Inspection Reports for Alzheimer’s Luxury Care

2951 Viking Road, Las Vegas, NV 89121, NV, 89121

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Deficiencies per Year

24 18 12 6 0
2008
2009
2010
2011
2012
2013
2014
2015
2019
2020
2021
2022
2023
2024
2025
Severe High Moderate Low Unclassified

Census Over Time

0 4 8 12 16 Dec '08 Jan '12 Jan '13 Dec '13 Dec '19 Feb '23 Mar '25
Census Capacity
Inspection Report Routine Census: 10 Capacity: 10 Deficiencies: 6 Mar 27, 2025
Visit Reason
The inspection was a mandatory grading resurvey conducted on 03/27/25 to assess compliance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.
Findings
The facility received a grade of A but had several regulatory deficiencies including failure to notify the Bureau of a Change of Ownership, poor maintenance of the exterior and backyard area, and medication administration and storage issues. Corrective actions were planned or underway for these deficiencies.
Severity Breakdown
Severity: 2: 2 Severity: F: 4
Deficiencies (6)
DescriptionSeverity
Failure to notify the Bureau and submit documentation for a Change of Ownership following new ownership since December 2024.Severity: 2
Facility failed to ensure the exterior was properly maintained and free of debris and broken equipment, including a dirty swimming pool with green water.Severity: 2
Failure to maintain proper records of medication administration including type, date/time, refusals, instructions, changes, and mistakes.Severity: F
Medication storage not compliant with requirements for locked, cool, and dry areas, and protection from misuse.Severity: F
Failure to ensure safety standards for Alzheimer's care including securing dangerous items and maintaining a fenced, safe outdoor area with adequate space.Severity: F
Failure to develop and implement policies concerning preferred names and pronouns, and adaptation of records to reflect gender identities or expressions.Severity: F
Report Facts
Licensed beds: 10 Resident census: 10 Repeat deficiency count: 1 Backyard space requirement: 40
Employees Mentioned
NameTitleContext
Basilia CasibangAdministratorNamed in relation to monitoring and follow-up on Change of Ownership and facility maintenance
Inspection Report Annual Inspection Census: 10 Capacity: 9 Deficiencies: 7 Jan 21, 2025
Visit Reason
The inspection was conducted as part of an annual State Licensure and complaint investigation surveys at the facility on 01/21/25, including investigation of one substantiated complaint.
Findings
The facility was found to have multiple deficiencies including failure to notify the Bureau of a Change of Ownership, presence of rodent droppings in resident areas, improper medication administration documentation, unsecured refrigerated medications, unsecured knives in the kitchen, an unlocked exterior gate leading to the street, and lack of documentation of residents' preferred pronouns, gender expression, and sexual orientation.
Complaint Details
One complaint (#NV00072785) was investigated and substantiated, related to the presence of rodent feces in resident areas.
Severity Breakdown
Level 1: 1 Level 2: 6
Deficiencies (7)
DescriptionSeverity
Failure to notify the Bureau and submit documentation for a Change of Ownership following new ownership.Level 1
Presence of rodent droppings in a resident common area accessible to residents, not properly cleaned and sanitized.Level 2
Medication Administration Records (MAR) not properly initialed for administration of medications for 3 residents.Level 2
Refrigerated medications were found unsecured with the key left in the lock box inside an unlocked refrigerator.Level 2
A kitchen drawer containing multiple knives was found unlocked and unsecured.Level 2
An exterior gate leading from the backyard to the street was found unlocked and unsecured.Level 2
Facility lacked updated policies and documentation of residents' preferred pronouns, gender expression, and sexual orientation in resident records.Level 2
Report Facts
Licensed beds: 9 Resident census: 10 Deficiency severity counts: 1 Deficiency severity counts: 6
Employees Mentioned
NameTitleContext
Basilia CasibangAdministratorConfirmed Change of Ownership, participated in interviews, and responsible for corrective actions.
Inspection Report Annual Inspection Census: 8 Capacity: 9 Deficiencies: 1 Feb 23, 2024
Visit Reason
The inspection was conducted as an annual State Licensure survey of the facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. One regulatory deficiency was identified related to improper storage of frozen food, where multiple frozen food items had accumulated ice crystals indicating they were not held at proper temperatures.
Severity Breakdown
2: 1
Deficiencies (1)
DescriptionSeverity
Facility failed to ensure frozen food was used or discarded prior to accumulating ice crystals, indicating improper temperature control and storage.2
Report Facts
Deficiency severity scope: 3
Employees Mentioned
NameTitleContext
Chris C. TanAdministratorConfirmed the presence of frozen food with ice crystals and acknowledged the issue
Inspection Report Renewal Census: 9 Capacity: 9 Deficiencies: 0 Aug 29, 2023
Visit Reason
The inspection was conducted as a bed increase State Licensure survey to evaluate the facility's application to add one bed, increasing total capacity from 9 to 10 beds.
Findings
No regulatory deficiencies were identified during the survey. No further action was necessary.
Report Facts
Bed capacity increase: 1
Inspection Report Annual Inspection Census: 7 Capacity: 9 Deficiencies: 0 Feb 22, 2023
Visit Reason
The inspection was conducted as an annual State Licensure and infection control survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the survey. The facility received a grade of A and no further action was necessary.
Report Facts
Resident files reviewed: 7 Employee files reviewed: 4
Inspection Report Annual Inspection Census: 7 Capacity: 9 Deficiencies: 4 Feb 23, 2022
Visit Reason
This inspection was conducted as an annual State Licensure and infection control survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. Several deficiencies were identified including a deadbolt on the front door requiring a key to open from the inside without State Fire Marshal approval, unsigned Ultimate User Agreement for one resident, incomplete medication administration records for one resident, and failure to complete an annual Activities of Daily Living assessment for one resident.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
DescriptionSeverity
The front door deadbolt required a key to open from the inside without approval from the State Fire Marshal.Severity: 2
Ultimate User Agreement allowing medications to be administered was unsigned for Resident #3.Severity: 2
Medication Administration Record (MAR) did not document all medications for Resident #5, missing Risperdal.Severity: 2
Annual Activities of Daily Living (ADL) assessment was not completed for Resident #7.Severity: 2
Report Facts
Licensed beds: 9 Residents present: 7 Deficiencies cited: 4 Occupancy Inspection approval date: Jun 1, 2021
Employees Mentioned
NameTitleContext
Chris C. TanAdministratorNamed as Administrator who confirmed deficiencies and signed the report
Inspection Report Complaint Investigation Census: 8 Capacity: 9 Deficiencies: 0 Nov 23, 2021
Visit Reason
The inspection was conducted as a result of a complaint investigation survey triggered by Complaint #NV00065066 with two allegations at the facility.
Findings
The complaint allegations were unsubstantiated based on observations, interviews with residents, caregivers, and the owner, and record reviews. No regulatory deficiencies were noted and the facility received a grade of A.
Complaint Details
Complaint #NV00065066 with two allegations was unsubstantiated. Allegation #1 involved caregivers slamming doors and yelling, which was disproven by observations and interviews. Allegation #2 involved a resident being removed without warning, which was also disproven by interviews and record review.
Report Facts
Resident files reviewed: 8 Employee files reviewed: 3 Complaint allegations: 2
Inspection Report Annual Inspection Census: 7 Capacity: 9 Deficiencies: 0 Jun 29, 2021
Visit Reason
The inspection was conducted as an annual and infection control State Licensure survey in accordance with Nevada Administrative Code, Chapter 449, Residential Facilities for Groups.
Findings
The facility was found to be compliant with no regulatory deficiencies identified. The facility received a grade of A after review of seven resident files and four employee files.
Report Facts
Resident files reviewed: 7 Employee files reviewed: 4
Inspection Report Abbreviated Survey Census: 3 Capacity: 9 Deficiencies: 1 Jul 27, 2020
Visit Reason
The inspection was a COVID-19 focused infection control survey conducted to assess compliance with infection prevention measures in the facility.
Findings
The facility failed to screen a visitor (health facility inspector) for COVID-19 symptoms and temperature prior to entry, contrary to CDC guidelines and facility policy. Other infection control measures such as resident temperature checks, PPE use, and sanitization practices were in place.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
DescriptionSeverity
Administrator failed to ensure a visitor was screened for COVID-19 symptoms and temperature prior to entry to the facility.Severity: 2
Report Facts
Licensed beds: 9 Resident census: 3 Hand sanitizer bottles: 6 Gloves: 100 Face shields: 3 Surgical masks: 1 COVID-19 positive residents: 3 COVID-19 negative residents: 3
Employees Mentioned
NameTitleContext
Chris C. TanAdministratorNamed in relation to oversight failure and plan of correction
Inspection Report Annual Inspection Census: 8 Capacity: 9 Deficiencies: 2 Dec 18, 2019
Visit Reason
The inspection was an annual state licensure survey conducted from 12/18/19 to 01/11/19 in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. Deficiencies were identified related to inaccurate Medication Administration Records for two residents and non-functioning audible alarms on two exit doors. Corrective actions were implemented including updating the MAR and replacing door alarms.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
DescriptionSeverity
The facility failed to ensure the Medication Administration Record (MAR) was accurate for 2 of 8 residents; medications Melatonin and Multivitamin were not documented on the MAR.Severity: 2
The facility failed to ensure audible alarms worked on two exit doors; one alarm had dead batteries and another was defective and replaced.Severity: 2
Report Facts
Residents reviewed: 8 Employee files reviewed: 4 Licensed beds: 9 Current census: 8
Employees Mentioned
NameTitleContext
Chris C TanAdministratorNamed as Administrator and signer of the report
Inspection Report Re-Inspection Census: 9 Deficiencies: 22 Apr 17, 2019
Visit Reason
This document is a Statement of Deficiencies generated as a result of a State licensure re-grading survey conducted on 4/17/19 at the facility.
Findings
The facility was found to have multiple deficiencies including health and sanitation hazards, medication storage issues, and failure to secure toxic substances and sharp items. The facility received a re-survey letter grade of B. Several corrective actions were planned and dated 4/17/19.
Severity Breakdown
F: 8 E: 5 D: 7 C: 1
Deficiencies (22)
DescriptionSeverity
Health and Sanitation - Hazards including obstacles impeding free movement of residents.F
Health and Sanitation - Dirt, garbage, refuse accumulation.F
Health and Sanitation - Backyard clutter and debris including leaves, broken furniture, cardboard boxes, and loose pipes.F
Laundry and Linen - Adequate accommodations required.D
Kitchen Equipment - Clean and sanitary condition required.F
Storage of Food - Perishable foods must be refrigerated at proper temperatures.F
Storage of Food - Adequate storage and packaging required.F
Service of Food - Substitutions must be documented and posted.D
Service of Food - Ill resident meal service requirements.E
Activities for Residents - Privacy and participation in activities required.E
Restriction on Use of Restraints - Staff restrictions and reporting requirements.E
Resident Rights - Procedure for grievance and complaint response.D
Admission Policy - Eligibility and bedfast conditions.E
Contractures - Residents with contractures must be supervised by trained medical professional.E
Pressure or Stasis Ulcers - Records of care and cause explanation required.D
Medication/OTCs/Supplements - Administration and documentation requirements.D
Medication Storage - Medications not secured properly; pills left unsecured in living areas.D
Medication Container - Medications not kept in original labeled containers.D
Resident File - Confidentiality and maintenance of records.D
Alzheimer's Facility - Sharp items not secured; razors and scissors left accessible.D
Alzheimer's Facility - Toxic substances not secured; Ajax cleanser and dishwashing liquid left unsecured.D
Placard Display - Facility grade not posted conspicuously; printing issues with letter grade.C
Report Facts
Census: 9 Severity 2 Deficiencies: 10 Severity 1 Deficiencies: 1
Inspection Report Annual Inspection Census: 9 Capacity: 9 Deficiencies: 3 Nov 2, 2015
Visit Reason
Annual State licensure survey conducted to assess compliance with regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but had deficiencies related to oxygen equipment security, medication storage, and resident file documentation for tuberculosis testing. Deficiencies were acknowledged by staff and corrective actions were planned and completed.
Severity Breakdown
2: 3
Deficiencies (3)
DescriptionSeverity
Facility failed to secure oxygen tanks in a rack or to the wall.2
Facility failed to ensure medications were kept in a locked container.2
Facility failed to ensure 1 of 9 residents met tuberculosis testing requirements.2
Report Facts
Census: 9 Total Capacity: 9 Deficiencies cited: 3
Inspection Report Annual Inspection Census: 9 Capacity: 9 Deficiencies: 3 Nov 2, 2015
Visit Reason
This document is a State licensure survey conducted as an annual inspection of the Alzheimer's Luxury Care facility to assess compliance with state regulations.
Findings
The facility received a grade of A but had several deficiencies including unsecured oxygen tanks, unsecured medications, and incomplete tuberculosis testing documentation for one resident.
Severity Breakdown
2: 3
Deficiencies (3)
DescriptionSeverity
Failed to secure oxygen tanks in a rack or to the wall.2
Failed to ensure medications were kept in a locked container; unsecured medications found in unlocked refrigerator and cabinet.2
Failed to ensure one resident met tuberculosis testing requirements; missing documented evidence of two-step TB skin test or positive TB skin test.2
Report Facts
Resident files reviewed: 9 Employee files reviewed: 5 Repeat deficiency: 1
Employees Mentioned
NameTitleContext
Employee #4 acknowledged deficiencies related to oxygen tank and medication storage.
AdministratorAcknowledged tuberculosis testing documentation deficiency.
Inspection Report Re-Inspection Census: 9 Capacity: 9 Deficiencies: 1 Dec 3, 2014
Visit Reason
This inspection was a required State Licensure grading re-survey conducted on 12/20/13 in accordance with NRS 449.0307, Powers of the Health Division.
Findings
The facility received a grade of A. One deficiency was identified related to tuberculosis testing where Resident #1 was missing a required second step TB test.
Severity Breakdown
2: 1
Deficiencies (1)
DescriptionSeverity
Facility failed to ensure Resident #1 met tuberculosis testing requirements; missing second step TB test.2
Report Facts
Resident files reviewed: 9 Employee files reviewed: 5
Inspection Report Re-Inspection Census: 9 Capacity: 9 Deficiencies: 1 Dec 20, 2013
Visit Reason
This inspection was a required State Licensure grading re-survey conducted to assess compliance with regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A. One deficiency was identified related to tuberculosis testing documentation for one resident, specifically a missing second step in TB testing.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
DescriptionSeverity
Failure to ensure 1 of 9 residents met the tuberculosis (TB) testing requirements, missing a second step in TB testing for Resident #1.Severity: 2
Report Facts
Resident census: 9 Total licensed capacity: 9 Deficiency count: 1
Inspection Report Re-Inspection Census: 8 Capacity: 9 Deficiencies: 2 Dec 20, 2013
Visit Reason
This inspection was a required State Licensure grading re-survey conducted to assess compliance with regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but was found deficient in medication storage and ensuring dangerous items were inaccessible to residents. Deficiencies included unsecured medications and dangerous items such as knives and sharp tools found unsecured in the caregiver's room and other areas.
Severity Breakdown
Severity: 2 Scope 3: 2
Deficiencies (2)
DescriptionSeverity
Medications found unsecured in caregiver's room in box on top of dresser including cough medicine, Bayer, itch and irritation cream, vitamins, sodium, eye drops and Lanacane.Severity: 2 Scope 3
Dangerous items such as screwdriver, wire cutter, nail scissors, scissors, space heater, and large sharps containers found unsecured in caregiver's room and bedroom #5.Severity: 2 Scope 3
Report Facts
Census: 8 Total Capacity: 9
Employees Mentioned
NameTitleContext
Chris C. TanLaboratory Director or Provider/Supplier RepresentativeSigned the statement of deficiencies
Inspection Report Re-Inspection Census: 8 Capacity: 9 Deficiencies: 2 Dec 20, 2013
Visit Reason
This inspection was a required State Licensure grading re-survey conducted to assess compliance with regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but was found deficient in medication storage and ensuring dangerous items were inaccessible to residents. Medications and dangerous items were found unsecured in caregiver's rooms and other areas, posing safety risks. These deficiencies were rated Severity 2, Scope 3, and included a repeat deficiency from a prior annual survey.
Severity Breakdown
Severity 2: 2
Deficiencies (2)
DescriptionSeverity
Medications found unsecured in caregiver's room in box on top of dresser including cough medicine, Bayer, itch and irritation cream, vitamins, sodium, eye drops and Lanacane.Severity 2
Dangerous items such as knives, screwdriver, wire cutter, nail scissors, scissors, space heater, and unsecured sharps containers found accessible to residents.Severity 2
Report Facts
Licensed beds: 9 Resident census: 8 Sharps container fill level: 75
Inspection Report Annual Inspection Census: 8 Capacity: 9 Deficiencies: 7 Sep 18, 2013
Visit Reason
This document is a State Licensure annual grading survey conducted on 9/18/13 to assess compliance with regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of C with multiple deficiencies identified related to personnel files, health and sanitation, premises maintenance, bedroom lighting, oxygen equipment security, and safety regarding dangerous items and toxic substances. Several deficiencies were repeat findings from prior surveys.
Severity Breakdown
Severity 2: 7
Deficiencies (7)
DescriptionSeverity
Failure to ensure 1 of 5 employees complied with tuberculosis testing requirements.Severity 2
Facility failed to ensure premises were free of insects and rodents (ants found in kitchen drawer).Severity 2
Facility failed to ensure premises were clean and well maintained (stagnant swimming pool, dirty hot tub, dirty refrigerator, buckling floor).Severity 2
Failure to provide operational light outside entrance to bedrooms #2 and #4.Severity 2
Failure to secure oxygen tanks in a rack or to the wall (one unsecured tank in bedroom #4).Severity 2
Failure to ensure dangerous items (gardening fork, lighter, ladder) were inaccessible to residents.Severity 2
Failure to ensure toxic substances were inaccessible to residents (Herbal Fresh Spray, Round-up, paint, vinegar, etc. found accessible).Severity 2
Report Facts
Facility licensed beds: 9 Resident census: 8 Employees reviewed: 5 Resident files reviewed: 8 Discharged resident files reviewed: 1
Inspection Report Annual Inspection Census: 8 Capacity: 9 Deficiencies: 7 Sep 18, 2013
Visit Reason
This document is a State Licensure annual grading survey conducted to assess compliance with regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of C with multiple deficiencies identified including failure to comply with tuberculosis testing requirements for staff, presence of insects (ants) in the kitchen, poor maintenance of premises (stagnant pool, dirty hot tub, buckling floor), inadequate bedroom entrance lighting, unsecured oxygen tanks, and accessibility of dangerous items and toxic substances to residents.
Severity Breakdown
Severity: 2: 7
Deficiencies (7)
DescriptionSeverity
Failed to ensure 1 of 5 employees complied with tuberculosis testing requirements (Employee #4 second step placement and read date recorded as 3/25/13).Severity: 2
Facility failed to ensure premises were free of insects and rodents (ants found in kitchen drawer).Severity: 2
Facility failed to ensure premises were clean and well maintained (stagnant swimming pool, hot tub filled with dirt, dirty refrigerator in garage, buckling floor in bedroom #5).Severity: 2
One of five bedrooms (Bedroom #2) failed to have an operational light operated from a switch outside the room.Severity: 2
Failed to secure oxygen tanks in a rack or to the wall (Bedroom #4 one unsecured O2 tank).Severity: 2
Failed to ensure dangerous items (gardening fork, lighter, ladder) were inaccessible to residents.Severity: 2
Failed to ensure toxic substances (Herbal Fresh Spray, Round-up, 409, paint, vinegar, degreaser, toilet cleaner) were inaccessible to residents.Severity: 2
Report Facts
Resident files reviewed: 8 Employee files reviewed: 5 Discharged resident files reviewed: 1 Facility grade: C
Notice Deficiencies: 0 Feb 26, 2013
Visit Reason
The Health Division is notifying the facility of its intent to impose sanctions based on deficiencies found in a prior survey dated September 6, 2012, including repeat deficiencies.
Findings
The notice details the imposition of monetary penalties totaling $600 for repeat deficiencies at TAG Y920 and Y930, referencing the severity and scope of the deficiencies as defined by Nevada Administrative Code.
Report Facts
Monetary Penalties: 600 Monetary Penalty per Repeat Deficiency: 300
Employees Mentioned
NameTitleContext
Dorothy SimsHealth Facilities Inspector IIISigned the notice regarding sanctions and penalties.
Inspection Report Re-Inspection Census: 7 Capacity: 9 Deficiencies: 3 Jan 14, 2013
Visit Reason
The inspection was a required grading re-survey conducted as a re-survey following a previous annual State Licensure survey to verify correction of deficiencies.
Findings
The facility was found to have repeat deficiencies related to medication storage, resident file storage, and tuberculosis testing compliance. The medication cabinet and resident files were found unlocked, and three residents were missing required tuberculosis testing documentation.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
DescriptionSeverity
Medication storage was not properly secured; medications belonging to 7 of 7 residents were found unlocked.Severity: 2
Resident files were not kept in a secured area; files for 7 of 7 residents were found unlocked.Severity: 2
Facility failed to ensure 3 of 7 residents complied with tuberculosis testing requirements, missing two-step TB skin tests.Severity: 2
Report Facts
Residents with medications unlocked: 7 Residents with files unlocked: 7 Residents missing TB testing compliance: 3 Total licensed beds: 9 Census at time of survey: 7
Inspection Report Re-Inspection Census: 7 Capacity: 9 Deficiencies: 3 Jan 14, 2013
Visit Reason
This document is a required grading re-survey conducted as a State Licensure survey to assess compliance with regulations at the Alzheimer's Luxury Care facility.
Findings
The facility received a re-survey grade of A but had repeat deficiencies related to medication storage, resident file security, and tuberculosis testing compliance. Specifically, medications and resident files were found unlocked, and some residents lacked required TB testing documentation.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
DescriptionSeverity
Failed to ensure medications belonging to 7 of 7 residents were kept in a locked area; medication file was unlocked.Severity: 2
Failed to keep files belonging to 7 of 7 residents in a secured area; file cabinet containing resident files was unlocked.Severity: 2
Failed to ensure 3 of 7 residents complied with tuberculosis testing requirements; missing two-step TB skin tests.Severity: 2
Report Facts
Licensed beds: 9 Residents present: 7 Residents with missing TB tests: 3
Notice Deficiencies: 0 Sep 6, 2012
Visit Reason
The Health Division conducted a survey at Alzheimer's Luxury Care on 9/6/12 and is imposing sanctions based on deficiencies found during that survey.
Findings
The facility received a grade of D for their survey and was assessed a monetary penalty of $300 for a repeat deficiency. The Plan of Correction submitted was accepted, and the facility was required to submit a grading system re-survey application with a $600 fee.
Report Facts
Monetary Penalty: 300 Re-survey Application Fee: 600
Employees Mentioned
NameTitleContext
Donald W. SampsonHealth Facilities Surveyor IISigned the notice of intent to impose sanctions
Wendy SimonsBureau ChiefSigned the notice of intent to impose sanctions
Inspection Report Annual Inspection Census: 8 Capacity: 9 Deficiencies: 11 Sep 6, 2012
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 9/6/2012 to assess compliance with state regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility was found deficient in multiple areas including personnel background checks, improper use of bedrooms, failure to restrain residents properly, unsecured oxygen tanks, failure to notify physicians and family after resident injury, improper medication destruction and storage, unsecured resident files, incomplete tuberculosis testing, and unsecured yard gate. The facility received a grade of D.
Severity Breakdown
1: 1 2: 10
Deficiencies (11)
DescriptionSeverity
Failed to ensure 2 of 4 employees met background check requirements (missing state and FBI checks).2
Bedrooms used for storage of medications, canned food, and administrative files.2
Failed to ensure 1 of 8 residents was restrained by use of a full bed rail.2
Oxygen tanks were not secured in 2 resident rooms.2
Failed to notify resident's physician and family after resident injury.2
Failed to destroy medications after discontinuation or resident discharge; expired and former resident medications found unsecured.2
Failed to ensure medications were kept in a locked area; medications found unsecured in cabinet.2
Failed to keep resident files in a secured area; files found in unlocked cabinet.1
Failed to ensure 3 of 8 residents complied with tuberculosis testing requirements.2
Backyard gate leading to front driveway was not locked; repeat deficiency from prior year.2
Failed to ensure 2 of 4 caregivers received annual training on elder abuse recognition and response.2
Report Facts
Number of residents present: 8 Total licensed beds: 9 Number of employees reviewed: 4 Number of resident files reviewed: 8 Severity 1 deficiencies: 1 Severity 2 deficiencies: 10
Inspection Report Annual Inspection Census: 8 Capacity: 9 Deficiencies: 11 Sep 6, 2012
Visit Reason
This document is the result of an annual State Licensure survey conducted on 9/6/2012 at Alzheimers Luxury Care, a residential facility licensed for nine beds providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of D with multiple deficiencies identified including failure to meet background check requirements for employees, improper use of bedrooms for storage, restraint use on a resident, unsecured oxygen tanks, failure to notify physician and family after resident injury, improper medication destruction and storage, unsecured resident files, missing tuberculosis testing documentation, unsecured fenced yard gate, and lack of annual elder abuse training for some employees.
Severity Breakdown
Level 1: 1 Level 2: 10
Deficiencies (11)
DescriptionSeverity
Failed to ensure 2 of 4 employees met background check requirements (missing state and FBI background checks).Level 2
Bedroom #5 was used as a storage room for medications, canned food, and administrative files.Level 2
Failed to ensure 1 of 8 residents was not restrained by the use of a full bed rail.Level 2
Failed to ensure oxygen tanks were secured in a rack or to the wall in 2 resident rooms.Level 2
Failed to notify resident's physician and family member after resident injury.Level 2
Did not destroy medications after discontinuation, expiration, or resident transfer; medications for former residents and employees found unsecured.Level 2
Failed to ensure medications were kept in a locked area; medications for current and former residents and employees found unsecured.Level 2
Failed to ensure resident files were kept in a secured area; files observed in an unlocked cabinet in the living room.Level 1
Failed to ensure 3 of 8 residents complied with tuberculosis testing requirements (missing initial two-step and annual one-step TB test results).Level 2
Failed to ensure the backyard gate leading to the front driveway was locked; repeat deficiency from prior annual survey.Level 2
Failed to ensure 2 of 4 caregivers received annual training in recognition, prevention, and response to elder abuse.Level 2
Report Facts
Licensed beds: 9 Current census: 8 Employees reviewed: 4 Resident files reviewed: 8 Deficiency severity Level 2: 10 Deficiency severity Level 1: 1
Employees Mentioned
NameTitleContext
Employee #2Failed background check requirements and did not receive annual elder abuse training
Employee #4Failed background check requirements and did not receive annual elder abuse training
Inspection Report Enforcement Deficiencies: 1 Jan 9, 2012
Visit Reason
The Bureau conducted a complaint investigation at Alzheimers Luxury Care from 12/19/11 through 1/9/12, which led to the imposition of sanctions.
Findings
The Health Division is imposing sanctions based on the severity and scope of deficiencies found during the complaint investigation. A monetary penalty of $400 was assessed for a deficiency at TAG Y823 with a severity level of three and scope level of two or less.
Complaint Details
The visit was a complaint investigation conducted from 12/19/11 through 1/9/12. The specific factual findings are detailed in the Statement of Deficiencies (SOD) in Attachment A. The Plan of Correction submitted was reviewed and found acceptable.
Severity Breakdown
Level 3: 1
Deficiencies (1)
DescriptionSeverity
Deficiency at TAG Y823 with a severity level of three and scope level of two or lessLevel 3
Report Facts
Monetary Penalties: 400 Working days until sanctions effective: 11 Training timeframe: 12
Employees Mentioned
NameTitleContext
Julie BellHealth Facilities Surveyor IISigned the notice imposing sanctions
Inspection Report Complaint Investigation Census: 7 Capacity: 9 Deficiencies: 2 Jan 9, 2012
Visit Reason
This inspection was conducted as a complaint investigation from 12/19/11 through 1/9/12 regarding care deficiencies at the facility.
Findings
The facility was found to have failed to ensure that a bedfast resident was not admitted and retained, and failed to ensure pressure ulcer precautions were taken for a resident at risk. The complaint was substantiated with deficiencies related to admission policy and pressure ulcers.
Complaint Details
Complaint #NV00030120 was substantiated based on findings related to admission policy and pressure ulcer care for Resident #1.
Severity Breakdown
Level D: 1 Level G: 1
Deficiencies (2)
DescriptionSeverity
Facility failed to ensure a bedfast resident was not admitted and retained.Level D
Facility failed to ensure pressure ulcer precautions were taken for a resident at risk.Level G
Report Facts
Licensed capacity: 9 Resident census: 7 Severity level: 2 Severity 2 Scope 1: 1 Severity 3 Scope 1: 1
Inspection Report Complaint Investigation Census: 7 Capacity: 9 Deficiencies: 2 Jan 9, 2012
Visit Reason
This inspection was conducted as a result of a complaint investigation from 12/19/2011 through 1/9/2012 regarding the care provided at the facility.
Findings
The facility was found to have admitted and retained a bedfast resident (Resident #1) contrary to admission policy, and failed to ensure pressure ulcer precautions for a resident at risk, resulting in the development of a stage II pressure ulcer and skin tears. The complaint was substantiated with deficiencies related to admission policy and pressure ulcer care.
Complaint Details
Complaint #NV00030120 was substantiated based on findings related to admission of a bedfast resident and inadequate pressure ulcer care.
Severity Breakdown
Level 2: 1 Level 3: 1
Deficiencies (2)
DescriptionSeverity
Facility failed to ensure a bedfast resident was not admitted and retained.Level 2
Facility failed to ensure pressure ulcer precautions were taken for a resident at risk, resulting in a stage II pressure ulcer and skin tears.Level 3
Report Facts
Licensed beds: 9 Resident census: 7 Resident age: 92 Skin tear size: 2 Pressure ulcer stage: 2
Employees Mentioned
NameTitleContext
Home Health Registered Nurse (RN)Interviewed regarding Resident #1's condition and care
Facility AdministratorProvided turning schedule documentation for Resident #1
Inspection Report Re-Inspection Deficiencies: 0 Nov 16, 2011
Visit Reason
This document is a statement of deficiencies generated as a result of a requested grading re-survey conducted at the facility on 11/16/11 by the Health Division under the authority of NRS 449.150.
Findings
No deficiencies were identified during this re-survey. The facility received a re-survey grade of A.
Inspection Report Annual Inspection Census: 6 Capacity: 9 Deficiencies: 4 Oct 5, 2011
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 10/5/2011 at the Alzheimer's Luxury Care facility.
Findings
The facility received a grade of B and was found deficient in several areas including medication administration errors, improper medication labeling, accessibility of dangerous items, and unsecured yard gates.
Severity Breakdown
Severity: 1: 1 Severity: 2: 3
Deficiencies (4)
DescriptionSeverity
Failed to ensure 2 of 6 residents received medications as prescribed (Resident #1-Ativan given every 6 hours instead of every 4 hours as needed; Resident #2-Nexium ran out and was unavailable).Severity: 2
Failed to ensure medications were plainly labeled for 2 of 6 residents (Resident #1-Aspirin and Resident #2-Benadryl).Severity: 1
Failed to ensure dangerous items were inaccessible to residents; knife drawer in kitchen was left unlocked accessible to all 6 residents.Severity: 2
Failed to ensure the backyard gate leading to the front driveway was locked, compromising the secured fenced area.Severity: 2
Report Facts
Licensed beds: 9 Residents present: 6 Resident files reviewed: 6 Employee files reviewed: 6
Inspection Report Re-Inspection Deficiencies: 0 Dec 15, 2010
Visit Reason
This document is a required grading re-survey conducted as a state licensure survey by the authority of NRS 449.150.
Findings
The facility received a re-survey grade of A with no deficiencies identified.
Report Facts
Re-survey grade: A
Inspection Report Annual Inspection Census: 9 Capacity: 9 Deficiencies: 8 Sep 14, 2010
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This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 09/14/2010 at Alzheimer's Luxury Care, a residential facility for persons with Alzheimer's disease.
Findings
The facility was found deficient in multiple areas including licensing requirements for mental illness care, health and sanitation, food storage temperatures, resident privacy, medication administration, resident file storage, Alzheimer's facility pool safety, and awake staff requirements. The facility received a grade of C.
Severity Breakdown
1: 2 2: 6
Deficiencies (8)
DescriptionSeverity
Facility was caring for a resident with mental illness without proper endorsement and training.2
Facility failed to maintain cleanliness and proper sanitation in the kitchen.2
Perishable foods were not refrigerated at required temperatures; refrigerator was 44 degrees and freezer 16 degrees.1
Facility failed to provide privacy for 2 of 9 residents; caregiver was sleeping in occupied resident room.2
Medication administration deficiency: one resident's medications were not at maintenance level and required medical assessment.2
Resident files, including hospice files, were not properly stored in locked cabinets.1
Swimming pool gate was not locked to ensure safety for residents.2
Facility failed to ensure at least one staff member was awake and on duty at all times; caregivers admitted to sleeping at night.2
Report Facts
Census: 9 Total Capacity: 9 Severity 1 Deficiencies: 2 Severity 2 Deficiencies: 6
Inspection Report Annual Inspection Census: 9 Capacity: 9 Deficiencies: 8 Sep 14, 2010
Visit Reason
This document is the result of an annual State Licensure survey conducted at the Alzheimer's Luxury Care facility on 9/14/2010 to assess compliance with state regulations for residential care facilities.
Findings
The facility was found deficient in multiple areas including failure to obtain necessary training for caring for residents with mental illness, poor kitchen sanitation, improper food storage temperatures, lack of resident privacy, medication administration errors, unsecured resident files, unlocked swimming pool gate, and failure to ensure awake staff at all times. The facility received a grade of C.
Severity Breakdown
Level 1: 2 Level 2: 6
Deficiencies (8)
DescriptionSeverity
Facility was caring for 1 of 9 persons with mental illness without an endorsement and failed to obtain necessary training (Resident #3 - bi-polar disorder).Level 2
Facility failed to ensure the kitchen was clean and well maintained (grease buildup on kitchen cabinets, grease hood, and top of refrigerator).Level 2
Facility failed to ensure refrigerator was at 40 degrees or less and freezer at 0 degrees or less (refrigerator at 44 degrees, freezer at 16 degrees).Level 1
Facility failed to provide privacy for 2 of 9 residents (caregiver sleeping in occupied resident room - Bedroom #5).Level 2
Facility failed to comply with medication administration requirements; 1 of 9 residents' medications not at maintenance level and required medical assessment before administering (Resident #9 - Diovan 160 mg, hold if BP <110).Level 2
Facility failed to ensure 5 of 9 resident hospice files were kept in a locked place (files located on kitchen shelf).Level 1
Facility failed to ensure the gate to the swimming pool was locked.Level 2
Facility failed to ensure at least one staff member was awake and on duty at all times; caregivers admitted to sleeping at night (repeat deficiency).Level 2
Report Facts
Residents present: 9 Total licensed capacity: 9 Resident files reviewed: 9 Employee files reviewed: 6 Discharged resident files reviewed: 1 Temperature of refrigerator: 44 Temperature of freezer: 16 Medication dosage: 160
Inspection Report Re-Inspection Deficiencies: 0 Sep 22, 2009
Visit Reason
This document is a statement of deficiencies generated as a result of a required grading re-survey conducted at the facility on 09/22/2009.
Findings
No further regulatory deficiencies were identified during this re-survey. The facility received a grade of A.
Inspection Report Enforcement Deficiencies: 0 Sep 14, 2009
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This document is a Notice of Intent to Impose Sanctions on Alzheimer's Luxury Care due to deficiencies found in a prior survey dated 12/17/08, including repeat deficiencies.
Findings
The Health Division is imposing monetary penalties of $300 for repeat deficiencies, with severity and scope scores assigned to the deficiencies as detailed in an attachment. The facility received a grade of D and must submit a grading system re-survey application with a $500 fee.
Report Facts
Monetary Penalties: 300 Fee: 500
Employees Mentioned
NameTitleContext
Patricia ChambersHealth Facilities Surveyor IIISigned the Notice of Intent to Impose Sanctions
Inspection Report Complaint Investigation Census: 8 Capacity: 9 Deficiencies: 9 Aug 5, 2009
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 7/15/09 and completed during an annual State Licensure survey on 8/5/09.
Findings
The facility was found to have multiple deficiencies including fire safety violations, medication administration errors, failure to secure oxygen tanks, incomplete medication records, inadequate tuberculosis compliance, lack of awake staff at all times, and failure to secure dangerous items and toxic substances from residents.
Complaint Details
Complaint #NV00022541 was substantiated.
Severity Breakdown
Severity: 2: 9
Deficiencies (9)
DescriptionSeverity
The designated exit out of the game room was completely blocked, impeding egress in case of fire.Severity: 2
The front door was equipped with a lock requiring a key to open it from the inside without approval.Severity: 2
Oxygen tanks were not secured in a rack or to the wall.Severity: 2
Two of eight residents did not receive medications as prescribed.Severity: 2
Medication record was incomplete for one resident receiving PRN medications.Severity: 2
Two residents failed to comply with tuberculosis testing requirements.Severity: 2
Facility failed to ensure a caregiver was awake and on duty at all times.Severity: 2
Knives, scissors, nail file, nail clippers, and large cooking fork were accessible to residents.Severity: 2
Toxic substances including bleach, pest control, tilex, and paint were unsecured and accessible to residents.Severity: 2
Report Facts
Licensed beds: 9 Residents present: 8 Residents reviewed: 8 Employee files reviewed: 5 Deficiency severity counts: 9
Inspection Report Annual Inspection Census: 7 Capacity: 9 Deficiencies: 11 Dec 17, 2008
Visit Reason
The inspection was conducted as the annual state licensure survey for the residential facility providing care to persons with Alzheimer's Disease.
Findings
The facility was found deficient in multiple areas including personnel file documentation, tuberculosis screening, medication administration and storage, medication labeling, resident file maintenance, and compliance with tuberculosis screening requirements. Several employees and residents' records lacked required documentation and proper procedures were not consistently followed.
Severity Breakdown
Level 1: 3 Level 2: 8
Deficiencies (11)
DescriptionSeverity
Failed to ensure 1 of 7 employees had required tuberculosis screening test documentation.Level 2
Failed to investigate references for 2 of 7 employees.Level 1
Failed to ensure 1 of 7 employees had copies of fingerprints in the file.Level 2
Failed to ensure medication profile review was performed at least every six months for 3 of 7 residents.Level 2
Failed to ensure ultimate user agreement was signed for 2 of 7 residents.Level 1
Failed to obtain physician orders to administer over-the-counter medications for 1 of 7 residents.Level 2
Failed to document results of administration of as needed medication for 1 of 7 residents.Level 2
Failed to ensure medication was kept in a locked container for 7 of 7 residents.Level 2
Failed to ensure medications were plainly labeled for 1 of 7 residents.Level 2
Failed to ensure 2 of 7 residents complied with tuberculosis screening tests requirements.Level 2
Failed to have the rules of the facility signed by the administrator and/or resident for 2 of 7 residents.Level 1
Report Facts
Total licensed beds: 9 Current census: 7 Employees reviewed: 7 Residents reviewed: 7 Deficiency severity counts: 3 Deficiency severity counts: 8
Employees Mentioned
NameTitleContext
Employee #1Named in tuberculosis screening and medication review deficiencies
Employee #3Named in medication administration and labeling deficiencies
Employee #5Named in fingerprint documentation deficiency
Employee #6Named in reference check deficiency
Employee #7Named in reference check deficiency

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