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 12 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
5D
2E
1F
Potential for minimal harm
0A
1B
1C
January 8, 2026Standard inspection · 1 citation
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations and staff interviews, the facility failed to label and date open containers of food and discard expired food items in 1 of 1 walk-in cooler, and secure open food containers in the freezer, and prevent the freezer compressor from dripping condensation directly into open boxes stored under the compressor in 1 of 1 freezer.
October 24, 2024Standard inspection, Complaint inspection · 8 citations
- J
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and interviews with hospital system's transportation staff (Driver #1), Passenger Services Manager and Nurse Practitioner (NP), the facility failed to leave Resident #45 in place for a clinical assessment of injury after a fall that occurred during transport. Resident #45 was being transported to dialysis in a hospital system owned transport van. Driver #1 made a sudden stop which caused Resident #45 to slide forward out his wheelchair onto the van floor when his seatbelt loosened. Driver #1 pulled the van into the median of the road and attempted to transfer Resident #45 back into his wheelchair. When Driver #1 was unsuccessful in transferring Resident #45 back to his wheelchair, she continued to transport Resident #45 to the dialysis center while the resident was seated on the floor of the transportation van. [...]
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review, review of audio/video footage, and Nurse Practitioner (NP), Passenger Services Manager, resident and staff interviews, the facility failed to provide safe transportation for Resident #45 in the hospital system transportation van to the dialysis center. On 2/9/24 while en route Driver #1 stopped abruptly, and Resident #45 slid out of his wheelchair to the floor of the van. Driver #1 was unable to assist Resident #45 back into his wheelchair and proceeded to drive to the dialysis center with Resident #45 sitting on the floor of the van. In addition, on 8/12/24, Driver #1 failed to ensure the lift gate was in the elevated position before unloading Resident #62 from the back from the van. Driver #1 stood behind Resident #62's wheelchair and wheeled Resident #62 towards the back of the van and lift gate. [...]
- E
Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on observation, record review, and staff, family, resident and Nurse Practitioner (NP) interviews, the facility failed to obtain a referral, schedule or arrange an audiology appointment, or and screening for a resident with sensory neural hearing loss whose hearing aids did not fit properly for 1 of 1 resident (Resident #45) reviewed with hearing loss.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations and staff interviews, the facility failed to secure residents personal health information by leaving shift report documentation and a medication cart laptop unattended with resident information exposed in an area accessible and visible to the public on 1 of 3 Medication Carts (600 Hall Medication Cart).
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on record review, observations and staff interviews, the facility failed to label the gastrostomy feeding formula with the flow rate and the time the formula was hung for 1 of 1 resident reviewed for tube feeding (Resident #40).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, record review and staff interview, the facility failed to post cautionary and safety signage indicating the use of oxygen outside resident rooms for 3 of 3 sampled residents reviewed for respiratory care (Resident #40, Resident #41 and Resident #56).
- 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 observations, record review,and pharmacist and staff interviews, the facility failed to label and date an opened vial of Purified Protein Derivative (PPD) stored in 1 of 1 medication room refrigerator reviewed for medication storage.
- C
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Inspectors wroteBased on record review, and staff and the Executive Director of the NC Board of Nursing Home Administrators interviews, the facility failed to have a licensed Administrator in place to oversee the daily staff and resident operations of the skilled nursing facility. This failure had the potential to affect all residents residing in the facility.
November 29, 2023Complaint inspection · 1 citation
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on record review, staff interview, resident interview and outside transportation vendor, the facility failed to maintain a resident's dignity when a nurse yelled and spoke rudely towards 1 of 3 resident's (Resident #3) reviewed for abuse.
May 25, 2023Standard inspection · 2 citations
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on record review and staff interviews the facility failed to have a Registered Nurse (RN) scheduled for 8 consecutive hours a day for 7 of 30 days (1/2/22, 1/3/22,1/8/22,1/9/22,1/15/22,1/16/22 and 1/8/23) reviewed for staffing. This failure had the potential to affect all residents in the facility.
- B
Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on record reviews and staff interviews, the facility failed to complete quarterly assessments within the required 14-day timeframe for 2 of 18 residents reviewed for Minimum Data Set (MDS) assessments (Resident #26 and Resident #4).
Fire safety inspections
13 fire safety citations on file: 6 on January 8, 2026, 5 on October 24, 2024, 2 on May 25, 2023.
Every fire safety citation13 citations
- D
Use approved construction type or materials.
K 161 · January 8, 2026 · Corrected (the home has a date of correction)
- 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 · January 8, 2026 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 8, 2026 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 8, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · January 8, 2026 · Corrected (the home has a date of correction)
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · January 8, 2026 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 24, 2024 · Corrected (the home has a date of correction)
- 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 · October 24, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 24, 2024 · Corrected (the home has a date of correction)
- D
Have an externally vented heating system.
K 522 · October 24, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · October 24, 2024 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · May 25, 2023 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · May 25, 2023 · Corrected (the home has a date of correction)