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 7 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
5D
0E
2F
Potential for minimal harm
0A
0B
0C
August 21, 2025Standard inspection · 3 citations
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H). Based on record review and interview the facility failed to ensure daily weights were obtained for 1 (Resident 1) of 1 sampled resident and failed to implement neurological evaluations after an unwitnessed fall for 1 (Resident 3) of 4 sampled residents. The facility staff identified a census of 40.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iv)(4) Based on observation, interview and record review the facility failed to secure a catheter in a manner to prevent skin trauma for 1 (Resident 29) of 1 residents sampled. The facility census was 40.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.10DBased on observation, interview and record review the facility failed to ensure a medication error rate of 5% of less, as evidenced by 3 errors out of 25 opportunities for error resulting in a 12% medication error rate. The facility census was 40.
July 23, 2024Standard inspection · 4 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 a sanitary environment, equipment, and food storage spaces were maintained in a manner to prevent potential food borne illness. This had the potential to affect 37 of 38 residents that consumed food from the kitchen.
- F
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Licensure Reference Number 175 NAC 12-006.18(D) Based on observation, interview, and record review, the facility failed to ensure contaminated laundry and linens were contained during transport and the laundry carts were sanitized, wear required Personal Protective Equipment (PPE) during laundry sorting, and clean laundry and linens were transported without touching staff clothing to prevent cross contamination, this had the potential to affect all residents in the facility. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteLicensure Reference Number 175 NAC 12.006.09 Based on observation, interview, and record review, the facility failed to ensure wound care was completed as ordered for 1 (Resident 2) of 2 sampled residents. The facility census was 38.
- 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 interview; the facility staff failed to implement non-phrampharmocological interviews prior to administering a as needs medication for 1 (Resident 18) of 5 sampled residents. The facility census was 38. A review of the facilities policy dated 2023 and named Use of Psychotropic Medication Guideline revealed that PRN medications shall be documented with a rationale in the resident medical record. Also the indications for initiating as well as the use of non-pharmacological approaches be determined by assessing the residents underlying condition current signs, symptoms, expressions, and preferences and goals for treatment. A record review of resident Clinical Resident Profile dated 7/18/24 Revealed Resident 18 was admitted on [DATE]. [...]
August 15, 2023Standard inspection · 0 citations
Fire safety inspections
22 fire safety citations on file: 2 on August 21, 2025, 18 on July 23, 2024, 2 on August 15, 2023.
Every fire safety citation22 citations
- 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 · August 21, 2025 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · August 21, 2025 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · July 23, 2024 · Corrected (the home has a date of correction)
- F
Use approved construction type or materials.
K 161 · July 23, 2024 · 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 · July 23, 2024 · Corrected (the home has a date of correction)
- F
Install proper backup exit lighting.
K 281 · July 23, 2024 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · July 23, 2024 · 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 · July 23, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · July 23, 2024 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · July 23, 2024 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 500 · July 23, 2024 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · July 23, 2024 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · July 23, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · July 23, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · July 23, 2024 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · July 23, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 23, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · July 23, 2024 · Corrected (the home has a date of correction)
- E
Meet requirements for the use and maintenance of medical gas equipment.
K 922 · July 23, 2024 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · July 23, 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 · August 15, 2023 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · August 15, 2023 · Corrected (the home has a date of correction)