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 28 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
16D
4E
5F
Potential for minimal harm
0A
0B
1C
April 14, 2026Standard inspection · 9 citations
- F
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.11Based on record review, observation, and interview the facility failed to ensure the amount of protein served at a meal was in the amount stated on the facility supplied menu for 32 residents (1, 3, 5, 6, 7, 10, 11, 12, 13, 14, 15, 16, 17, 18, 20, 21, 23, 25, 26, 27, 29, 30, 31, 32, 34, 35, 36, 37, 38, 39, 46, and 47) of 36 residents. The facility census was 36.
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D)Based on record review, observations, and interviews, the facility failed to ensure that the medication error rate was less than 5% with an actual medication error rate of 20% based on 25 observations. The facility census was 36. Record review of the facility policy Medication Errors dated 03/02/2026 revealed the purpose of the of the policy was to provide guidance in documenting and auditing medication errors. The location will have medication error rates of 5% or less and those residents are free of significant medication errors. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference Number 175 NAC 1-005.06(D)Licensure Reference Number 175 NAC 12-006.18(D)Based on record review, observations, and interviews, the facility failed to ensure that hand hygiene was completed during the administration of medications between each resident who received medications. This affected 8 of 8 sampled residents (Residents 30, 34, 3, 46, 47, 15, 26 and 39). The facility census was 36.
- 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 record review and interview, the facility failed to complete documentation of non pharmalogical interventions used prior to the administration of an as needed psychotropic medication for 1 resident (Resident 19) of 2 sampled residents. The facility census was 36.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(D)Based on record review and interview the facility failed to complete Care Area Assessments (a core component of the Resident Assessment Instrument(RAI), used in Medicare/Medicaid-certified nursing homes to evaluate a resident's functional status, identify potential care problems, and develop an individualized care plan (CAA's)) for 2 residents (Resident 9 and Resident 19) of 2 sampled residents. The facility census was 36.
- 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 NAC12-006.09 (F)Based on record review, observation, and interview, the facility failed to review and revise a residents care plan when the residents care needs changed for 1 resident (Resident 19) of 3 sampled residents. The facility census was 36.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09Based on record review and interview, the facility failed to follow a provider order to hold/not administer a medication based on ordered parameters for 1 resident (Resident 9) of 1 sampled residents. The facility census was 36.
- D
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 review and interview the facility failed to provide care and services to promote regular bowel movements for 1 resident (Resident 19) of 2 sampled residents. The facility census was 36.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)Based on observation, record review, and interview the facility failed to ensure that it implemented care and services for hemodialysis (a life-sustaining medical treatment that filters waste, toxins, and excess fluids from the blood when the kidneys have failed) resident nutrition as required for 1 of 1 resident reviewed (Resident 3). The facility census was 36.
April 16, 2025Complaint inspection · 2 citations
- J
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 reviews and interviews, the facility failed to follow physician orders for 1 of 4 sampled residents (Resident 1). The facility census was 42. The facility Administrator was notified on 4/16/25 at 7:48 PM of an Immediate Jeopardy (IJ) which began on 3/18/25. The IJ was removed on 4/16/25, as confirmed by surveyor onsite verification.
- J
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 Based on record reviews and interviews, the facility failed to ensure pharmacy provided medications for 1 of 4 sampled residents (Resident 1). The facility census was 42. The facility Administrator was notified on 4/16/25 at 7:48 PM of an Immediate Jeopardy (IJ) which began on 3/18/25. The IJ was removed on 4/16/25, as confirmed by surveyor onsite verification.
January 28, 2025Standard inspection, Complaint inspection · 12 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 observation, record review, and interview the facility failed to ensure they had either a full time Registered Dietitian (RD) or that the Director of food and nutritional services met the regulatory requirements. This had the potential to affect all 41 residents who consumed foods prepared in the facility kitchen. The facility census was 41.
- F
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 that staff performed hand hygiene as required and did not place potentially soiled hangers in the clean linen cart during laundry delivery service to prevent the potential for cross-contamination for 21 (Residents 9, 37, 25, 20, 192, 15, 24, 29, 18, 26, 32, 33, 7, 13, 10, 1, 14, 16, 91, 30, 21) of 21 residents observed. The facility census was 41.
- F
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(B)(i) Based on record review, and interview the facility failed to ensure staff completed initial orientation per facility policy for 1 of 5 sampled staff members. This had the potential to affect all residents who resided within the facility. The facility census was 41. Findings Are: A record review of a facility policy titled Orientation and dated 07/21/2023 revealed orientation must be completed with in 30 days of the employee's start date. A record review of an untitled document supplied by the facility on 01/28/2025 revealed Registered Nurse (RN)-F's date of hire was listed as 06/25/2024. A record review of a document supplied by the facility on 1/28/2025 titled General Staff Nurse Pathway revealed RN-F's name and a start date of 05/31/2025. [...]
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review, observation, and interview the facility failed to report an accident with major injury within the required time frames for 1 (Resident 31) of 2 sampled residents. The facility states census of 41. Record review of a facility policy titled Fall Prevention and Management dated 07/29/24 revealed to report to the state and regulatory agency when appropriate. A review of an admission Record indicated the facility admitted Resident 31 on 08/30/23 with diagnoses of dementia (which is a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior), history of falls, and atrial fibrillation (which is when the heart has an irregular rhythm). [...]
- 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 Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) accuracy related to psychotropic medication use for one (Resident 13) of one sampled resident. The facility identified a census of 41.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(vi) Based on record review and interview, the facility failed to develop a care plan with measurable goals and interventions to address the care and treatment for residents with dementia for 2 (Residents 31 and 35) of 2 sampled residents. The facility census was 41.
- D
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Inspectors wroteBased on record review and interviews, the facility failed to provide life saving measures to a resident who desired cardiopulmonary resuscitation (CPR, a lifesaving attempt combination of rescue breathing and chest compressions when someone's heart has stopped ) for 1 (Resident 39) of 42 residents sampled. The facility census was 41.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteLicensure Reference Number 175 NAC 12.006.09D3(5) Based on record review and interview, the facility failed to ensure bowel care management was provided to prevent constipation for one (Resident 30) of two sampled residents. The facility identified a census of 41.
- 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 record review, observation, and interview the facility failed to use cause analysis to place intervention to prevent accidents for 1 (Resident 35) of 2 sampled residents to prevent accidents. Facility states census of 41.
- D
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the frequency of physician visits were completed within federal guidelines. This affected 2 residents, Resident 31 and Resident 35. The facility census was 41. Findings Are: A facility policy titled, Physicians Visits-Rehab/Skilled, dated 03/04/2024, was reviewed. The policy revealed the procedure: -Timing of physician's visits is based on the admission date of the resident. -Visits are required every 30 days for the first 90 days. -After 90 days, physician visits are required every 60 days. -Physician visits are considered timely if the visit occurs no later than 10 days after the due date. -The date these time periods are calculated from does not change due to a late visit. The dates continue to be calculated from the admission and thus, would be due in a shorter period if visits were made late. [...]
- 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(B)(3) Based on observation, interview and record review; the facility failed to ensure that medications were administered per facility policy for 1 (Resident 28) of 3 sampled residents. The facility identified a census of 41.
- 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 12.006.09B(8)(b) Based on interview and record review the facility failed to ensure behavior monitoring and documentation supported the use of psychotropic medications and that there was clinical rationale when a gradual dose reduction was not done for a psychotropic medication for 1 (Resident 13) of 5 sampled residents. The facility identified a census of 41. Findings Are: A. A record review of Resident 13's admission Record, reviewed on 1/22/25, revealed that Resident 13 had been admitted into the facility on 2/9/24 with a primary diagnosis of hemiplegia (paralysis or weakness on one side of the body). [...]
February 5, 2024Standard 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 12-006.11E Based on observation, record review, and interview, the facility failed to distribute and serve food in a manner to prevent food borne illness and ensure dishes and utensils were cleaned in a sanitary manner. This had the potential to affect 34 residents. The facility census was 34.
- 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 wroteLicensure Reference Number 175 NAC 12-006.18A Based on observation, record review, and interview, the facility failed to 1) ensure mechanical lifts were kept clean, 2) ensure the bathroom vents were clean in rooms 101, 102, 103, 105, 106, 107, 109, 3) ensure toilet bowls were clean in rooms [ROOM NUMBER], and 3) ensure the 200 bath house linoleum was in a safe, clean, homelike condition. The facility census was 34.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.04A2a Licensure Reference Number 175 NAC 12-006.17D Based on record review and interview, the facility failed to ensure that pre-employment health screens were completed for 5 of 8 sampled staff as required to prevent the potential for the spread of infectious disease and failed to provide personal cares to prevent the potential for cross contamination to 1 Resident (Resident #9) of 5 sampled residents. This had the potential to affect all facility residents. The facility census was 34.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on observation, record review, and interview the facility failed to provide bathing as required for 1 resident (Resident 20) of 5 sampled residents. The facility census was 34.
- C
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteLicensure Reference Number 175NAC 12-006.04A3b Based on observation, record review, and interview the facility failed to ensure that pre-employment screens were completed to prevent the potential for abuse and neglect for 1 of 8 sampled staff. The facility census was 34.
Fire safety inspections
14 fire safety citations on file: 5 on April 14, 2026, 5 on January 28, 2025, 4 on February 5, 2024.
Every fire safety citation14 citations
- F
Meet other general requirements.
K 200 · April 14, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · April 14, 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 · April 14, 2026 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · April 14, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · April 14, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 28, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 28, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · January 28, 2025 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · January 28, 2025 · 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 28, 2025 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · February 5, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 5, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · February 5, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 5, 2024 · Corrected (the home has a date of correction)