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
0G
0H
0I
Potential for more than minimal harm
13D
0E
0F
Potential for minimal harm
0A
0B
1C
July 31, 2026Standard inspection · 1 citation
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on review of clinical records and Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview, it was determined that the facility failed to ensure that the MDS assessments accurately reflected the status for one of 19 residents reviewed (Resident R67).
July 2, 2025Standard inspection · 8 citations
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on review of facility policy and clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that the resident was offered the opportunity to participate in the development, review, and/or revision of their person-centered care plan for one of 18 residents reviewed (Resident R6).
- 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 and clinical records, and staff interview, it was determined that the facility failed to ensure physician's orders and resident Resuscitation Authorization (a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent for one of 18 residents reviewed (Resident R18).
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to notify the resident and the resident's representative, in writing regarding the reason for transfer to the hospital and to ensure that a bed-hold notice was provided to the resident's responsible party for three of 18 residents reviewed (Residents R24, R37, and R40) and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for two of 18 residents reviewed (Residents R24 and R40).
- 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 review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 18 residents reviewed (Resident R7).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to obtain a physician's order for hospice services for one of two hospice residents reviewed (Resident R58).
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days and failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN psychotropic medication for one of three residents reviewed (Resident R58).
- 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 policies, observations, and staff interviews it was determined that the facility failed to appropriately discard outdated medications for one of three medication carts reviewed and one of two medication rooms reviewed (Avonia Springs medication room and medication cart).
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to ensure that the most recent Department of Health Survey results were in a place readily accessible to residents and visitors for five of five neighborhoods (Eagle Ridge, [NAME], Avonia Springs, Blue [NAME], and Sandpiper).
August 8, 2024Standard inspection · 5 citations
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop a baseline care plan for one of 19 residents (Resident R65) and failed to provide a resident and his/her representative with a summary of the baseline care plan for one of 19 residents (Resident R175).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one of seven residents observed for medication administration (Resident R227).
- 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 and clinical records, and staff interview, it was determined the facility failed to ensure recommendations made from the consultant pharmacist were acted upon for one of five residents reviewed for unnecessary medications (Resident R36).
- 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 upon observation and staff interview, it was determined that the facility failed to ensure that medications subject to abuse were stored in a separately locked, permanently affixed compartment in one of five medication refrigerators (Blue [NAME]).
- D
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 policy, observations, and staff interview, it was determined that the facility failed to maintain sanitary food service operations for one of six kitchens (Blue [NAME] kitchen).
Fire safety inspections
6 fire safety citations on file: 2 on July 31, 2026, 2 on July 2, 2025, 2 on August 8, 2024.
Every fire safety citation6 citations
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 31, 2026 · deficient, provider has
- E
Have proper medical gas storage and administration areas.
K 923 · July 31, 2026 · deficient, provider has
- C
Provide properly protected cooking facilities.
K 324 · July 2, 2025 · Corrected (the home has a date of correction)
- B
Have power receptacles that are properly grounded.
K 912 · July 2, 2025 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · August 8, 2024 · Corrected (the home has a date of correction)
- C
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · August 8, 2024 · Corrected (the home has a date of correction)