Inspection Report
Annual Inspection
Census: 118
Capacity: 144
Deficiencies: 3
Jul 22, 2025
Visit Reason
The inspection was conducted as an annual State Licensure and complaint and bed change survey in accordance with Nevada Administrative Code Chapter 449. The facility also applied for a bed change which was approved during this survey.
Findings
The facility received a grade of A with one complaint substantiated without deficient practice. Deficiencies identified included failure to maintain kitchen cleanliness, incomplete medication administration reviews, and incomplete tuberculosis screenings for some residents.
Complaint Details
One complaint (NV00074549) was investigated and substantiated without deficient practice. The investigation included observations, interviews with staff and residents, clinical record reviews, and document reviews.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Black grime and pink biofilm build-up on internal components of the ice machine in the kitchen. | Severity: 2 |
| Failure to ensure medication reviews were conducted every six months for 2 of 25 residents and medication reviews were not reviewed and initialed by the Administrator for 3 of 25 residents. | Severity: 2 |
| Failure to ensure an initial two-step tuberculosis screening was completed for 1 of 25 residents and an annual TB screening was completed for 1 of 25 residents. | Severity: 2 |
Report Facts
Licensed beds: 144
Current census: 118
Complaint investigated: 1
Resident files reviewed: 25
Employee files reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Markie Hamlin | Administrator | Acknowledged medication review deficiencies and signed the report. |
| Director of Culinary Services | Interviewed during complaint investigation and involved in kitchen cleanliness corrective actions. | |
| Executive Director | Interviewed during complaint investigation and involved in corrective actions and monthly reviews. | |
| Registered Nurse | Interviewed during complaint investigation. |
Inspection Report
Complaint Investigation
Census: 106
Capacity: 144
Deficiencies: 0
Sep 12, 2024
Visit Reason
The inspection was conducted as a complaint investigation survey triggered by complaint #NV00072070, in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The complaint was unsubstantiated with no regulatory deficiencies identified. The investigation included observations of infection control procedures, interviews with staff and residents, and review of medical records and facility documents.
Complaint Details
Complaint #NV00072070 was investigated and found to be unsubstantiated with no deficiencies identified.
Report Facts
Sample size: 5
Category I residents: 103
Category II residents: 41
Inspection Report
Complaint Investigation
Census: 109
Capacity: 144
Deficiencies: 0
Sep 12, 2024
Visit Reason
The inspection was conducted as a complaint investigation survey following two complaints received by the facility.
Findings
Two complaints were investigated; one was substantiated without deficient practice and the other was unsubstantiated. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00072604 was substantiated with no deficient practice. Complaint #NV00072699 was unsubstantiated with no regulatory deficiencies identified.
Report Facts
Sample size: 5
Category I residents: 103
Category II residents: 41
Inspection Report
Annual Inspection
Census: 144
Capacity: 144
Deficiencies: 6
Jul 16, 2024
Visit Reason
The inspection was conducted as an Annual State Licensure and complaint survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility was found to have multiple regulatory deficiencies including personnel TB screening, food service violations, incomplete resident physical exams, medication administration and storage issues, and lack of infection control training for some employees. Two complaints were investigated, one substantiated without deficient practice and one unsubstantiated.
Complaint Details
Two complaints were investigated: Complaint #NV00071504 was substantiated without deficient practice; Complaint #NV00071617 was unsubstantiated with no regulatory deficiencies identified.
Severity Breakdown
2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure annual and initial two-step tuberculosis (TB) tests were completed for 2 of 10 employees (Employee #5 and #10). | 2 |
| Failed to ensure kitchen and dining services complied with NAC 446 standards including critical violations related to raw shell eggs and food storage, and major violations related to hair restraints and cleanliness. | 2 |
| Failed to ensure 2 of 25 residents received an annual physical examination (Resident #15 and #17). | 2 |
| Failed to ensure medications were administered as prescribed for 1 of 25 residents (Resident #5). | 2 |
| Failed to ensure medications were stored securely for 2 of 16 residents who self-administered medications (Resident #7 and #9). | 2 |
| Failed to ensure 2 of 10 employees (Employee #3 and #4) obtained required infection control training from a nationally recognized organization. | 2 |
Report Facts
Resident files reviewed: 26
Employee files reviewed: 10
Complaints investigated: 2
Residents sampled for physical exams: 25
Residents sampled for medication administration: 25
Residents sampled for medication storage: 16
Employees sampled for TB screening: 10
Employees sampled for infection control training: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Markie Hamlin | Executive Director | Signed the report and mentioned in relation to oversight and corrective actions. |
| Employee 5 | Residential Aide | Named in TB screening deficiency. |
| Employee 10 | Residential Aide | Named in TB screening deficiency. |
| Employee 3 | Medication Technician | Named in infection control training deficiency. |
| Employee 4 | Medication Technician | Named in infection control training deficiency. |
| Maintenance Director | Acknowledged medication storage deficiencies for Residents #7 and #9. | |
| Resident Services Director | Acknowledged medication administration deficiency for Resident #5 and involved in corrective actions. | |
| Administrator | Acknowledged missing annual physical exams for Residents #15 and #17 and infection control training deficiencies for Employees #3 and #4. | |
| Director of Culinary Services | Responsible for corrective actions related to food service deficiencies. |
Inspection Report
Re-Inspection
Census: 114
Capacity: 144
Deficiencies: 0
Aug 28, 2023
Visit Reason
This inspection was a State Licensure voluntary grading resurvey conducted at the facility on 08/28/23 in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A with no regulatory deficiencies identified. One new resident file was reviewed during the survey.
Report Facts
Licensed beds: 144
Residents present: 114
Category I residents: 103
Category II residents: 41
Inspection Report
Annual Inspection
Census: 112
Capacity: 144
Deficiencies: 3
Jul 11, 2023
Visit Reason
The inspection was conducted as an annual State Licensure and complaint survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility was found to have an immediate jeopardy situation due to failure to maintain a safe fire suppression and automatic sprinkler system, which was impaired and not repaired timely. Additionally, a medication labeling deficiency was identified for one resident. The immediate jeopardy was abated the same day by implementing temporary repairs and an hourly fire watch.
Complaint Details
One complaint (Complaint #NV00068062) was investigated and found to be unverified with no regulatory deficiencies identified.
Severity Breakdown
Level 1: 2
Level 2: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure the fire suppression and automatic sprinkler systems were functional in the event of a fire emergency, including impaired air compressor and non-operational sprinkler heads. | Level 1 |
| Failure to comply with regulations adopted by the State Fire Marshal and local ordinances relating to safety from fire. | Level 1 |
| Failure to ensure medication was properly labeled for one resident, missing resident's name, prescriber, route, and directions for administration. | Level 2 |
Report Facts
Resident files reviewed: 26
Employee files reviewed: 10
Residents Category I: 103
Residents Category II: 41
Severity 1 Deficiencies: 2
Severity 2 Deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Masich | Executive Director | Named in interviews and responsible for fire safety oversight and abatement plan |
Inspection Report
Annual Inspection
Census: 113
Capacity: 144
Deficiencies: 1
Jul 26, 2022
Visit Reason
This 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
The facility received a grade of A. One regulatory deficiency was identified related to food service compliance, including two dietary staff not wearing hair restraints and soiled kitchen equipment.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Two dietary staff were not in hair restraints while handling food and beverages; deli slicer and can opener were soiled with debris and metal shavings. | Severity: 2 |
Report Facts
Licensed beds: 144
Residents present: 113
Resident files reviewed: 25
Employee files reviewed: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Masich | Executive Director | Signed the report and mentioned in plan of correction |
Inspection Report
Annual Inspection
Census: 103
Capacity: 144
Deficiencies: 3
Sep 30, 2021
Visit Reason
The 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 but had several deficiencies including failure to maintain current CPR certifications for 11 employees, lack of annual physical examinations for 3 residents, and failure to ensure annual tuberculosis testing for 16 residents.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to maintain current Cardiopulmonary Resuscitation (CPR) certification for 11 out of 18 sampled employees. | Level 2 |
| Failed to ensure 3 of 25 residents had an annual physical examination signed by a physician. | Level 2 |
| Failed to ensure 16 of 25 residents met the requirements concerning annual tuberculosis (TB) testing. | Level 2 |
Report Facts
Employees with expired CPR certifications: 11
Residents without annual physical examination: 3
Residents without annual TB testing: 16
Licensed bed capacity: 144
Resident census: 103
Inspection Report
Complaint Investigation
Census: 73
Capacity: 144
Deficiencies: 1
May 5, 2021
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 2021-04-27 and completed on 2021-05-05 regarding allegations of failure to notify a responsible party of a resident's change in condition.
Findings
The facility was found to have failed to notify the responsible party of a resident's progression of a pressure ulcer from Stage 2 to Stage 3 and then Stage 4, violating their policy on notification of changes in condition. The complaint was substantiated and the facility received a grade of A.
Complaint Details
Complaint #NV00063485 with two allegations was substantiated. Allegation #1 involved failure to notify the responsible party of a resident's change in condition related to pressure sores.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify the responsible party of a resident's change in condition related to pressure ulcers. | D |
Report Facts
Licensed beds: 144
Residents present: 73
Category I residents: 103
Category II residents: 41
Severity level D deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Masich | Executive Director | Named in signature and plan of correction |
Inspection Report
Abbreviated Survey
Census: 74
Capacity: 144
Deficiencies: 0
Sep 29, 2020
Visit Reason
The inspection was a focused COVID-19 infection control survey conducted to assess compliance with infection prevention measures in accordance with Nevada Administrative Code Chapter 449.
Findings
The facility was found to have implemented appropriate COVID-19 screening, infection control policies, and preventive measures including temperature checks, PPE use, social distancing, and sanitization. No residents or staff tested positive for COVID-19 and no deficiencies were identified.
Report Facts
Hand sanitizer volume: 52
Electronic temporal thermometers: 5
Gloves: 7900
Surgical masks: 5940
Gowns: 202
N-95 masks: 1072
Face shields: 60
Licensed beds: 144
Category I residents: 103
Category II residents: 41
Inspection Report
Annual Inspection
Census: 116
Capacity: 144
Deficiencies: 8
Aug 13, 2019
Visit Reason
The inspection was an annual State Licensure survey conducted in accordance with Nevada Administrative Code (NAC) Chapter 449 for a Residential Facility for Groups.
Findings
The facility was found to have multiple deficiencies including failure to maintain health and sanitation standards, improper storage and labeling of medications, failure to secure oxygen tanks and equipment, and incomplete annual physical examinations for residents. The facility received a grade of C.
Severity Breakdown
Severity: 2: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to ensure a garden hose was secured in a common courtyard area, creating hazards and obstacles. | Severity: 2 |
| Double doors leading to residential courtyard and exterior were not closing properly and weather stripping was coming off. | Severity: 2 |
| Expired food items found in walk-in cooler and reach-in refrigerator; cutting board stained and had deep abrasions; ventilation hood filters soiled; dumpster enclosure soiled. | Severity: 2 |
| Service rates were not posted in a conspicuous place. | Severity: 2 |
| Residents requiring oxygen did not have proper physician orders; oxygen tanks were unsecured; equipment malfunctioning; staff unaware of oxygen orders and use. | Severity: 2 |
| Medications were not stored in a locked, secured area for 2 of 15 residents; medication visible in resident rooms. | Severity: 2 |
| Medications were not properly labeled with resident's name and prescribing physician for 3 of 15 sampled residents. | Severity: 2 |
| Annual physical examinations were not completed for 3 of 15 sampled residents. | Severity: 2 |
Report Facts
Census: 116
Total Capacity: 144
Residents Sampled: 15
Employees Sampled: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Services Director | Acknowledged issues with garden hose and oxygen tank security; indicated lack of physician orders for oxygen | |
| Maintenance Director | Acknowledged issues with garden hose and double doors; adjusted doors and replaced weather stripping | |
| Director of Culinary Services | Director of Culinary Services (DCS) | Discarded expired food items; planned staff training on checking expired items and cleaning filters |
| Resident Medication Assistant R12 | Reported oxygen use without physician order; attempted to operate oxygen equipment | |
| Resident Medication Assistant R15 | Unable to self-administer medications; acknowledged unsecured medication storage | |
| Resident Services Director | Indicated medications should not be in resident rooms without physician approval |
Inspection Report
Annual Inspection
Census: 118
Capacity: 144
Deficiencies: 3
Aug 3, 2016
Visit Reason
The inspection was conducted as an annual State Licensure survey to assess compliance with regulatory requirements for the facility licensed for assisted living services.
Findings
The facility received a grade of A. Deficiencies were identified related to medication storage security in resident rooms and incomplete employee training on chronic illness and mental illness care within mandated timeframes.
Severity Breakdown
2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure medications were stored and secured in a locked area in 7 of 30 resident rooms observed. | 2 |
| Facility failed to ensure 2 of 15 employees completed required chronic illness training within 60 days of hire. | 2 |
| Facility failed to ensure 2 of 15 employees completed required mental illness training within 60 days of hire. | 2 |
Report Facts
Resident files reviewed: 25
Employee files reviewed: 15
Rooms with unsecured medications: 7
Employees lacking chronic illness training: 2
Employees lacking mental illness training: 2
Inspection Report
Annual Inspection
Census: 118
Capacity: 144
Deficiencies: 3
Aug 3, 2016
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility on 8/3/16 by the Division of Public and Behavioral Health.
Findings
The facility received a grade of A. Deficiencies were identified related to medication storage security in 7 of 30 resident rooms observed, and failures to ensure required employee training for mental illness and chronic illness care within mandated timeframes for 2 of 15 employees. These training deficiencies were repeat findings from the prior annual survey.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure medications were stored and secured in a locked area in 7 of 30 resident rooms observed. | Level 2 |
| Failed to ensure 2 of 15 employees completed required mental illness training within 60 days of employment. | Level 2 |
| Failed to ensure 2 of 15 employees completed required chronic illness training within 60 days of employment. | Level 2 |
Report Facts
Resident rooms with unsecured medications: 7
Resident census: 118
Total licensed capacity: 144
Employee files reviewed: 15
Resident files reviewed: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Resident Services Attendant | Failed to complete required mental illness and chronic illness training within 60 days of employment |
| Employee #2 | Resident Services Assistant | Failed to complete required mental illness and chronic illness training within 60 days of employment |
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 1
Jun 2, 2016
Visit Reason
The inspection was conducted as a complaint investigation following a complaint alleging that a resident developed a pressure sore while residing in the facility.
Findings
The facility failed to ensure timely notification of a physician upon a change of condition for one of six residents reviewed. Resident #1 developed stage II pressure ulcers and the facility did not document or communicate changes in the resident's skin condition appropriately.
Complaint Details
Complaint #NV00045886 was substantiated. The allegation that a resident developed a pressure sore while residing in the facility was substantiated.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure a physician was notified timely upon a change of condition for Resident #1 who developed pressure sores. | Severity: 2 |
Report Facts
Census: 116
Sample size: 6
Residents with condition change: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Services Director (RSD) | Explained awareness of Resident #1's pressure ulcers and facility policies on reporting changes of condition | |
| Caregiver | Provided care to Resident #1 and explained observations and reporting practices |
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 1
Jun 2, 2016
Visit Reason
This inspection was conducted as a complaint investigation triggered by complaint #NV00045886 regarding a resident who developed a pressure sore while residing in the facility.
Findings
The facility failed to ensure timely notification of a physician upon a resident's change of condition related to pressure ulcers. The investigation substantiated the complaint that a resident developed pressure sores, with documentation showing delayed communication and lack of timely incident reporting by staff.
Complaint Details
Complaint #NV00045886 was substantiated. The allegation that a resident developed a pressure sore while residing in the facility was confirmed.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure a physician was notified timely upon a change of condition for 1 of 6 residents (Resident #1) who developed pressure ulcers. | 2 |
Report Facts
Census: 116
Sample size: 6
Complaint count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Services Director (RSD) | Provided explanation about awareness of pressure ulcers and facility communication policies | |
| Caregiver | Provided care to Resident #1 and described observations and reporting practices related to skin sores |
Notice
Deficiencies: 1
May 24, 2016
Visit Reason
The Division of Public and Behavioral Health is notifying the facility of sanctions and monetary penalties imposed due to deficiencies found during regulatory oversight.
Findings
The notice details the imposition of a $400 monetary penalty for a deficiency with a severity level of three and a scope level of two or less, as defined by Nevada Revised Statutes and Administrative Code.
Severity Breakdown
Level 3: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiency at TAG Y878 with a severity level of three and scope level of two or less. | Level 3 |
Report Facts
Monetary penalties: 400
Working days until sanctions effective: 11
Days for payment due: 15
Penalty reduction percentage: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pat Elkins | Health Facilities Inspector III | Signed the sanction notice |
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 0
May 5, 2016
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding allegations that the facility requested a resident to be relocated due to previous behavioral concerns.
Findings
The complaint was investigated through interviews and review of relevant files and policies, and the allegations were not substantiated. No regulatory deficiencies were identified.
Complaint Details
Complaint #NV00045824 was investigated with allegations that the facility requested the resident to be relocated due to previous behavioral concerns; these allegations could not be substantiated.
Report Facts
Sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Services Director | Interviewed during the complaint investigation | |
| Community Business Director | Interviewed during the complaint investigation |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 144
Deficiencies: 2
May 3, 2016
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 2016-04-19 and completed on 2016-05-03 regarding medication management and administration at the facility.
Findings
The facility was found to have substantiated complaints related to failure to manage a resident's blood thinner medication requiring monitoring and failure to administer medications according to doctor's orders for two residents. Deficiencies included improper medication administration and lack of adherence to physician orders.
Complaint Details
Complaint #NV00045706 was substantiated. The facility failed to manage the resident's blood thinner medication requiring monitoring and failed to administer medications according to doctor's orders.
Severity Breakdown
Level 2: 1
Level 3: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure medication was not administered to a resident who was physically unstable and required monitoring (Resident #1). | Level 2 |
| Facility failed to ensure 2 of 5 residents received medications following doctor's orders (Residents #1 and #2). | Level 3 |
Report Facts
Total licensed beds: 144
Census: 112
Sample size: 5
Medication administration days missed: 10
Medication administration days missed: 5
Medication administration days: 5
Medication administration days: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Services Director (RSD) | Acknowledged findings and explained medication technician interruption. | |
| Medication Technician | Acknowledged failure to administer Warfarin from 2/1/16 through 2/10/16 due to interrupted order processing. | |
| Administrator | Unable to provide a policy on medication errors. |
Inspection Report
Complaint Investigation
Census: 111
Capacity: 144
Deficiencies: 0
Apr 25, 2016
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 04/25/2016 regarding an allegation that the facility failed to ensure medication was on site.
Findings
The complaint was investigated through interviews with staff, review of policies, and medication records for five residents. The complaint could not be substantiated and no regulatory deficiencies were identified.
Complaint Details
Complaint #NV00045559 was investigated and found to be unsubstantiated.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 112
Capacity: 144
Deficiencies: 2
Apr 19, 2016
Visit Reason
This inspection was conducted as a complaint investigation initiated on 2016-04-19 regarding the facility's management of residents' blood thinner medication and medication administration according to doctor's orders.
Findings
The investigation substantiated that the facility failed to manage blood thinner medication requiring monitoring and failed to administer medications according to doctor's orders. Deficiencies were identified related to medication administration and monitoring of anticoagulant therapy for residents.
Complaint Details
Complaint #NV00045706 was substantiated. The allegations that the facility failed to manage the resident's blood thinner medication because it required monitoring and failed to administer medications according to doctor's orders were substantiated.
Severity Breakdown
Level 2: 1
Level 3: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure medication was administered to a resident who was physically unstable and required monitoring (Resident #1). | Level 2 |
| Facility failed to ensure 2 of 5 residents received medications following doctor's orders (Residents #1 and #2). | Level 3 |
Report Facts
Licensed capacity: 144
Census: 112
Sample size: 5
Severity 2 deficiencies: 1
Severity 3 deficiencies: 1
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Mar 30, 2016
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #NV00045428 regarding an allegation of a water leak causing water damage and mold in resident rooms.
Findings
The complaint investigation found that the allegation of water leak and mold could not be substantiated after observations, interviews with the Administrator and Maintenance Director, and review of repair agreements and invoices. No regulatory deficiencies were identified.
Complaint Details
One complaint was investigated with one allegation which could not be substantiated.
Report Facts
Complaint count: 1
Allegations: 1
Inspection Report
Re-Inspection
Census: 122
Capacity: 144
Deficiencies: 0
Nov 19, 2015
Visit Reason
This was a required grading re-survey conducted by the Division of Public and Behavioral Health to assess compliance and licensure status of the facility.
Findings
The facility received a re-survey grade of A with no deficiencies identified during the inspection.
Report Facts
Category I residents: 103
Category II residents: 41
Employee files reviewed: 5
Resident files reviewed: 4
Inspection Report
Annual Inspection
Census: 125
Capacity: 144
Deficiencies: 10
Oct 15, 2014
Visit Reason
This annual State Licensure survey was conducted to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of B with several deficiencies identified including critical and major violations related to food service, medication administration, medication storage, tuberculosis testing, and chronic illness endorsement.
Severity Breakdown
Severity: 2: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Meatloaf in the walk-in refrigerator had an internal temperature of 56-58 degrees Fahrenheit. | Severity: 2 |
| Raw beef meatballs and raw fish were stored above cooked meatloaf and cooked chicken in the walk-in refrigerator. | Severity: 2 |
| Cutting boards on the cook's line and smaller cutting boards were worn and no longer smooth and easily cleanable. | Severity: 2 |
| Numerous soiled wiping cloths were on the cook's line food preparation surfaces. | Severity: 2 |
| The meat slicer was soiled with food debris. | Severity: 2 |
| The hand soap dispenser in the food preparation area was not operating. | Severity: 2 |
| Facility failed to ensure 1 of 26 residents received medications administered by the facility per the Ultimate User Agreement. | Severity: 2 |
| Facility failed to ensure medications for 1 of 26 residents were locked (Resident #27). | Severity: 2 |
| Facility failed to ensure compliance with tuberculosis testing for 1 of 26 residents (Resident #3). | Severity: 2 |
| Facility failed to obtain a Chronic Illness endorsement prior to admitting a chronically ill resident (Resident #13). | Severity: 2 |
Report Facts
Residents reviewed: 26
Employee files reviewed: 15
Deficiencies cited: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Atria Seville | Administrator | Named in preparation and submission of plan of correction |
| Senior Resident Services Director | Provided information about medication administration and resident agreements | |
| Director of Maintenance | Witnessed unsecured medication and explained door locking | |
| Executive Director | Acknowledged lack of Chronic Illness endorsement |
Inspection Report
Annual Inspection
Census: 125
Capacity: 144
Deficiencies: 6
Oct 15, 2014
Visit Reason
This inspection was an annual State Licensure survey conducted to assess compliance with regulatory standards for the residential facility.
Findings
The facility received a grade of B with multiple deficiencies identified including critical and major violations in kitchen food safety, medication administration and storage issues, lack of tuberculosis testing documentation, and failure to obtain a Chronic Illness endorsement for a resident.
Severity Breakdown
Severity: 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Kitchen failed to comply with NAC 446 standards including improper food storage temperatures and cross-contamination risks. | Severity: 2 |
| Cutting boards were worn and not easily cleanable; soiled wiping cloths and food debris on meat slicer; handsoap dispenser not operating. | Severity: 2 |
| Failed to ensure 1 of 26 residents received medications per Ultimate User Agreement. | Severity: 2 |
| Medications for 1 of 26 residents were not stored in a locked area. | Severity: 2 |
| Failed to ensure tuberculosis testing documentation for 1 of 26 residents. | Severity: 2 |
| Failed to obtain Chronic Illness endorsement prior to admitting a chronically ill resident. | Severity: 2 |
Report Facts
Resident files reviewed: 26
Employee files reviewed: 15
Facility licensed capacity: 144
Facility census: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Senior Resident Services Director | Provided information regarding medication administration and tuberculosis testing | |
| Director of Maintenance | Witnessed unsecured medication in resident's room | |
| Executive Director | Acknowledged lack of Chronic Illness endorsement |
Inspection Report
Annual Inspection
Census: 58
Capacity: 144
Deficiencies: 9
Oct 29, 2013
Visit Reason
The inspection was conducted as a State Licensure annual grading survey to evaluate compliance with state regulations for a residential facility providing assisted living services.
Findings
The facility received a grade of A but had deficiencies related to kitchen sanitation and food service permits, as well as failure to obtain a mental illness endorsement for a resident with bipolar disorder. Several cleaning and maintenance issues were noted in the kitchen and food preparation areas.
Severity Breakdown
2: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| No thermometer in the cook's line reach-in refrigerator. | 2 |
| Cook was touching ready to eat food with bare hands. | 2 |
| Handle of the ice scoop was in contact with ice in the ice machine. | 2 |
| Person washing dishes did not have hair effectively restrained. | 2 |
| Numerous soiled wet wiping cloths on food preparation tables. | 2 |
| Sanitizer solution for wiping cloth storage was heavily soiled. | 2 |
| Food preparation tables and interior of ice machine were soiled. | 2 |
| Grease receptacle and ground surrounding outside trash enclosure were heavily soiled. | 2 |
| Facility failed to obtain a mental illness endorsement for a resident with bipolar disorder. | 2 |
Report Facts
Licensed capacity: 144
Current census: 58
Employee files reviewed: 15
Resident files reviewed: 15
Inspection Report
Annual Inspection
Capacity: 144
Deficiencies: 3
Oct 29, 2013
Visit Reason
The inspection was conducted as a State Licensure annual grading survey to assess compliance with regulatory standards for the facility.
Findings
The facility was found deficient in kitchen sanitation and food service permit compliance, with multiple cleaning and maintenance issues observed. Additionally, the facility failed to obtain a required mental illness endorsement despite providing care for a resident with bipolar disorder.
Severity Breakdown
F: 1
2: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| No thermometer in the cook's line reach-in refrigerator; cook touching ready to eat food with bare hands; ice scoop handle in contact with ice; dish washer's hair not effectively restrained; soiled wet wiping cloths on food preparation tables; heavily soiled sanitizer solution; soiled food preparation tables and interior of ice machine. | F |
| Grease receptacle and surrounding ground in outside trash enclosure heavily soiled. | 2 |
| Facility failed to obtain a mental illness endorsement despite providing care for a resident diagnosed with bipolar disorder. | 2 |
Report Facts
Total licensed capacity: 144
Inspection Report
Complaint Investigation
Capacity: 144
Deficiencies: 0
Jul 19, 2013
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 7/19/13, finalized on 7/31/13.
Findings
The complaint #NV00036196 was not substantiated based on record review and interviews with the Administrator, Medical Tech, and Residents. The investigation included review of resident files, policies, and incident/complaint logs.
Complaint Details
Complaint #NV00036196 was investigated and found not substantiated based on record review and interview.
Report Facts
Total licensed capacity: 144
Category I resident beds: 103
Category II beds: 41
Inspection Report
Complaint Investigation
Capacity: 125
Deficiencies: 1
Jun 3, 2013
Visit Reason
The inspection was conducted as a result of a complaint investigation from 5/22/13 to 6/3/13 regarding compliance with food service permits and storage regulations.
Findings
The facility was found to have numerous potentially hazardous foods held at improper temperatures in the kitchen's reach-in refrigerator during a routine inspection. The complaint was substantiated, and follow-up inspections confirmed ongoing temperature violations.
Complaint Details
Complaint #NV00035781 was substantiated regarding food service permit compliance and improper food storage temperatures.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure the kitchen complied with NAC 446 standards for food storage and permits, with hazardous foods held at improper temperatures (58-64 degrees F) in the reach-in refrigerator. | Severity: 2 |
Report Facts
Total licensed capacity: 125
Severity level: 2
Scope: 3
Inspection Report
Complaint Investigation
Capacity: 125
Deficiencies: 1
Jun 3, 2013
Visit Reason
This Statement of Deficiencies was generated as a result of a complaint investigation conducted on the facility from 2013-05-22 to 2013-06-03.
Findings
The facility failed to ensure the kitchen complied with NAC 446 standards. Numerous potentially hazardous foods were found held at improper temperatures in a reach-in refrigerator on the cook's line during inspections on 2013-05-22 and 2013-06-03. Facility staff were unclear about corrective actions taken.
Complaint Details
Complaint #NV00035781 was substantiated.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure the kitchen complied with NAC 446 standards related to food storage and temperature control. | Severity: 2 |
Report Facts
Facility licensed capacity: 125
Category I residents: 103
Category II residents: 22
Temperature readings: 58
Temperature readings: 64
Temperature readings: 60
Temperature readings: 56
Temperature readings: 56
Temperature readings: 57
Temperature readings: 58
Temperature readings: 56
Temperature readings: 59
Temperature readings: 60
Reach-in refrigerator temperature: 50
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 2
Apr 24, 2013
Visit Reason
This complaint investigation was conducted from 2013-04-04 to 2013-04-24 by the Nevada State Health Division following complaint #NV00034800.
Findings
The facility failed to notify the family of a resident who sustained a fracture to the right hand and failed to request emergency services for that resident. The complaint was substantiated based on observations, interviews, and record reviews.
Complaint Details
Complaint #NV00034800 was substantiated. The complaint investigation was initiated on 2013-04-04. The facility failed to notify the family and request emergency services for Resident #1 who sustained a fracture to the right hand.
Severity Breakdown
Severity 2: 1
Severity 3: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to contact the family for 1 of 72 residents who sustained a fracture to the right hand (Resident #1). | Severity 2 |
| Failed to request emergency services for 1 of 72 residents who sustained a fracture to the right hand (Resident #1). | Severity 3 |
Report Facts
Licensed beds: 72
Residents affected: 1
Inspection Report
Complaint Investigation
Census: 128
Capacity: 125
Deficiencies: 4
Apr 1, 2013
Visit Reason
This document is a Statement of Deficiencies generated as a result of a complaint investigation conducted on the facility from 3/21/13 to 4/1/13. The investigation was triggered by complaint #NV00034820 which was substantiated.
Findings
The facility failed to provide protective supervision for one resident diagnosed with Alzheimer's disease, who eloped from the facility and was found wandering several blocks away. The resident was admitted without a physical exam and the facility was not licensed to care for residents with Alzheimer's disease. Additionally, the facility failed to maintain a separate resident file with required physician statements.
Complaint Details
Complaint #NV00034820 was substantiated. The complaint involved Resident #1, an 85-year-old female with Alzheimer's disease who eloped from the facility and was found wandering several blocks away. The resident was admitted without a physical exam and the facility was not licensed to care for residents with Alzheimer's disease.
Severity Breakdown
Severity: 3: 3
Severity: 2: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide protective supervision for 1 of 128 residents (Resident #1) diagnosed with Alzheimer's disease who eloped from the facility. | Severity: 3 |
| Resident #1 was admitted without a physical exam completed by a physician prior to admission. | Severity: 3 |
| Facility not licensed to care for residents with Alzheimer's disease. | Severity: 3 |
| Failure to maintain a separate file for each resident including a physician's statement concerning the mental and physical condition of the resident. | Severity: 2 |
Report Facts
Licensed capacity: 125
Resident census: 128
Deficiency severity count: 3
Deficiency severity count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director | Stated during interview that resident was admitted without physical exam and described resident's condition |
| Administrator | Administrator | Named in facility's plan of correction to review physician reports and assure compliance |
| Licensed Practical Nurse | Licensed Practical Nurse | Stated that resident's next of kin told staff the resident was depressed due to recent family deaths |
Inspection Report
Re-Inspection
Census: 110
Capacity: 125
Deficiencies: 2
Dec 13, 2012
Visit Reason
This document is a Statement of Deficiencies generated as a result of a voluntary grading re-survey conducted from 12/12/12 through 12/13/12 at the facility.
Findings
The facility received a re-survey grade of A. Deficiencies were identified related to the facility caring for a resident with advanced dementia without appropriate endorsement or training, and failure to comply with food service standards including sanitation and equipment maintenance issues.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility was caring for a resident with advanced dementia without the appropriate endorsement and failed to obtain necessary training. | Severity: 2 |
| Facility failed to ensure the kitchen complied with standards of NAC 446, including sanitation issues such as an undated opened container of sour cream, soiled equipment, soiled floors, and improper storage of food and cleaning equipment. | Severity: 2 |
Report Facts
Residents present: 110
Total licensed capacity: 125
Category I residents: 103
Category II residents: 22
Severity 2 deficiencies: 2
Inspection Report
Plan of Correction
Census: 110
Capacity: 125
Deficiencies: 4
Dec 12, 2012
Visit Reason
This document is a plan of correction submitted following a voluntary grading re-survey conducted from 12/12/12 through 12/13/12 for a residential facility providing assisted living services.
Findings
The facility was found deficient in multiple areas including failure to obtain necessary training for caring for residents with advanced dementia and non-compliance with food service permits and kitchen sanitation standards. The facility received a re-survey grade of A.
Severity Breakdown
Severity 2: 3
Severity F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to obtain necessary training to care for residents with advanced dementia (Resident #1). | Severity 2 |
| Non-compliance with permits related to food service. | Severity F |
| Cleaning and sanitation issues including an undated opened container of sour cream in the walk-in refrigerator, soiled equipment and floors on the cook's line. | Severity 2 |
| Equipment and maintenance issues such as improper storage of bottled and canned food, and soiled mop bucket stored in janitor closet. | Severity 2 |
Report Facts
Residents present: 110
Total licensed capacity: 125
Category I residents: 103
Category II residents: 22
Inspection Report
Capacity: 125
Deficiencies: 0
Dec 7, 2012
Visit Reason
This inspection was conducted as a Bed Increase inspection to request licensure for 19 additional Residential Facility for Group beds for elderly and disabled, Category II residents.
Findings
No regulatory deficiencies were identified during this State Licensure inspection. No further action is necessary.
Report Facts
Licensed beds: 125
Additional beds requested: 19
Inspection Report
Annual Inspection
Census: 72
Capacity: 125
Deficiencies: 6
Oct 31, 2012
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with state regulations for a residential assisted living facility.
Findings
The facility received a grade of B with multiple deficiencies identified, including caregiver medication training, personnel file requirements, food service permits and sanitation, oxygen tank security, and medication storage issues.
Severity Breakdown
D: 4
F: 1
C: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 15 caregivers completed initial medication management training as required. | D |
| Facility failed to ensure 1 of 11 caregivers was trained in first aid and CPR. | D |
| Facility failed to comply with food service permits and sanitation standards; critical violations included sausage patties held at improper temperature and uncovered food items. | F |
| Dietary reports were not conducted on a quarterly basis as required. | C |
| Facility failed to ensure oxygen tanks were secured in 1 of 20 rooms where oxygen was used. | D |
| Facility failed to ensure medications were secured in 2 of 20 resident rooms. | D |
Report Facts
Caregivers missing medication training: 1
Caregivers missing first aid training: 1
Resident census: 72
Total licensed capacity: 125
Rooms with unsecured oxygen tanks: 1
Rooms with unsecured medications: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #9 | Missing total of 8 hours of medication management training | |
| Employee #11 | Missing first aid training; completed CPR/AED & First Aid training on November 7, 2012 |
Inspection Report
Annual Inspection
Census: 72
Capacity: 125
Deficiencies: 6
Oct 31, 2012
Visit Reason
This document is the result of an annual State Licensure survey conducted at the facility on 10/31/2012 to assess compliance with state regulations for assisted living services.
Findings
The facility received a grade of B with multiple deficiencies identified including caregiver training deficiencies, kitchen sanitation and maintenance issues, failure to conduct quarterly dietary reports, oxygen equipment safety concerns, and medication storage violations.
Severity Breakdown
1: 1
2: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 15 caregivers completed the required initial medication management training (Employee #9 missing 8 hours of training). | 2 |
| Failed to ensure 1 of 11 caregivers was trained in first aid and CPR (Employee #11 missing first aid training). | 2 |
| Kitchen failed to comply with food service standards including critical violation of sausage patties held at unsafe temperatures, uncovered food items, improper food handling, soiled equipment, and maintenance issues. | 2 |
| Failed to ensure dietary consultant reports were conducted quarterly; last report dated December 2011. | 1 |
| Failed to ensure oxygen tanks were secured in 1 of 20 rooms where oxygen was used (Room #241). | 2 |
| Failed to ensure medications were secured in 2 of 20 resident rooms (Rooms #115 and #117). | 2 |
Report Facts
Residents present: 72
Total licensed capacity: 125
Caregivers reviewed: 15
Resident files reviewed: 15
Rooms with oxygen tanks: 20
Rooms with unsecured medications: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #9 | Missing required medication management training hours | |
| Employee #11 | Missing first aid and CPR training |
Inspection Report
Re-Inspection
Census: 75
Capacity: 125
Deficiencies: 0
Nov 10, 2011
Visit Reason
This State Licensure survey was conducted as a re-survey grading visit to the facility on 11/10/2011.
Findings
The facility received a re-survey grade of A with no regulatory deficiencies cited during this survey.
Report Facts
Category I residents: 103
Category II residents: 22
Employee files reviewed: 5
Resident files reviewed: 6
Inspection Report
Annual Inspection
Census: 68
Capacity: 125
Deficiencies: 6
Sep 6, 2011
Visit Reason
This document is the result of an annual State Licensure survey conducted on 9/6/2011 to assess compliance with state regulations for the facility.
Findings
The facility was found to have multiple deficiencies including failure to meet background check requirements for one employee, critical food service violations, failure to monitor auditory systems in resident rooms, unsecured oxygen tanks in resident rooms, and medication administration and destruction issues.
Severity Breakdown
Severity: 2: 5
Severity: 3: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 15 employees met background check requirements; fingerprints not renewed after 5 years. | Severity: 2 |
| Critical food service violations including improper food storage temperatures, unlabeled and undated food containers, and sanitation issues in the kitchen. | Severity: 2 |
| Failed to monitor auditory system in 2 of 2 rooms tested. | Severity: 3 |
| Oxygen tanks not secured in 4 of 15 resident rooms where oxygen was used. | Severity: 2 |
| Failed to ensure 1 of 15 residents was not on a maintenance level medication as prescribed. | Severity: 2 |
| Did not destroy medications after they were discontinued, expired, or after resident transfer. | Severity: 2 |
Report Facts
Residents present: 68
Total licensed capacity: 125
Employees reviewed: 15
Residents reviewed: 15
Resident rooms with unsecured oxygen tanks: 4
Rooms tested for auditory system: 2
Inspection Report
Annual Inspection
Census: 58
Capacity: 125
Deficiencies: 3
Sep 22, 2009
Visit Reason
This document is a result of an annual State Licensure survey conducted at the facility on 09/22/2009 to assess compliance with state regulations and licensing requirements.
Findings
The facility received a grade of A but was found deficient in several areas including failure to comply with standards for proper food cooling and sanitation, and failure to ensure bedroom and bathroom doors with locks opened with a single motion from the inside.
Severity Breakdown
Level 2: 1
Level 3: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to comply with standards prescribed in chapter 446 of NAC including improper cooling of beef brisket, improper sanitation readings, improper chemical concentrations, and cleanliness issues in food preparation areas. | Level 2 |
| Bedroom doors equipped with locks did not open with a single motion from the inside as required. | Level 3 |
| Bathroom doors equipped with locks did not open with a single motion from the inside as required. | Level 3 |
Report Facts
Resident files reviewed: 15
Employee files reviewed: 15
Discharged resident files reviewed: 1
Total beds licensed: 125
Current census: 58
Interior bedroom doors with locks: 125
Bathroom doors with locks: 125
Inspection Report
Annual Inspection
Census: 125
Capacity: 125
Deficiencies: 3
Oct 14, 2008
Visit Reason
The inspection was conducted as part of the annual state licensure survey and complaint investigation at the facility on 10/14/08.
Findings
The facility was found deficient in providing beds and bedding to residents, ensuring provision of toiletries, and conducting timely medication profile reviews for residents. Three complaints were investigated with two substantiated and one unsubstantiated.
Complaint Details
Three complaints were investigated: Complaint #NV19343 was unsubstantiated; Complaint #NV18976 and Complaint #NV18449 were substantiated.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure beds were made available to residents; residents must purchase their own beds upon admission. | Severity: 2 |
| Facility failed to ensure toiletries were provided to residents; residents were responsible for purchasing toilet paper. | Severity: 2 |
| Facility failed to ensure medication profile reviews were performed by a physician, pharmacist, or registered nurse at least once every six months for 5 of 25 residents. | Severity: 2 |
Report Facts
Total licensed beds: 125
Residents present: 125
Complaints investigated: 3
Residents with medication review deficiencies: 5
Inspection Report
Annual Inspection
Census: 125
Capacity: 125
Deficiencies: 1
Oct 14, 2008
Visit Reason
The inspection was conducted as part of the annual state licensure survey and complaint investigation at the facility on 10/14/08.
Findings
The facility was found deficient in ensuring medication profile reviews were performed by a physician, pharmacist, or registered nurse at least once every six months for 5 of 25 residents reviewed. Three complaints were investigated, two substantiated and one unsubstantiated.
Complaint Details
Three complaints were investigated: Complaint #NV19343 was unsubstantiated; Complaint #NV18976 was substantiated (related to TAG Y 307 and Y 357); Complaint #NV18449 was substantiated (related to TAG Y 357).
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure a medication profile review was performed at least once every six months for 5 of 25 residents (#4, #6, #8, #15, #16). | 2 |
Report Facts
Total licensed beds: 125
Residents present: 125
Resident records reviewed: 25
Employee files reviewed: 10
Complaints investigated: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Residential Services Director | Interviewed on 10/14/08 regarding medication profile review inconsistencies |
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