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 27 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
15D
8E
3F
Potential for minimal harm
0A
0B
1C
May 7, 2025Complaint inspection · 1 citation
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on record review and interview, the facility failed to implement their facility abuse policy when a staff member failed to report a suspicion of abuse of a cognitively impaired resident, which delayed the initiation of the facility investigation and reporting to the appropriate agencies, for 1 of 3 residents reviewed for abuse. (Resident B, RN 3 and QMA 1)
April 1, 2025Complaint inspection · 2 citations
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, record review, and interview, the facility failed to allow residents to continue to gather around the nurses' station, as was their preference and common practice, for 4 of 4 residents reviewed for resident preferences. (Residents C, D, E, & F)
- D
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Inspectors wroteBased on record review and interview, the facility failed to prevent a resident's involuntary seclusion by placing her in an activity room, alone and without explanation as to the reason for the deviation from her normal preferred activity and routine, for 1 of 1 residents reviewed for involuntary seclusion. (Resident B)
March 7, 2025Standard inspection · 7 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared and served using safe sanitary food preparation and handling methods. This deficient practice has the potential to impact 69 of 69 residents who received their meals from the kitchen.
- E
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who received psychoactive medications had gradual dose reductions or statements of clinical contraindication and/or had identified and documented targeted behavioral systems for the use of psychotropic medications for 2 of 5 residents reviewed for unnecessary mediation (Residents 19 and 54) and 2 of 2 residents reviewed for side effect monitoring of psychoactive medications and/or opioids (Residents 32 and 48).
- D
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Inspectors wroteBased on observation, interview, and record review, the facility failed to manage resident funds using acceptable accounting principles for 2 of 3 residents reviewed for personal funds. (Residents 34 and 27)
- 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 observation, record review, and interview, the facility failed to ensure preventative interventions were implemented for 1 of 3 residents reviewed for pressure ulcers. (Resident 5)
- 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 observation and interview, the facility failed to ensure insulin (a medication to treat diabetes mellitus) pens were dated when opened and disposed of when expired for 1 of 4 carts reviewed for medication storage. (Hickory Hall 2 cart)
- D
Provide and implement an infection prevention and control program.
Inspectors wroteA. Based on observation and interview, and record review, the facility failed to utilize infection prevention and control practices related to hand hygiene during medication administration for 2 of 3 random residents reviewed during medication administration. (Residents 26 and 6) B. Based on observation, interview, and record review, the facility failed to implement and follow enhanced barrier precautions (EBP) for a resident at higher risk for infection with a wound and indwelling urinary catheter for 1 of 3 residents reviewed for pressure ulcers. (Residents 22)
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, record review, and interview, the facility failed to post the daily facility census number and actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care per shift daily during random observations.
February 6, 2025Complaint inspection · 2 citations
- F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on interview and record review, the facility failed to employ a qualified Food Services Director. This deficient practice had the potential to impact 70 of 70 facility residents.
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on record review and interview, the facility failed to prevent misappropriation of a resident's medication for 1 of 3 residents reviewed for misappropriation. (Resident C). The deficient practice was corrected on 1/15/25, prior to the start of survey, and was therefore past noncompliance.
May 16, 2024Complaint inspection · 1 citation
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure anti-depressant medication and mood stabilizer medication was not started without indication for use for 1 of 3 residents reviewed for abuse (Resident D).
February 23, 2024Standard inspection, Complaint inspection · 8 citations
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure cogntively impaired residents were offered services during dining to promote dignity and a homelike, comfortable atmosphere for 6 of 23 resident observed during dining observation. (Residents 9, 13, 23, 25, 31, and 66)
- E
Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on interview and record review, the facility failed to resolve Resident Council concerns and provide a response to the group regarding their concerns.
- 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 observation and interview, the facility failed to ensure medications were labeled with resident identifiers and directions for 1 of 2 medications storage rooms reviewed (Hickory) and for 2 of 4 medication carts reviewed (Hickory 2 and South carts).
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to ensure a communication process was utilized between the facility and dialysis center to maintain complete and accurate records for continuity of care for 1 of 1 resident reviewed for dialysis. (Resident 4)
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record review and interview, the facility failed to follow the pharmacy services and procedures manual during pharmacy delivery to ensure medication deliveries were accepted according to facility protocol, resulting in a missed dose of pain medication. (Resident 48)
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store food in accordance with facility policy for food service safety and storing of leftover foods.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain proper hot water temperatures for personal hygiene in a comfortable and homelike manner for 3 of 5 residents reviewed for environment. (Residents B, D, and C)
- E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on observation, interview, and record review, the facility staff failed to utilize the grievance process to address and resolve resident grievances/concerns/complaints, to ensure follow up with a corrective action for 3 of 3 residents reviewed for grievances about lack of hot water availability. (Residents B, D, and C)
November 3, 2023Complaint inspection · 1 citation
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review, the facility failed to notify a cognitively impaired resident's (Resident D) representative when there was a change in the resident's condition.
January 30, 2023Standard inspection · 5 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain cooking equipment in a clean, sanitary manner and failed to ensure dishes were washed in a manner to prevent cross contamination. This deficient practice had the potential to impact 67 of 67 residents who received meals from the kitchen.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interview, the facility failed to ensure the carpet in hallways and common areas utilized by residents, staff, and visitors was maintained in a clean manner for 2 of 3 units reviewed for environmental cleanliness. (Hickory Hall Unit and Southern Pines Unit)
- E
Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure wheelchair arms were in good repair in order to prevent possible skin tears or injury for 4 of 4 residents reviewed for equipment. (Resident 53, 20, 1 and 34)
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteA. Based on interview and record review, the facility failed to ensure resident monitoring and treatment following a resident reported fall, which resulted in a delay for treatment for a fracture for 1 of 9 residents reviewed for accidents. (Resident 49) B. Based on record review and interview, the facility failed to follow physician's orders regarding medication administration parameters for a hypertensive medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 44) C. Based on observation, interview, and record review, the facility failed to obtain a therapy assessment/treatment per physicians order for 1 of 1 residents reviewed for therapy orders. (Resident 51)
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and document fluids consumed by 1 of 1 residents on fluid restrictions reviewed for dialysis. (Resident 44)
Fire safety inspections
29 fire safety citations on file: 17 on March 7, 2025, 5 on February 23, 2024, 7 on January 30, 2023.
Every fire safety citation29 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · March 7, 2025 · Corrected (the home has a date of correction)
- F
Develop Emergency Preparedness policies and procedures.
E 13 · March 7, 2025 · Corrected (the home has a date of correction)
- F
Create arrangements with other facilities to receive patients.
E 25 · March 7, 2025 · Corrected (the home has a date of correction)
- F
Develop a communication plan.
E 29 · March 7, 2025 · Corrected (the home has a date of correction)
- F
Establish emergency prep training and testing.
E 36 · March 7, 2025 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · March 7, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 7, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 7, 2025 · Corrected (the home has a date of correction)
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
K 916 · March 7, 2025 · deficient, provider has
- E
Provide properly protected cooking facilities.
K 324 · March 7, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 7, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · March 7, 2025 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · March 7, 2025 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 7, 2025 · Corrected (the home has a date of correction)
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
K 927 · March 7, 2025 · Corrected (the home has a date of correction)
- C
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · March 7, 2025 · Corrected (the home has a date of correction)
- C
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · March 7, 2025 · Corrected (the home has a date of correction)
- E
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
K 232 · February 23, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · February 23, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · February 23, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · February 23, 2024 · Corrected (the home has a date of correction)
- C
Meet other general requirements that are deficient.
K 500 · February 23, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · January 30, 2023 · Corrected (the home has a date of correction)
- E
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 30, 2023 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · January 30, 2023 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · January 30, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · January 30, 2023 · Corrected (the home has a date of correction)
- C
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 30, 2023 · Corrected (the home has a date of correction)
- C
Meet other general requirements that are deficient.
K 500 · January 30, 2023 · Corrected (the home has a date of correction)