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 36 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
32D
3E
1F
Potential for minimal harm
0A
0B
0C
April 23, 2026Complaint inspection · 5 citations
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interviews, record review and document review, the facility failed to ensure residents were free from physical abuse for four sampled residents (Residents 1, 4, 5 and 10). The deficient practice placed other residents at risk of being physically abused.
- E
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on interview, record, and document review, the facility failed to:1) provide a trauma evaluation after a physical abuse incident for 2 of 10 sampled residents (Residents 1 and 4), and2) implement meaningful interventions for 2 residents (Residents 2 and 5) with psychiatric histories, aggressive behaviors, and refusal of prescribed psychotropic medications. These failures placed residents at risk for mental and emotional harm and increased the risk of physical abuse.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews and document review, the facility failed to ensure allegations of physical abuse were reported to the state agency in a timely manner for four sampled residents (Residents 1, 4, 6 and 10). The deficient practice had the potential to place residents at risk from abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview, record review, and document review, the facility failed to investigate an incident of physical abuse for 1 of 10 sampled residents (Resident 10). The deficient practice placed other residents at risk for abuse.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a resident's care plan was developed for a newly identified wandering behavior for 1 of 10 sampled residents (Resident 1). The deficient practice placed the resident at risk for a repeat resident to resident altercation.
November 18, 2025Complaint inspection · 2 citations
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure a resident was safely discharged to a facility which could meet the care needs of the resident for 1 of 5 sampled residents (Resident 2). The deficient practice had the potential to result in the resident's care needs not being met.
- D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure a resident with severe cognitive impairment received a competency assessment to determine decision-making capacity and the need for a guardian or representative for 1 of 5 sampled residents (Resident 2). The deficient practice had the potential for a severely cognitive impaired resident to not understand or make an informed decision on the care and treatment being provided.
June 27, 2025Standard inspection · 6 citations
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure consents for psychotropic medications were not obtained from a resident who was assessed to have severely impaired cognition for 1 of 19 sampled residents (Resident 79). The deficient practice potentially deprived the resident and the resident's representative the right to be informed of the medications' purpose, risks, benefits and potential side effects.
- 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 wroteBased on observation, interview, record review, and document review, the facility failed to ensure enteral feeding and water flush orders administered through the gastrostomy tube (GT) were followed as ordered, and the total volume delivered was monitored and documented for 1 of 26 sampled residents (Resident 34). This deficient practice had the potential to result in inadequate nutritional and fluid intake, leading to malnutrition, dehydration, electrolyte imbalances, delayed wound healing, and increased susceptibility to infections.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure staff foods were stored properly and frozen meat was thawed correctly. This deficient practice posed a potential risk to safety and health standards which could lead to contamination and placed residents at risk of foodborne illness.
- D
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Inspectors wroteBased on interview and document review, the facility failed to ensure dementia training was provided for 3 of 11 employee files reviewed (Employees 4, 5, and 8) as outlined in Nevada Administrative Code (NAC) 449.74522
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure visitors and staff wore appropriate personal protective equipment (PPE) and hand hygiene had been performed when cleaning a room under transmission-based precautions (TBP). These deficient practices had the potential to expose residents, staff, and visitors to infectious agents and compromise the facility's infection prevention and control measures.
- D
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on interview and document review, the facility failed to ensure abuse training was provided in accordance with the facility assessment and facility policy for 3 of the 11 employee files reviewed (Employees 4, 5, and 8). The deficient practice had the potential to allow unqualified employees to provide care for residents.
March 12, 2025Complaint inspection · 3 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a resident was kept safe from physical abuse for 1 of 5 sampled residents (Resident 2) and a resident was protected from abuse by another resident with increasingly aggressive behaviors for 1 of 5 sampled residents (Resident 4). The deficient practice had the potential for the residents to experience emotional and physical harm.
- 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 wroteBased on observation, interview and document review, the facility failed to ensure medications left on top of a medication cart were secured. The deficient practice had the potential risk of unauthorized access to medications, medication errors, theft, or misuse of medication within the facility.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview, the facility failed to ensure a blood glucose monitor with a used test strip was not left unattended on top of medication cart. The deficient practice had the potential to compromise the safety and well-being of residents by allowing exposure to blood borne pathogens.
August 29, 2024Complaint inspection · 1 citation
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure showers were provided as scheduled for 1 of 8 sampled residents (Resident 1). The deficient practice had the potential to negatively impact the resident's overall well-being.
May 10, 2024Standard inspection, Complaint inspection · 10 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and document review, the facility failed to ensure food items stored inside the stand-alone cooler and freezer were labeled, dated, and not expired; containers for juice machine were stored according to manufacturer instruction; items in the unit nourishment rooms were labeled, dated, and not expired. The deficient practice posed a potential risk to safety and health standards which could lead to contamination, inadequate storage, and place residents at risk of foodborne illness.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteResident 28 (R28) R28 was re-admitted on [DATE], with primary diagnoses including anxiety disorder, depression, bipolar disorder, schizophrenia, and a psychotic disorder (other than schizophrenia). On 05/07/2024 in the morning, R28 laid in bed with eyes on telephone with headphones on. R28 appeared lethargic and spoke stating R28 had been in the facility for a little while. The resident was able to make needs known asking about the ability to smoke marijuana in the facility and being able to use a power wheelchair in the facility. On 05/08/2024 in the afternoon, R28 laid in bed with eyes on telephone with headphones on and appeared lethargic. While talking to the resident about the facility's policy on no marijuana smoking, R28 was not able to talk in complete sentences and was not making sense. R28 was talking nonsensical. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interviews, record reviews, and document review, the facility failed to ensure the medication administration record was not signed off before the medications were administered for 2 of 20 sampled residents (Residents 75 and 246). The deficient practice could have the potential risk to resident safety, medication errors, missed doses, or incorrect dosages, and adverse health outcomes.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observations, interviews, record reviews, and document reviews, the facility failed to ensure: 1) A resident's wound was cleansed, dressing was replaced or applied as ordered when the wound was soaked with urine and feces for 1 of 20 sampled residents (Resident 70), and 2) The wound treatment orders were obtained and transcribed before the treatment was provided for 1 of 20 sampled residents (Resident 55). The deficient practice could have the potential to cause delayed healing, worsened wounds, infection, and further complications. Findings Include: Resident 70 (R70) R70 was admitted on [DATE] and readmitted on [DATE], with diagnoses including pressure-induced deep tissue damage of the sacral region and the presence of a right artificial hip joint. [...]
- 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 wroteBased on observations, interviews, record reviews, and document review, the facility failed to ensure: 1) The formula bag or container was labeled with the resident's name, TF rate, date/time, and nurse's initials as ordered, 2) A physician's order of the tube feeding (TF) rate was obtained and transcribed for 1 of 20 sampled residents (Resident 55) and, 3) The care orders for the gastrostomy (GT) site and dressing change were obtained, transcribed, and implemented for 1 of 20 sampled residents (Resident 55). These deficient practices could have led to complications such as ineffective nutrition, aspiration, or infection, jeopardizing the resident's health and well-being.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure care and management orders were obtained, transcribed, and carried out for residents who were admitted with an intravenous (IV) access for 2 of 19 sampled residents (Residents 65 and 245). The deficient practice placed the residents at risk for an infection.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observations, interviews, record reviews, and document review, the facility failed to ensure the resident's arteriovenous fistula (AVF) for dialysis access was assessed, a physician order was obtained, and the bruit/thrill was monitored for 1 of 20 sampled residents (Resident 70). This deficient practice posed a potential risk of infection and ineffectiveness in dialysis treatment.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observations, interviews, record reviews, and document reviews, the facility failed to ensure their medication error rate was below five (5) percent (%) when two errors were identified with 25 opportunities observed, calculating an error rate of 8 %. Failure to follow physician orders and timely administer medications posed a potential risk of injury or harm to the resident.
- D
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on interview and document review, the facility failed to ensure the facility assessment was reviewed and updated when staffing levels were reduced beginning October 2023, and the input of department heads were taken into consideration in accordance with the facility's policy. The deficient practice had the potential to ensure resident's care needs were met.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure 1 of 20 sampled residents (Resident 101) was free of abuse by a staff member, specifically, an incident involving a staff member who was witnessed to have pushed a resident, which resulted in a fall. The deficient practice had the potential to cause physical harm to the resident.
June 29, 2023Standard inspection · 9 citations
- E
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a pre-admission screening and resident review (PASSAR) was completed prior to admission for 6 of 31 sampled residents (Residents #68, #4, #284, #79, #76 and #75) and 11 unsampled residents. The deficient practice potentially placed residents at risk for inappropriate placement with regards to required level of care.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a consent for a Do Not Resuscitate order was obtained from a person holding a legal power of attorney for medical decision-making for a resident with cognitive impairment for 1 of 31 residents (Resident #140). The deficient practice had the potential to deny the provision of emergency medical treatment, the right to request, deny, or discontinue treatment, and to formulate an advance directive.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure the accuracy of the admission nursing assessment by reflecting the actual vision and hearing health impairments for 1 of 31 sampled resident (Resident #140). The deficient practice had the potential to deny the provision of vision and hearing services to improve the quality of life of the resident.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a baseline care plan included the actual vision and hearing impairment status for 1 of 31 residents (Resident #140). The deficient practice had the potential to deny the provision of vision and hearing services to improve the quality of life of the resident.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure 1) a resident with wandering behaviors was re-assessed for wandering and elopement behaviors for 1 of 31 sampled residents (Resident #79) and 2) a resident with swallowing issues who required one-on-one assistance with meals was provided assistance for 1 of 31 sampled residents (Resident #235). The deficient practice placed the residents of concern and other residents at risk for unsafe wandering, elopement, and aspiration.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure clarification orders were obtained for a resident's peripheral intravenous (IV) access which was no longer in use and maintenance care orders were consistently provided for the resident's IV line prior to removal. The deficient practice placed the resident at risk for phlebitis (site infection).
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a physician's order was followed for oxygen therapy for 1 of 31 sampled residents (Resident #334). The deficient practice had the potential to impact the well-being of the resident.
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure dietary orders were followed for a resident with mechanically textured diet and a history of weight loss for 1 of 31 sampled residents (Resident #15). This deficient practice placed the resident at risk for choking and weight loss.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food products were labeled, proper sanitation was being utilized for three-compartment sink and juice beverage station, dishwasher was properly cleaned, and nourishment room was free from pests. The failure had the potential to put residents at the facility at risk for receiving contaminated food or drinks. On 06/27/2023 at 7:40 AM the stand alone freezer contained a food product which was removed from box and sitting on shelf in plastic, dated, no label to identify product. On 06/27/2023 at 7:45 AM, the dietary aide was working at the three compartment sink and was not able to describe correct sequence for cleaning the dishes using the three compartment sink. There was no sanitizer being utilized and only had water with soap in the middle section of the sink. [...]
Fire safety inspections
33 fire safety citations on file: 8 on June 27, 2025, 10 on May 10, 2024, 15 on June 29, 2023.
Every fire safety citation33 citations
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 27, 2025 · no revisit needed
- F
Have properly installed electrical wiring and gas equipment.
K 511 · June 27, 2025 · no revisit needed
- E
Address subsistence needs for staff and patients.
E 15 · June 27, 2025 · no revisit needed
- E
Develop a communication plan.
E 29 · June 27, 2025 · no revisit needed
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · June 27, 2025 · no revisit needed
- D
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 · June 27, 2025 · no revisit needed
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · June 27, 2025 · no revisit needed
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · June 27, 2025 · no revisit needed
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · May 10, 2024 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · May 10, 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 · May 10, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · May 10, 2024 · Corrected (the home has a date of correction)
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · May 10, 2024 · Corrected (the home has a date of correction)
- D
Develop a communication plan.
E 29 · May 10, 2024 · Corrected (the home has a date of correction)
- D
Provide family notifications of emergency plan.
E 35 · May 10, 2024 · Corrected (the home has a date of correction)
- D
Establish emergency prep training and testing.
E 36 · May 10, 2024 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · May 10, 2024 · Corrected (the home has a date of correction)
- D
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · May 10, 2024 · Corrected (the home has a date of correction)
- E
Conduct risk assessment and an All-Hazards approach.
E 6 · June 29, 2023 · Corrected (the home has a date of correction)
- E
Develop Emergency Preparedness policies and procedures.
E 13 · June 29, 2023 · Corrected (the home has a date of correction)
- E
Develop a communication plan.
E 29 · June 29, 2023 · Corrected (the home has a date of correction)
- E
Establish emergency prep training and testing.
E 36 · June 29, 2023 · Corrected (the home has a date of correction)
- E
Establish staff and initial training requirements.
E 37 · June 29, 2023 · Corrected (the home has a date of correction)
- E
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 29, 2023 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 29, 2023 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 29, 2023 · Corrected (the home has a date of correction)
- D
Implement emergency and standby power systems.
E 41 · June 29, 2023 · Corrected (the home has a date of correction)
- D
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 · June 29, 2023 · Corrected (the home has a date of correction)
- D
Install a fire alarm system that can be heard throughout the facility.
K 341 · June 29, 2023 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · June 29, 2023 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · June 29, 2023 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 29, 2023 · Corrected (the home has a date of correction)
- D
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K 926 · June 29, 2023 · Corrected (the home has a date of correction)