Inspection Report
Annual Inspection
Census: 38
Capacity: 72
Deficiencies: 8
Apr 29, 2025
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation regarding alleged inadequate care resulting in pressure sores.
Findings
The facility received a grade of C with multiple deficiencies identified including lapses in elder abuse prevention training, CPR and first aid training, incomplete first aid kits, incomplete dementia training, failure to notify residents of their rights, improper non-discrimination statement posting, incomplete cultural competency training, and missing initial physician assessments and placement determinations for some residents.
Complaint Details
Complaint #NV00073993 alleging failure to provide adequate care resulting in pressure sores was investigated and could not be substantiated due to lack of evidence.
Severity Breakdown
Level 1: 1
Level 2: 7
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure annual elder abuse prevention training was completed timely for 1 of 10 sampled employees. | Level 2 |
| Failed to ensure cardiopulmonary resuscitation (CPR) and first aid training was completed timely for 1 of 10 sampled employees. | Level 2 |
| Failed to ensure 3 of 3 first aid kits contained all required supplies including adhesive tape and thermometer/fever strips. | Level 2 |
| Failed to ensure two hours of dementia training was completed within 40 hours and eight hours within 90 days for 1 of 10 sampled employees. | Level 2 |
| Failed to notify residents upon admission of their rights as listed in NRS 449A.100 and 449A.106 to 449A.115. | Level 2 |
| Non-discrimination statement was not posted in the required 22 point font size and was missing from the facility's website. | Level 1 |
| Failed to ensure initial cultural competency training was completed within 90 days of hire for 1 of 10 sampled employees. | Level 2 |
| Failed to obtain initial Standard Physician Assessment and Placement Determination for 3 of 10 sampled residents. | Level 2 |
Report Facts
Facility licensed capacity: 72
Census: 38
Complaint count: 1
Grade: C
Lapse months: 27
Lapse months: 3
Number of first aid kits missing supplies: 3
Number of residents missing initial physician assessment: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #9 | Caregiver | Named in elder abuse prevention training deficiency |
| Employee #7 | Caregiver | Named in CPR and first aid training deficiency |
| Employee #3 | Medication Technician | Named in dementia and cultural competency training deficiencies |
| Amanda Jenkins | Executive Director | Interviewed and referenced in multiple findings and corrective actions |
| Business Office Director | Interviewed and referenced in multiple findings and corrective actions | |
| Wellness Director | Referenced in corrective actions and interview regarding resident assessments | |
| Maintenance Director | Interviewed regarding first aid kit deficiencies |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 2
Dec 27, 2024
Visit Reason
The inspection was conducted as a result of a State Licensure complaint investigation triggered by Complaint #NV00072863 alleging that ordered medications were not administered to residents.
Findings
The investigation substantiated that medications were not administered to one resident due to delayed medication refills and lack of timely follow-up with the pharmacy. The facility failed to ensure staff followed medication refill policies, resulting in missed doses for three days. Other allegations regarding resident care were not substantiated.
Complaint Details
Complaint #NV00072863 was substantiated regarding ordered medications not being administered. Other allegations about residents being left in wet clothing and not being fed were not substantiated due to lack of evidence.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure timely medication refills and administration for Resident #1, resulting in missed doses of Divalproex Sprinkles and Pravastatin for three days. | Severity: 2 |
| Failure to administer two scheduled medications per physician orders for Resident #1. | Severity: 2 |
Report Facts
Sample size: 7
Missed medication days: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Jenkins | Executive Director | Provided statements regarding medication refill policies and confirmed deficiencies |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 3
Jul 3, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by three complaints alleging medication errors and resident abuse at the facility.
Findings
The investigation substantiated that two caregivers mentally and physically abused Resident #7, resulting in their termination. Medication administration deficiencies were found including medication errors involving Residents #5 and #6, and inaccurate medication administration records for Resident #1.
Complaint Details
Three complaints were investigated. Complaint #NV00071270 and #NV00071340 regarding medication errors were substantiated. Complaint #NV00071537 regarding failure to prevent mental and physical abuse was substantiated.
Severity Breakdown
E: 1
D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure a resident was safe from mental and physical abuse by staff, substantiated for Resident #7. | E |
| Medication administration errors including administering another resident's medication to a resident and failure to have proper medication change order documentation. | D |
| Failure to maintain accurate medication administration records for a resident. | D |
Report Facts
Resident census: 48
Complaints investigated: 3
Employees terminated: 2
Deficiency severity counts: 3
Inspection Report
Annual Inspection
Census: 49
Capacity: 72
Deficiencies: 5
Mar 27, 2024
Visit Reason
This inspection was a State Licensure annual grading survey conducted to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of B with multiple deficiencies identified including failure to ensure timely elder abuse training for employees, rodent infestation and food safety violations in the kitchen, delayed medication profile review and provider notification, incomplete resident physician placement documentation, and lack of required infection control training for the infection control designee.
Severity Breakdown
D: 3
F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure 2 of 10 sampled employees received initial elder abuse prevention training prior to starting work with residents. | D |
| Rodent infestation observed in kitchen dry storage room and laundry services; multiple food safety violations including uncovered desserts, soiled kitchen and storage areas, improperly stored chafing dish sterno, and disrepair of kitchen equipment. | F |
| Administrator failed to ensure medication profile reviews were reviewed and initialed within 72 hours for 6 residents and failed to notify providers within 72 hours for 3 residents. | F |
| Failure to obtain a dated initial Physician Placement Determination for one resident. | D |
| Infection control designee lacked documented evidence of required 15 hours infection control training. | D |
Report Facts
Residents reviewed: 15
Employees reviewed: 10
Residents affected by medication profile review deficiency: 6
Residents affected by provider notification deficiency: 3
Residents affected by infection control training deficiency: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assaad Zeid | Administrator | Administrator named in medication profile review and infection control training deficiencies |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Feb 14, 2024
Visit Reason
The inspection was conducted as a result of a State Licensure complaint investigation regarding an allegation of no hot water in the facility.
Findings
The complaint was unsubstantiated due to lack of evidence after interviews with the Executive Director and Maintenance Director and review of an invoice. No regulatory deficiencies were identified and no further action is necessary.
Complaint Details
Complaint #NV00073415 alleged no hot water in the facility; the allegation was unsubstantiated due to lack of evidence.
Report Facts
Complaint count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed during complaint investigation | |
| Maintenance Director | Interviewed during complaint investigation |
Inspection Report
Renewal
Census: 45
Capacity: 72
Deficiencies: 10
Aug 9, 2023
Visit Reason
This inspection was a mandatory State Licensure survey conducted as part of the facility's licensure renewal process in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A; however, several regulatory deficiencies were identified including incomplete TB testing documentation for one employee, unsecured toxic substances in a resident's room, and insufficient initial caregiver training for four employees. The facility has implemented corrective actions including additional training and audits to ensure compliance.
Severity Breakdown
F: 3
D: 5
E: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Qualifications of Caregivers-Age-Eng-Training requirements not fully met. | F |
| Personnel file lacked complete tuberculin (TB) testing documentation for one employee. | D |
| Health and sanitation standards not fully maintained. | D |
| Permits for food service not fully compliant with NAC 446. | D |
| First Aid and CPR training requirements not fully met. | D |
| Written policy on admissions not fully adhered to. | F |
| Maintenance and contents of separate resident files not fully compliant. | E |
| Toxic substances were accessible to residents in one secured unit room. | D |
| Elderly care training for caregivers incomplete for four employees within 60 days of hire. | F |
| Cultural competency training requirements not fully documented. | E |
Report Facts
Licensed capacity: 72
Census: 45
Employees reviewed: 7
Residents reviewed: 7
Severity 2 deficiencies: 2
Severity 2 Scope: 1
Severity 2 Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assaad Zeid | Administrator | Signed the report and responsible for compliance |
| Employee #5 | Named in TB testing documentation deficiency and caregiver training deficiency | |
| Employee #4 | Named in caregiver training deficiency | |
| Employee #6 | Named in caregiver training deficiency | |
| Employee #7 | Named in caregiver training deficiency | |
| Business Office Director | Confirmed deficiencies and responsible for auditing employee training and TB testing | |
| Executive Director | Responsible for ensuring compliance with corrective actions | |
| Administrator | Confirmed toxic substance was unsecured in resident room |
Inspection Report
Annual Inspection
Census: 32
Capacity: 72
Deficiencies: 11
Mar 15, 2023
Visit Reason
This inspection was conducted as a State Licensure annual grading survey of the residential facility for groups, in accordance with Nevada Administrative Code Chapter 449.
Findings
The facility received a grade of D with multiple deficiencies identified including inadequate caregiver training hours, delayed pre-employment physicals, facility maintenance issues, medication labeling errors, incomplete resident assessments, unsecured toxic substances, and incomplete cultural competency training for employees.
Severity Breakdown
Level 1: 1
Level 2: 10
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure 3 of 3 sampled employees working at the facility one year or greater completed at least eight hours of annual caregiver training. | Level 2 |
| Failed to ensure 1 of 10 sampled employees met the requirements concerning pre-employment physical examination; physical conducted 26 days after employment start. | Level 2 |
| Failed to ensure basic upkeep of the facility; pipe leaking in laundry room and excessive lint behind dryer. | Level 2 |
| Failed to ensure kitchen and supportive dining services complied with standards; worn cabinets, damaged dishwashing area with foul odor, dirty floors. | Level 2 |
| Failed to ensure 1 of 10 sampled employees received CPR and first aid training within 30 days of employment. | Level 2 |
| Failed to ensure residents receiving skilled nursing services were not admitted or allowed to remain without required waivers. | Level 2 |
| Failed to ensure an over-the-counter medication had a physician and resident name on the label for 1 of 10 sampled residents. | Level 1 |
| Failed to ensure annual Activities of Daily Living (ADL) assessments were completed for 4 of 10 residents. | Level 2 |
| Failed to ensure toxic substances were inaccessible to residents in the memory care unit; unsecured items found in multiple rooms. | Level 2 |
| Failed to ensure 4 of 6 sampled employees working less than one year received four hours of initial caregiver training within 60 days of hire. | Level 2 |
| Failed to ensure cultural competency training was completed within 30 business days of hire for 3 of 10 sampled employees. | Level 2 |
Report Facts
Facility licensed capacity: 72
Census: 32
Grade: D
Resurvey application fee: 600
Employees sampled: 10
Residents sampled: 10
Employees not meeting annual training hours: 3
Residents receiving skilled nursing care: 13
Employees lacking initial caregiver training within 60 days: 4
Employees lacking cultural competency training within 30 business days: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assaad Zeid | Administrator | Signed Attestation of Compliance form and provided information during inspection |
| Employee #2 | Failed to complete 8 hours annual caregiver training; completed cultural competency training late | |
| Employee #3 | Failed to complete 8 hours annual caregiver training | |
| Employee #5 | Medication Technician/Caregiver | Pre-employment physical conducted late; lacked initial caregiver training within 60 days |
| Employee #6 | Medication Technician/Caregiver | Failed to receive CPR and first aid training within 30 days; lacked initial caregiver training within 60 days |
| Employee #7 | Medication Technician/Caregiver | Lacked initial caregiver training within 60 days; completed cultural competency training late |
| Employee #8 | Medication Technician/Caregiver | Lacked initial caregiver training within 60 days |
| Employee #10 | Medication Technician/Caregiver | Failed to complete 8 hours annual caregiver training; lacked cultural competency training; no longer employed as of 02/23/2023 |
Inspection Report
Renewal
Census: 43
Capacity: 72
Deficiencies: 5
Dec 13, 2022
Visit Reason
This inspection was a mandatory State Licensure re-licensure survey conducted to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but had several repeat deficiencies including failure to ensure timely CPR and first aid training for one employee, failure to ensure annual physical examination for one resident, failure to document review of a quarterly medication pharmacy report by the administrator, failure to affix change labels on medication containers, and failure to properly label over-the-counter medications with resident and physician names.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 9 sampled employees received CPR and first aid training within 30 days of employment. | Severity: 2 |
| Failed to ensure a physical examination was performed annually for 1 of 15 sampled residents. | Severity: 2 |
| Administrator failed to document review of quarterly medication pharmacy report dated 10/30/22. | Severity: 2 |
| Failed to affix a change label to medication for 1 of 15 sampled residents. | Severity: 2 |
| Failed to properly label over-the-counter medication with resident and ordering physician name for 1 of 15 sampled residents. | Severity: 2 |
Report Facts
Number of resident files reviewed: 15
Number of employee files reviewed: 9
Medication pharmacy review report date: Oct 30, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assaad Zeid | Administrator | Named as Administrator and signatory on the report |
Inspection Report
Annual Inspection
Census: 41
Capacity: 72
Deficiencies: 18
Jun 16, 2022
Visit Reason
This Statement of Deficiencies was generated as a result of a State Licensure annual grading survey conducted at the facility on 06/16/22 by the Division of Public and Behavioral Health in accordance with Nevada Administrative Code Chapter 449.
Findings
The facility received a grade of D with multiple deficiencies identified including failure to ensure elder abuse training, tuberculosis screening, pre-employment physicals, background checks, proper garbage container maintenance, food service compliance, first aid and CPR training and supplies, resident rights protection, physical examinations, medication administration and reviews, Alzheimer's and dementia care training, safety regarding toxic substances, and weight measurement training for caregivers.
Severity Breakdown
Severity: 1: 1
Severity: 2: 15
Severity: 3: 1
Deficiencies (18)
| Description | Severity |
|---|---|
| Failure to ensure 2 of 10 sampled employees completed annual elder abuse prevention training or initial training before providing care. | Severity: 2 |
| Failure to ensure tuberculosis screening was completed for 1 of 10 sampled employees and pre-employment physicals for 3 of 10 sampled employees. | Severity: 2 |
| Failure to ensure a Registered Dietitian met background check requirements including fingerprints and clearance letter. | Severity: 2 |
| Failure to ensure garbage dumpster lid was kept closed to prevent rodent and pest infestations. | Severity: 2 |
| Failure to comply with kitchen and dining service standards including improper handwashing and unlabeled/dated potentially hazardous foods. | Severity: 2 |
| Failure to ensure 2 of 10 sampled employees received training and certification to perform CPR and first aid. | Severity: 2 |
| Failure to maintain required contents of first aid kit including germicide and CPR shield/mask. | Severity: 2 |
| Failure to protect a resident from abuse by an employee involving rough and forceful transfer. | Severity: 3 |
| Failure to post service rates in a conspicuous place at the time of inspection. | Severity: 1 |
| Failure to ensure initial physical examination prior to admission and annual physical examination for sampled residents. | Severity: 2 |
| Failure to ensure medication profile review was conducted at least once every six months for 2 of 15 residents. | Severity: 2 |
| Failure to maintain current medication management training for the Administrator. | Severity: 2 |
| Failure to affix change label to medication for 1 of 15 sampled residents. | Severity: 2 |
| Failure to ensure tuberculosis testing compliance for 2 residents with late or missing annual tests. | Severity: 2 |
| Failure to ensure toxic substances such as toothpaste and hand sanitizer were inaccessible to residents in secured unit and common areas. | Severity: 2 |
| Failure to ensure 1 of 10 sampled employees received four hours of initial training to care for elderly and disabled residents within 60 days of hire. | Severity: 2 |
| Failure to ensure 1 of 10 sampled employees received two hours of Alzheimer's training within 40 hours of employment. | Severity: 2 |
| Failure to provide protocols, training and competency assessments for 19 Caregivers and nine Medication Technicians performing monthly resident weight measurements. | Severity: 2 |
Report Facts
Resident files reviewed: 15
Employee files reviewed: 10
Facility licensed capacity: 72
Current census: 41
Training hours: 4
Training hours: 2
Training hours: 16
Training hours: 8
Fine fee: 600
Employees performing weight measurements: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #9 | Life Enrichment Director | Failed to complete annual elder abuse prevention training |
| Employee #11 | Caregiver | Failed to complete initial elder abuse prevention training and initial training to care for elderly and disabled residents within 60 days |
| Employee #7 | Registered Dietitian | Lacked tuberculosis screening, pre-employment physical, and background check documentation; contracted consultant no longer providing services |
| Employee #12 | Medication Technician | Lacked pre-employment physical, failed to complete Alzheimer's training within 40 hours |
| Employee #15 | Caregiver | Lacked pre-employment physical, CPR and first aid certification, no longer employed |
| Employee #1 | Executive Director | Lacked CPR and first aid certification at time of survey |
| Employee #4 | Removed from schedule due to resident abuse incident |
Inspection Report
Abbreviated Survey
Census: 37
Deficiencies: 3
Aug 23, 2021
Visit Reason
The inspection was a focused COVID-19 infection control survey conducted to investigate regulatory compliance with infection control and prevention measures at the facility.
Findings
The facility failed to provide a safe environment by not having a quarantine unit for newly admitted residents, lacking a separate entrance and exit for the COVID-19 isolation unit, and staff not properly donning and doffing PPE within the isolation unit. The Visqueen barrier separating the isolation unit was not properly sealed, potentially exposing COVID-19 negative residents, and staff working in the isolation unit included asymptomatic COVID-19 positive individuals.
Severity Breakdown
F: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to provide a safe environment by not having a quarantine unit for newly admitted residents. | F |
| No separate entrance and exit in the COVID-19 isolation unit, and improper separation of the isolation unit from the rest of the facility. | F |
| Staff did not properly don and doff PPE within the COVID-19 isolation unit, increasing risk of re-exposure. | F |
Report Facts
Census: 37
COVID-19 positive staff: 8
COVID-19 negative staff: 34
COVID-19 positive residents: 3
COVID-19 negative residents: 34
Isolation unit rooms: 4
Barrier gap height: 2
Barrier unsealed section height: 6
PPE tray sterilization time: 4
Isolation monitoring period: 10
Inspection Report
Re-Inspection
Census: 58
Capacity: 72
Deficiencies: 1
Mar 3, 2016
Visit Reason
The visit was a required grading re-survey conducted as a State Licensure survey by the Division of Public and Behavioral Health to assess compliance and deficiencies at the facility.
Findings
The facility was found to have deficiencies related to medication administration, including failure to administer medications as prescribed and issues with medication records and equipment. The facility received a re-survey grade of A.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure 1 out of 6 sampled residents received medications as prescribed, including acetaminophen and nebulizer treatments not administered or documented properly. | Severity: 2 |
Report Facts
Licensed capacity: 72
Census: 58
Deficiencies cited: 1
Date of survey: Mar 3, 2016
Inspection Report
Annual Inspection
Census: 54
Capacity: 72
Deficiencies: 9
Jan 5, 2016
Visit Reason
This document is an amended statement of deficiencies generated as a result of an annual State Licensure survey conducted on 1/5/16 at a residential facility for elderly and disabled persons and/or persons with Alzheimer's disease.
Findings
The facility was found deficient in multiple areas including personnel files for tuberculosis testing, first aid and CPR training, food service permits and kitchen conditions, safety requirements for residents, fire drill documentation, medication administration, resident file maintenance for tuberculosis testing, dangerous items in resident rooms, and toxic substances accessibility. The facility received a grade of C.
Severity Breakdown
Level 1: 1
Level 2: 6
Deficiencies (9)
| Description | Severity |
|---|---|
| Personnel file failed to ensure 5 of 15 employees met tuberculosis testing requirements. | — |
| Personnel file failed to ensure 4 of 15 employees were trained in first aid and CPR within 30 days of hire. | Level 2 |
| Facility failed to comply with food service permits and kitchen storage standards. | Level 1 |
| Safety requirements not met for auditory system pull cords in resident rooms and bathrooms. | Level 2 |
| Facility failed to ensure monthly fire drills were performed and documented for 4 of 12 months. | — |
| Medication administration records showed medications not on-site for 3 of 15 residents. | Level 2 |
| Resident files failed to meet tuberculosis testing requirements for 7 of 15 residents. | Level 2 |
| Facility failed to ensure dangerous items were stored securely and removed from resident access. | Level 2 |
| Facility failed to ensure toxic substances were inaccessible to residents. | Level 2 |
Report Facts
Resident census: 54
Total capacity: 72
Employees reviewed: 15
Resident files reviewed: 15
Deficiency severity counts: 7
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