Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 116
Capacity: 123
Deficiencies: 0
Apr 8, 2025
Visit Reason
This inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility received a grade of A with no regulatory deficiencies identified. Twenty-five resident files and ten employee files were reviewed during the survey.
Report Facts
Category I residents: 85
Category II residents: 28
Resident files reviewed: 25
Employee files reviewed: 10
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 0
Sep 26, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 09/26/24.
Findings
The complaint was substantiated without any deficient practice. Observations, interviews, and record reviews were conducted, and no regulatory deficiencies were identified.
Complaint Details
Complaint #NV00071933 was substantiated with no deficient practice.
Report Facts
Sample size: 5
Complaints investigated: 1
Inspection Report
Annual Inspection
Census: 113
Capacity: 123
Deficiencies: 1
Apr 2, 2024
Visit Reason
The inspection was conducted as a result of a State Licensure annual and complaint investigation survey at the facility on 04/02/2024.
Findings
The facility received a grade of A. One complaint was substantiated with no deficient practice. A regulatory deficiency was identified related to the failure to provide an audible alarm on the door to the Alzheimer's Unit, which was corrected by replacing the batteries on the same day.
Complaint Details
One complaint (#NV00070336) was investigated and substantiated with no deficient practice.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide an audible alarm which activated upon opening the door to the Alzheimer's Unit. | Severity: 2 |
Report Facts
Licensed beds: 123
Current census: 113
Category I residents: 85
Category II residents: 28
Resident files reviewed: 25
Employee files reviewed: 10
Severity 2 deficiencies: 1
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Eugene Trail | Administrator | Indicated the door to the Alzheimer's Unit should have sounded an alarm upon opening |
| Maintenance Director | Acknowledged the alarm did not activate upon opening the door and verbalized the battery needed replacement |
Inspection Report
Census: 113
Capacity: 113
Deficiencies: 0
Sep 26, 2023
Visit Reason
The inspection was conducted due to an endorsement addition and bed increase at the facility, in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the inspection. The facility received a grade of A and no further action was necessary.
Report Facts
Bed increase: 10
Employee files reviewed: 8
Inspection Report
Annual Inspection
Census: 111
Capacity: 113
Deficiencies: 2
Apr 13, 2023
Visit Reason
The inspection was conducted as a State Licensure annual and infection control survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility received a grade of A but had regulatory deficiencies including unsafe hot water temperatures exceeding the acceptable range of 100-110 degrees Fahrenheit and heavy dust buildup on kitchen equipment. The facility acknowledged these issues and implemented corrective actions.
Severity Breakdown
Level 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure water temperatures were at safe temperatures for residents and within the acceptable range of 100-110 degrees Fahrenheit, with measured temperatures up to 140 degrees Fahrenheit. | Level 2 |
| Heavy dust buildup on the internal components of the kitchen range. | Level 2 |
Report Facts
Resident files reviewed: 25
Employee files reviewed: 10
Water temperature readings: 140
Water temperature readings: 133.8
Water temperature readings: 135.3
Water temperature readings: 132.4
Water temperature readings: 133.4
Water temperature readings: 126.3
Water temperature readings: 115.8
Deficiency severity scope: 3
Deficiency severity scope: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael E Trail | Administer | Signed the Statement of Deficiencies report |
| Maintenance Director | Acknowledged unsafe water temperatures and monthly water temperature logs | |
| Administrator | Acknowledged unsafe water temperatures for residents | |
| Dietary Director | Responsible for inspecting monthly kitchen cleaning | |
| Contracted Dietician | Responsible for inspecting monthly kitchen cleaning | |
| Plant Technician | Will investigate water temperature issues with plumbing vendor and review temperature logs with Administrator |
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 0
Jan 12, 2023
Visit Reason
The inspection was conducted as a complaint investigation triggered by one complaint with eight allegations at the facility.
Findings
The investigation found all eight allegations unsubstantiated after review of records, observations, and interviews. No regulatory deficiencies were identified and the facility received a grade of A.
Complaint Details
Complaint #NV00067374 with eight allegations was unsubstantiated. Allegations included missed medications, inadequate hygiene care, denied visitation, residents left soiled, unexplained injuries without family notification, residents wearing others' clothes, improper staff training, and improperly cleaned linens. All were found unsubstantiated based on documentation, observations, and interviews.
Report Facts
Sample size: 6
Number of allegations: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Technician | Interviewed regarding medication administration, hygiene care, visitation, clothing, linens, and training | |
| Wellness Director | Interviewed regarding medication administration, hygiene care, visitation, family notification, staff training, and linens | |
| Administrator | Interviewed regarding visitation, family notification, staff training, and other allegations | |
| Caregiver | Interviewed regarding hygiene care, visitation, clothing, and linens |
Inspection Report
Renewal
Census: 103
Capacity: 113
Deficiencies: 0
Jun 15, 2022
Visit Reason
This inspection was a State Licensure voluntary regrading survey conducted at the facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility was found to have no regulatory deficiencies and received a grade of A after reviewing three resident files.
Report Facts
Category I residents: 85
Category II residents: 28
Resident files reviewed: 3
Inspection Report
Annual Inspection
Census: 99
Capacity: 113
Deficiencies: 6
Apr 21, 2022
Visit Reason
The inspection was conducted as a result of a State Licensure Annual Grading, infection control, and Complaint Investigation survey at the facility from 04/13/22 through 04/21/22.
Findings
The facility received a grade of B with multiple deficiencies identified including issues with memory care staffing ratios, kitchen sanitation and food handling, special diet compliance, call light response times, medication administration, and maintenance of facility doors. One complaint was substantiated regarding staffing levels in the Memory Care Unit.
Complaint Details
Complaint #NV00065654 was substantiated with two allegations: 1) Only two staff members working in the Memory Care Unit for 18 residents was substantiated. 2) One staff member working both first and second floors with over 50 residents was substantiated without deficiencies as staffing ratios were not regulated and care was not interrupted.
Severity Breakdown
Level 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Difficulty opening locked doors in the Alzheimer's Care Unit which could limit egress in an emergency. | Level 2 |
| Kitchen failed to comply with food service standards including dented cans, improper handwashing, unlabeled food products, cracked equipment, grime buildup, soiled surfaces, and broken tiles. | Level 2 |
| Failure to provide a special cardiac diet for one resident as prescribed by physician. | Level 2 |
| Call bell response times were delayed, with some residents waiting over 10 to 30 minutes for assistance. | Level 2 |
| Medication administration did not comply with physician's orders for one resident due to unclear dosage instructions. | Level 2 |
| Memory Care Unit staffing ratio did not meet the required one caregiver per six residents during waking hours. | Level 2 |
Report Facts
Facility licensed beds: 113
Resident census: 99
Memory Care residents: 19
Call bells pushed: 2472
Call bells unanswered: 119
Call bells answered >10 minutes: 716
Medication dosage discrepancy: 1500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debra Meyer | Licensed Dietician, RDN, LDN | Conducted food service site visit and in-service on handwashing and food storage |
| Michael Trail | Administrator | Named in relation to facility maintenance and oversight of deficiencies |
| Dr. Thomas Alfreda | Physician | Prescribing physician involved in medication order clarification for Resident #7 |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 0
Oct 26, 2021
Visit Reason
The inspection was conducted as a complaint investigation triggered by complaint #NV00064845 with three allegations regarding facility conditions and resident care.
Findings
The complaint investigation substantiated one allegation regarding a bathroom ceiling leak and black water stains without deficiency, as repairs were made promptly. Two other allegations about bugs in a resident's room and failure to notify a responsible party of a resident's change in condition were unsubstantiated. No regulatory deficiencies were identified.
Complaint Details
Complaint #NV00064845 with three allegations was investigated. One allegation about a bathroom ceiling leak was substantiated without deficiency. Allegations about bugs in a resident's room and failure to notify a responsible party of a resident's change in condition were unsubstantiated.
Report Facts
Sample size: 5
Number of complaints investigated: 1
Number of allegations: 3
Inspection Report
Annual Inspection
Census: 102
Capacity: 113
Deficiencies: 2
Jul 29, 2021
Visit Reason
The inspection was conducted as an Annual Grading Survey, infection control survey, and Complaint Investigation at the facility on 07/29/2021.
Findings
The facility received a grade of A. Two complaints were investigated and found unsubstantiated. Two regulatory deficiencies were identified: failure to ensure a resident was re-evaluated by a physician due to changes in cognition, and failure to secure medications in the Memory Care unit.
Complaint Details
Two complaints were investigated: Complaint #NV00064427 alleging a caregiver pushed a resident resulting in a fall was unsubstantiated; Complaint #NV00064203 alleging poor food quality and short staffing was unsubstantiated.
Severity Breakdown
2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure a resident was re-evaluated by a physician due to changes in cognition (Resident #16). | 2 |
| Medications were found unsecured in an unlocked kitchen cabinet in the Memory Care unit. | 2 |
Report Facts
Licensed beds: 113
Residents present: 102
Residents reviewed: 20
Employee records reviewed: 10
Meal options observed: 4
Staff on duty: 3
Severity level 2 deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Trail | Administrator | Administrator interviewed and involved in complaint investigation and plan of correction |
Inspection Report
Renewal
Census: 26
Deficiencies: 1
Sep 3, 2019
Visit Reason
This State Licensure Survey was conducted as a result of a revisit initiated on 09/03/19 to assess compliance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility failed to ensure a gate located by the Memory Care unit leading to the parking lot was secured. The gate had a locking mechanism that was not latching properly, and the Maintenance Director verified the gate was not working correctly and needed repair.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to ensure a gate located by the Memory Care unit leading to the parking lot was secured, violating Alzheimer's Care Standards for Safety. | Severity: 2 |
Report Facts
Census: 26
Severity: 2
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul Ortega | Administrator | Verified gate was not secured and explained locking mechanism |
| Maintenance Director | Attempted to lock the gate and verified it was not working correctly |
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