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 13 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
1F
Potential for minimal harm
0A
0B
0C
April 22, 2025Standard inspection · 1 citation
- 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 12-006.09(H) Based on record review and an interview, the facility failed to ensure an as needed psychotropic medication (work by altering brain chemistry) had a 14-day stop date as required for Resident 18. This affected 1 of 3 residents review for unnecessary medication use. The facility census was 85. Findings Are: A record review of the facility policy Use of Psychotropic Medication Guideline with a date implemented of 2023 revealed: [...]
May 14, 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 observations, interviews, and record review; the facility failed to ensure food items were dated upon opening to prevent the potential for food borne illness, this had the potential to affect 85 of 85 residents who ate meals from the kitchen. The facility identified a census of 85.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteLicensure Reference Number 175 NAC 12.006.09D6(7) Licensure Reference Number 175 NAC 12.006.09D6(5) Licensure Reference Number 175 NAC 12.006.09D3(5) Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 32) of 5 sampled resident's physician order was followed to add oxygen to keep oxygen saturations greater than 90%, ensure 1 (Resident 36) of 1 sampled resident's fluid intake restriction was followed per physician's order, failed to prevent constipation for 2 (Residents 7 and 27) of 3 sampled residents, and failed to follow physician orders regarding medication parameters for 1 (Residents 8) of 5 sampled residents. The facility census was 85.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteE. A record review of Resident 30's Clinical Census page printed 05/13/2024 revealed the resident was admitted on [DATE]. A record review of Resident 30's Medical Diagnosis list printed 05/09/2024 revealed the resident had diagnoses of obstructive sleep apnea (OSA-a sleep disorder that occurs when throat muscles relax and block the flow of air into your lungs while you sleep), and central cord syndrome (CCS-an incomplete spinal cord injury) at level C2 (C2 is one of the top bones in the spine. Someone with a CCS at this level is at risk of developing breathing problems). [...]
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteLicensure Reference 175 NAC 12-006.09B Based on record review and interviews; the facility failed to ensure the accuracy of the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) for Resident 73 regarding discharge and for Resident 62 regarding the presence and use of a feeding tube. This affected 2 of 19 residents sampled for MDS accuracy. The facility census was 85.
- 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 record review and interviews; the facility failed to complete a discharge summary including a recapitulation of stay for Resident 73. This affected 1 resident sampled for discharge. The facility census was 85.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D Based on record review and interviews; the facility failed to ensure residents were free from unnecessary medications related to giving acetaminophen (a medication used to treat minor aches and pains and reduce fever) over the recommended daily dosages for 1 (Resident 175) of 5 sampled residents. The facility identified a census of 85.
- 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 12-006.12E1 Based on observation, interviews and record review, the facility failed to secure two medications for 1 (Resident 7) of 4 sampled residents. Facility identified census of 85.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D3(1), 12-006.09D6(7) Based on observations, record reviews and interviews, the facility failed to ensure indwelling catheter (a tube inserted into the bladder to drain urine) cares were performed in a manner to prevent urinary tract infections (UTIs) for Resident 63, failed to ensure the Continuous Positive Airway Pressure (CPAP-a machine that delivers just enough air pressure to a mask worn over the nose or mouth to keep the upper airway passages open) mask was cleaned daily, and failed to ensure the nasal cannulas (a device that delivers supplemental oxygen through a tube and into the nose) for Residents 36 and 175 were stored when not in use in a manner to prevent cross contamination. This affected 3 of 10 resident sampled for infection control. The facility census was 85.
June 21, 2023Standard inspection · 4 citations
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteSurveyor: [NAME], [NAME] Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on interview and record review, the facility staff failed to notify 1 (Resident 60) of 3 sampled residents representative of an injury. The facility identified a census of 80.
- 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 ensure a non-slip material was placed above and below a pressure relieving cushion in the recliner to prevent a fall for 1 (Resident 47) of 6 sampled residents. Total facility census was 80.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D Based on record review and interview; the facility failed to ensure non-pharmacological interventions were attempted prior to administration of an as needed (PRN) pain medication for 1 (Resident 43) of 5 sampled residents. The facility census was 80.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.17D Based on observation, interview, and record review, the facility failed to ensure 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( Residents 47) of 3 sampled residents . The facility census was 80.
Fire safety inspections
20 fire safety citations on file: 2 on April 22, 2025, 3 on May 14, 2024, 15 on June 21, 2023.
Every fire safety citation20 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 22, 2025 · Corrected (the home has a date of correction)
- E
Meet requirements for the use and maintenance of medical gas equipment.
K 922 · April 22, 2025 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · May 14, 2024 · 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 · May 14, 2024 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · May 14, 2024 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · June 21, 2023 · 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 · June 21, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 21, 2023 · Waiver
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 21, 2023 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · June 21, 2023 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 21, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · June 21, 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 · June 21, 2023 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · June 21, 2023 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · June 21, 2023 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · June 21, 2023 · Corrected (the home has a date of correction)
- E
Provide a written emergency evacuation plan.
K 711 · June 21, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · June 21, 2023 · Corrected (the home has a date of correction)
- D
Install an approved automatic sprinkler system.
K 351 · June 21, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · June 21, 2023 · Corrected (the home has a date of correction)