Inspection Reports for Cottages at Green Valley

The inspection was conducted as a result of an annual survey, a Facility Reported Incident (FRI), and a complaint investigation at the facility on 05/20/2025.

The facility received a grade of C with deficiencies identified in caregiver training, background checks, CPR certification, facility cleanliness, kitchen sanitation, and dementia care training. Several employees lacked required annual training and certifications, and the facility was found to be poorly maintained with sanitation issues in kitchens and resident areas.

Complaint #NV00073788 was substantiated. The complaint involved issues with facility cleanliness, caregiver training, and kitchen sanitation. The Facility Reported Incident #11366 was substantiated with no deficient practice.

The inspection was conducted as a result of a complaint investigation at the facility on 04/16/2025, triggered by Complaint #NV00073615.

The complaint was substantiated without any deficient practice. Observations, interviews, and record reviews found no regulatory deficiencies, and no further action was necessary.

Complaint #NV00073615 was substantiated with no deficient practice.

The inspection was conducted as a result of a complaint investigation at the facility on 03/05/25 in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.

The complaint was substantiated with no deficient practice found. The investigation included observations, interviews, and record reviews, and no regulatory deficiencies were identified. No further action was necessary.

One complaint (#NV00073291) was investigated and substantiated without deficient practice.

The inspection was conducted as a result of a complaint investigation at the facility on 01/14/25, triggered by two complaints received.

Two complaints were investigated and both were substantiated with no deficient practice found. The facility received a grade of A and no regulatory deficiencies were identified, requiring no further action.

Two complaints were investigated: Complaint #NV 00072950 and Complaint #NV 00072693, both substantiated with no deficient practice.

The inspection was conducted as a result of a mandatory grading resurvey and complaint investigation in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.

The facility received a grade of B with one complaint investigated which was unsubstantiated. No regulatory deficiencies were identified related to the complaint. However, several deficiencies were cited related to facility maintenance, safety in Alzheimer’s care areas, and employee training.

One complaint (#NV00071801) was investigated and found to be unsubstantiated with no regulatory deficiencies identified.

The inspection was conducted as a result of an annual survey and a Facility Reported Incident in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.

The facility was found deficient in multiple areas including employee CPR and first aid training, water temperature exceeding acceptable limits in resident rooms, cleanliness and maintenance issues, laundry room sanitation, kitchen sanitation, medication administration and storage, unsecured medications, memory care safety including door alarms and sharp objects, toxic substances accessibility, cultural competency training, infection control training, and unlicensed caregiver infection control training.

The inspection was conducted as a result of a complaint investigation at the facility on 02/15/24, in accordance with Nevada Administrative Code (NAC), Chapter 449, Residential Facility for Groups.

The complaint investigated was unverified and no regulatory deficiencies were identified. The investigation included observations, interviews, clinical record reviews, and document reviews, with no further action necessary.

One complaint (#NV00070255) was investigated but could not be verified. No regulatory deficiencies were identified.

The inspection was conducted as a result of a State Licensure complaint investigation and a Facility Reported Incident at the facility on 10/24/23.

The investigation included two complaints and one Facility Reported Incident. One complaint was substantiated with deficiencies related to safety and discharge procedures, while the other complaint was unsubstantiated. Deficiencies included failure to maintain a working auditory call bell alert system, failure to provide appropriate discharge paperwork for a resident transferred to the hospital, and inadequate caregiver staffing ratios during the day.

Two complaints and one Facility Reported Incident were investigated. Complaint #NV00069704 was substantiated with deficiencies. Complaint #NV00069491 was unsubstantiated. Facility Reported Incident #9014 was verified with no deficient practice.

The inspection was conducted as a result of a complaint investigation at the facility on 07/26/23, in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.

The investigation included observations, interviews, and record reviews. One complaint was verified with no deficient practice, and another complaint could not be verified. No regulatory deficiencies were identified and no further action is required.

One complaint (#NV00069054) was verified with no deficient practice. Another complaint (#NV00068831) could not be verified. No regulatory deficiencies were identified.

The inspection was conducted as a result of a complaint investigation triggered by two complaints alleging resident care issues and infection control concerns.

The investigation included observations, interviews, and record reviews, and found that none of the allegations were substantiated. No regulatory deficiencies were identified and no further action was necessary.

Two complaints were investigated: Complaint #NV00050901 with allegations of residents being left wet, not dressed properly, and diet not provided as prescribed; and Complaint #NV00050881 with allegations of improper infection control and failure to keep the facility free of insects. None of the allegations were substantiated.

This Statement of Deficiencies was generated as a result of an annual State Licensure survey conducted in the facility on 4/6/16 by the Division of Public and Behavioral Health.

The facility received a grade of A. One deficiency was identified related to medication storage where medications were found improperly stored in a resident's room. The facility took corrective actions including removal of medications and implementation of a check-off sheet for medication management.

This annual State Licensure survey was conducted on 4/6/16 by the Division of Public and Behavioral Health to assess compliance with state regulations for the facility.

The facility was found to have a deficiency related to medication storage, specifically medications being stored improperly in a resident's room. The facility received a grade of A overall.

The inspection was conducted as a result of a complaint investigation regarding facility staffing.

The complaint was investigated through observations, interviews, and review of staffing schedules and policies. The allegation was not substantiated and no regulatory deficiencies were identified.

Complaint #NV00044562 regarding facility staffing was investigated and found to be unsubstantiated.

This visit was an annual State Licensure survey conducted by the Division of Public and Behavioral Health to assess compliance with state regulations.

The facility was found to be in substantial compliance with no deficiencies identified and received a grade of A.

The inspection was conducted as a result of a complaint investigation initiated by the Division of Public and Behavioral Health on 2/24/15 regarding allegations of deficient client services.

The investigation substantiated one allegation that client services were not performed per Plan of Care and physician orders, specifically related to medication administration and use of compression stockings. Two other allegations regarding resident ambulation and grooming were not substantiated.

Complaint #NV00041941 contained three allegations: 1) Client services not performed per Plan of Care and physician (substantiated); 2) Resident not ambulated regularly (not substantiated); 3) Resident not groomed adequately (not substantiated).

The inspection was conducted as a result of a complaint investigation initiated on 2015-02-24 regarding allegations of inadequate client services, irregular ambulation, and inadequate grooming of residents.

The complaint was substantiated for failure to perform client services per Plan of Care and physician orders, specifically medication administration. Two allegations regarding ambulation and grooming were not substantiated. One deficiency was cited related to medication administration for Resident #1 not receiving prescribed compression stockings.

Complaint #NV00041941 contained three allegations: 1) Client services not performed per Plan of Care and physician (substantiated), 2) Resident not ambulated regularly (not substantiated), 3) Resident not groomed adequately (not substantiated).

This inspection was conducted as a complaint investigation from 11/17/14 through 11/21/14 based on complaint #NV00040894 which contained two substantiated allegations regarding quality of care, resident safety/falls, and facility staffing.

The facility failed to provide necessary evaluation, care plans, and protective supervision to prevent falls for 5 of 8 sampled residents, and failed to maintain the required staffing ratio of one caregiver per six residents in the Transitional/Memory Care units. Multiple incidents of resident falls with injuries were documented, and staffing policies did not adequately address Memory Care unit needs.

Complaint #NV00040894 contained two allegations which were substantiated: (1) Quality of care and treatment, resident safety/falls; (2) Quality of care and treatment, facility staffing.

The inspection was conducted as a complaint investigation from 11/17/14 through 11/21/14 based on complaint #NV00040894 which contained two substantiated allegations regarding quality of care, treatment, resident safety/falls, and facility staffing.

The facility failed to provide necessary evaluation, care plans, and protective supervision to prevent falls for 5 of 8 residents reviewed. Staffing ratios in the Memory Care Units did not meet regulatory requirements. Multiple incidents of resident falls with injuries were documented, and deficiencies in supervision and care planning were identified.

Complaint #NV00040894 contained two allegations: (1) Quality of care and treatment, resident safety/falls, substantiated; (2) Quality of care and treatment, facility staffing, substantiated.

The inspection was conducted as a complaint investigation initiated by the Division of Public and Behavioral Health on 10/1/14, following complaint #NV00040563 alleging failure to provide a 1:6 staffing ratio in Alzheimer's cottages.

The complaint was substantiated with deficiencies identified including failure to maintain the required 1:6 caregiver to resident ratio, failure to ensure operational alarms on exit doors, and failure to secure yard gates. Multiple inservice trainings were conducted to address these issues.

Complaint #NV00040563 contained one allegation regarding staffing ratios in Alzheimer's cottages, which was substantiated.

The inspection was conducted as a complaint investigation triggered by Complaint #NV00040563, which alleged the facility failed to maintain a 1:6 staffing ratio in Alzheimer's cottages.

The investigation substantiated the complaint and identified deficiencies including failure to maintain the required staffing ratio, a disabled exit door alarm, and unsecured exit gates in the Alzheimer's unit.

Complaint #NV00040563 contained one allegation regarding staffing ratios in Alzheimer's cottages, which was substantiated.

This document is a State Licensure re-survey conducted on 8/11/14 to assess compliance with regulatory standards following a previous inspection.

The facility received a re-survey grade of A. Deficiencies were identified related to food service permits and storage, including expired food items and improper storage of linens and single service items. Additionally, dangerous items such as disposable razors were found unlocked in memory care units, representing a repeat deficiency from the prior annual survey.

This document is a required grading re-survey conducted as a State Licensure survey to assess compliance with regulatory standards at the facility.

The facility received a re-survey grade of A. Deficiencies were identified related to food service permits and kitchen standards, storage of dangerous items accessible to residents in the memory care unit, and improper storage of linens and single service items. These deficiencies were classified as critical and major violations with severity level 2.

This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 5/21/14 to assess compliance with regulatory requirements for a residential facility providing care to elderly or disabled persons.

The facility was found deficient in multiple areas including caregiver training, elder abuse training, health and sanitation, food service compliance, use of restraints, tuberculosis testing, storage of dangerous items, and dementia training. Several deficiencies were noted with severity levels mostly at level 2, indicating moderate issues requiring correction.

This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at Pacifica Senior Living Green Valley on 5/21/2014.

The facility received a grade of D with multiple deficiencies identified including failure to ensure caregivers received required training, failure to maintain the facility premises, kitchen and food service violations, improper use of restraints, incomplete resident tuberculosis testing, unsecured dangerous items, and inadequate dementia training for employees.

The inspection was conducted as a complaint investigation from 2014-05-02 through 2014-05-09 following a substantiated complaint regarding failure to provide protective supervision for a memory care resident who was an elopement risk.

The facility was found deficient in providing adequate protective supervision to residents, appropriate admission policies, completion of incident reports, and required training for caregivers related to elderly, disabled, and dementia care. Multiple falls were documented for residents, and training records for several employees were incomplete or missing.

Complaint #NV00039134 was substantiated. The complaint alleged failure to provide protective supervision for a memory care resident who was an elopement risk.

The inspection was conducted as a complaint investigation initiated by the Division of Public and Behavioral Health due to a complaint about failure to provide protective supervision for a memory care resident who was an elopement risk.

The facility was found to have multiple deficiencies including failure to provide adequate protective supervision for Resident #1, inappropriate admission of Resident #2, incomplete incident reports for Residents #1 and #2, and insufficient training for caregivers related to care of elderly and disabled residents and dementia training. The complaint was substantiated and the facility received a grade of D.

Complaint #NV00039134 was substantiated. The complaint contained one allegation that the facility failed to provide protective supervision for a memory care resident who was an elopement risk.

The inspection was conducted as a complaint investigation initiated by the Bureau of Health Care Quality and Compliance on 4/11/14 and completed on 4/23/14, based on complaint #NV00038615 which contained three allegations regarding medication administration, falsification of medication records, and response to resident call bells.

The investigation substantiated allegations of medication not given according to physician instructions and falsification of medication records, while the allegation regarding call bell response was not substantiated. Deficiencies included failure to ensure medication technicians completed required annual training, failure to administer medications as prescribed, and failure to maintain accurate medication administration records.

Complaint #NV00038615 contained 3 allegations: medication not given according to physician instructions was substantiated; falsification of medication records was substantiated; resident call bell/lights not answered timely was not substantiated.

The inspection was conducted as a result of a complaint investigation initiated by the Bureau of Health Care Quality and Compliance on 4/11/14 and completed on 4/23/14, triggered by complaint #NV00038615 containing three allegations related to medication administration, falsification of medication records, and call bell response times.

The investigation substantiated two allegations: resident medications were not given according to physician instructions and falsification of medication records. The allegation regarding call bell response times was not substantiated. Additionally, a regulatory deficiency was identified regarding medication training for staff.

Complaint #NV00038615 contained three allegations: (1) resident medications not given according to physician instructions (substantiated), (2) falsification of facility medication records (substantiated), and (3) resident call bell/lights not answered timely by staff (not substantiated). The complaint investigation was conducted from 4/11/14 to 4/23/14.

This complaint investigation was conducted due to allegation #NV00036729 that the facility did not report verbal abuse and financial exploitation by a caregiver against a resident to the Aging and Disability Services Division (ADSD).

The facility failed to ensure that an allegation of verbal abuse and financial exploitation was reported to ADSD as required. The Administrator provided training to an employee regarding the responsibility to notify ADSD within 24 hours of any suspected abuse or neglect, and corrective actions were completed by 9/24/2013.

Complaint #NV00036729 alleged the facility did not report verbal abuse and financial exploitation by a caregiver against a resident to ADSD. The allegation was substantiated.

This inspection was conducted as a complaint investigation based on allegations that the facility did not report verbal abuse and financial exploitation by a caregiver against a resident to the Aging and Disability Services Division (ADSD).

The facility was found to have failed to ensure that an allegation of verbal abuse and financial exploitation was reported to ADSD, substantiating the complaint.

Complaint #NV00036729 was substantiated regarding failure to report verbal abuse and financial exploitation by a caregiver against a resident to ADSD.

This document is a plan of correction submitted by the facility following a required grading re-survey conducted on 8/22/2013 by the Division of Public and Behavioral Health.

The facility was found deficient in medication administration and record-keeping for several residents, including failure to ensure medications were given as prescribed and incomplete medication administration records. These deficiencies were repeat issues from prior surveys.

This document is a State Licensure re-survey conducted on 08/22/2013 as a required grading re-survey of the facility.

The facility received a re-survey grade of A. Deficiencies were identified related to medication administration and medication administration records, including failure to administer medications as prescribed for 5 of 15 residents and inaccuracies in medication administration records for 5 of 15 residents.

The inspection was conducted as a complaint investigation initiated by the Division of Public and Behavioral Health from 5/28/13 through 7/3/13 regarding allegations of improper infection control measures at the facility.

The allegation of improper infection control was not substantiated. Interviews with the administrator and staff, review of resident testing records, and observation of cleaning agents confirmed proper infection control practices were in place, including frequent testing for Clostridium Difficile with negative results and use of appropriate cleaning agents.

Complaint #NV00035659 alleged improper infection control measures. The complaint was not substantiated based on document review and interviews.

This document is a complaint investigation conducted from 2013-05-29 through 2013-06-19 regarding allegations of abuse at the facility.

The complaint regarding facility administration and personnel was not substantiated after interviews and document review. The investigation included interviews with the facility administrator and an Aging and Disabilities Services Division Supervisor, review of incident reports, and relevant statutes. The facility employees were found to be mandatory reporters and had reported the alleged abuse as required by law.

Complaint #NV00035215 was initiated on 2013-05-29. Allegations of abuse were reported by caregivers and hospice staff, investigated by Elder Protective Services and local law enforcement, but the allegation regarding facility administration and personnel was not substantiated.

The inspection was conducted as an annual grading State Licensure survey of a residential facility providing assisted living services and care to persons with Alzheimer's disease and other chronic illnesses.

The facility received a grade of B with multiple deficiencies identified related to health and sanitation, food service permits, medication administration and storage, and safety in the Alzheimer's unit. Several deficiencies were repeat issues from prior surveys.

This document is the result of an annual grading State Licensure survey conducted at the facility on 6/4/2013 to assess compliance with state regulations for assisted living and residential care.

The facility received a grade of B with multiple deficiencies identified including issues with cleanliness and maintenance, kitchen sanitation and food safety, medication administration and record accuracy, medication storage security, and accessibility of dangerous items to residents.

The inspection was conducted as a complaint investigation initiated on 2013-03-20 regarding allegations about a resident not being assessed after a change in condition, oversedation, lack of fall precautions, and not being fed.

The complaint allegations were not substantiated based on record reviews and interviews with facility staff. The resident was placed in a secured memory care unit after an episode of confusion, medications were administered as prescribed, fall precautions were taken, and the resident was eating small portions.

Complaint #NV00034736 was investigated and found not substantiated for all allegations including lack of assessment after change in condition, oversedation, failure to take fall precautions, and not being fed.

The inspection was conducted as a complaint investigation regarding allegation #NV 00034467 that medications were not given in accordance with physician's orders.

The complaint was not substantiated after review of the resident's file, doctor's orders, staff interviews, and family statements. The facility was found to be administering medications according to physician's orders.

Complaint #NV 00034467 alleged medications were not given according to physician's orders. The allegation was not substantiated based on file review, staff and family interviews.

The visit was a required grading re-survey conducted on 8/9/12 to assess compliance following a previous inspection.

The facility failed to ensure the kitchen complied with standards of NAC 446, with critical violations including improper thawing of chicken and cleaning/sanitation issues with the dish machine. The facility received a re-survey grade of A.

This document is a required grading re-survey conducted as a State Licensure survey to assess compliance with regulatory standards.

The facility received a re-survey grade of A. Deficiencies were identified related to kitchen compliance with NAC 446 standards, including critical violations such as thawed chicken stored at 66 degrees F and cleaning/sanitation issues with dishmachine wash cycle temperature at 90 degrees F.

This visit was an annual State Licensure survey conducted on 6/20/2012 to assess compliance with state regulations for the Cottages of Green Valley, a residential facility providing care for elderly and disabled persons including those with Alzheimer's disease.

The facility received a grade of C with multiple deficiencies identified including issues with personnel files and tuberculosis testing, food service permits and sanitation, safety requirements, admission policies, medication administration and storage, and dangerous items accessibility in the memory care unit. Several deficiencies were cited with severity levels mostly at level 2.

This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 6/20/2012 at the Cottages of Green Valley, a residential facility providing assisted living services.

The facility received a grade of C with multiple deficiencies identified including failure to comply with tuberculosis testing for employees, kitchen sanitation and equipment issues, auditory system monitoring failures, improper use of restraints, medication administration errors, medication storage violations, accessibility of dangerous items in the memory care unit, and admission of a resident with a chronic illness without proper endorsement.

This Statement of Deficiencies was generated as a result of a complaint investigation conducted on the facility from 5/23/12 through 5/25/12 regarding an allegation that a resident did not receive medications according to his physician's instructions.

The complaint was not substantiated. Interviews and record reviews confirmed the resident received medications as prescribed by his physician from admission on 9/6/11 until discharge on 1/6/12.

Complaint #NV00031840 was not substantiated. The allegation that a resident did not receive medications according to his physician's instructions was unsubstantiated through interview and record review.

The Health Division intends to impose sanctions on the Cottages of Green Valley facility based on deficiencies found during a complaint investigation conducted from 8/9/11 to 10/18/11.

The Bureau conducted a complaint investigation and found deficiencies with severity level three and scope level two or less, resulting in an initial monetary penalty of $400. The Plan of Correction submitted by the facility was reviewed and found acceptable.

The Bureau conducted a complaint investigation at Cottages of Green Valley from 8/9/11 to 10/18/11. Specific factual findings are set forth in the Statement of Deficiencies (SOD) in Attachment A. The Plan of Correction submitted in response to the survey was acceptable.

This inspection was conducted as a complaint investigation triggered by complaint #NV00029770 regarding the physical environment and linen condition at the facility.

The allegation regarding poor physical environment and linen condition was not substantiated. Interviews with residents and staff, and observations of apartments and common areas found the facility clean and well maintained, including kitchens, lobby, dining areas, floors, bathrooms, and linens.

Complaint #NV00029770 alleged poor physical environment and linen condition. The complaint was not substantiated after investigation including interviews and observations.

This inspection was conducted as a complaint investigation from 8/2/11 to 10/18/11 regarding allegations of inaccurate record keeping and medications not given as prescribed.

The facility was found to have substantiated deficiencies related to medication administration and record keeping for one resident, including failure to administer prescribed medication Advair and failure to maintain accurate medication administration records.

Complaint #NV00029010 alleged inaccurate record keeping and medications not given as prescribed; both allegations were substantiated.

This inspection was conducted as a complaint investigation from 8/9/11 to 10/18/11 regarding allegations of inaccurate record keeping and medications not being given as prescribed.

The facility was found to have substantiated deficiencies related to medication administration and record keeping. Specifically, one resident did not receive prescribed medication (Advair) as ordered, leading to exacerbation of asthma, and medication administration records were inaccurate, failing to reflect resident absences.

Complaint #NV00029010 - The allegation regarding inaccurate record keeping was substantiated. The allegation regarding medications not given as prescribed was substantiated.

This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 5/5/2011 at the Cottages of Green Valley.

The facility was found to have multiple deficiencies related to food service permits, cleaning and sanitation issues, equipment maintenance, medication administration, and medication destruction. The facility received a grade of A despite these findings.

This document is the result of an annual State Licensure survey conducted on 5/5/2011 to assess compliance with state regulations for the Cottages of Green Valley facility.

The facility received a grade of A but had several deficiencies including critical violations related to food service permits and kitchen sanitation, medication administration errors, and failure to destroy discontinued medications. Multiple cleaning, maintenance, and medication management issues were identified.

This Statement of Deficiencies was generated as a result of a complaint investigation conducted on the facility from 2/17/11 through 2/28/11.

The facility was found to have admitted and retained a resident who was not physically and mentally capable of caring for all aspects of an indwelling catheter, and failed to request an exemption to admit or retain this resident with a Foley catheter.

Complaint NV00027636 was substantiated.

This document is a Plan of Correction submitted in response to a Change of Category survey conducted at the facility on 01/11/2011.

The facility was found deficient in several areas including failure to ensure exit door alarms were operational, dangerous items such as knives were accessible to residents, unsafe yard conditions, and toxic substances were not properly secured. The plan of correction outlines immediate actions taken and ongoing monitoring to ensure compliance.

This State Licensure survey was conducted as a Change of Category survey to evaluate the facility's request to change the category in the Red Cottage to 12 beds for care to persons with Alzheimer's disease.

The facility was found deficient in multiple areas related to care for persons with Alzheimer's disease, including failure to have operational door alarms on exit doors, accessibility of dangerous items to residents, unsafe outdoor yard conditions, and toxic substances accessible to residents.

This Statement of Deficiencies was generated as a result of a complaint investigation conducted on the facility from 10/18/10 through 11/22/10.

The administrator failed to ensure that no more than one caregiver was scheduled in a memory care unit when interacting with more than six residents during hours when the residents are awake.

Complaint #NV00026726 was substantiated.

The inspection was conducted as a result of a complaint investigation from 10/18/10 through 11/22/10 regarding the facility's compliance with Alzheimer's care policies.

The administrator failed to ensure that more than one caregiver was scheduled in a memory care unit when interacting with more than six residents during hours when the residents were awake.

Complaint #NV00026726 was substantiated.

This document is a State Licensure survey conducted as a required grading re-survey of the facility on 2/23/2010 by the authority of NRS 449.150.

The facility received a grade of A; however, deficiencies were found related to bathroom door locks that did not open with a single motion from the inside on 6 of 6 bathroom doors.

The inspection was conducted as a result of a complaint investigation initiated on 2009-07-06 and completed during an annual State Licensure survey on 2009-08-04.

The facility was found deficient in multiple areas including personnel tuberculosis testing, health and sanitation related to garbage containers, compliance with permits and standards, safety requirements for auditory systems, oxygen equipment safety, catheter care, physical examinations, medication administration and documentation, medication labeling, resident tuberculosis testing, dangerous items accessibility in Alzheimer's care cottages, and toxic substances accessibility. Several deficiencies were repeat findings from a prior survey.

Complaint #NV00022444 was substantiated as part of this investigation.

The inspection was conducted as a result of a complaint state licensure survey on 01/13/2009.

The facility failed to provide an additional employee to be available to provide care within 10 minutes after being informed during the night shift hours between 10:00 PM and 6:00 AM.

Complaint #NV000020459 was substantiated.

The inspection was conducted as an annual state licensure survey combined with a complaint investigation at the facility.

The facility was found deficient in multiple areas including fire extinguisher maintenance, smoke detector testing, physical examinations for residents, medication administration agreements, tuberculosis screening compliance, resident file documentation, Alzheimer's unit safety including door alarms, accessibility of knives and toxic substances to residents, and medication refusal notification.

Five complaints were investigated: #NV00018350, #NV00018966, #NV00016952 were unsubstantiated; #NV00017215 and #NV00017663 were substantiated without deficiencies.

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