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 8 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
6D
1E
1F
Potential for minimal harm
0A
0B
0C
April 15, 2026Standard inspection · 4 citations · risk-based survey (a shorter visit CMS gives only to higher performing homes)
- E
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 (B & D)Licensure Reference Number 175 NAC 1-005.06(D)Based on observation, interview, and record review, the facility failed to ensure staff followed hand washing and gloving practices following cares for 2 (Resident 2 and 3) of 2 sampled residents; failed to ensure staff donned (applied) and doffed (removed) required personal protective equipment (PPE) while working with a resident in contact isolation for 1 (Resident 2) of 1 sampled residents; failed to ensure staff did not allow potentially contaminated surfaces to contact staff clothing; and failed to sanitize potentially contaminated resident care equipment after use. This had the potential to affect all 24 residents who resided on the secured unit.
- 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 interview, the facility failed to update the care plan with new interventions to prevent the potential for accidents for 1 (Resident 23) of 2 sampled residents. Facility staff identified a census of 95.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(vi)(3)Based on record review, observation, and interview, the facility failed to obtain an order for tube feeding that included the formula type and strength and failed to record the amount of tube feeding administered for 1 (Resident 2) of 2 sampled residents. Facility staff identified a census of 95.
- D
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on interview and record review, the facility failed to ensure the initial comprehensive and alternating regulatory visits for 2 (Residents 2 and 3) of 2 sampled residents were completed by a physician. The facility census was 95.
November 18, 2025Complaint inspection · 1 citation
- 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)(6)Based on interview and record review the facility failed to change an indwelling catheter and monitor post void residuals for 1(Resident 1) of 3 residents sampled. The facility census was 93.
October 31, 2024Standard inspection · 2 citations
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.08 Based on interview and record review, the facility failed to notify a resident's medical practitioner of a significant weight loss for one (Resident 8) of one sampled resident. The facility census was 71.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference Number 175 NAC 12.006.17B Based on observation, interview, and record review, the facility staff failed to sanitize multiple resident use equipment when exiting an Enhanced Barrier Precaution room for 1 (Resident 24) of 1 sampled residents, and failed to store oxygen tubing to prevent potential cross contamination for 1 (Resident 18) of 1 sampled residents. The facility identified a census of 71.
September 6, 2023Standard inspection · 1 citation
- 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 12-006.11D Licensure Reference Number 12-006.17D Based on observation, interview and record review, the facility failed to ensure proper hand hygiene was performed during food preparation and assisting residents with eating, maintain a fan in clean condition in the kitchen, and failed to store foods in a manner to prevent cross-contamination. The facility failure had the potential to affect all residents. The facility identified a census of 85.
Fire safety inspections
8 fire safety citations on file: 2 on April 15, 2026, 2 on October 31, 2024, 4 on September 6, 2023.
Every fire safety citation8 citations
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 15, 2026 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · April 15, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · October 31, 2024 · Corrected (the home has a date of correction)
- E
Meet requirements for the use and maintenance of medical gas equipment.
K 922 · October 31, 2024 · Corrected (the home has a date of correction)
- F
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · September 6, 2023 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · September 6, 2023 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · September 6, 2023 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · September 6, 2023 · Corrected (the home has a date of correction)