Inspection Report
Re-Inspection
Census: 51
Capacity: 56
Deficiencies: 10
Mar 18, 2025
Visit Reason
This inspection was a State Licensure grading resurvey conducted due to the facility receiving a grade of D on a prior survey, requiring a resurvey application and fee submission within 30 days.
Findings
The facility was found deficient in multiple areas including food service sanitation, supervision and treatment of residents, posting requirements, medical care, medication administration and storage, Alzheimer’s care standards, and employee training. Deficiencies ranged from critical violations in kitchen sanitation to failure to ensure proper medication administration and training compliance.
Severity Breakdown
Severity: 2: 8
Severity: 1: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Kitchen dishwashing machines were not sanitizing properly; ice machine had biofilm buildup; refrigerators and kitchen floors were soiled. | Severity: 2 |
| Failed to ensure person-centered service plans were reviewed with residents or representatives for 15 sampled residents. | Severity: 2 |
| Failed to post Administrator's designee contact information and facility rates in a conspicuous place. | Severity: 1 |
| Failed to ensure annual physical examination was completed for 1 of 15 residents. | Severity: 2 |
| Administrator failed to ensure medication profile reviews were initialed and recommendations forwarded within 72 hours for multiple residents. | Severity: 2 |
| Medication was not administered as prescribed for 2 residents; medication change labels missing; medication not available on site for 1 resident. | — |
| Resident medications were not secured in locked areas in 51 resident rooms. | Severity: 2 |
| Toxic items were accessible to residents in multiple rooms and public areas. | Severity: 2 |
| 7 of 9 sampled employees did not complete required 2 hours of Tier 2 dementia training within first 40 hours of employment. | Severity: 2 |
| 2 of 6 sampled employees did not complete required 3 hours of annual continuing education for dementia care by anniversary date. | Severity: 2 |
Report Facts
Facility licensed capacity: 56
Census: 51
Deficiency count: 10
Resurvey fee: 600
Employee training hours: 1.5
Employee training hours required: 2
Employee continuing education hours required: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Samuel Garcia-Felix | Executive Director | Signed the Statement of Deficiencies report |
| Health and Wellness Director | Named in multiple findings related to service plan reviews, medication administration, and training compliance | |
| Business Office Coordinator | Responsible for employee training records and compliance monitoring |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 56
Deficiencies: 1
Sep 30, 2024
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #NV00072176 regarding alleged failure to follow infection control policies and an incident involving a resident being wheeled naked through the facility.
Findings
The complaint allegations were not substantiated due to lack of evidence. However, a deficiency unrelated to the allegations was identified concerning infection control training requirements for the secondary infection control person, who did not complete the required 15 hours of training.
Complaint Details
Complaint #NV00072176 with allegations that the facility was not following infection control policies and that a resident was wheeled naked through the facility were investigated and found not substantiated due to lack of evidence.
Severity Breakdown
Severity: 1: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure the secondary infection control person met the required 15 hours of initial infection control training per Legislative Council Bureau File Number R048-22, Section 5. | Severity: 1 |
Report Facts
Licensed beds: 56
Resident census: 47
Residents potentially affected: 23
Training hours required: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Samuel Garcia-Felix | Executive Director | Presented training certificate and was interviewed during complaint investigation |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 56
Deficiencies: 4
Aug 8, 2024
Visit Reason
The inspection was conducted as a result of a State Licensure grading resurvey and complaint investigation at the facility on 08/08/2024.
Findings
The facility was found deficient in multiple areas including failure to provide adequate oversight by the administrator, medication management issues such as medications not onsite or improperly labeled, unsecured medications accessible to residents, and failure to maintain proper personnel training and documentation. The facility received a grade of B.
Complaint Details
The visit was triggered by a complaint investigation combined with a state licensure grading resurvey.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight and direction to ensure residents received needed services and protective supervision. | Severity: 2 |
| Medications were not onsite and available as prescribed for 4 of 6 sampled residents; medication labels did not reflect current orders; medication lacked physician's order. | Severity: 2 |
| Medications were not stored securely and were accessible to residents in a memory care unit. | Severity: 2 |
| Over-the-counter medication lacked proper labeling with resident's and physician's name. | Severity: 2 |
Report Facts
Licensed capacity: 56
Census: 40
Residents sampled: 6
Employee files reviewed: 7
Grade: B
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Samuel Garcia-Felix | Executive Director | Signed the report and responsible for oversight |
| Health and Wellness Director | Named in medication availability and labeling findings | |
| Medication Technician 1 (MT1) | Confirmed medications not onsite and labeling issues | |
| Medication Technician 2 (MT2) | Confirmed medications not onsite |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 56
Deficiencies: 13
May 15, 2024
Visit Reason
The inspection was conducted as a result of a State Licensure grading resurvey and complaint investigation triggered by complaint #NV00070154 with multiple allegations including medication security, administration, and staffing concerns.
Findings
The facility received a grade of D with multiple deficiencies including failure to secure medications, improper medication administration, insufficient staffing, incomplete personnel training and documentation, unsafe storage of hazardous and toxic items in resident rooms, and failure to meet Alzheimer's care staffing and safety standards.
Complaint Details
Complaint #NV00070154 was substantiated with allegations including unsecured medications, improper medication administration, and insufficient staffing. Other allegations such as environmental concerns and resident abuse were not substantiated due to lack of evidence.
Severity Breakdown
Level 2: 12
Level 3: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight and direction to ensure residents received needed services and protective supervision. | Level 2 |
| Failure to ensure 1 of 7 employees received initial elder abuse training prior to employment. | Level 2 |
| Failure to maintain monthly staffing schedule as required. | Level 3 |
| Failure to meet tuberculosis screening and pre-employment physical requirements for 1 of 7 employees. | Level 2 |
| Failure to ensure background checks for 1 of 7 employees. | Level 2 |
| Failure to ensure kitchen equipment and storage met sanitation and safety requirements. | Level 2 |
| Failure to ensure medications were onsite and administered as prescribed for multiple residents; medication labels did not match orders. | Level 2 |
| Medication carts were unsecured and accessible to residents. | Level 2 |
| Failure to maintain accurate medication administration records for multiple residents. | Level 2 |
| Failure to ensure one caregiver per interaction group of no more than six residents during waking hours in Alzheimer's units. | Level 2 |
| Failure to secure hazardous items such as razors in resident rooms in memory care unit. | Level 2 |
| Failure to secure toxic substances such as personal care products in resident rooms in memory care unit. | Level 2 |
| Failure to ensure timely cultural competency training for 1 of 7 employees. | Level 2 |
Report Facts
Facility licensed capacity: 56
Resident census: 32
Inspection date: May 15, 2024
Medication carts unlocked: 1
Staffing ratio: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Administrator | Failed to complete elder abuse training, cultural competency training, background check, and TB screening timely |
| Employee #2 | Executive Director | Failed to complete elder abuse training and CPR/first aid training timely |
| Samuel Garcia-Felix | Executive Director | Signed attestation of compliance and plan of correction |
Inspection Report
Annual Inspection
Census: 33
Capacity: 56
Deficiencies: 22
Sep 21, 2023
Visit Reason
The inspection was conducted as a result of a State Licensure annual grading survey and complaint investigation at the facility on 09/21/23.
Findings
The facility received a grade of D with multiple deficiencies including failure to maintain adequate staffing, incomplete training and personnel files, medication administration errors, inadequate infection control program, and failure to meet Alzheimer's care staffing and safety standards.
Complaint Details
Two complaints (#NV00069250 and #NV00069332) were investigated with substantiated allegations including insufficient staffing and lack of Medication Technician during a weekend shift causing delayed medication administration. Other allegations were not substantiated due to lack of evidence.
Severity Breakdown
Level 1: 2
Level 2: 21
Deficiencies (22)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight and direction to ensure residents received needed services and protective supervision. | Level 2 |
| Failure to ensure all employees received elder abuse training prior to employment and annually thereafter. | Level 2 |
| Failure to maintain monthly written staff schedules including changes for at least six months. | Level 1 |
| Lack of personnel files for some employees and incomplete TB screening documentation. | Level 2 |
| Failure to ensure facility was free from offensive odors and premises were well maintained. | Level 2 |
| Failure to ensure kitchen staff wore hair restraints and dry storage floors were clean. | Level 2 |
| Failure to discard expired food and ensure proper labeling and storage of food. | Level 2 |
| Failure to post current menus in areas visible to residents and visitors. | Level 1 |
| Failure to ensure Administrator and caregivers received first aid and CPR training within 30 days of employment. | Level 2 |
| Failure to protect residents from neglect by not ensuring a Medication Technician was available to administer morning medications and failure to self-report the incident. | Level 2 |
| Failure to ensure residents had required physical examinations on or prior to admission. | Level 2 |
| Failure to ensure medications were on-site and administered as prescribed for sampled residents. | Level 2 |
| Medication Administration Records were inaccurate for some residents. | Level 2 |
| Failure to ensure residents had required tuberculosis testing upon admission and annually. | Level 2 |
| Failure to ensure initial or annual Activities of Daily Living assessments were completed by the facility for sampled residents. | Level 2 |
| Failure to maintain required staffing ratio of one caregiver per six residents during waking hours in Alzheimer's endorsed unit. | Level 2 |
| Failure to secure dangerous items such as push pins, matches, and lighters from residents in memory care unit. | Level 2 |
| Failure to secure toxic substances in memory care unit accessible to residents. | Level 2 |
| Failure to ensure caregivers received required initial training related to care of elderly or disabled persons within 60 days of hire. | Level 2 |
| Failure to ensure employees received required dementia training within 90 days of hire and ongoing training thereafter. | Level 2 |
| Failure to ensure employees received required additional dementia training by hire anniversary date. | Level 2 |
| Failure to designate primary and secondary persons responsible for infection control program and ensure they received required training. | Level 2 |
Report Facts
Facility licensed capacity: 56
Resident census: 33
Deficiency severity counts: 23
Fine for resurvey application: 600
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marjolijn Kirby | Administrator | Named in oversight and compliance failures |
| Employee #1 | Administrator | Failed elder abuse training prior to employment |
| Employee #3 | Resident Care Coordinator | Failed elder abuse training prior to employment |
| Employee #6 | Caregiver | Failed elder abuse training prior to employment |
| Employee #7 | Program Assistant | Failed elder abuse training prior to employment |
| Employee #10 | Caregiver | Failed elder abuse training prior to employment |
| Employee #11 | Health and Wellness Director | Lacked personnel file and required trainings |
| Employee #12 | Maintenance Director | Lacked personnel file and required trainings |
Inspection Report
Re-Inspection
Census: 34
Capacity: 56
Deficiencies: 9
Jun 15, 2023
Visit Reason
This inspection was a mandatory regrading conducted as a State Licensure Survey in accordance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.
Findings
The facility received a re-survey grade of A. Several regulatory deficiencies were identified including medication administration errors, failure to ensure timely tuberculosis testing for residents, failure to maintain confidentiality of resident medical information, and failure to secure dangerous items in resident rooms for Alzheimer's care residents.
Severity Breakdown
D: 4
E: 3
F: 2
G: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Provision of dental, optical and hearing care and social services; report of suspected abuse, neglect, isolation or exploitation; restrictions on use of restraints, confinement or sedatives. | D |
| Rights of residents; procedure for filing grievance, complaint or report of incident; investigation and response. | G |
| Medication administration: facility failed to ensure a medication was on-site to administer as prescribed for 1 of 6 sampled residents (Resident #4). | D |
| Medication destruction: failure to properly destroy discontinued or expired medications in presence of witness and document destruction. | D |
| Maintenance and contents of separate file for each resident; confidentiality of information. Facility failed to keep medical information confidential; medication card with visible resident information was left exposed on medication cart. | E |
| Failure to ensure 3 of 6 sampled residents met requirements for timely tuberculosis testing in accordance with Nevada Administrative Code. | E |
| Alzheimer's care: failure to establish interaction groups with no more than six residents per caregiver during awake hours. | F |
| Alzheimer's care standards for safety: dangerous items (metal bed frame, adaptive steak knife) were unsecured and accessible to residents in Alzheimer's care unit. | F |
| Alzheimer's care standards for safety: failure to ensure toxic substances are not accessible to residents. | E |
Report Facts
Licensed beds: 56
Census: 34
Sampled residents: 6
Residents affected by TB testing deficiency: 3
Residents affected by Alzheimer's care safety deficiency: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Krystal Guerrero | Executive Director | Signed the report and confirmed findings related to unsecured dangerous items in Alzheimer's care unit |
| Health and Wellness Director | Confirmed deficiencies related to tuberculosis testing and confidentiality breaches | |
| Resident Care Coordinator | Confirmed medication was missing for Resident #4 and acknowledged HIPAA violation regarding exposed medication card | |
| Medication Technician | Acknowledged leaving resident information exposed on medication cart |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 56
Deficiencies: 7
Mar 6, 2023
Visit Reason
The inspection was conducted as a mandatory regrading and complaint investigation triggered by a substantiated complaint alleging short staffing and other unsubstantiated allegations including resident sexual abuse and untidy conditions.
Findings
The facility was found to have multiple deficiencies including failure to report suspected resident sexual abuse to the appropriate authorities, inadequate staffing levels not meeting regulatory requirements, failure to ensure medication availability and proper medication destruction, incomplete tuberculosis testing records, unsafe storage of dangerous and toxic items in resident rooms, and failure to maintain safe environment standards for residents with Alzheimer's disease.
Complaint Details
Complaint #NV00068206 was substantiated for the allegation of short staffing. Other allegations including resident sexual abuse, untidy rooms, failure to respond to complaints, and residents left in soiled briefs were not substantiated due to lack of evidence.
Severity Breakdown
Severity: 3: 1
Severity: 2: 6
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to report suspected resident sexual abuse to the Aging and Disabilities Services Division (ADSD). | Severity: 3 |
| Failure to ensure staffing met the required ratio of one caregiver to six residents during waking hours in an Alzheimer's endorsed facility. | Severity: 2 |
| Failure to ensure medication was on-site and administered as prescribed for 3 of 6 sampled residents. | Severity: 2 |
| Failure to destroy discontinued medication for one resident. | Severity: 2 |
| Incomplete tuberculosis testing records including missing times given and read and missing second step tests for 2 of 6 sampled residents. | Severity: 2 |
| Failure to ensure dangerous items were inaccessible to residents in 5 of 32 resident rooms. | Severity: 2 |
| Failure to ensure toxic substances were inaccessible to residents in 15 of 32 resident rooms. | Severity: 2 |
Report Facts
Licensed beds: 56
Residents present: 33
Complaint severity: 2
Complaint scope: 3
Medication deficiencies: 3
Staffing ratio violations: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Krystal Guerrero | Executive Director | Named in relation to investigation and reporting of resident sexual abuse and staffing issues |
Inspection Report
Annual Inspection
Census: 36
Capacity: 56
Deficiencies: 9
Oct 24, 2022
Visit Reason
This inspection was a State Licensure annual grading survey conducted by the Division of Public and Behavioral Health in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of C with multiple deficiencies identified related to medication management, storage, Alzheimer's care safety standards, health and sanitation, and documentation. Deficiencies included failure to destroy discontinued medications, lack of written instructions for PRN medications, improper labeling of medications, unsafe storage of dangerous and toxic items in resident rooms, missing window screens, lack of physician orders for TB tests, failure to notify physicians of pharmacist recommendations, and missing change order labels on medications.
Severity Breakdown
Level 2: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure a discontinued medication was destroyed for 1 of 10 residents (Resident #8). | Level 2 |
| Failed to ensure written instructions indicating the specific symptom(s) for which an as needed (PRN) medication was to be given was documented for 1 of 10 sampled residents (Resident #7). | Level 2 |
| Failed to ensure an over-the-counter medication had a resident name and/or ordering physician's name on the label for 2 of 10 sampled residents (Resident #5 and #9). | Level 2 |
| Failed to ensure dangerous items were not stored in resident rooms endorsed for the care of residents with Alzheimer's disease. | Level 2 |
| Failed to ensure toxic substances were not stored in resident rooms endorsed for the care of residents with Alzheimer's disease. | Level 2 |
| Failed to ensure a resident's room (Room #25) had a screen covering an opened window. | Level 2 |
| Failed to ensure the facility had a physician order for facility licensed staff to administer tuberculosis (TB) tests to 3 of 10 residents (Resident #5, #7, and #2). | Level 2 |
| Failed to notify a resident's physician of the pharmacist's recommendation and/or initial the medication profile review within 72 hours for 3 of 10 sampled residents (Resident #8, #9, and #10). | Level 2 |
| Failed to ensure a change order label was completed and a medication was on-site to administer as prescribed for 1 of 10 sampled residents (Resident #10). | Level 2 |
Report Facts
Facility licensed capacity: 56
Resident census: 36
Grade: C
Medication cart audit frequency: 7
Resurvey application fee: 600
Number of resident files reviewed: 10
Number of employee files reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Krystal Guerrero | Executive Director | Signed the report and mentioned in relation to monitoring corrective actions |
| Health and Wellness Director | Named in multiple findings related to medication administration, storage, and TB testing | |
| Resident Care Coordinator | Responsible for weekly medication cart audits and monitoring medication documentation | |
| Medication Technician | Interviewed and confirmed medication administration and labeling deficiencies | |
| Maintenance Manager | Confirmed window screen deficiency and responsible for daily walkthroughs |
Inspection Report
Re-Inspection
Census: 35
Capacity: 56
Deficiencies: 6
Aug 25, 2022
Visit Reason
This inspection was a grading re-survey State Licensure Survey conducted to assess compliance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.
Findings
The facility received a grade of A with several deficiencies identified including personnel file certification for CPR and first aid, health and sanitation maintenance, medication administration compliance, resident file maintenance, Alzheimer's care safety standards, and securing hazardous chemicals accessible to residents.
Severity Breakdown
E: 1
F: 3
D: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Personnel file for caregiver lacked current certification for first aid and cardiopulmonary resuscitation. | E |
| Hand sanitizer dispenser was removed due to health and sanitation concerns. | F |
| Medication administration did not fully comply with physician orders and documentation requirements. | D |
| Medication orders for 'as needed' medications required updated physician orders and written instructions. | D |
| Resident files were not properly maintained and secured as required. | D |
| Alzheimer's care safety standards were not fully met; hazardous chemicals and toxic substances were accessible to residents. | F |
Report Facts
Licensed capacity: 56
Census: 35
Resident files reviewed: 6
Employee personnel files reviewed: 6
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Aug 30, 2021
Visit Reason
The inspection was conducted as a complaint investigation triggered by two complaints alleging medication administration failures and improper COVID-19 cohorting in the facility.
Findings
Both complaints were investigated and found to be unsubstantiated due to lack of evidence. No regulatory deficiencies were identified, and no further action was necessary.
Complaint Details
Complaint #NV00064675 alleged failure to administer medications for nine days resulting in hospitalization, which was unsubstantiated. Complaint #NV00064690 alleged improper mixing of COVID-19 positive and negative residents and lack of a cohorting plan, both unsubstantiated.
Report Facts
Sample size: 5
Complaints investigated: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed during the complaint investigation | |
| Health and Wellness Director | Interviewed during the complaint investigation |
Inspection Report
Annual Inspection
Census: 36
Capacity: 56
Deficiencies: 1
Dec 1, 2015
Visit Reason
Annual State Licensure survey conducted to assess compliance with regulatory standards for a residential facility for persons with Alzheimer's disease.
Findings
The facility received a grade of A but was cited for deficiencies related to food service permits and kitchen conditions. Major violations included heavily worn and damaged kitchen sinks, unsecured plumbing lines causing improper drainage, and potential pest infestation.
Severity Breakdown
Severity: 1: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure the kitchen complied with standards of NAC 446, including worn, damaged, soiled sinks and unsecured plumbing lines causing improper drainage and potential pest infestation. | Severity: 1 |
Report Facts
Residents present: 36
Licensed capacity: 56
Severity level: 1
Scope: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in plan of correction to oversee kitchen remodel project | |
| Regional Director of Property Management | Named in plan of correction to oversee kitchen remodel project |
Inspection Report
Annual Inspection
Census: 36
Capacity: 56
Deficiencies: 1
Dec 1, 2015
Visit Reason
This annual State Licensure survey was conducted to assess compliance with state regulations for a residential facility for persons with Alzheimer's disease.
Findings
The facility received a grade of A; however, a deficiency was identified related to kitchen maintenance where areas beneath sinks were damaged and plumbing lines unsecured, causing water and food debris to flow onto floors and under cabinets.
Severity Breakdown
Severity: 1: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The areas beneath all four sinks in each Country, Garden, Cottage and Boat serving kitchens were heavily worn, damaged, soiled and not maintained to prevent water damage, mold, odor and pest infestation. Plumbing lines were not secured to ensure proper drainage, allowing food debris and grey water to flow onto the floor and under the cabinets. | Severity: 1 |
Report Facts
Resident files reviewed: 9
Employee files reviewed: 10
Licensed capacity: 56
Census: 36
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 0
Oct 29, 2015
Visit Reason
The inspection was conducted as a complaint investigation based on allegations regarding resident medications not administered correctly and insufficient staffing and training.
Findings
The investigation found no substantiated complaints; observations and reviews indicated adequate staffing and no regulatory deficiencies were identified.
Complaint Details
Complaint #NV00044248 with allegations of resident medications not administered correctly and insufficient staffing and training was investigated but not substantiated.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 40
Capacity: 56
Deficiencies: 0
Nov 10, 2014
Visit Reason
The inspection was conducted as a complaint investigation initiated by the Division of Public and Behavioral Health between 2014-09-29 and 2014-11-10, in response to Complaint #NV00040179 containing four allegations regarding facility cleanliness, misappropriation of property, resident ambulation, and resident care per physician orders.
Findings
The investigation found no substantiated deficiencies; observations and document reviews confirmed the facility was clean, no misappropriation of property occurred, residents were ambulated properly, and care was provided according to physician orders. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00040179 contained four allegations: 1) Facility was not clean, 2) Misappropriation of property, 3) Resident not ambulated properly, 4) Resident care or services not received per physician order. All allegations were not substantiated based on observation, document review, interviews, and record review.
Report Facts
Licensed capacity: 56
Census: 40
Sample size: 6
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 29, 2014
Visit Reason
This document is a required grading re-survey conducted at the facility on 10/29/2014 as part of a state licensure survey by the Division of Public and Behavioral Health.
Findings
No deficiencies were identified during this re-survey, and the facility received a re-survey grade of A.
Inspection Report
Re-Inspection
Census: 52
Capacity: 56
Deficiencies: 7
Aug 8, 2014
Visit Reason
The inspection was a State Licensure re-survey and complaint investigation conducted from 7/14/14 through 8/8/14, including review of a complaint alleging insufficient staffing.
Findings
The facility was found to have deficiencies including failure to ensure appropriate staffing levels, over census for one month, lack of CPR training for one employee, unsecured medication storage, failure to meet tuberculosis testing requirements for two residents, presence of dangerous items accessible to residents, and failure to ensure all employees received required Alzheimer's training within 40 hours of hire.
Complaint Details
Complaint #NV00038816 was substantiated. The complaint alleged the facility failed to ensure the appropriate amount of staffing, which was confirmed during the investigation.
Severity Breakdown
Level 3: 1
Level 2: 6
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to ensure caregivers were available to provide services for two of seven residents' safety. | Level 3 |
| Facility was over census for one month (July 2013) with 57 residents while licensed for 56. | Level 2 |
| Facility failed to ensure one of six caregivers received first aid and CPR training within 30 days of employment. | Level 2 |
| Facility failed to ensure delivered medication was secured; medication was left unattended on front counter for approximately 15 minutes. | Level 2 |
| Facility failed to ensure two residents met tuberculosis testing requirements. | Level 2 |
| Facility failed to ensure dangerous items (Phillips head screwdriver) were not accessible to residents. | Level 2 |
| Facility failed to ensure 6 of 6 employees received at least two hours of Alzheimer's training within first 40 hours of hire. | Level 2 |
Report Facts
Licensed capacity: 56
Census at time of survey: 52
Over census count: 57
Deficiencies cited: 7
Employees lacking Alzheimer's training: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carrie Hellahan | Administrator | Signed the Statement of Deficiencies on 9/13/14. |
Inspection Report
Re-Inspection
Census: 52
Capacity: 56
Deficiencies: 6
Aug 8, 2014
Visit Reason
This Statement of Deficiencies was generated as a result of a State Licensure re-survey and complaint investigation conducted from 7/14/14 through 8/8/14. The visit included a complaint investigation regarding staffing levels.
Findings
The facility was found to be over census for one month, failed to ensure timely first aid and CPR training for one caregiver, failed to secure medications properly, did not maintain required tuberculosis documentation for two residents, allowed dangerous items accessible to residents, and failed to provide required Alzheimer's training to six employees within the first 40 hours of hire.
Complaint Details
Complaint #NV00038816 was substantiated. The complaint alleged the facility failed to ensure the appropriate amount of staffing.
Severity Breakdown
Severity: 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility was over census for one month (July 2013) with 57 residents while licensed for 56. | Severity: 2 |
| Failed to ensure 1 of 6 caregivers received first aid and CPR training within 30 days of employment. | Severity: 2 |
| Failed to ensure medications were secure; prescription delivery left unattended on front counter for approximately 15 minutes. | Severity: 2 |
| Failed to ensure 2 of 7 residents had required tuberculosis documentation including two-step TB tests. | Severity: 2 |
| Failed to ensure dangerous items (Phillips head screwdriver) were inaccessible to residents. | Severity: 2 |
| Failed to ensure 6 of 6 employees received at least two hours of Alzheimer's training within the first 40 hours of hire. | Severity: 2 |
Report Facts
Licensed capacity: 56
Census: 52
Over census count: 57
Number of resident files reviewed: 6
Number of employee files reviewed: 6
Number of discharged resident files reviewed: 1
Inspection Report
Annual Inspection
Census: 52
Capacity: 56
Deficiencies: 6
Jan 31, 2014
Visit Reason
This inspection was conducted as a State Licensure annual grading survey from 1/7/14 to 1/31/14 to assess compliance with regulatory requirements for a residential facility licensed for persons with Alzheimer's disease.
Findings
The facility received a grade of B with several deficiencies identified including failures in tuberculosis testing and pre-employment physicals, background checks, first aid and CPR training, medication administration, and ensuring dangerous and toxic items were inaccessible to residents. Corrections were planned or completed for all deficiencies.
Severity Breakdown
Severity: 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to ensure four of ten employees complied with tuberculosis (TB) testing and pre-employment physicals. | Severity: 2 |
| Facility did not ensure two of ten employees met background check requirements. | Severity: 2 |
| Facility did not ensure four of ten caregivers received first aid and CPR training within 30 days of employment. | Severity: 2 |
| Facility failed to ensure one of fifteen residents received medications as prescribed. | Severity: 2 |
| Facility failed to ensure dangerous items in the facility’s salon were not accessible to residents. | Severity: 2 |
| Facility failed to ensure toxic substances in the facility’s salon were not accessible to residents. | Severity: 2 |
Report Facts
Residents present: 52
Licensed capacity: 56
Employees reviewed: 10
Resident files reviewed: 15
Employee files reviewed: 10
Residents with medication deficiency: 1
Inspection Report
Annual Inspection
Census: 52
Capacity: 56
Deficiencies: 6
Jan 31, 2014
Visit Reason
This State Licensure annual grading survey was conducted from 2014-01-07 to 2014-01-31 to assess compliance with state regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of B with multiple deficiencies identified including failures in tuberculosis testing and pre-employment physicals for employees, incomplete background checks, lack of timely first aid and CPR training, medication administration errors, and unsafe access to dangerous and toxic items in the facility's salon.
Severity Breakdown
E: 2
D: 2
F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure 4 of 10 employees complied with tuberculosis testing and pre-employment physical requirements. | E |
| Failed to ensure 2 of 10 employees met background check requirements. | D |
| Failed to ensure 4 of 10 caregivers received first aid and CPR training within 30 days of employment. | E |
| Failed to ensure 1 of 15 residents received medications as prescribed, specifically incorrect Vitamin D3 administration. | D |
| Failed to ensure dangerous items in the facility's salon were inaccessible to residents; salon door left unlocked with unattended curling irons, scissors, hair clippers, and flat iron. | F |
| Failed to ensure toxic substances were inaccessible to residents in the facility's salon; salon door left unlocked with unattended hairstyling products. | F |
Report Facts
Employees non-compliant with TB testing: 4
Employees non-compliant with background checks: 2
Caregivers lacking timely First Aid and CPR training: 4
Residents with medication errors: 1
Facility licensed capacity: 56
Census at time of survey: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Non-compliance with TB testing, background check, and First Aid/CPR training | |
| Employee #4 | Non-compliance with TB testing | |
| Employee #7 | Non-compliance with TB testing and First Aid/CPR training | |
| Employee #8 | Non-compliance with TB testing and First Aid/CPR training | |
| Employee #2 | Non-compliance with background check | |
| Employee #10 | Non-compliance with First Aid/CPR training | |
| Administrator Designee | Failed to explain noted file issues with TB testing and pre-employment physicals | |
| Resident Care Director | Admitted medication error regarding Vitamin D administration | |
| Maintenance Director | Reported salon door left unlocked and unattended dangerous/toxic items |
Inspection Report
Annual Inspection
Census: 54
Capacity: 56
Deficiencies: 2
Jan 24, 2013
Visit Reason
The inspection was conducted as an annual State Licensure survey of the facility on 01/24/2013 to assess compliance with regulatory requirements 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 maintaining health and sanitation standards, including unclean premises and dangerous items accessible to residents. Specific issues included damaged showers, loose grab bars, and hazardous items under residents' beds.
Severity Breakdown
Severity: 2 Scope: 3: 1
Severity: 2 Scope: 2: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure the premises were clean and well maintained, including damaged showers and loose grab bars. | Severity: 2 Scope: 3 |
| Facility failed to ensure dangerous items such as knives, matches, firearms, tools, and other hazardous items were inaccessible to residents. | Severity: 2 Scope: 2 |
Report Facts
Licensed capacity: 56
Census: 54
Resident files reviewed: 15
Employee files reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joanne Campbell | Executive Director | Signed the plan of correction and report |
Inspection Report
Annual Inspection
Census: 54
Capacity: 56
Deficiencies: 2
Jan 24, 2013
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at the facility on 01/24/2013 by the Nevada State Health Division.
Findings
The facility received a grade of A but was cited for deficiencies including failure to maintain the premises clean and well-maintained, with issues such as missing caulk sealing, cracked tiles, unsealed openings, and loose grab bars in showers. Additionally, dangerous items such as a glass vase and a metal rod were found accessible to residents, creating safety hazards.
Severity Breakdown
Level 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure the premises was clean and well maintained; issues included missing caulk sealing, cracked tiles, unsealed openings, and loose grab bars in showers. | Level 2 |
| Facility failed to ensure dangerous items were inaccessible to residents; a glass flower vase and an 83-inch metal rod were found accessible. | Level 2 |
Report Facts
Licensed capacity: 56
Census: 54
Resident files reviewed: 15
Employee files reviewed: 10
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 17, 2012
Visit Reason
This document is a required grading re-survey conducted at the facility on 2/17/12 as part of a State Licensure survey by the Health Division.
Findings
The facility received a re-survey grade of A with no deficiencies identified during this inspection.
Report Facts
Re-survey grade: A
Inspection Report
Annual Inspection
Census: 48
Capacity: 56
Deficiencies: 7
Jan 23, 2012
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted from 2012-01-12 to 2012-01-23 to assess compliance with regulatory requirements for a residential facility licensed for persons with Alzheimer's disease.
Findings
The facility was found to have multiple deficiencies including failure to ensure employee tuberculosis testing compliance, unresolved background check results, poor maintenance and cleanliness of premises, noncompliance with kitchen sanitation standards, failure to respond to the auditory system in resident living areas, inaccurate medication administration records, and failure to keep medications in original containers.
Severity Breakdown
1: 3
2: 4
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to ensure two of ten employees received their annual TB testing and one employee received a pre-employment physical. | 2 |
| Facility did not ensure one employee resolved undecided results of background check. | 2 |
| Facility failed to ensure the premises was clean and well maintained, including excessive lint build-up, water heater disrepair, leaking furnace condensate drain line, and dirty furnace/sprinkler riser room. | 2 |
| Facility failed to ensure kitchens complied with sanitation standards; issues included dirty cabinets, uncovered garbage container, and soiled outside storage area. | 1 |
| Facility failed to respond to auditory system in 1 of 4 resident living areas. | 2 |
| Facility failed to ensure medication administration record was accurate for 4 of 15 residents. | 1 |
| Facility failed to keep medications belonging to 1 of 15 residents in their original container. | 1 |
Report Facts
Census: 48
Total Capacity: 56
Employees reviewed: 10
Employees reviewed: 15
Residents reviewed: 15
Inspection Report
Annual Inspection
Census: 48
Capacity: 56
Deficiencies: 7
Jan 23, 2012
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted from 1/12/12 to 1/23/12 at the facility Emeritus at Reno.
Findings
The facility received a grade of B and multiple deficiencies were identified including personnel file issues related to tuberculosis testing and background checks, health and sanitation problems, kitchen permit and sanitation violations, safety system failures, and medication administration and storage errors.
Severity Breakdown
Level 1: 3
Level 2: 4
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 10 employees complied with tuberculosis testing requirements; one employee lacked evidence of pre-employment physical exam. | Level 2 |
| Failed to ensure 1 of 15 employees complied with background check requirements; FBI and State background check results were undecided and unresolved. | Level 2 |
| Facility premises were not clean and well maintained, including excessive lint build-up on dryer, leaking water heater, disrepair of furnace condensate drain line causing rust and erosion, and excessive dirt in furnace/sprinkler riser room. | Level 2 |
| Kitchens failed to comply with standards including dirty cabinets under sinks, uncovered and unmaintained outside garbage container with trash, and dishwashers in disrepair leaking water during operation. | Level 1 |
| Failed to respond to auditory system alarm in 1 of 4 resident living areas (Boat House common bathroom). | Level 2 |
| Medication administration record (MAR) was inaccurate for 4 of 15 residents, including incomplete records and missing medications. | Level 1 |
| Failed to keep medications belonging to 1 of 15 residents in their original container (Atrovent inhaler). | Level 1 |
Report Facts
Residents present: 48
Total licensed capacity: 56
Employees reviewed: 10
Resident files reviewed: 15
Discharged resident files reviewed: 1
Residents with inaccurate MAR: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #7 | Named in tuberculosis testing deficiency and background check deficiency | |
| Employee #8 | Named in tuberculosis testing deficiency |
Inspection Report
Plan of Correction
Capacity: 56
Deficiencies: 0
Feb 24, 2011
Visit Reason
The facility completed a self-attestation questionnaire in lieu of the 2010 annual survey as it was in good standing with no major deficiencies found in the 2009 annual survey.
Findings
The questionnaire indicated the facility was in regulatory compliance and will receive a grade of A. No deficiencies were cited and no further action is necessary.
Inspection Report
Original Licensing
Census: 55
Capacity: 56
Deficiencies: 2
Feb 16, 2010
Visit Reason
This document is a 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 was found deficient in kitchen equipment cleanliness and maintenance, and in ensuring dementia training for employees. Specifically, kitchen equipment and utensils were dirty and in poor condition, and one employee failed to complete required dementia training within the first 40 hours of employment.
Severity Breakdown
Level 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The facility failed to ensure kitchen equipment and utensils were clean and in good working condition, including dirty food brushes, contaminated can opener, and dirty floors under food prep areas. | Level 2 |
| The facility failed to ensure 1 of 12 employees who have contact with residents with dementia completed at least 2 hours of dementia training within the first 40 hours of employment. | Level 2 |
Report Facts
Resident files reviewed: 15
Employee files reviewed: 12
Discharged resident files reviewed: 1
Facility licensed capacity: 56
Facility census: 55
Inspection Report
Re-Inspection
Capacity: 56
Deficiencies: 1
Mar 6, 2009
Visit Reason
This Statement of Deficiencies was generated as a result of a requested grading re-survey conducted in the facility on 3/5-6/09 by the authority of NRS 449.150.
Findings
The facility did not ensure all refrigerators and microwaves were commercial grade; however, there was no mold on the surfaces above the sink and the area around the toaster was not damaged.
Severity Breakdown
Severity: 1: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility did not ensure all refrigerators and microwaves were commercial grade. | Severity: 1 |
Report Facts
Licensed capacity: 56
Inspection Report
Annual Inspection
Census: 56
Capacity: 56
Deficiencies: 7
Feb 4, 2009
Visit Reason
This visit was an annual State Licensure survey conducted by the Health Division on 2/4/09 to assess compliance with regulatory requirements for a residential facility providing care to persons with Alzheimer's disease.
Findings
The survey identified multiple deficiencies related to kitchen equipment sanitation, use of commercial-grade appliances, medication administration, medication records accuracy, resident files, and tuberculosis testing compliance. Severity levels ranged from 1 to 2 with various scopes.
Severity Breakdown
F: 3
C: 1
A: 1
D: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| The kitchen equipment was not clean and sanitary; dishwashing machines were not in good working condition. | F |
| Facility did not ensure toasters and slow cookers met commercial-grade NSF standards. | C |
| Facility did not obtain over-the-counter medications as prescribed by the physician for one resident. | A |
| Facility failed to ensure medication was administered as prescribed for one resident. | D |
| Medication administration record (MAR) was inaccurate for one resident; repeat deficiency from prior survey. | D |
| Facility failed to maintain a separate resident file for at least 5 years after discharge, including required records and documentation. | F |
| Facility failed to ensure tuberculosis testing compliance for one resident affecting all residents. | F |
Report Facts
Resident files reviewed: 15
Employee files reviewed: 12
Discharged resident files reviewed: 1
Severity 1 deficiencies: 2
Severity 2 deficiencies: 3
Severity 3 scope: 3
Inspection Report
Annual Inspection
Census: 56
Capacity: 56
Deficiencies: 6
Feb 4, 2009
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at the facility on 2/4/09 by the authority of NRS 449.150.
Findings
The facility was found deficient in several areas including kitchen equipment not being in good working condition, use of non-commercial-grade cooking equipment, failure to obtain and administer over-the-counter medications as prescribed, inaccurate medication administration records, and failure to ensure resident compliance with tuberculosis regulations.
Severity Breakdown
Level 1: 3
Level 2: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| The facility did not ensure its kitchen equipment (dishwashing machines) were in good working condition. | Level 2 |
| The facility did not ensure its toasters and slow cookers met commercial-grade NSF standards. | Level 1 |
| The facility did not obtain over-the-counter medications to administer as prescribed by the physician for 1 of 15 residents (Resident #3). | Level 1 |
| The facility failed to ensure that 1 of 15 residents (Resident #11) received medications as prescribed. | Level 2 |
| The facility failed to ensure the medication administration record (MAR) was accurate for 1 of 15 residents (Resident #6). | Level 1 |
| The facility failed to ensure that 1 of 15 residents complied with tuberculosis regulations (Resident #6), affecting all residents. | Level 2 |
Report Facts
Resident files reviewed: 15
Employee files reviewed: 12
Discharged resident files reviewed: 1
Severity 2 deficiencies: 3
Severity 1 deficiencies: 3
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