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 16 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
13D
1E
2F
Potential for minimal harm
0A
0B
0C
April 29, 2026Standard 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 wroteLicensure Reference Number 175 NAC 12.006.11(E) Based on observation, interview, and record review, the facility failed to ensure all food stored in the facility's kitchen was labeled, dated, and/or sealed, ensure refrigerators (fridge) and freezers did not contain expired products to prevent foodborne illness, and ensure the interior bottom, bottom vents of refrigerators and freezer, top of the double door oven, and all dishes, plates, and serving containers were stored and maintained in a clean and sanitary manner to prevent cross contamination. This had the potential to affect all residents that consumed food prepared in the facility kitchen. The total facility census was 49.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(G) Based on interview and record review, the facility failed to ensure a gradual dose reduction (GDR),tapering of a dose of medication) was completed in the required timeframe for 1 (Resident 1) of 4 sampled residents' duloxetine (a medication used to treat depression), monitor for behaviors and adverse consequences (negative outcomes), and document non-pharmalogical interventions related to 1 (Resident 1) of 4 sampled residents' duloxetine and trazodone (a medication used to treat depression that can be used to treat insomnia) medications. The facility census was 49.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, intervention and record review, the facility failed to maintain a Medication Error rate of less than 5%. Observation of 26 medications revealed 2 errors with a resulting rate of 7.69%. The medication errors are related to 1 (Resident 8) of 4 sampled residents. The facility staff identified a census of 49.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview and record review the facility staff failed to prime an insulin pen prior to administering insulin on 2 of 2 observations for 1 (Resident 8) of 1 sampled resident who received insulin, resulting in a significant medication error. The facility identified a census of 49.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference Number 175 NAC 12.006.18(B) Based on observation, interview, and record review, the facility failed to ensure hospice staff donned (put on) personal protective equipment (PPE) during wound care in a manner to prevent cross contamination for 1 (Resident 45) of 2 sampled residents. The facility census was 49.
April 15, 2026Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteLicense Reference Number 175 NAC 12.006.09(H)(iii)(2)Based on observation, interview and record review, the facility failed to ensure staff members performed hand hygiene when providing wound care to 2 residents (Residents 2 and 3) of 3 residents surveyed. The facility had a census of 46. A record review of the facilities Infection Prevention and Control Program, reviewed on 1/1/2025 revealed the following:Policy:This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines:All staff are responsible for following all policies and procedures related to the Program. [...]
March 20, 2025Complaint inspection · 1 citation
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview and record review the facility failed to implement interventions to prevent falls for 2 (Resident 1 and 2) of 3 residents sampled. The facility census was 40.
January 6, 2025Standard inspection, Complaint inspection · 4 citations
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(i)(3) Based on interview and record review the facility failed to provide baths according to the plan of care for 2 (Resident 17 and 34) of 3 residents sampled. The facility census was 40.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iii) Based on observation, interview and record review the facility failed to follow practitioner's orders for wound care and skin integrity for 2 (Resident 5 and 34) of 4 sampled residents. The facility census was 40.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)(i)(B) Based on observation, interview and record review the facility failed to implement interventions to prevent potential falls for 1 (Resident 17) of 4 residents sampled. The facility census was 40.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(J)(ii) Based on observation, interview and record review the facility failed to provide assistive equipment for eating for 1 (Resident 17) of 2 residents sampled. The facility census of 40.
May 21, 2024Complaint inspection · 1 citation
- D
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference Number 175 NAC 12.006.17D Based on observations, interviews, and record review; the facility failed to ensure that staff performed hand hygiene (sanitizing) using hand sanitizer or wash hands with soap and water for at least 20 seconds to prevent cross contamination for 1 (Resident #9) of 1 sampled resident. The facility census was 50.
November 30, 2023Standard inspection, Complaint inspection · 4 citations
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.11D Based on observation, interview and record review, the facility failed to serve food that was palatable and at safe temperatures to prevent the potential for food borne illness. This had the potential to affect all residents receiving food from the kitchen.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.17 Based on observation, interview, and record review, the facility failed to clean and store respiratory equipment in a manner to prevent the potential for cross contamination for four (Residents 8, 9, 36, and 41) of four residents sampled. The facility identified a census of 38.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(1) Based on record review and interview, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case) within the required timeframe for 1 (Resident 2) of 3 sampled residents. The facility identified a census of 38. Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09C3 Based on interview and record review the facility failed to complete a recapitulation of stay for 1 (Residents 33) of 3 sampled residents. The facility identified a census of 38.
Fire safety inspections
19 fire safety citations on file: 5 on April 29, 2026, 4 on January 6, 2025, 10 on November 30, 2023.
Every fire safety citation19 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 · April 29, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 29, 2026 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · April 29, 2026 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · April 29, 2026 · Corrected (the home has a date of correction)
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · April 29, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · January 6, 2025 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · January 6, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · January 6, 2025 · Corrected (the home has a date of correction)
- E
Meet requirements for the use and maintenance of medical gas equipment.
K 922 · January 6, 2025 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · November 30, 2023 · 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 · November 30, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · November 30, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · November 30, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · November 30, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · November 30, 2023 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · November 30, 2023 · Corrected (the home has a date of correction)
- E
Address patient/client population and determine types of services needed.
E 7 · November 30, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · November 30, 2023 · 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 · November 30, 2023 · Corrected (the home has a date of correction)