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
10D
2E
2F
Potential for minimal harm
0A
0B
0C
June 4, 2026Standard inspection · 3 citations
- E
Have enough outside ventilation via a window or mechanical ventilation, or both.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.17(E)(v) Based on observations and interview, the facility failed to ensure resident bathrooms were well-ventilated for resident rooms on the 100 and 200 halls for 14 sampled residents. The facility identified a census of 55 residents. An observation on 6/4/26 at 10:30 AM in the bathroom of resident room [ROOM NUMBER] revealed the ceiling exhaust vent was not moving any air, as evidenced by no movement of a single ply of a toilet tissue square held up to the vent. No residents were assigned to room [ROOM NUMBER] at that time. An observation on 6/2/2026 at 11:00 AM in the bathroom of resident room [ROOM NUMBER] revealed the ceiling exhaust vent was not moving any air. room [ROOM NUMBER] was occupied by Resident 14. [...]
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on record review and interview, the facility failed to ensure pre-and post-dialysis assessments were completed as required for one (Resident 30) of one sampled resident. The facility identified a census of 55. A record review of Resident 39's admission Record dated 6/4/2026 revealed an admission date of 5/4/2026. [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteL:icensure Reference Number 175 NAC 12-006.18(B)Licensure Reference Number 175 NAC 1-005.06 Based on record review, observation, and interview, the facility failed to ensure catheter bags were maintained in a manner to prevent the potential for cross contamination and/or infection for two (Residents 4 and 13) of three sampled residents. The facility identified a census of 55.
April 3, 2025Standard inspection, Complaint inspection · 3 citations
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iv)(5) Based on record reviews and interviews, the facility failed to follow their bowel protocol to prevent constipation (a condition characterized by infrequent or difficult bowel movements, resulting in hard, dry, and difficult-to-pass stools) for 3 (Residents 9, 11, and 16) of 6 sampled residents. The facility identified a census of 56.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review and interview, the facility failed to provide a written notice of discharge as required to 1 (Resident 112) of 1 sampled resident or their representative. The facility census was 56. Findings Are: A record review of Resident 112's Progress Notes revealed that on 3/2/25, Resident 112 was sent by the facility to the emergency department due to adverse behaviors toward another resident. Resident 112 was admitted to the hospital due to delirium and hypoxia. Further review of Resident 112's Progress Notes revealed that on 3/3/25, the facility notified Resident 112's child that the facility would not be admitting the resident back to the facility from the hospital due to the potential for putting other residents in harm's way. The notes revealed Resident 112's child voiced understanding and declined a bed hold. [...]
- 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 reviews and interview, the facility failed to ensure the physician had documented a clinical rationale for not taking action regarding the pharmacist's identified medication irregularity as required of 1 (Resident 11) of 5 sampled residents. The facility identified a census of 56.
March 21, 2024Standard inspection · 8 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.11E Based on observation, record review and interviews, the facility failed to ensure food was labeled and dated to prevent the potential of food borne illness. This had the potential to affect all residents who consumed food from the kitchen. The facility census was 60.
- F
Dispose of garbage and refuse properly.
Inspectors wroteLicensure Reference Number 175 NAC 12.006.18A Based on observations and interviews, the facility failed to ensure garbage was stored in a manner to prevent harborage and feeding of pests by failing to ensure trash receptacles were covered and not open. This had the potential to affect all the facility's residents. The facility identified a census of 60 at the time of survey. An observation on March 18, 2024 at 10:45 AM of the facility outside of the back entry to the kitchen revealed the following: - 1 trash receptable which had the back of the receptable open with no coverings and trash was visible inside, - 1 trash receptable which had the front and the back of the receptable open with no coverings and trash was visible inside. Interview with Dietary superviosor (DS) on March 20, 2024, at 10:45 AM confirmed the lids the 2 trash receptables were uncovered with trash inside. [...]
- D
Provide activities to meet all resident's needs.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D5b Based on observations, interviews, and record review, the facility failed to provide activities of choice to 1 (Resident 9) of 1 sampled residents. The facility identified a census of 60.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on record review and interviews, the facility failed to follow physician's orders regarding daily weights for 1 (Resident 36) of 1 sampled resident. The facility census was 60. The Findings Are: A record review of Resident 36's admission record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of pneumonia, unspecified organism. A record review of Resident 36's undated Care Plan revealed the resident had a diagnosis of congestive heart failure and had an intervention in place for weight monitoring. A record review of Resident 36's Physician's Orders revealed an order for daily weights to be obtained on the day shift related to their diagnosis of Unspecified Diastolic (Congestive) Heart Failure. [...]
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D2b Based on observations, interviews, and record review, the facility failed to provide treatment of a pressure ulcer for 1 (Resident 9) of 4 sampled residents. The facility identified a census of 60.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D6 (7) Based on observation, record review and interview; the facility staff failed to change oxygen tubing for 2 (Resident 10 and 49) of 2 sampled residents and failed to change the nebulizer mask with tubing for 1 (Resident 49) of 1 sampled resident which had the potential to cause infection. The facility census was 60.
- 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 wroteLicensure Reference Number 175 NAC 12-006.10 Based on interviews and record review, the facility failed to ensure an as needed antipsychotic medication was limited to 14 days and had a physician documented rationale for continuance. This affected 1 (Resident 114) of 6 sampled residents. The facility identified a census of 60.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.17D Based on observation, record review and interview; the facility failed to ensure hand hygiene was performed to prevent the spread of infection or prevent cross contamination during and after incontinence care with appropriate change of gloves for 1 (Resident 49) of 1 sampled resident. The facility census was 60.
Fire safety inspections
15 fire safety citations on file: 9 on June 4, 2026, 4 on April 3, 2025, 2 on March 21, 2024.
Every fire safety citation15 citations
- F
Have properly located and lighted "Exit" signs.
K 293 · June 4, 2026 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 4, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · June 4, 2026 · Corrected (the home has a date of correction)
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · June 4, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 4, 2026 · Corrected (the home has a date of correction)
- F
Provide properly sized and located linen or trash receptacles.
K 754 · June 4, 2026 · 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 · June 4, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 4, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · June 4, 2026 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 3, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 3, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · April 3, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · April 3, 2025 · Corrected (the home has a date of correction)
- F
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
K 361 · March 21, 2024 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · March 21, 2024 · Corrected (the home has a date of correction)