Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 0
Oct 6, 2025
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 10/06/2025, in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
One complaint was investigated and found to be unsubstantiated due to lack of evidence. Observations and interviews were conducted with residents and staff, with no clinical record review performed. The facility received a grade of A.
Complaint Details
One complaint (#NV00074853) was investigated and determined to be unsubstantiated due to lack of evidence.
Report Facts
Sample size: 6
Complaints investigated: 1
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 0
Sep 16, 2025
Visit Reason
The inspection was conducted as a complaint investigation survey following two complaints received by the facility.
Findings
Two complaints were investigated and both were substantiated without deficient practice. No regulatory deficiencies were identified and no further action was required.
Complaint Details
Two complaints were investigated: Complaint #NV00074344 and Complaint #NV00074746, both substantiated without deficient practice.
Report Facts
Sample size: 2
Complaints investigated: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver | Interviewed during the investigation | |
| Medication Technician | Interviewed during the investigation | |
| Wellness Director | Interviewed during the investigation | |
| Administrator | Interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Jun 16, 2025
Visit Reason
The inspection was conducted as a result of a complaint investigation involving three complaints, one of which was substantiated regarding wound care at the facility.
Findings
The facility failed to ensure a timely wound care assessment was provided per physician's instructions for Resident #1, who had a wound related to type 2 diabetes mellitus. The Administrator acknowledged no wound care services were provided as ordered.
Complaint Details
Three complaints were investigated: Complaint #NV00074215 was substantiated; Complaints #NV00074214 and #NV00074264 were unsubstantiated with no regulatory deficiencies identified.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide timely wound care assessment and services per physician's orders for Resident #1 with a pressure or stasis ulcer. | Severity: 2 |
Report Facts
Census: 88
Complaints investigated: 3
Sample size: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Eugene Trail | Administrator | Acknowledged lack of wound care assessment and services for Resident #1 |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 125
Deficiencies: 0
Feb 10, 2025
Visit Reason
The inspection was conducted due to a bed increase request and a complaint investigation at the facility.
Findings
No regulatory deficiencies were identified during the investigation. The complaint was unsubstantiated and no further action was necessary.
Complaint Details
Complaint #NV00073044 was investigated and found to be unsubstantiated after observation, interviews, and record review.
Report Facts
Licensed beds: 125
Census: 86
Complaint count: 1
Inspection Report
Complaint Investigation
Census: 130
Deficiencies: 0
Dec 3, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by three complaints received regarding the facility.
Findings
No regulatory deficiencies were identified during the investigation. All three complaints were unsubstantiated after observation, interviews, and record reviews.
Complaint Details
Three complaints were investigated: Complaint #NV00072778, Complaint #NV00072746, and Complaint #NV00072197. All were found unsubstantiated with no regulatory deficiencies identified.
Report Facts
Complaints investigated: 3
Sample size: 5
Inspection Report
Annual Inspection
Census: 93
Capacity: 125
Deficiencies: 5
May 21, 2024
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation at the facility on 05/21/24.
Findings
The facility received a grade of A. Six complaints were investigated with no regulatory deficiencies found related to the complaints. However, regulatory deficiencies were identified related to food service and kitchen sanitation, including improper food storage, ice scoop contamination, mold and grime buildup, pest presence, and structural issues in the kitchen.
Complaint Details
Six complaints were investigated: three were unsubstantiated with no regulatory deficiencies identified; three were substantiated but with no deficient practice found.
Severity Breakdown
Critical Violation: 1
Major Violation: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Three pans of raw chicken were stored above a bowl of cut fruit, a container of hard boiled eggs and a container of pickles on a speed rack in the walk-in cooler. | Critical Violation |
| The ice scoop was stored in the ice bin with the scoop handle directly touching the ice. | Major Violation |
| There was pink grime and mold build-up on the interior metal shield of the ice machine. | Major Violation |
| There was food, debris and dead cockroaches along the coving tiles and under equipment throughout the kitchen. | Major Violation |
| The coving tiles behind the ice machine were separating from the wall which left a large gap between the wall and the tiles. | Major Violation |
Report Facts
Number of complaints investigated: 6
Resident files reviewed: 20
Employee files reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Eugene Trail | Administrator | Named as the Administrator responsible for the facility |
| Dietary Supervisor | Responsible for training and ongoing inspections related to food storage and cleanliness | |
| Dining Room Supervisor | Conducted training with Dietary Supervisor on proper food storage and cleaning | |
| Plant Director | Responsible for maintenance items such as tile repairs |
Inspection Report
Annual Inspection
Census: 79
Capacity: 100
Deficiencies: 4
May 21, 2024
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation at the facility on 05/21/24.
Findings
The facility received a grade of A. One complaint was investigated and found unsubstantiated. Several regulatory deficiencies were identified including failure to ensure CPR and first aid training for 6 of 15 sampled employees, failure to comply with food service permits and kitchen cleanliness standards, failure to submit medical exemptions for two residents with prohibited conditions, and failure to ensure infection control training for 7 of 15 sampled employees.
Complaint Details
One complaint (#NV00071062) was investigated and found unsubstantiated after observation, interviews, and record review.
Severity Breakdown
Severity: 2 Scope: 2: 2
Severity: 2 Scope: 1: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 6 of 15 sampled employees received required CPR and first aid training. | Severity: 2 Scope: 2 |
| Failed to ensure kitchen and supportive dining services complied with NAC 446 standards; floors soiled with food and debris. | Severity: 2 Scope: 1 |
| Failed to submit medical exemption requests for two residents with prohibited conditions (indwelling catheter and open wounds). | Severity: 2 Scope: 1 |
| Failed to ensure 7 of 15 sampled employees acquired required infection control training through a nationally recognized course. | Severity: 2 Scope: 2 |
Report Facts
Licensed capacity: 100
Census: 79
Employees sampled: 15
Residents sampled: 20
Employees lacking CPR/First Aid training: 6
Employees lacking infection control training: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael E Trail | Administrator | Administrator acknowledged employees did not have required CPR/First Aid and infection control training. |
| Employee #2 | Caregiver | Lacked documented evidence of current first aid training. |
| Employee #5 | Caregiver | CPR and first aid training completed online only; lacked in-person training evidence. |
| Employee #8 | Director of Community Liaison | CPR and first aid training completed online only; lacked in-person training evidence; lacked infection control training. |
| Employee #12 | Medication Technician | CPR and first aid training completed online only; lacked in-person training evidence; lacked infection control training. |
| Employee #13 | Wellness Director | CPR and first aid training completed online only; lacked in-person training evidence; lacked infection control training. |
| Employee #14 | Wellness Coordinator | CPR and first aid training completed online only; lacked in-person training evidence. |
| Employee #9 | Dietary Aide | Lacked infection control training. |
| Employee #10 | Medication Technician | Lacked infection control training. |
| Employee #11 | Administrator | Lacked infection control training. |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Mar 5, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 03/05/24, in accordance with Nevada Administrative Code (NAC), Chapter 449, Residential Facility for Groups.
Findings
One complaint was investigated and substantiated without deficient practice. The investigation included observation of meal service, staff/resident interactions, interviews, clinical record review, and document review. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00070219 was substantiated without deficient practice.
Report Facts
Complaint count: 1
Sample size: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Interviewed during complaint investigation | |
| Dietary Supervisor | Interviewed during complaint investigation |
Inspection Report
Annual Inspection
Census: 66
Capacity: 100
Deficiencies: 4
May 23, 2023
Visit Reason
The inspection was conducted as an annual State Licensure survey of the facility on 05/23/2023 in accordance with Nevada Administrative Code, Chapter 449, Residential Facilities for Groups.
Findings
The facility received a grade of A but was found deficient in several areas including food service compliance with NAC 446, safety requirements for residents with restricted mobility or poor eyesight, and timely response to call light and pendant system requests. Specific issues included an unapproved bistro bar without a hand washing sink, elevated storage room temperature, exposed electrical wiring, and delayed caregiver response times to call lights.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| A bistro bar was added near the front lobby without prior approval and lacked a hand washing sink. | Severity: 2 |
| Ambient air temperature in the dry storage room was 85 degrees Fahrenheit. | Severity: 2 |
| Open electrical box with exposed wires in the ceiling of the dry storage room. | Severity: 2 |
| Facility failed to ensure staff responded to residents' call light and pendant system requests in a timely manner, with documented delays ranging from 15 minutes to over an hour. | Severity: 2 |
Report Facts
Resident records reviewed: 15
Employee records reviewed: 10
Delayed call light responses: 24
Facility licensed capacity: 100
Census: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marcus Pegross | Executive Director | Signed the report and referenced in corrective action plans |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 100
Deficiencies: 1
Dec 22, 2020
Visit Reason
The inspection was conducted as a result of a complaint investigation involving three complaints related to COVID-19 screening, PPE usage, and staffing adequacy at the facility.
Findings
The facility was found to have failed in implementing safe infection control practices related to COVID-19, including improper screening of visitors and employees for symptoms and temperature checks, and employees not wearing face masks properly. One complaint regarding inadequate staffing was unsubstantiated.
Complaint Details
Three complaints were investigated: Complaint #NV00062790 and Complaint #NV00062785 were substantiated regarding improper COVID-19 screening and PPE usage; Complaint #NV00062430 was unsubstantiated regarding staffing adequacy.
Severity Breakdown
Severity: 2 Scope: 3: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to implement safe infection control practices for COVID-19, including lack of screening visitors and employees for symptoms and temperature checks, and improper use of face masks by employees. | Severity: 2 Scope: 3 |
Report Facts
Licensed capacity: 100
Census: 84
Sample size: 5
Complaints investigated: 3
Inspection Report
Annual Inspection
Census: 82
Capacity: 100
Deficiencies: 4
Apr 26, 2016
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation on 4/26/16.
Findings
The facility received a grade of A. Several deficiencies were identified including issues with maintenance of windows and air vents, kitchen sanitation violations, and unsecured oxygen tanks in resident rooms. The complaint regarding poorly maintained windows was substantiated.
Complaint Details
Complaint # NV45300 was substantiated regarding poorly maintained windows. Other allegations about bad sewer smell and resident illness from food were not substantiated.
Severity Breakdown
Severity: 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Administrator failed to ensure the interior premises were clean and well-maintained, including dust buildup on air vents and worn weather stripping on windows. | — |
| Three windows needed replacement due to damage including cracked double pane windows. | Severity: 2 |
| Kitchen failed to comply with sanitation standards; a pork roast was stored at improper temperature and dish machine lacked detectable sanitizer. | Severity: 2 |
| Oxygen tanks in 2 of 47 rooms were unsecured, violating safety regulations. | Severity: 2 |
Report Facts
Census: 82
Total Capacity: 100
Windows to be replaced: 3
Oxygen tanks unsecured: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Low | Executive Director | Signed the report and acknowledged findings |
| Maintenance Director | Acknowledged ongoing window issues and findings related to oxygen tanks | |
| Administrator | Acknowledged findings and explained bids for window repairs | |
| Dining Director | Monitored food safety and dish machine repairs |
Inspection Report
Annual Inspection
Census: 82
Capacity: 100
Deficiencies: 3
Apr 26, 2016
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation on 4/26/2016.
Findings
The facility received a grade of A. The complaint regarding poorly maintained windows was substantiated, while allegations about bad sewer smell and food-related illness were not substantiated. Deficiencies were found related to maintenance of windows and air vents, kitchen food safety violations, and unsecured oxygen tanks in resident rooms.
Complaint Details
Complaint #NV45300 was substantiated regarding poorly maintained windows. Other allegations about bad sewer smell and food-related illness were not substantiated.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Interior premises were not clean and well-maintained, including dust buildup on air vents and worn weather stripping around multiple windows, some with cracked or separated glass. | Level 2 |
| Kitchen failed to comply with food service standards: a pork roast was stored at unsafe temperatures (70-76°F) and the dish machine lacked detectable sanitizer. | Level 2 |
| Oxygen tanks in two resident rooms were unsecured, posing safety risks. | Level 2 |
Report Facts
Resident census: 82
Total licensed capacity: 100
Resident files reviewed: 21
Employee files reviewed: 14
Windows with issues: 13
Oxygen tanks unsecured: 2
Inspection Report
Renewal
Census: 73
Capacity: 100
Deficiencies: 1
Aug 27, 2014
Visit Reason
This visit was a required grading re-survey conducted as a State Licensure survey for a residential facility providing assisted living services to elderly and disabled persons.
Findings
The facility failed to maintain cleanliness and proper maintenance of the interior building, including stained toilets, dirty carpets, unsecured carbon dioxide tanks, stained baseboards, and worn carpeting. Several corrective actions were noted and scheduled.
Severity Breakdown
Level 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure the cleanliness of the interior building was maintained, including stained toilet bowls, buildup of dust, dirty carpets with stains, and stained ceiling tiles. | Level 2 |
Report Facts
Census: 73
Total Capacity: 100
Severity Level: 2
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #8 | Maintenance Director | Indicated issues with the toilet and acknowledged observations |
| Employee #1 | Executive Director | Revealed administrative team is notified of housekeeping issues and indicated resident receiving more frequent room cleaning |
Inspection Report
Re-Inspection
Census: 73
Capacity: 100
Deficiencies: 1
Aug 27, 2014
Visit Reason
This document is a required grading re-survey conducted as a state licensure survey to assess compliance with health and sanitation regulations at the facility.
Findings
The facility failed to maintain cleanliness of the interior building, with multiple observations of stained toilets, dirty carpets, dust buildup, worn paint, and unsecured carbon dioxide tanks. The facility received a re-survey grade of A despite these deficiencies.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure the cleanliness of the interior building was maintained, including stained toilets, dirty carpets, dust buildup, worn paint, and unsecured carbon dioxide tanks. | Severity: 2 |
Report Facts
Resident census: 73
Total licensed capacity: 100
Resident files reviewed: 9
Employee files reviewed: 10
Survey date: Aug 27, 2014
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Acknowledged issues with toilet and observations of facility cleanliness | |
| Director of Food Services | Unaware that carbon dioxide tank should be secured | |
| Executive Director | Provided information about housekeeping notifications and cleaning frequency |
Inspection Report
Annual Inspection
Census: 77
Capacity: 100
Deficiencies: 9
Jun 9, 2014
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation initiated by the Bureau of Health Care Quality and Compliance on 2014-05-07.
Findings
The facility was found to have multiple deficiencies including substantiated complaints related to dietary services, medication administration training deficiencies for staff, expired employee health certifications, environmental sanitation issues including offensive odors and maintenance problems, food service violations, failure to document menu substitutions, incomplete smoke detector testing, and medication administration discrepancies for residents.
Complaint Details
Complaint #NV00038718 was substantiated with 3 allegations: Resident Neglect-Medications was unsubstantiated; Dietary Services - Food is Cold was substantiated; Dietary Services - Therapeutic Diets Not Provided/Monitored was substantiated.
Severity Breakdown
Level 2: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 9 medication technicians completed initial medication management training as required. | Level 2 |
| Failed to ensure 1 of 15 employees met tuberculosis and pre-employment physical examination requirements. | Level 2 |
| Failed to ensure 1 of 15 employees were trained in first aid and cardiopulmonary resuscitation; training expired. | Level 2 |
| Facility failed to be free from offensive odors including strong sewage and urine odors in multiple areas. | Level 2 |
| Facility failed to maintain cleanliness and maintenance including water temperature issues, clogged sinks, damaged ceiling tiles, soiled carpets, and damaged walls. | Level 2 |
| Kitchen failed to comply with food service standards including no food-safety certified person on site, improper food storage and labeling, unsanitary conditions, and equipment maintenance issues. | Level 2 |
| Failed to document and retain menu substitutions during gastrointestinal virus outbreak affecting meal service. | Level 2 |
| Failed to ensure smoke detectors were tested monthly throughout the facility; testing rotated floors monthly instead. | Level 2 |
| Failed to ensure 2 of 21 residents received medications as prescribed; discrepancies in medication administration times and documentation. | Level 2 |
Report Facts
Deficiencies cited: 9
Resident census: 77
Total licensed capacity: 100
Employee files reviewed: 15
Resident files reviewed: 20
Complaint allegations: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #6 | Medication Technician | Failed to complete initial medication management training. |
| Employee #10 | Medication Technician | Failed to complete initial medication management training. |
| Employee #12 | Staff Member | Failed to meet tuberculosis and pre-employment physical examination requirements. |
| Employee #9 | Staff Member | Had expired first aid and CPR training. |
| Medication Technician | Acknowledged medication administration discrepancies for Residents #9 and #20. |
Inspection Report
Annual Inspection
Census: 77
Capacity: 100
Deficiencies: 8
May 27, 2014
Visit Reason
The inspection was conducted as a result of an annual State Licensure survey and a complaint investigation from 5/27/14 through 6/9/14.
Findings
The facility was found to have multiple deficiencies including failure to ensure medication management training for caregivers, incomplete personnel files, expired first aid training, offensive odors, environmental maintenance issues, food safety violations, and medication administration discrepancies. Some complaints were substantiated, such as dietary services issues, while others like medication neglect were unsubstantiated.
Complaint Details
Complaint #NV00038718 was substantiated with 3 allegations: Resident Neglect-Medications was unsubstantiated; Dietary Services, Food is Cold was substantiated; Dietary Services, Therapeutic Diets Not Provided/Monitored was substantiated.
Severity Breakdown
Severity: 2: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to ensure 2 of 9 medication technicians had completed initial medication management training as required. | Severity: 2 |
| Facility failed to ensure 1 of 15 employees met tuberculosis and pre-employment physical examination requirements. | Severity: 2 |
| Facility failed to ensure 1 of 15 employees were trained in first aid and cardiopulmonary resuscitation. | Severity: 2 |
| Facility failed to ensure the premises were free from offensive odors; strong sewage and urine odors noted. | Severity: 2 |
| Facility failed to maintain interior and exterior premises clean and free of hazards; multiple environmental issues noted including water temperature inconsistencies, clogged sinks, damaged ceilings, soiled carpets, and damaged walls. | Severity: 2 |
| Facility failed to comply with food service permits and food safety standards; multiple critical and major violations including lack of food safety certified person in charge, improper food storage, and unsanitary conditions. | Severity: 2 |
| Facility failed to ensure smoke detectors were tested monthly throughout the facility. | Severity: 2 |
| Facility failed to ensure proper administration of medications for 2 residents; discrepancies in medication administration records noted. | Severity: 2 |
Report Facts
Licensed capacity: 100
Census: 77
Number of resident files reviewed: 20
Number of employee files reviewed: 15
Number of allegations in complaint: 3
Number of medication technicians: 9
Number of employees: 15
Number of eggs in flat: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julie Mason | Executive Director | Signed the statement of deficiencies and mentioned as monitoring corrective actions |
| Employee #6 | Failed to have documented initial medication management training | |
| Employee #10 | Failed to have documented initial medication management training | |
| Employee #2 | Completed new hire physical | |
| Employee #12 | Failed to meet TB and pre-employment physical requirements | |
| Employee #9 | Failed first aid and CPR training; medication administration discrepancies | |
| Resident #9 | Medication administration discrepancy noted | |
| Resident #20 | Medication administration discrepancy noted |
Inspection Report
Complaint Investigation
Capacity: 100
Deficiencies: 0
Mar 21, 2014
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 2014-03-14 regarding allegations of physician notification failure, untimely resident assessment, and inappropriate personnel response to a visitor.
Findings
The complaint investigation found all allegations unsubstantiated after review of resident records, interviews with staff, and examination of incident reports. The facility followed proper procedures for physician notification and resident assessment. An incident involving a visitor was managed appropriately with police intervention to ensure resident safety.
Complaint Details
Complaint #NV00037977 was unsubstantiated. Allegations regarding physician notification for change in condition, timely resident assessment, and personnel response to a visitor were not substantiated based on document review and interviews.
Report Facts
Licensed capacity: 100
Resident files reviewed: 5
Inspection Report
Re-Inspection
Census: 76
Capacity: 100
Deficiencies: 5
Feb 4, 2014
Visit Reason
This document is a required grading re-survey conducted on 2/4/14 to assess compliance with state licensure regulations for a residential facility.
Findings
The facility received a re-survey grade of A but failed to comply with NAC 446 food service standards, including expired food items and improper storage. Several critical, major, and equipment maintenance violations were identified.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Two containers of sour cream and one container of cottage cheese were expired and found in refrigerators. | Severity: 2 |
| Raw eggs were improperly stored above pasteurized eggs and milk in refrigerators. | Severity: 2 |
| An undated container of macaroni and cheese was found in the walk-in refrigerator. | Severity: 2 |
| The interior of a reach-in on the cook's line and the fryer cabinet were soiled with grease and food debris. | Severity: 2 |
| The mop bucket containing soiled mop water was stored in the food preparation/three-compartment sink area. | Severity: 2 |
Report Facts
Facility licensed capacity: 100
Census at time of survey: 76
Severity level: 2
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julia Mason | Executive Director | Signed the statement of deficiencies |
Inspection Report
Re-Inspection
Census: 76
Capacity: 100
Deficiencies: 5
Feb 4, 2014
Visit Reason
This document is a Statement of Deficiencies generated as a result of a required grading re-survey conducted at Desert Springs Senior Living on 2/4/2014 to assess compliance with state licensure regulations.
Findings
The facility received a re-survey grade of A. Deficiencies were identified related to food service permits and kitchen standards compliance, including expired food items, improper food storage, undated food containers, and equipment cleanliness issues.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Two containers of sour cream expired on 2/2/14 and one container of cottage cheese expired on 1/25/14 were found in refrigerators. | Severity: 2 |
| A case of raw eggs was stored above pasteurized eggs and milk, and raw eggs were stored above condiments in refrigerators. | Severity: 2 |
| An undated container of macaroni and cheese was found in the walk-in refrigerator. | Severity: 2 |
| The interior of a reach-in refrigerator and fryer cabinet were soiled with grease and food debris. | Severity: 2 |
| A mop bucket containing soiled mop water was stored in the food preparation/three-compartment sink area. | Severity: 2 |
Report Facts
Licensed capacity: 100
Census: 76
Inspection Report
Annual Inspection
Census: 78
Capacity: 100
Deficiencies: 7
May 16, 2013
Visit Reason
This document is an annual State Licensure grading survey conducted to assess compliance with state regulations for a residential facility providing assisted living services.
Findings
The facility received a grade of B with multiple deficiencies identified including issues with cleanliness and maintenance, food service sanitation violations, safety requirements, fire safety referrals, physical examinations, medication storage, and resident file maintenance.
Severity Breakdown
Level 2: 6
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to ensure premises were clean and well maintained, including air handler issues, worn carpet, storage room clutter, damaged windows, unlocked stairwell doors, rust buildup, and missing trash can lids. | Level 2 |
| Facility failed to comply with food service permits and sanitation standards, including improper food storage, food handler hygiene violations, cleaning and sanitation issues, and equipment maintenance problems. | Level 2 |
| Facility failed to ensure all auditory alarms were operational in resident rooms #338 and #113. | Level 2 |
| Facility did not ensure monthly evacuation drills were conducted regularly; State Fire Marshall referral issued. | — |
| Facility failed to ensure 3 of 20 residents received required physical examinations after significant changes in condition. | Level 2 |
| Facility failed to ensure medications administered by capable residents were kept in locked containers in sampled rooms. | Level 2 |
| Facility failed to maintain resident files with required tuberculosis testing documentation for 2 of 20 residents. | Level 2 |
Report Facts
Deficiencies cited: 7
Resident files reviewed: 20
Employee files reviewed: 15
Residents not receiving physical exams: 3
Residents missing TB testing: 2
Residents census: 78
Facility capacity: 100
Inspection Report
Annual Inspection
Census: 78
Capacity: 100
Deficiencies: 7
May 16, 2013
Visit Reason
This document is an annual State Licensure grading survey conducted to assess compliance with state regulations for Desert Springs Senior Living, an assisted living facility.
Findings
The facility received a grade of B with multiple deficiencies identified including issues with building maintenance, food service permits and sanitation, safety requirements, physical examinations of residents, medication storage, and resident file maintenance related to tuberculosis testing.
Severity Breakdown
2: 6
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to ensure premises were clean and well maintained, including inconsistent air conditioning, worn carpet, improper storage of paint and gasoline, damaged windows, unlocked stairwell doors, rust buildup, lint accumulation, and missing trash can lids. | 2 |
| Facility failed to comply with NAC 446 food service standards including critical violations such as improper food storage (raw beef in contact with fries), food handlers not washing hands or changing gloves, sanitation issues, and equipment maintenance problems. | 2 |
| Facility failed to ensure all auditory alarms were operational in resident bathrooms. | 2 |
| Facility did not ensure monthly evacuation drills were conducted on an irregular schedule for 9 of 12 months; State Fire Marshal referral made. | — |
| Facility failed to ensure 3 of 20 residents received required physical examinations after significant changes in condition. | 2 |
| Facility failed to ensure medications administered by residents capable of self-administration were kept in locked containers in 4 of 5 sampled rooms. | 2 |
| Facility failed to ensure 2 of 20 residents complied with tuberculosis testing requirements. | 2 |
Report Facts
Licensed capacity: 100
Census: 78
Resident files reviewed: 20
Employee files reviewed: 15
Residents without required physical exam: 3
Rooms with unlocked stairwell doors: 2
Windows with damaged strips: 15
Rooms with air conditioning issues: 10
Sampled rooms with unlocked medication storage: 4
Residents non-compliant with TB testing: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #16 acknowledged problems with air handler systems |
Inspection Report
Plan of Correction
Capacity: 100
Deficiencies: 0
May 16, 2013
Visit Reason
This Statement of Deficiencies was generated as a result of a request for a Change of Administrator for the facility's license.
Findings
A desk review was completed and approval was given on 5/16/13. The facility must ensure the new administrator attends initial medication training and Elder Abuse training, with evidence of these trainings maintained in the administrator's facility file. Administrators providing direct care must obtain at least four hours of Chronic Illness training within 60 days of hire, to be verified during the next on-site survey.
Report Facts
Licensed capacity: 100
Inspection Report
Complaint Investigation
Capacity: 100
Deficiencies: 0
Feb 4, 2013
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations of improper infection control and infestation of bed bugs and scabies at the facility.
Findings
The complaint was not substantiated; interviews with staff and residents, as well as observations of seven apartments and common areas, found no evidence of bed bugs or scabies infestation.
Complaint Details
Complaint #NV00034454 alleged improper infection control and infestation of bed bugs and scabies. The allegation was not substantiated after document review, interviews, and observations.
Report Facts
Licensed capacity: 100
Inspection Report
Complaint Investigation
Capacity: 100
Deficiencies: 0
Oct 17, 2012
Visit Reason
The inspection was conducted as a complaint investigation from 10/03/12 through 10/17/12 regarding allegations of bed bugs and failure to maintain personal hygiene of a resident.
Findings
The complaint regarding bed bugs was unsubstantiated based on room observations and document review. The allegation of failure to maintain personal hygiene was also unsubstantiated after review of resident records and interviews with staff.
Complaint Details
Complaint #NV00033274 alleged bed bugs and failure to maintain personal hygiene. Both allegations were unsubstantiated after investigation including observations, document review, and interviews with facility staff and a social worker.
Report Facts
Total licensed capacity: 100
Inspection Report
Complaint Investigation
Capacity: 100
Deficiencies: 0
Aug 20, 2012
Visit Reason
The inspection was conducted as a complaint investigation regarding an allegation that the facility was hot and without air conditioning.
Findings
The complaint alleging the facility was hot and without air conditioning was not substantiated after interviews with the Executive Director and several residents, observations, and review of maintenance records.
Complaint Details
Complaint #NV00032818 alleged the facility was hot and without air conditioning; this was not substantiated through document review, interviews, and observations.
Report Facts
Licensed capacity: 100
Inspection Report
Re-Inspection
Census: 82
Capacity: 100
Deficiencies: 4
Jun 28, 2012
Visit Reason
This document is a required grading re-survey conducted as a State Licensure survey to assess compliance with regulations at the Desert Springs Senior Living facility.
Findings
The facility received a re-survey grade of A but was found deficient in kitchen food safety and sanitation standards, equipment maintenance, and oxygen tank safety. Multiple critical violations and cleaning issues were identified, along with a repeat deficiency related to unsecured oxygen tanks.
Severity Breakdown
Severity 1 (Critical Violations): 1
Severity 2: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure the kitchen complied with NAC 446 standards including expired and undated food items, improper food storage, lack of food-safety-certified person-in-charge, and mislabeling of cleaning products. | Severity 1 (Critical Violations) |
| Numerous cleaning and sanitation issues including undated potentially hazardous foods, food stored on the floor, uncovered food items, employee personal items in kitchen, lack of sanitizer in wiping cloth solution, and soiled kitchen equipment and floors. | — |
| Equipment and maintenance issues such as damaged cove tile, walk-in freezer door not closing properly, water pooled in refrigerator, improper hood filter installation, and ice buildup in milk dispenser. | Severity 2 |
| Failed to ensure oxygen tanks were secured in a rack or to the wall in 1 of 10 resident rooms where oxygen was used; repeat deficiency from prior survey. | Severity 2 |
Report Facts
Resident census: 82
Total licensed capacity: 100
Number of resident files reviewed: 10
Number of employee files reviewed: 6
Number of resident rooms with oxygen tanks: 10
Number of rooms with unsecured oxygen tanks: 1
Inspection Report
Re-Inspection
Census: 82
Capacity: 100
Deficiencies: 25
Jun 28, 2012
Visit Reason
This inspection was a required grading re-survey conducted by the Health Division to evaluate compliance with state licensure regulations.
Findings
The facility received a re-survey grade of A. Deficiencies were identified related to food service permits, kitchen sanitation, equipment maintenance, and oxygen caregiver monitoring. Corrective actions were noted as completed or scheduled.
Severity Breakdown
Critical Violation: 6
Severity 2: 7
Deficiencies (25)
| Description | Severity |
|---|---|
| A container of cottage cheese had a manufacturer's expiration date of 6/23/12. | Critical Violation |
| An undated container of tuna salad was spoiled with brown discoloration and runny liquid. | Critical Violation |
| A package of biscuit mix was stored directly next to raw fish in the walk-in refrigerator. | Critical Violation |
| No food-safety-certified person-in-charge was present during the inspection. | Critical Violation |
| A container of wound cleaner was stored above containers of spices. | Critical Violation |
| A spray bottle of unidentified, light yellow cleaning product was mislabeled as glass cleaner. | Critical Violation |
| Numerous potentially hazardous foods were not dated, including fish, cut melon, tuna salad, cottage cheese, and cooked pasta. | — |
| Two bags of onions were on the floor. | — |
| Various food items including sugar, flour, and fish were not covered. | — |
| Chopped salad lettuce was covered with a wet brown paper towel. | — |
| An employee's purse and keys were stored in the kitchen. | — |
| A scoop was in the sugar container with the handle laying on the sugar. | — |
| A container of staff food was stored with resident food in a kitchen refrigerator. | — |
| No detectable sanitizer was in the solution for storage of wiping cloths. | — |
| Interior of reach-ins and hot holding cabinets, shelves, grill, fryer, slicer, cart, can opener, milk and juice dispensers, mixer, microwave, food storage bins and lids, and ice machine vent were soiled. | — |
| A hose was draped over the faucet of the handsink in the dish room. | — |
| Floors under the cook's line equipment were greasy and soiled with food residue and debris. | — |
| Cove tile was damaged on a wall in the kitchen and no base cove on one wall in the server area. | Severity 2 |
| Walk-in freezer door did not close properly. | Severity 2 |
| Reach-in refrigerator had water pooled in the interior. | Severity 2 |
| Steamer drain line did not have an air gap. | Severity 2 |
| One hood filter was not properly installed. | Severity 2 |
| Particle board shelf was installed above the ice cream case in the server area. | Severity 2 |
| Build up of ice in the milk dispenser unit. | Severity 2 |
| Oxygen tanks were not secured in a rack or to the wall in 1 of 10 resident rooms where oxygen was used (Bedroom #344). | Severity 2 |
Report Facts
Census: 82
Total Capacity: 100
Severity 2 Deficiency Scope: 3
Number of resident rooms with unsecured oxygen tanks: 1
Inspection Report
Complaint Investigation
Census: 63
Capacity: 100
Deficiencies: 1
Nov 29, 2011
Visit Reason
This inspection was conducted as a result of a complaint investigation from 10/10/11 through 11/29/11 regarding pressure or stasis ulcers at the facility.
Findings
The facility failed to ensure pressure ulcer precautions were taken for 1 of 63 residents, resulting in an infected sacral decubitus pressure ulcer requiring emergency medical treatment. The complaint #NV00028643 was substantiated.
Complaint Details
Complaint #NV00028643 was substantiated related to pressure or stasis ulcers.
Severity Breakdown
3: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure pressure ulcer precautions were taken for Resident #1, resulting in an infected sacral decubitus pressure ulcer. | 3 |
Report Facts
Residents reviewed: 63
Total licensed capacity: 100
Severity level: 3
Scope: 1
Inspection Report
Complaint Investigation
Census: 63
Capacity: 100
Deficiencies: 1
Nov 29, 2011
Visit Reason
This Statement of Deficiencies was generated as a result of a complaint investigation conducted on the facility from 10/10/11 through 11/29/11. Complaint #NV00028643 was substantiated.
Findings
The facility failed to ensure pressure ulcer precautions were taken for one resident, resulting in the resident developing an infected sacral decubitus pressure ulcer requiring emergency hospital treatment.
Complaint Details
Complaint #NV00028643 was substantiated. The investigation found that the facility did not inform the family of the pressure ulcer until 12/27/10, when the resident was taken to the hospital for treatment of an infected sacral decubitus ulcer.
Severity Breakdown
3: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure pressure ulcer precautions were taken for Resident #1, leading to an infected sacral decubitus pressure ulcer. | 3 |
Report Facts
Resident census: 63
Total licensed capacity: 100
Severity level: 3
Inspection Report
Complaint Investigation
Capacity: 88
Deficiencies: 4
Oct 12, 2011
Visit Reason
The inspection was conducted as a complaint investigation initiated on 2011-09-21 regarding allegations including inappropriate admission, lack of protective supervision, inadequate cleaning of dining room tables, HVAC maintenance and sanitation, lack of hot water, improper food handling, improper infection control, and resident illness outbreaks.
Findings
The investigation substantiated allegations of inappropriate admission and inadequate cleaning of dining room tables and HVAC maintenance. The allegations of lack of protective supervision, lack of hot water, improper food handling, improper infection control, and resident illness outbreaks were not substantiated. Additional deficiencies were found related to medication management, admission policy, and facility cleanliness.
Complaint Details
Complaint #NV00029359 regarding inappropriate admission was substantiated; lack of protective supervision was not substantiated. Complaint #NV00029292 regarding inadequate cleaning of dining room tables and HVAC maintenance was substantiated; allegations regarding lack of hot water, improper food handling, improper infection control, and resident illness outbreaks were not substantiated.
Severity Breakdown
Severity: 1 Scope: 3: 1
Severity: 2 Scope: 1: 1
Severity: 2 Scope: 2: 1
Severity: 2 Scope: 3: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure premises were clean and well maintained, including extremely dirty and clogged air filters and soiled dining room tables not cleaned promptly. | Severity: 2 Scope: 2 |
| Facility failed to follow admission policy by admitting a resident on hospice care contrary to policy. | Severity: 2 Scope: 1 |
| Facility failed to maintain a medication plan including all required components, specifically not following medication destruction procedures. | Severity: 1 Scope: 3 |
| Facility did not destroy discontinued, expired, or unclaimed medications properly; sharps container was overflowing with medications and needles. | Severity: 2 Scope: 3 |
Report Facts
Total licensed capacity: 88
Date complaint investigation initiated: Sep 21, 2011
Inspection Report
Re-Inspection
Census: 61
Capacity: 88
Deficiencies: 4
Oct 10, 2011
Visit Reason
This document is a required grading re-survey conducted as a state licensure survey to assess compliance with regulatory standards at the facility.
Findings
The facility received a re-survey grade of A. Deficiencies were identified related to personnel background checks and kitchen compliance with food service standards, including mislabeled cleaning chemicals, sanitation issues, and equipment maintenance problems.
Severity Breakdown
Severity 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 8 employees met background check requirements of NRS 449.176 to 449.188. | — |
| A spray bottle containing degreaser was labeled as glass cleaner. | Severity 2 |
| Cleaning and sanitation issues including pans with food residue, wet stacked pans, soiled soda nozzles and equipment, missing paper towels in dispenser, uncovered waste receptacles at handwashing sinks, soiled floors and ceiling vents. | Severity 2 |
| Equipment and maintenance issues including a freezer rack in disrepair and a damaged wall in the dry storage room. | Severity 2 |
Report Facts
Employees reviewed: 8
Resident files reviewed: 0
Licensed capacity: 88
Census: 61
Inspection Report
Annual Inspection
Census: 64
Capacity: 88
Deficiencies: 14
Jun 21, 2011
Visit Reason
Annual State Licensure survey and bed increase survey conducted at the facility.
Findings
The facility was found deficient in multiple areas including caregiver training, personnel file compliance, health and sanitation, safety requirements, and medication management. Several repeat and critical violations were noted, resulting in a grade of D.
Severity Breakdown
Level 1: 1
Level 2: 12
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to ensure that 1 of 15 caregivers received eight hours of annual training. | Level 2 |
| Failed to ensure 3 of 15 employees complied with tuberculosis testing requirements. | Level 2 |
| Failed to ensure 6 of 15 employees met background check requirements. | Level 2 |
| Failed to ensure that 2 of 15 caregivers were trained in first aid and CPR. | Level 2 |
| Failed to provide window screens to prevent entry of insects (24 of 300 windows missing screens). | Level 2 |
| Multiple critical violations and sanitation issues in kitchen and food service areas including improper food storage temperatures, unlabeled food, personal beverages stored with resident food, worn cutting boards, soiled equipment and surfaces, and damaged equipment. | Level 2 |
| Failed to ensure locks on 2 of 8 bedroom doors could be opened with a single motion. | Level 2 |
| Failed to ensure 2 of 3 public bathrooms were vented to the outside. | Level 2 |
| Failed to ensure locks on 2 of 8 bathroom doors could be opened with a single motion. | Level 2 |
| Failed to provide auditory system monitored by staff in 2 of 3 public restrooms. | Level 2 |
| Failed to ensure 7 of 12 fire doors closed completely during fire alarm testing - State Fire Marshall referral. | — |
| Allowed a resident who required confinement in locked quarters to remain in the facility (Resident #15 with severe Alzheimer's disease). | Level 2 |
| Failed to ensure oxygen tanks were secured in a rack or to the wall in 2 of 9 resident rooms using oxygen. | Level 2 |
| Failed to prepare a medication plan including all required components; facility did not have a medication plan. | Level 1 |
Report Facts
Resident census: 64
Total licensed capacity: 88
Window screens missing: 24
Fire doors not closing: 7
Bedroom doors with lock issues: 2
Bathroom doors with lock issues: 2
Public bathrooms without ventilation: 2
Public bathrooms without auditory system: 2
Employees missing background checks: 6
Caregivers missing first aid/CPR training: 2
Caregivers missing annual training: 1
Employees missing TB testing: 3
Oxygen tanks unsecured: 2
Inspection Report
Complaint Investigation
Census: 80
Capacity: 88
Deficiencies: 0
Jan 12, 2011
Visit Reason
This Statement of Deficiencies was generated as a result of a complaint investigation conducted in the facility from 12/6/10 through 1/12/11 regarding an allegation that the facility did not perform monthly fire drills for the past two years.
Findings
The investigation included review of monthly fire drill logs from October 2008 through October 2010 and interviews with the Executive Director and Maintenance Manager, which revealed that monthly fire drills had been performed as required. The allegation was not substantiated.
Complaint Details
Complaint #NV00026889 alleged the facility did not perform monthly fire drills for two years; this was not substantiated through record review and interviews.
Report Facts
Licensed capacity: 88
Census: 80
Inspection Report
Re-Inspection
Census: 52
Capacity: 62
Deficiencies: 0
Dec 14, 2009
Visit Reason
This Statement of Deficiencies was generated as a result of a required grading re-survey conducted in the facility on December 14, 2009.
Findings
No deficiencies were found during this State Licensure survey. The facility received a survey grade of A.
Report Facts
Resident files reviewed: 15
Employee files reviewed: 10
Notice
Deficiencies: 0
Dec 4, 2009
Visit Reason
The Health Division is notifying the facility of its intent to impose sanctions and monetary penalties due to repeat deficiencies cited in a prior survey dated 7/10/08.
Findings
The facility received a grade of C on the survey and is required to submit a grading system re-survey application with a $500 fee. Monetary penalties of $300 are imposed for repeat deficiencies.
Report Facts
Monetary penalties: 300
Fee: 500
Working days: 11
Working days: 10
Days: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Chambers | RN, Health Facilities Surveyor III | Signed the notice imposing sanctions. |
| Marla L. McDade Williams | MPA, Bureau Chief | Official for whom the notice was signed. |
Inspection Report
Annual Inspection
Census: 52
Capacity: 62
Deficiencies: 7
May 14, 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 5/14/2009.
Findings
The facility received a grade of C and was found to have multiple deficiencies including failure to comply with tuberculosis testing requirements for employees and residents, improper food safety and sanitation practices, inadequate emergency drills and smoke detector testing, unsecured oxygen tanks, improper medication storage, and incomplete resident files.
Severity Breakdown
Level 2: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure that 2 of 10 employees complied with tuberculosis testing requirements. | Level 2 |
| Failed to comply with food safety standards including improper food temperatures, poor hand hygiene, lack of proper labeling, unclean equipment and surfaces, and poor kitchen maintenance. | Level 2 |
| Failed to conduct monthly evacuation drills on an irregular schedule for 4 of 12 months. | Level 2 |
| Failed to ensure smoke detectors in resident rooms were tested monthly for 12 out of the past 12 months. | Level 2 |
| Failed to secure oxygen tanks in a rack in 2 of 8 resident rooms and lacked appropriate signage in 1 of 8 rooms. | Level 2 |
| Failed to ensure medications were secured in locked drawers or locked resident rooms for 2 of 16 residents who self-administer medications. | Level 2 |
| Failed to ensure that 2 of 15 residents complied with tuberculosis testing requirements affecting all residents. | Level 2 |
Report Facts
Facility licensed capacity: 62
Census at time of survey: 52
Employees reviewed: 10
Resident files reviewed: 15
Discharged resident files reviewed: 1
Residents self-administering medications with unsecured storage: 2
Resident rooms with unsecured oxygen tanks: 2
Resident rooms lacking appropriate oxygen signage: 1
Months without irregularly scheduled evacuation drills: 4
Months without smoke detector testing: 12
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_AMENDED
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