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 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
8D
2E
0F
Potential for minimal harm
0A
0B
0C
January 15, 2026Standard inspection, Complaint inspection · 8 citations
- 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 observations, manufacturer's instructions, and staff interviews, the facility failed to record an opened date on multi-dose insulin pen injectors and an insulin vial for 3 of 4 medication carts that were reviewed for medication storage (100 and 400 hall medication carts).
- 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 opened packages of food in 2 of 2 freezers (the front freezer and the outside freezer), label and date opened packages of food in 1 of 1 dry goods storage room, and discard expired foods stored for use in 2 of 2 nourishment room refrigerators (100 and 400 hall nourishment rooms). This deficient practice had the potential to affect the food served to the residents.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on record review, Nurse Practitioner and staff interviews, the facility failed to obtain and document consent for treatment with psychotropic medications and review with the resident or resident representative in advance of the risks versus benefits of psychotropic medications (any medication that affects behavior, mood, thoughts, or perception) prior to administration of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (Resident #98).
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, record review, and staff, and the Medical Director's interview, the facility failed to follow the physician's order for the care of a surgical wound for 1 of 2 residents reviewed for wound care (Resident #33).
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observations, record review, resident and staff and Nurse Practitioner interviews, the facility failed to obtain orders to assess and manage a new arterial venous (A/V) fistula (A surgical connection of an artery to a vein, usually in the arm, to create a long-lasting access point for dialysis needles) that was maturing for 1 of 1 resident reviewed for dialysis (Resident #7).
- 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 record review, and staff and the Consultant Pharmacist's interviews, the Consultant Pharmacist failed to identify and report a medication irregularity during 2 consecutive monthly medication regimen reviews (MRR) (November and December 2025) for 1 of 6 residents reviewed for unnecessary medications (Resident #72).
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on record review and staff interviews, the facility failed to maintain accurate documentation on the Medication Administration Record (MAR) the administration of a medication for 1 of 6 residents reviewed for medications (Resident #72).
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review, and staff interviews and Nurse Practitioner interviews, the facility failed to 1.) implement the infection control policy and procedures for Enhanced Barrier Precautions (EBP) when providing direct care activities to a resident (Resident #4) with a tracheostomy (a surgical opening into the trachea that provides an airway for breathing.), a gastrostomy tube (a feeding tube placed through the abdominal wall into the stomach and used to provide essential nutrition) and a Stage IV pressure ulcer on the sacrum. This occurred with 2 of 10 staff members (Nurse Aide #1 and Nurse Aide #2) observed for infection control practices 2.) implement the infection control policy for Tuberculosis control by not completing Tuberculosis skin testing following admission for 1 of 5 residents reviewed for infection control practices (Resident #24).
September 3, 2025Complaint inspection · 1 citation
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review and resident, staff, Responsible Party/Power of Attorney, North Carolina Nursing Assistant Registry investigator, former Director of Nursing and law enforcement interviews, the facility failed to protect a resident's (Resident #1) right to be free from misappropriation of property when Nursing Assistant (NA) #1 used Resident #1's bank account information, without Resident #1's permission, to create a Cash App account (Cash App is an app on your phone that works like a digital wallet; it is connected to your bank account and can be used to send or receive money instantly between users as well as be used to pay bills or for services) in Resident #1's name and then used that Cash App account to transfer money to her adult son, fiance, and mother on several occasions. [...]
September 20, 2024Standard inspection · 0 citations
May 4, 2023Standard inspection · 1 citation
- 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 records reviews and staff interviews, the facility failed to have advance directives in the resident's records for 1 of 7 sampled residents. (Resident #52).
Fire safety inspections
13 fire safety citations on file: 3 on January 15, 2026, 5 on September 20, 2024, 5 on May 4, 2023.
Every fire safety citation13 citations
- E
Use approved construction type or materials.
K 161 · January 15, 2026 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 15, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · January 15, 2026 · Corrected (the home has a date of correction)
- E
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 · September 20, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · September 20, 2024 · Corrected (the home has a date of correction)
- E
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · September 20, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 20, 2024 · Corrected (the home has a date of correction)
- D
Properly provide smoke detection systems in areas open to corridors.
K 347 · September 20, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · May 4, 2023 · 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 · May 4, 2023 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · May 4, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · May 4, 2023 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · May 4, 2023 · Corrected (the home has a date of correction)