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
12D
1E
0F
Potential for minimal harm
0A
0B
1C
September 11, 2025Standard inspection · 3 citations
- 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 wroteLicensure Reference Number 175 NAC 12-006.09(F)(iii) Based on record review and interviews, the facility failed to complete the care plan (a comprehensive, written document that outlines the personalized healthcare needs, goals, and interventions for a resident, based on a thorough assessment of the medical, functional, and psychosocial status) and to conduct the interdisciplinary care conference on three residents (Resident 1, 21, and 46) out of three residents sampled. The facility census was 74.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteThe facility failed to ensure physician orders for CPAP ( Continuous Positive Airway Pressure) devices included the required pressure setting for Residents 53 and 60. F695 - Respiratory CareLicensure Reference Number: 175 NAC 12-006.09(H)(vi)(3)(g) Based on observation, interview, and record review the facility failed to ensure that physician orders for Continuous Positive Airway Pressure (CPAP) therapy (a type of non-invasive ventilator that delivers pressurized air through a mask to keep the airway open during sleep) included complete and specific settings (pressure, ramp time, humidity, or other specifications) for 2 of 2 sampled residents (Resident 53 and Resident 60) in a facility census of 74. This failure had the potential to result in inadequate or unsafe respiratory care delivery. [...]
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that the posted Daily Nurse Staffing Form had an accurate census. This had the potential to affect all the residents in the facility. The facility census was 74 at the time of survey.
August 29, 2024Standard inspection, Complaint inspection · 2 citations
- 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 12-006.09D(l)(i)(3) Based on observations, record review, and interviews; the facility failed to implement, to revise and/or develop new interventions to prevent further falls for 2 (Residents 14 and 41) of 4 sampled residents. The facility census was 75.
- 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 12-006.09D Based on record review and interview; the facility failed to have a diagnosis for the use of an antipsychotic (a drug or substance that affects how the brain works) medication and to attempt a gradual dose reduction (GDR) and/or have a documented contraindication for use of the antipsychotic medication for 1 (Resident 50) of 5 sampled residents. The facility census was 75.
August 3, 2023Standard inspection · 9 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.17 Based on observations, record review and interview, the facility failed to wear personal protective equipment (PPE) and clean reusable equipment in accordance with facility policy to prevent the potential spread of Covid-19. The sample size was 22 and the facility census was 57.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on record review and interview, the facility failed to notify the provider for a condition change for 1 resident (Resident 39). The sample size was 1 and the facility census was 57.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(1) Based on record review and interview, the facility failed to submit transfer and discharge notifications to the State Ombudsman (an official appointed to investigate individuals' complaints and serves as a consumer advocate) as required for Resident 9. The facility census was 57.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(1) Based on record review and interview, the facility failed to provide Resident 9 or the resident's representative, bed hold information when the resident was transferred to the hospital. The sample size was 22 and the facility census was 57.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09B1 Based on record review and interview, the facility failed to ensure Resident 4's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) was coded to reflect the resident's health status. The sample size was 22 and the facility census was 57.
- D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Inspectors wroteLicense Reference Number 175 NAC 12-006.09C3 Based on record review and interview, the facility failed to complete a discharge summary for Resident 56. The sample size was 3 and the facility census was 57 residents at the time of the survey.
- 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 12-006.09D7 Based on observation, interview, and record review: the facility failed to implement interventions to protect from a potential burn from a hot liquid spill for Resident 10. The sample size was 5 and the facility census was 57.
- 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 12-006.09D Based on record review and interview, the facility failed to ensure Resident 9's antipsychotic (medication that works by altering brain chemistry to help reduce psychotic symptoms like hallucinations (seeing things not present), delusions (fixed and firm belief not supported by evidence), and disordered thinking) medication had an appropriate indication for use. The sample size was 5 and the facility census was 57.
- 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 wroteLicensure Reference Number 175 NAC 12-006.10B1 Based on observation, record review and interview the facility failed to ensure 1 resident (Resident 13's) medications were properly secured. The sample size was 1 and the facility census was 57.
Fire safety inspections
20 fire safety citations on file: 15 on September 11, 2025, 2 on August 29, 2024, 3 on August 3, 2023.
Every fire safety citation20 citations
- F
Implement emergency and standby power systems.
E 41 · September 11, 2025 · Corrected (the home has a date of correction)
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · September 11, 2025 · Corrected (the home has a date of correction)
- 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 · September 11, 2025 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · September 11, 2025 · 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 · September 11, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · September 11, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 11, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 11, 2025 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · September 11, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 11, 2025 · Corrected (the home has a date of correction)
- F
Meet requirements for the use of electrical equipment.
K 919 · September 11, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · September 11, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · September 11, 2025 · Corrected (the home has a date of correction)
- E
Meet requirements for the use and maintenance of medical gas equipment.
K 922 · September 11, 2025 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · September 11, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 29, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · August 29, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · August 3, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 3, 2023 · Corrected (the home has a date of correction)
- E
Have simulated fire drills held at unexpected times.
K 712 · August 3, 2023 · Corrected (the home has a date of correction)