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 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
7D
1E
0F
Potential for minimal harm
0A
0B
0C
March 17, 2026Complaint inspection · 1 citation
- D
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Inspectors wroteBased on facility policy review, personnel file review, facility document review and interview, Administration failed to ensure that nursing services were provided by qualified personnel when the facility hired an imposter nurse (Imposter Nurse A) to function as a Registered Nurse (RN) using another RN's (RN C) Tennessee license. Imposter Nurse A worked at the facility from 06/12/2024 to 11/24/2024The
October 5, 2023Standard inspection, Complaint inspection · 8 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on Prevention and Treatment of Pressure Ulcers/Injuries Quick Reference Guide 2019, policy review, medical record review, observation, and interview, the facility failed to provide skin and wound assessments, and wound treatments for residents' pressure ulcers for 2 of 4 residents (Resident #7 and #8) reviewed for pressure ulcers. The facility's failure to perform treatments and conduct assessments in accordance with facility policy contributed to the development and deterioration of pressure ulcers/injury for Resident #7 and #8 resulting in harm.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on policy review, observation, and interview the facility failed to ensure infection control practices to prevent the spread of infection when 2 of 4 (Licensed Practical Nurse (LPN) #2 and #3) and when 1 of 1 (Wound Care Nurse) staff members failed to perform hand hygiene during medication administration and wound care.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to maintain and enhance resident's dignity and respect when 1 of 1 (Wound Care Nurse) nurse failed to provide privacy for 1 of 2 (Resident #7) residents observed during wound care.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to report an allegation of abuse for 1 of 4 (Resident #285) sampled residents reviewed for allegation of abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on policy review, medical record review, review of facility investigation, and interview, the facility failed to ensure a thorough investigation was completed for 1 of 4 (Resident #285) sampled residents reviewed for an allegation of abuse.
- D
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 policy review, Family/Staff Conference form, medical record review, and interview, the facility failed to conduct quarterly Interdisciplinary Care Plan Meetings for 2 of 24 (Resident #8 and #19) residents reviewed for Care Plan Meetings.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to follow physician's orders for medication administration and failed to obtain a physician's order to apply a foot strap to a resident's wheel chair for 2 of 24 (Resident #35 and #44) sampled residents reviewed for physician orders.
- 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 policy review, observation, and interview, the facility failed to ensure medications were properly stored in 2 of 16 medication storage areas (One South Nurse Station Medication Room and One North Medication Cart #1) where an expired medication was found a medication cart was left unlocked and unattended.
November 6, 2019Standard inspection · 0 citations
January 15, 2019Standard inspection · 0 citations
Fire safety inspections
5 fire safety citations on file: 2 on October 5, 2023, 3 on November 6, 2019.
Every fire safety citation5 citations
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · October 5, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · October 5, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · November 6, 2019 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · November 6, 2019 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · November 6, 2019 · Corrected (the home has a date of correction)