Inspection Reports for Escalante at the Lakes
2620 Lake Sahara Dr, Las Vegas, NV 89117, United States, NV, 89117
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Inspection Report
Re-Inspection
Census: 37
Capacity: 150
Deficiencies: 1
Jun 3, 2025
Visit Reason
The inspection was a mandatory regrading survey conducted to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility received a grade of A overall, but a regulatory deficiency was identified related to food service permits and kitchen cleanliness. Specifically, the South Memory Care serving kitchen floors and floor drain were heavily soiled with debris and grime. The deficiency was a subsequent finding from a prior survey dated 03/05/2025.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The floors in the South Memory Care serving kitchen were soiled with debris and the floor drain was heavily soiled with grime build-up and debris. | Severity: 2 |
Report Facts
Licensed beds: 150
Census: 37
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Augustine Farias | Administrator | Signed the report and plan of correction |
Inspection Report
Annual Inspection
Census: 44
Capacity: 150
Deficiencies: 9
Mar 5, 2025
Visit Reason
The inspection was conducted as an annual State Licensure and Complaint Investigation survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility was found to have multiple deficiencies including food service violations, medication administration issues, failure to obtain required waivers for bedfast residents, missing medication regimen reviews, incomplete tuberculosis testing, malfunctioning safety alarms on exit doors, and failure to document residents' preferred names and pronouns. One complaint was investigated and found unsubstantiated.
Complaint Details
One complaint (Complaint #NV00073253) was investigated and found to be unsubstantiated.
Severity Breakdown
Level 2: 8
Level 1: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Expired food items and improper food storage in the kitchen, lack of chlorine sanitizer in dish machine, soiled ventilation hood filters, and disrepair in janitor's closet ceiling. | Level 2 |
| Failure to comply with medication availability policy for Resident #9; medication not onsite as ordered. | Level 2 |
| Failure to obtain bedfast waivers for residents who were bedfast (Resident #13). | Level 2 |
| Failure to obtain wound waivers for residents with wounds (Resident #6 and Resident #13). | Level 2 |
| Failure to complete medication regimen reviews every six months for 6 residents. | Level 2 |
| Failure to ensure medication was onsite and administered as ordered for Residents #2 and #9. | Level 2 |
| Failure to complete two-step tuberculosis test for Resident #2 and annual TB tests for Residents #3 and #12. | Level 2 |
| Audible alarm on exit door of patio in memory care unit was not working and door was unlocked. | Level 2 |
| Failure to document preferred name, pronoun, and gender expression in resident files for all 15 sampled residents. | Level 1 |
Report Facts
Deficiencies cited: 9
Resident files reviewed: 16
Employee files reviewed: 10
Facility licensed capacity: 150
Resident census: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Sanderson | Administrator | Named in relation to medication availability and overall facility administration. |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Sep 17, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 09/17/2024, in accordance with Nevada Administrative Code (NAC), Chapter 449, Residential Facilities for Groups.
Findings
One complaint was investigated and substantiated without deficient practice. The investigation included observations, interviews, and record reviews, and no regulatory deficiencies were identified. No further action was necessary.
Complaint Details
Complaint #NV00071898 was substantiated with no deficient practice.
Report Facts
Sample size: 5
Number of complaints investigated: 1
Inspection Report
Re-Inspection
Census: 59
Deficiencies: 11
Jun 6, 2024
Visit Reason
This inspection was a mandatory grading resurvey conducted to assess compliance with Nevada Administrative Code, Chapter 449, for Residential Facilities for Groups.
Findings
The facility received a new grade of A. Several regulatory deficiencies were identified including issues with employee certifications, health and sanitation, medication administration, tuberculosis testing for residents, and training requirements.
Severity Breakdown
Level 1: 1
Level 2: 3
Level 4: 7
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure one of five employees had certification in first aid and cardiopulmonary resuscitation (CPR). | Level 2 |
| Non-food contact surfaces of kitchen equipment were soiled with grease and dust build-up. | Level 2 |
| Failed to provide tuberculosis (TB) testing for two of five residents as required. | Level 2 |
| Failed to maintain personnel files with required health certificates and training documentation. | Level 4 |
| Failed to ensure the premises were clean and well maintained. | Level 4 |
| Failed to ensure all windows and doors used for ventilation were screened to prevent insect entry. | Level 4 |
| Failed to comply with fire safety regulations as required by the State Fire Marshal. | Level 1 |
| Failed to ensure medication administration was accurate and properly documented. | Level 4 |
| Failed to ensure medication storage was secure and appropriate. | Level 4 |
| Failed to provide required cultural competency training documentation. | Level 4 |
| Failed to provide required infection control training documentation. | Level 4 |
Report Facts
Census: 59
Sample size: 5
Completion dates: 6
Inspection Report
Annual Inspection
Census: 55
Capacity: 150
Deficiencies: 23
Mar 22, 2024
Visit Reason
The inspection was conducted as an annual State Licensure and Complaint Investigation survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility received a grade of D with multiple deficiencies identified including failure to maintain fire safety systems, incomplete caregiver training, unsecured medications and oxygen tanks, inadequate maintenance and sanitation, and failure to ensure resident safety in memory care units. One complaint was investigated and found unsubstantiated.
Complaint Details
One complaint (#NV00070298) was investigated and found unsubstantiated with no regulatory deficiencies identified.
Severity Breakdown
Severity: 3: 2
Severity: 2: 20
Deficiencies (23)
| Description | Severity |
|---|---|
| Failure to maintain the facility's dry automatic sprinkler and fire alarm system in operational condition and failure to implement fire watch protocol. | Severity: 3 |
| Failure to ensure initial and/or annual caregiver training was completed for 6 of 10 employees. | Severity: 2 |
| Failure to ensure initial two-step tuberculosis (TB) test and annual TB test and physical examination were completed for some employees. | Severity: 2 |
| Failure to ensure 2 of 10 employees met requirements for CPR and first aid training. | Severity: 2 |
| Failure to maintain premises clean and well maintained with multiple maintenance issues observed. | Severity: 2 |
| Failure to ensure residents' bedroom windows had window screens (23 windows missing screens). | Severity: 2 |
| Failure to ensure kitchen and dining services complied with health standards including lack of hot and cold water, grime buildup, and equipment maintenance issues. | Severity: 2 |
| Failure to maintain automatic sprinkler system and fire alarm system operational, failure to implement fire watch as directed by fire authority, and failure to ensure annual fire extinguisher inspection. | Severity: 3 |
| Failure to ensure safe environment in memory care unit including unlocked electrical room and unsecured courtyard door. | Severity: 2 |
| Failure to secure oxygen tanks in resident rooms. | Severity: 2 |
| Failure to complete fall risk evaluation and incident report following fall with injury for one resident. | Severity: 2 |
| Failure to ensure medication review was completed every six months for one resident. | Severity: 2 |
| Failure to ensure pharmacy medication reports were communicated to physicians and reviewed by Administrator for two residents. | Severity: 2 |
| Failure to provide ultimate user agreements authorizing medication administration for three residents. | Severity: 2 |
| Failure to ensure medications were onsite and available as prescribed for one resident. | Severity: 2 |
| Failure to document medication administration changes on Medication Administration Record for one resident. | Severity: 2 |
| Failure to ensure resident medications were stored securely; unsecured medications found in resident rooms and memory care unit. | Severity: 2 |
| Failure to provide documented TB testing results for three residents. | Severity: 2 |
| Failure to ensure sharp items such as fingernail clippers and tweezers were inaccessible to residents in memory care unit. | Severity: 2 |
| Failure to ensure memory care unit courtyard gate was locked to secure residents. | Severity: 2 |
| Failure to ensure toxic substances were secured and inaccessible to residents in memory care unit. | Severity: 2 |
| Failure to ensure cultural competency training was completed for 3 employees. | Severity: 2 |
| Failure to ensure primary and secondary infection control designees completed 15 hours of infection control training. | Severity: 2 |
Report Facts
Deficiencies cited: 22
Resident files reviewed: 17
Employee files reviewed: 10
Oxygen tanks unsecured: 13
Window screens missing: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Sanderswon | Administrator | Named as Administrator responsible for oversight and signature on report. |
| Employee #1 | Caregiver | Named in deficiencies related to lack of caregiver training, CPR/first aid training, and cultural competency training. |
| Employee #3 | Health Services Director | Named in deficiencies related to lack of caregiver training, TB testing, cultural competency training, infection control training, and medication administration. |
| Employee #8 | Lifestyle Director | Named in deficiencies related to lack of caregiver training and cultural competency training. |
| Employee #4 | Executive Director / Administrator | Named in deficiencies related to caregiver training, infection control training, and oversight failures. |
| Employee #12 | Business Office Manager | Named as secondary infection control designee lacking required training. |
Inspection Report
Original Licensing
Capacity: 150
Deficiencies: 0
Oct 26, 2023
Visit Reason
The inspection was conducted as a Change of Ownership State Licensure survey for the facility in accordance with Nevada Administrative Code, Chapter 449, Requirements for Residential Facilities for Groups.
Findings
No regulatory deficiencies were identified during the survey. No action is necessary.
Report Facts
Licensed beds: 150
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