Inspection Report
Complaint Investigation
Census: 118
Capacity: 142
Deficiencies: 1
Jun 4, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #NV00074379, which included allegations regarding facility temperature, activities for residents, missing resident clothes, and medication technician knowledge.
Findings
The complaint allegations were not substantiated due to lack of sufficient evidence. However, a regulatory deficiency was identified related to an employee lacking current first aid and CPR training, with the CPR certification expired and no documented first aid training.
Complaint Details
Complaint #NV00074379 was investigated with allegations that could not be substantiated due to lack of sufficient evidence. Allegations included unsafe temperature, lack of activities, missing resident clothes, and medication technician knowledge. Investigation included observations and interviews with staff and residents.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure an employee had current first aid and cardiopulmonary resuscitation (CPR) training; Employee #4's CPR certification was expired and lacked first aid training. | 2 |
Report Facts
Licensed beds: 142
Beds for elderly or disabled persons: 104
Beds for persons with Alzheimer's disease: 38
Census: 118
Personnel files reviewed: 3
Employees sampled: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Apolinario Gozon | Executive Director | Confirmed the expired CPR certification and lack of first aid training for Employee #4. |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 142
Deficiencies: 2
Apr 10, 2025
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by three complaints alleging issues such as lack of heat in a resident's room, failure to follow specialized diets, inadequate resident care, insufficient staffing in memory care, and failure to monitor and treat residents properly.
Findings
The investigation found that none of the complaints could be substantiated due to lack of sufficient evidence. However, regulatory deficiencies were identified related to the administrator's failure to ensure complete and accurate records, incomplete documentation for residents' use of personal attendants, and inadequate care coordination and person-centered service plans, particularly for residents with fall risks.
Complaint Details
Three complaints were investigated: Complaint #NV00073614 alleging lack of heat, failure to follow specialized diets, inadequate resident care, and medication administration issues; Complaint #NV00073647 alleging insufficient staff in memory care; Complaint #NV00073724 alleging failure to monitor resident, lack of dignity and respect, failure to provide care per physician order, untimely turning/positioning, and unsupervised toileting. None of these allegations were substantiated due to lack of sufficient evidence.
Severity Breakdown
Level 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Administrator failed to adhere to Admission and Discharge policy, complete required documents for residents' use of personal attendants, and provide care coordination for sampled residents. | Level 2 |
| Resident's person-centered service plan lacked documented evidence of care coordination for personal care attendant and did not include appropriate toileting assistance for a resident with fall history. | Level 2 |
Report Facts
Licensed beds: 142
Census: 90
Resident files reviewed: 5
Complaints investigated: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Apolinario Gozon | Administrator | Named in relation to failure to ensure facility adherence to admission and discharge policy and record accuracy. |
| Health Services Director | Confirmed residents had personal attendants and discussed deficiencies in service plans and care coordination. | |
| Memory Support Director | Interviewed during investigation and involved in care coordination and policy adherence. | |
| Operations Specialist | Interviewed during investigation regarding resident care and staffing. |
Inspection Report
Re-Inspection
Census: 117
Capacity: 142
Deficiencies: 13
Jan 29, 2025
Visit Reason
This inspection was a State Licensure mandatory re-grading survey conducted by the Division of Public and Behavioral Health in accordance with NAC 449, Residential Facility for Groups.
Findings
The facility was found to have multiple regulatory deficiencies including failure to ensure annual tuberculosis screenings for some employees, improper medication storage for some residents, incomplete personnel files, and training deficiencies. The facility received a grade of A and corrective actions were planned or implemented for each deficiency.
Severity Breakdown
Level 2: 7
Level 3: 4
Level 5: 1
Level 6: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to ensure annual tuberculosis (TB) screenings had been completed for 3 of 15 sampled employees. | Level 2 |
| Failure to maintain personnel files with evidence of background checks as required. | Level 3 |
| Failure to maintain a first aid kit with required items including a CPR mask. | Level 2 |
| Failure to obtain and maintain resident physical examinations and follow-up as required. | Level 2 |
| Failure to properly administer and document medications including over-the-counter medications and change orders. | Level 2 |
| Failure to maintain medication administration records accurately and completely. | Level 2 |
| Failure to ensure medication restrictions for PRN medications were properly documented and followed. | Level 2 |
| Failure to ensure resident medications were stored securely and appropriately for 2 of 12 sampled residents. | Level 2 |
| Failure to ensure all medications, including over-the-counter medications, were plainly labeled with resident and physician information. | Level 3 |
| Failure to maintain separate locked files for each resident containing all required records and assessments. | Level 3 |
| Failure to ensure dementia care staff completed required dementia training. | Level 5 |
| Failure to obtain consent prior to weighing residents as required. | Level 6 |
| Failure to post nondiscrimination statements and policies as required. | Level 3 |
Report Facts
Beds licensed: 142
Beds for elderly/disabled: 104
Beds for Alzheimer's disease: 38
Census: 117
Employees sampled: 15
Residents sampled: 15
Employees missing TB screening: 3
Residents with unsecured medications: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Baumgartner | Executive Director | Signed the inspection report and responsible for audit compliance with TB testing requirements. |
| Todd South | Administrator | Contacted to update NABS account following change of ownership. |
| Business Office Manager | Confirmed annual TB screenings had not been completed for certain employees. | |
| Memory Care Support Director | Responsible for monitoring compliance with medication storage, training, and audits. | |
| Health Services Director | Confirmed medication storage deficiencies and educated residents on medication policy. |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 142
Deficiencies: 0
Dec 5, 2024
Visit Reason
The inspection was conducted as a result of a State Licensure complaint investigation triggered by complaint #NV00072881 regarding allegations about the facility's HVAC system and notification practices.
Findings
The investigation found that the allegations of failure to maintain a safe and comfortable temperature due to a broken HVAC system and failure to notify a resident's responsible party were not substantiated due to lack of sufficient evidence. The facility received a grade of A.
Complaint Details
Complaint #NV00072881 with two allegations was investigated but could not be substantiated due to lack of sufficient evidence.
Report Facts
Licensed beds: 142
Census: 92
Resident files reviewed: 5
Employee files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed during the investigation. | |
| Memory Support Assistant | Interviewed during the investigation. | |
| Executive Director | Interviewed during the investigation. |
Inspection Report
Annual Inspection
Census: 121
Capacity: 142
Deficiencies: 13
Aug 29, 2024
Visit Reason
This inspection was an annual State Licensure survey conducted by the Division of Public and Behavioral Health to assess compliance with regulations for a residential facility for groups.
Findings
The facility was found deficient in multiple areas including caregiver training, personnel file documentation (physical exams, TB screening, background checks), medication administration and storage, resident assessments, dementia care training, weight consent, and posting of non-discrimination statements. The facility received a grade of D.
Severity Breakdown
D: 8
C: 3
E: 1
F: 2
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to provide documented evidence that 4 of 25 sampled employees completed at least eight hours of annual caregiver training. | D |
| Failed to provide documented evidence that 2 of 25 sampled employees had a physical examination prior to working at the facility and 4 of 25 sampled employees met TB testing requirements. | D |
| Failed to ensure Nevada Automated Background System clearance was completed under the current facility license for all employees. | C |
| First aid kit in Memory Support Unit did not contain a CPR mask. | D |
| Failed to ensure an annual general physical examination was completed for 1 of 25 sampled residents (Resident #3). | D |
| Failed to ensure proper labeling, availability, and change order documentation for medications for multiple residents. | D |
| Failed to ensure written instructions indicating specific symptoms for PRN medication administration for 1 of 25 sampled residents (Resident #6). | D |
| Failed to ensure resident medications were kept secured in the facility for 2 of 28 resident rooms with self-administering residents and 2 of 25 sampled residents. | F |
| Failed to properly label over-the-counter medications with resident's and prescribing physician's name for 2 of 25 sampled residents. | D |
| Failed to ensure an annual Activities of Daily Living assessment was completed for 1 of 25 residents (Resident #6). | D |
| Failed to provide documented evidence that 8 of 25 sampled employees completed the required minimum of three hours of dementia training by hire anniversary date. | E |
| Failed to obtain resident or resident representative consent to obtain monthly resident weight measurements. | F |
| Failed to post a non-discrimination statement with the State Agency's contact information for filing a complaint in the Memory Support Unit and on the facility's Internet website. | C |
Report Facts
Licensed beds: 142
Beds for elderly/disabled: 104
Beds for Alzheimer's: 38
Resident census: 121
Employees sampled: 25
Residents sampled: 25
Resurvey fee: 600
Deficiency severity D count: 8
Deficiency severity C count: 3
Deficiency severity E count: 1
Deficiency severity F count: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Baumgartner | Executive Director | Signed the Statement of Deficiencies report |
| Todd South | Contacted to update NABS account following change of ownership | |
| Business Office Director | Provided personnel checklist, attestation of compliance, and explained training requirements | |
| Memory Support Director | Confirmed missing CPR mask, lack of non-discrimination posting, and involved in medication and training compliance | |
| Health Services Director | Confirmed weight measurement practices and medication storage issues | |
| Medication Technician | Confirmed medication labeling and administration deficiencies |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 142
Deficiencies: 0
May 15, 2024
Visit Reason
This inspection was conducted as a result of a State Licensure complaint investigation regarding an allegation that a resident was burned due to lack of protective supervision.
Findings
The complaint was investigated and could not be substantiated. The facility was licensed for 142 beds and received a grade of A. Five resident and five employee files were reviewed during the survey.
Complaint Details
Complaint #NV00069734 alleged a resident was burned due to lack of protective supervision; the allegation was not substantiated.
Report Facts
Licensed beds: 142
Census: 92
Resident files reviewed: 5
Employee files reviewed: 5
Inspection Report
Re-Inspection
Census: 111
Capacity: 142
Deficiencies: 10
Mar 26, 2024
Visit Reason
This inspection was a State Licensure mandatory regrading survey conducted by the Division of Public and Behavioral Health in accordance with NAC 449, Residential Facility for Groups.
Findings
The facility was found to have multiple deficiencies related to advertising accuracy, food service permits, first aid and CPR training, residents' rights, medication administration and storage, maintenance of resident files, Alzheimer's care safety standards, and environmental safety in the memory care unit. The facility received a grade of A and corrective actions were planned or implemented for all deficiencies.
Severity Breakdown
C: 1
F: 3
D: 6
Deficiencies (10)
| Description | Severity |
|---|---|
| Advertising and promotional materials for the residential facility were not accurate and misrepresented accommodations, services or programs. | C |
| Failure to comply with NAC 446 on Food Service including obtaining necessary permits. | F |
| Administrator or caregiver not trained in first aid and cardiopulmonary resuscitation within 30 days of employment. | D |
| Facility failed to ensure residents' rights and safe, comfortable environment. | F |
| Improper administration of medication and supplements without proper physician approval or documentation. | D |
| Medications were not stored securely; unsecured medications found in resident rooms. | D |
| Medications and dietary supplements were not plainly labeled or kept in original containers until administered. | D |
| Failure to maintain and secure separate resident files for at least 5 years after discharge. | D |
| Failure to ensure safety standards for persons with Alzheimer's disease including inaccessibility of dangerous items. | F |
| Toxic substances were accessible to residents in the memory care unit, including Dove body wash found unsecured in a resident's room. | D |
Report Facts
Licensed beds: 142
Census: 111
Resident files reviewed: 15
Employee files reviewed: 15
Severity 2 deficiencies: 2
Severity 1 deficiencies: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary E Baumgartner | Executive Director | Signed the report and confirmed findings related to medication storage and toxic substances. |
Inspection Report
Annual Inspection
Census: 131
Capacity: 142
Deficiencies: 10
Oct 25, 2023
Visit Reason
This inspection was an annual State Licensure survey conducted in the facility and included a change of ownership review.
Findings
The facility was found to have multiple deficiencies including misrepresentation in advertising, food service violations, failure to ensure timely first aid and CPR training, unsafe environment related to COVID-19 protocols, medication administration and storage issues, incomplete tuberculosis testing documentation, and unsafe conditions in the memory care unit with dangerous and toxic items accessible to residents.
Severity Breakdown
Level 1: 1
Level 2: 9
Deficiencies (10)
| Description | Severity |
|---|---|
| Advertising and promotional materials misrepresented assisted living services by advertising a licensed nurse on-site when none performed nursing duties. | Level 1 |
| Memory care staff failed to practice proper hygiene and the dishmachine was not sanitizing properly during the final rinse cycle. | Level 2 |
| Failure to ensure first aid and CPR training was received within 30 days of employment for one employee. | Level 2 |
| Facility failed to provide a safe environment from infection and did not follow COVID-19 protocols including failure to post required signage. | Level 2 |
| Failure to affix change labels to medication labels for 3 sampled residents. | Level 2 |
| Medications were found unsecured in resident rooms in the memory care unit. | Level 2 |
| Medication labeling failure: an over-the-counter cannabidiol (CBD) bottle was not labeled with the resident's or prescriber's name. | Level 2 |
| Failure to ensure tuberculosis testing compliance for 2 residents; one had an indeterminate test without follow-up chest x-ray, the other lacked a 2023 TB test. | Level 2 |
| Memory care unit contained dangerous items accessible to residents including blow dryers and pill cutters. | Level 2 |
| Memory care unit contained toxic substances accessible to residents in multiple rooms. | Level 2 |
Report Facts
Licensed beds: 142
Beds for elderly or disabled persons: 104
Beds for persons with Alzheimer's disease: 38
Resident census: 131
Resident files reviewed: 25
Employee files reviewed: 23
Fee for resurvey application: 600
Change order medication label errors: 3
Unsecured medication rooms: 3
Residents with TB testing issues: 2
Rooms with toxic substances accessible: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Baumgartner | Executive Director | Signed the Statement of Deficiencies report |
Loading inspection reports...
