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 46 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
2G
2H
0I
Potential for more than minimal harm
23D
9E
9F
Potential for minimal harm
0A
0B
0C
June 16, 2026Standard inspection, Complaint inspection · 5 citations
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(D)(i)Based on record review and interview, the facility failed to submit a director of nursing continuous coverage notification to the state agency as required. This had the potential to affect all residents.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wrote175 NAC 12-006.11(E)Based on observations and record reviews, the facility failed to perform hand hygiene with soap and water for a minimum of 20 seconds. The facility failed to ensure cleanliness of the kitchen to prevent the potential for cross contamination. The facility also failed to label and seal stored foods. This had the potential to affect all residents. The facility showed a census of 25.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteLicensure number 175 NAC 12-006.05Based on record review and interviews, the facility failed to ensure residents and/or resident representatives were informed of and consented to treatment prior to the administration of psychotropic medications for 2 (Resident 4 and Resident 21) of 5 sampled residents. The facility identified a census of 25 residents.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(D)Based on record review, observation, and interview, the facility failed to ensure the MDS was coded accurately to reflect wandering behavior for one (Resident 16) of twelve sampled residents. The facility identified a census of 25.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on record review and interview, the facility failed to provide behavioral health care and services to one sampled resident (Resident 5). The facility identified a census of 25 residents.
February 18, 2026Complaint inspection · 2 citations
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.12(D)(vii) Based on observation and record review, the facility failed to ensure a secure disposal of medication for 1 (Resident 4) of 3 sampled residents. The facility identified a census of 23.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on observation, record review, and interview, the facility failed to ensure their medication error rate was less than 5%. Out of 31 medication administration opportunities, there were 6 medication errors affecting 2 (Residents 6 and Resident 4) of 3 sampled residents, resulting in a 19.35% medication error rate. The facility identified a census of 23.
November 17, 2025Complaint inspection · 9 citations
- H
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iii)(1)Licensure Reference Number 175 NAC 12-006.09(H)(iii)(2) Based on observations, record reviews, and interviews; the facility failed to develop and implement interventions to prevent the development of a pressure ulcer for 1 (Resident 6) of 1 sample resident and the failed to implement interventions and complete wound care treatments as ordered for 4 (Resident 2, 3, 6, and 18) of 4 sampled residents. The facility identified a census of 25.
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteLicensure Reference 175 NAC 12-006.09(H) Based on interviews and record reviews, the facility failed to ensure residents were free from neglect by ensuring adequate supplies to meet residents' needs for 2 (Resident 2 and Resident 14) of 2 sampled residents. The facility identified a census of 25.
- G
Honor each resident's preferences, choices, values and beliefs.
Inspectors wroteLicensure Reference 175 NAC 12-006.09(H)Based on observations, interviews, and record review, the facility failed to identify and address uncontrolled pain and withdrawal symptoms when the resident could no longer reliably swallow their oral medications for 1 (Resident 6) of 1 sampled resident. The facility identified a census of 25.
- E
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 12-006.04(F)(i)(5) Based on record review and interviews, the facility failed to notify the provider of a change in condition for 3 (Residents 2, 6, and 14) of 6 sampled residents and failed to notify the provider of the inability to follow provider orders for diabetic care for 3 (Residents 14, 7, and 17) of 3 sampled residents. The facility census was 25. A record review of the facility's policy Change in a Resident's Condition or Status (dated February 2021) revealed the nurse would notify the resident's attending physician or physician on call when there has been a significant in the resident's physical/emotion/mental condition or the need to alter the resident's medical treatment significantly within 24 hours. A. A record review of Resident 6's admission Record revealed the facility admitted Resident 6 on 12/11/2018. [...]
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteLicensure Reference 175 NAC 12-006.09(H)(i)(3) Based on record review and interview, the facility failed to assist residents with bathing for 3 (Resident 2, 6, and 18) of 3 sample residents. The facility identified a census of 24.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iii)&(iv)Licensure Reference Number 175 NAC 12-006.10 Based on observations, interviews, and record reviews; the facility failed to follow their bowel protocol to prevent constipation for 1 (Resident 6) of 4 sampled residents, and failed to implement orders as written by the provider for 4 (Residents 1, 3, 11, and 17) of 5 sampled residents. The facility census was 25. A. A record review of a facility policy titled Bowel and Bladder program and Toileting Program dated October 2010 stated every night shift, the charge nurse is responsible for reviewing the Clinical Dashboard Alerts and completing the Bowel Movement (BM) Monitoring Form: -Interventions for no BM x 3 days: Milk of Magnesia 30 ml (Milliliter), by mouth (po) -monitor for effectiveness. -Interventions for no BM x 4 days: [...]
- E
Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on record review and interviews, the facility failed to provide and report timely laboratory services for 4 (Residents 7, 8, 14, and 17) of 7 sampled residents and failed to perform blood glucose monitoring per the provider's orders for 3 (Residents 7, 14, and 17) of 3 sampled residents. The facility census was 25. A. A record review of Resident 7's face sheet revealed Resident 7 was admitted on [DATE] with diagnoses of congestive heart failure, Type 2 diabetes mellitus (a disease in which the body cannot regulate blood sugar effectively), obesity, hypertension, and atrial fibrillation (an abnormal heart rhythm that is irregular in the chambers of the heart are out of sync). [...]
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on record review and interviews, the facility failed to ensure significant medication errors did not occur for 2 (Residents 10 and 14) of 14 sampled residents. The facility census was 25. A.A record review of Resident 10's admission Record revealed the resident was admitted to the facility on [DATE] and had diagnoses of postlaminectomy syndrome (a complication after spinal surgery involving persistent pain), chronic pain syndrome and muscle spasms of the back. A record review of Resident 10's Provider Visit note dated 10/23/2025 revealed the resident was seen due to recent drowsiness and dizziness. The resident had described these symptoms as emerging after their Baclofen (a muscle relaxer) dose was increased from 10 milligrams (mg) to 15 mg, in addition to their ongoing use of tizanidine (a muscle relaxer). [...]
- D
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Based on observations, interviews, and record review; the facility failed to prevent the potential for cross contamination during wound care for 2 (Residents 3 and 6) of 3 sampled residents. The facility census was 25. Findings Are: A record review of the facility policy Wound Care with revision date of December 2011 revealed in the Steps in the Procedure section that Step 1 was to use a disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. A.A record review of Resident 3's Order Summary Report dated 11/12/2025 revealed the resident was admitted to the facility on [DATE]. [...]
August 18, 2025Complaint inspection · 1 citation
- F
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.18(B)Licensure Reference Number 175 NAC 12-006.18(D) Based on observation, interview, and record review, the facility failed to: a) implement contact precautions as ordered by the physician, b) implement Enhanced Barrier Precautions (EBP) and adhere to infection control standards during wound care, c) and adhere to infection control standards during medication administration for 3 residents (Residents 3, 12 and 18.) These lapses created a risk of cross-contamination and potential transmission of infection to all residents residing within the facility. The facility identified a census of 28.
June 11, 2025Complaint inspection · 8 citations
- K
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.04 Based on observations, record review, and interview; the facility failed to have sufficient staff on duty to prevent the potential for serious harm or injury while performing transfers via Hoyer or sit-to-stand mechanical lifts, this had the potential to affect 11 (Residents 1, 4, 6, 9, 10, 11, 12, 13, 14, 15, and 16) of 11 residents sampled. The facility failed to have sufficient staff on duty to ensure residents receive assistance with their Activities of Daily Living per their plan of care for 6 (Resident 1,2,3,4,12,and 19). The total survey sample was 19. The facility identified a census of 36. The facility administrator was notified on 6/7/2025 at 9:20 PM of an Immediate Jeopardy (IJ) which began on 5/5/2025. The IJ was removed on 6/7/2025, as confirmed by surveyor onsite verification. Findings Are: [...]
- H
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iii)(1) Licensure Reference Number 175 NAC 12-006.09(H)(iii)(2) Based on record review and interviews, the facility failed to ensure 1 (Resident 4) did not develop pressure ulcers (also known as bed sores, areas of damaged skin caused by staying in one position for too long, commonly formed under boney prominence's) that were unavoidable and failed to provide monitoring, treatment and care as ordered to promote healing for 3 (Residents 4, 6, and 18) of 3 sampled residents' pressure ulcers. The facility identified a census of 36.
- F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteLicensure Reference Number 175 NAC 12-00604(D)Nebraska Revised Statute 71-6018.02(a) Based on record reviews and interviews, the facility failed to maintain acceptable documentation (timecards, time sheets, payroll information) that a Registered Nurse (RN) was on duty for a minimum of 8 consecutive hours a day, 7 days a week, as required. This had the potential to affect all 28 residents by limiting access to RN-level assessment, oversight, and decision-making related to resident care.
- E
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 observations, record review, and interview; the facility failed to ensure residents received assistance with their Activities of Daily Living per their plan of care for 6 (Residents 1, 2, 3, 4, 12, and 19) of 6 sampled residents. The facility identified a census of 36. Findings Are: A record review of the facility policy Activities of Daily Living (ADL), Supporting with a revision date of March 2018 revealed that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. An interview on 6/7/25 at 10:14 PM with Nursing Assistant ( NA)-L and NA-M revealed both NA's worked the night shift. [...]
- E
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 record review and interview the facility failed to prevent the potential for serious harm or injury while performing transfers via Hoyer or sit-to-stand mechanical lifts, this had the potential to affect 11 (Residents 1, 4, 6, 9, 10, 11, 12, 13, 14, 15, and 16) of 11 residents sampled. The facility identified a census of 36. Findings Are: A record review of the facility policy Lifting Machine, Using a Mechanical with revision date of July 2017 revealed in the General Guidelines that at least two nursing assistants are needed to safely move a resident with a mechanical lift. The policy also revealed that the types of lifts that may be available in the facility are a floor-based full body sling lift, an overhead full body sling lift, and a sit to stand lift. [...]
- 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)(3) Based on observations, interviews, and record review; the facility failed to implement interventions of repositioning and failed to re-evaluate and revise ineffective interventions for 1 (Resident 9) of 1 sampled resident with Moisture Associated Skin Damage (MASD, a condition that occurs when skin is repeatedly exposed to various sources of bodily secretions or effluents, often leading to irritant contact dermatitis with inflammation, with or without denudation of affected skin). The facility identified a census of 28.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on observations, record reviews and interview; the facility staff failed to ensure a medication error rate of less than 5%. Observations of 25 opportunities of medication administration revealed 5 medication errors resulting in a medication error rate of 20%. The medication errors effected 2 (Resident 4 and 17). The survey had a total sample size of 19. The facility identified a census of 36.
- D
Ensure that residents are free from significant medication errors.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on record review and interview, the facility failed to ensure three doses of an intravenous (IV) antibacterial medication were not omitted for 1 (Resident 7) of 1 sampled resident. The facility identified a census of 36.
March 17, 2025Standard inspection, Complaint inspection · 11 citations
- F
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Inspectors wroteLicensure Reference 175 NAC 12-006.04(A)(iii)(2)(a) Based on record reviews and interview, the facility failed to complete a nurse aide registry check prior to hire as required for 5 [Nurse Aide (NA) - E, NA-O, Assistant Director of Nursing (ADON), Dietary Aide (DA) - A, and Dietary Supervisor (DS)] of 5 sampled employees. This had the potential to affect all residents who reside within the facility. The census was 36.
- F
Observe each nurse aide's job performance and give regular training.
Inspectors wroteLicensure Reference 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and interview, the facility failed to ensure 12 hours of ongoing training had been completed for the year for 5 [Nurse Aide (NA) - G, NA-H, NA- F, MA-I, and NA- K] of 5 sampled employees. This had the potential to affect all residents who reside within the facility. The facility identified a census of 36.
- 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 dispose of expired foods, clean dry storage area and freezer, failed to implement hand hygiene practices to prevent the potential for cross contamination, use hair and beard restraints, and obtain food temperatures prior to serving to prevent the potential for foodborne illness. This had the potential to affect all residents who ate from the kitchen. The facility census was 36 .
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteLicensure Reference 175 NAC 12-006.09(H)(i)(3) Based on observations, interviews, and record reviews, the facility failed to provide assistance with bathing services in order to maintain good hygiene for 3 (Residents 13, 15, and 16) of 3 sampled residents. The facility identified a census of 36.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteLicensure Reference 175 NAC 12-006.09 (I) Licensure Reference 175 NAC 12-006.19(A) Based on observations, interviews, and record reviews, the facility failed to: develop and implement interventions for Resident 32's falls, failed to ensure Resident 17's carpet was free from buckling to prevent the potential for an avoidable accident. The sample size was 4. The facility identified a census of 36.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteLicensure Reference 175 NAC 12-006.02(H) Based on record reviews and interviews, the facility failed to report allegations of staff-to-resident abuse to the required State agency within 2 hours involving 1 (Resident 33) of 1 sampled resident. The facility identified a census of 36.
- 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 notify 1 (Resident 17) of 1 sampled resident's representative in writing, as required, of the reason for Resident 17's transfer to the hospital. The facility census was 36. Findings Are: A record review of the facility policy Transfer or Discharge, Facility-Initiated with revision date of October 2022 revealed in the Policy Statement, Facility-Initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification. A record review of Resident 17's Progress Notes dated 3/7/25 revealed the resident had a change in condition, the facility had received an order from the provider to transfer the resident to the hospital for evaluation, and the facility called the resident's Power of Attorney (POA) and notified them that Resident 17 was being transferred. [...]
- 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 wroteBased on record review and interview, the facility failed to notify 1 (Resident 17) of 1 sampled resident's representative of the facility's bed hold policy at the time of Resident 17's transfer to the hospital. The facility census was 36. Findings Are: A record review of the facility policy Bed-Holds and Returns with a revision date of October 2022 revealed that all residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence. Residents, regardless of payer source, are provided written notice about these policies at least twice: -notice 1: well in advance of any transfer; and -notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours). [...]
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteLicensure Reference 175 NAC 12-006.09(F)(i) Based on record reviews and interview, the facility failed to develop a baseline care plan (BCP, a document that serves as initial instruction and guidance for the resident's care) within 48 hours as required by state regulations for 1 (Resident 139) of 7 sampled residents. The facility identified a census of 36.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteLicensure Reference 175 NAC 12-006.09(H)(iv)(5) Based on record reviews and interviews, the facility failed to follow their bowel protocol orders to prevent constipation for 2 (Residents 16 and 27) of 5 sampled residents. The facility identified a census of 36.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 (H)(vi)(3) Based on interviews and record review, the facility failed to administer oxygen as ordered by the physician to 1 of 1 (Resident 19) residents. The facility identified a census of 36.
January 6, 2025Complaint inspection · 2 citations
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteLicense Reference Number 175 NAC 12-006.02 (H) Based on record review and interview, the facility failed to submit their investigation of an incident within 5 working days as required for 1 (Resident 1) of 2 sampled residents. The facility identified a census of 37. Findings Are: A record review of a facility document titled Abuse, Neglect, or Misappropriation and dated 10/23/24, revealed Resident 1 had a fall with injury on 10/15/24 at 10:00 PM. The document further revealed the investigation was submitted to the State Agency on 10/23/24. An interview on 1/6/25 at 1:15 PM with the Administrator confirmed the facility did not submit their investigation of Resident 1's fall with injury that occurred on 10/15/24 to the State Agency within 5 working days as required.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteLicensure Reference175 NAC 12-006.09(I) Based on record reviews and interview, the facility failed to develop new interventions for falls for 1 (Resident 2) of 3 sampled residents. The facility identified a census of 37. Findings Are: A record review of a facility policy, Falls and Fall Risk, Managing, with a last revised date of March 2018 indicated if falls recur despite initial interventions, staff will implement additional or different interventions. A record review of an admission Record indicated the facility admitted Resident 2 on 5/27/2022 with diagnoses of history of falling, dystonia (a brain condition that causes uncontrollable muscle movement,) hemiplegia (weakness on one side of the body,) muscle weakness, unsteadiness on feet, and abnormalities of gait and mobility. [...]
April 24, 2024Standard inspection, Complaint inspection · 8 citations
- F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteLicensure Reference 175 NAC 12-006.11D Based on observations, interviews, and record reviews, the facility failed to prepare foods following the recipe to ensure nutritive value. This had the potential to affect all 41 facility residents that ate food prepared in the kitchen. The facility identified a census of 41.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteLicensure Reference 12-006.11E Based on observations, interviews, and record review, the facility failed to ensure foods were labeled, dated, and served within best by dates, and prepare food under sanitary conditions, the facility failed to ensure potentially hazardous foods of meat and dairy products were held at 135 degrees or higher on the steam table. This had the potential to affect all 41 residents that ate food prepared in the kitchen. The facility identified a census of 41 residents.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.10D Based on observations, interviews, and record reviews; the facility failed to maintain a medication error rate less than 5%, which affected 3 (Resident 8, Resident 16, and Resident 34) of 9 sampled residents. The medication error rate was 11.11%. The facility census was 41. A record review of facility policy Administering Medications with a last revised date of April 2019 revealed the following: - Medications are administered within one hour of their prescribed time. - Verify the right resident, right medication, right dosage, right time and right route. - The charge nurse must accompany new nursing personnel on their medication rounds for minimum of 3 days to ensure established procedures are followed and proper resident identification methods are learned. A. [...]
- 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 12-006.04C3a(6) Based on record review and interview; the facility failed to ensure to notify the physician of low blood pressures for 1 (Resident 2) of 5 residents who was on blood pressure medication. The facility census was 41 at the time of survey.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure completion of the admission Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) within the required time for 1 (Resident 95) resident. This affected 1 of 6 residents reviewed for MDS accuracy. The facility census at the time of the survey was 41.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09C1a Based on record review and interview; the facility failed to ensure that the written summary of the baseline care plan (written plan required to be developed within 48 hours of admission detailing the instructions needed to provide initial effective and person centered care of the resident that meet professional standards of quality care) for 1 (Resident 94) of 6 sampled residents. The facility census at the time of survey was 41.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteLicensure Reference 175 NAC 12-006.09D7b Based on interviews and record reviews; the facility failed to identify causative factors and implement new interventions to prevent falls for 1 (Resident 13) of 2 sampled residents. The facility identified a census of 41.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference 175 NAC 12-006.17 Based on observations and record review, the facility failed to implement infection control practices during medication administration for 3 (Resident 16, Resident 31, and Resident 95) of 9 sampled residents. The facility identified a census of 41. An observation on 4/22/2024 at 12:02 PM revealed Registered Nurse (RN) -C had prepared a insulin syringe with 6 units of insulin. RN-C then applied gloves. RN-C then touched the inner rim of the trash to throw away an empty box of gloves and did not change gloves after touching the inner rim of the trash can. RN-C then injected the insulin into Resident 16. An observation on 4/22/2024 at 12:12 PM revealed RN-C had dialed a insulin pen with 10 units of insulin. RN-C then applied gloves. RN-C had knocked and attempted to enter the room by turning the doorknob with the gloved hand. [...]
Fire safety inspections
7 fire safety citations on file: 2 on June 16, 2026, 3 on March 17, 2025, 2 on April 24, 2024.
Every fire safety citation7 citations
- F
Have simulated fire drills held at unexpected times.
K 712 · June 16, 2026 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 16, 2026 · Corrected (the home has a date of correction)
- F
Create arrangements with other facilities to receive patients.
E 25 · March 17, 2025 · Corrected (the home has a date of correction)
- F
Provide family notifications of emergency plan.
E 35 · March 17, 2025 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · March 17, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · April 24, 2024 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · April 24, 2024 · Corrected (the home has a date of correction)