025, 2 on January 25, 2024.
Every fire safety citation6 citations
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 12, 2026 · Not yet corrected
- D
Have proper medical gas storage and administration areas.
K 923 · June 12, 2026 · Not yet corrected
- D
Use approved construction type or materials.
K 161 · May 7, 2025 · Corrected (the home has a date of correction)
- D
Have an alternate power supply for its alarm system.
K 344 · May 7, 2025 · Corrected (the home has a date of correction)
- 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 · January 25, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · January 25, 2024 · Corrected (the home has a date of correction)