Inspection Reports for Garden Breeze Alzheimer Villa
950 Garden Breeze Way, Las Vegas, NV 89123, NV, 89123
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 3
Nov 14, 2024
Visit Reason
This inspection was conducted as an annual State Licensure survey of the Garden Breeze Alzheimer Villa facility to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The inspection identified regulatory deficiencies related to bedroom and bathroom door locks not opening with a single motion from the inside, and failure to submit a medical exemption request for a bedfast resident. The facility received a grade of A overall.
Severity Breakdown
2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Residents' bedroom doors had locks requiring more than one motion to open, not providing facility security. | 2 |
| Residents' bathroom doors had locks requiring more than one motion to open, not providing facility security. | 2 |
| Failure to submit a medical exemption request to retain a bedfast resident (Resident #5). | 2 |
Report Facts
Licensed beds: 8
Residents present: 7
Deficiency severity: 2
Deficiency scope: 3
Deficiency scope: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alfredo Bartolome | Caregiver | Acknowledged double motion locks and lack of medical exemption documentation |
Inspection Report
Annual Inspection
Census: 6
Capacity: 8
Deficiencies: 0
Nov 20, 2023
Visit Reason
This inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the survey. The facility received a grade of A and no further action was necessary.
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 0
Dec 7, 2022
Visit Reason
The inspection was conducted as an annual and infection control State Licensure survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the survey. The facility received a grade of A and no further action was necessary.
Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 2
Nov 17, 2021
Visit Reason
Annual state licensure and infection control survey conducted in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facilities for Groups.
Findings
The facility received a grade of A but had regulatory deficiencies including unsecured oxygen tanks in a resident's bedroom and failure to ensure tuberculosis testing documentation for two residents.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure 3 of 5 oxygen tanks were stored secured to the wall or in a stand in Resident #7's bedroom. | Severity: 2 |
| Failed to ensure 2 of 8 residents met tuberculosis testing requirements; Residents #4 and #6 lacked documented evidence of initial two-step TB tests. | Severity: 2 |
Report Facts
Number of oxygen tanks unsecured: 3
Number of residents lacking TB test documentation: 2
Facility licensed bed capacity: 8
Resident census at time of survey: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Theresa Brushfield | Assistant to Administrator | Signed the Statement of Deficiencies report |
| Employee #1 acknowledged oxygen tanks were unsecured and TB test documentation was missing for Residents #4 and #6 |
Inspection Report
Abbreviated Survey
Census: 6
Capacity: 8
Deficiencies: 0
Nov 17, 2020
Visit Reason
This inspection was a COVID-19 focused infection control survey conducted to assess compliance with infection control measures related to COVID-19 at the facility.
Findings
The survey found that the facility implemented appropriate COVID-19 infection control practices including screening, social distancing, PPE usage, sanitization, and staff training. No deficiencies were identified during the survey.
Report Facts
Hand sanitizer quantity: 67.7
Licensed beds: 8
Current census: 6
PPE inventory: 3
PPE inventory: 50
PPE inventory: 10
PPE inventory: 50
PPE inventory: 24
PPE inventory: 4
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 2
Sep 5, 2019
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but had deficiencies including failure to dispose of expired perishable foods and inaccuracies in the Medication Administration Record (MAR) for one resident.
Severity Breakdown
2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Expired perishable food items were found in the kitchen refrigerator including Hershey's Strawberry Syrup, potato salad, pickle relish, and French dressing. | 2 |
| The Medication Administration Record (MAR) was inaccurate for one resident; the documented medication administration times did not match the physician's order. | 2 |
Report Facts
Licensed beds: 8
Resident census: 7
Deficiency severity level 2: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alfredo Bartolome | Caregiver | Signed the Statement of Deficiencies |
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 0
Sep 27, 2018
Visit Reason
This Statement of Deficiencies was generated as a result of an annual survey conducted at the facility on September 27, 2018, in accordance with Nevada Administrative Code (NAC), Chapter 449, Residential Facility for Groups.
Findings
The facility received a grade of A with no regulatory deficiencies identified. No further action was necessary.
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 0
Sep 11, 2017
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility on 9/11/2017.
Findings
The facility received a grade of A with no regulatory deficiencies identified at the time of the survey.
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 0
Jul 27, 2016
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility to assess compliance with regulatory requirements.
Findings
The facility was found to be in substantial compliance with regulations, receiving a grade of A, with no deficiencies identified during the survey.
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 0
Jul 27, 2016
Visit Reason
This Statement of Deficiencies was generated as a result of an annual State Licensure survey conducted in the facility on 7/27/16 by the Division of Public and Behavioral Health.
Findings
The facility received a grade of A with no deficiencies identified and is in substantial compliance with the regulations.
Inspection Report
Annual Inspection
Census: 6
Capacity: 8
Deficiencies: 0
Jul 28, 2015
Visit Reason
This Statement of Deficiencies was generated as a result of an annual State Licensure survey conducted in the facility on 7/28/15 by the Division of Public and Behavioral Health.
Findings
The facility received a grade of A with no deficiencies identified and is in substantial compliance with the regulations.
Inspection Report
Annual Inspection
Census: 5
Capacity: 8
Deficiencies: 2
Aug 7, 2014
Visit Reason
This document is a State Licensure survey conducted as an annual inspection of a residential facility for persons with Alzheimer's disease.
Findings
The facility received a grade of A. Two deficiencies were identified: one related to a non-functioning door alarm on an exit door, and another related to an unsecured yard gate. Both deficiencies were corrected during the survey.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Alzheimer's Facility door alarm was not working at the time of the survey. | Severity: 2 |
| Alzheimer's Facility yard fenced gate was not locked during the survey. | Severity: 2 |
Report Facts
Licensed beds: 8
Census: 5
Exit doors with alarms: 1
Severity level: 2
Scope: 3
Inspection Report
Annual Inspection
Census: 5
Capacity: 8
Deficiencies: 2
Aug 7, 2014
Visit Reason
This document is the result of an annual State Licensure survey conducted at the facility on 08/07/2014 to assess compliance with state regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but was found deficient in two areas: failure to ensure one of three exit doors had an operational alarm, and failure to secure the gate leading from the secured yard to an unsecured area. Both deficiencies were rated with severity level 2 and scope 3.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 3 exit doors had an alarm that operated when the exit door was opened. | Severity: 2 |
| Failed to ensure the gate in an Alzheimer's endorsed facility was secured; the front gate lock was observed to be unlocked. | Severity: 2 |
Report Facts
Licensed beds: 8
Resident census: 5
Employee files reviewed: 4
Resident files reviewed: 5
Exit doors: 3
Severity level: 2
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 acknowledged the door alarm was faulty and the gate was unlocked; no full name provided. |
Inspection Report
Annual Inspection
Census: 6
Capacity: 8
Deficiencies: 5
Aug 15, 2013
Visit Reason
This document is a State Licensure annual grading survey conducted to assess compliance with regulations at a residential facility for persons with Alzheimer's disease.
Findings
The facility received a grade of B with several deficiencies identified related to oxygen tank storage, medication administration, medication records, PRN medication orders, and resident file documentation including tuberculosis testing.
Severity Breakdown
1: 1
2: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to secure two oxygen tanks in a rack or to the wall. | 2 |
| Facility failed to ensure 2 of 6 residents received medications as prescribed (Resident #2 Lorazepam and Resident #3 Spiriva). | 2 |
| Medication administration record (MAR) was inaccurate for 3 of 6 MARs inspected (Residents #1, #3, and #5). | 1 |
| PRN medications were not given routinely with physician orders for 3 of 6 residents (Residents #1, #4, and #6). | 2 |
| Facility failed to ensure 1 of 6 residents complied with tuberculosis testing requirements (Resident #3). | 2 |
Report Facts
Deficiencies identified: 5
Facility licensed capacity: 8
Resident census at time of survey: 6
Inspection Report
Annual Inspection
Census: 6
Capacity: 8
Deficiencies: 5
Aug 15, 2013
Visit Reason
This document is a State Licensure annual grading survey conducted to assess compliance with regulations for the Garden Breeze Alzheimer Villa facility.
Findings
The facility received a grade of B with multiple deficiencies identified including failure to secure oxygen tanks properly, medication administration errors, inaccurate medication administration records, routine administration of PRN medications without physician orders, and incomplete tuberculosis testing documentation.
Severity Breakdown
Severity: 1: 1
Severity: 2: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to secure two oxygen tanks in a rack or to the wall. | Severity: 2 |
| Failed to ensure 2 of 6 residents received medications as prescribed (Resident #2 Lorazepam and Resident #3 Spiriva). | Severity: 2 |
| Failed to ensure the medication administration record (MAR) was accurate for 3 of 6 MARs inspected (Residents #1, #3, and #5). | Severity: 1 |
| Failed to ensure PRN medications were not given routinely to 3 of 6 residents (Residents #1, #4, and #6). | Severity: 2 |
| Failed to ensure 1 of 6 residents complied with tuberculosis testing requirements; two-step TB skin tests did not include the month tests were completed. | Severity: 2 |
Report Facts
Licensed capacity: 8
Census: 6
Deficiencies cited: 5
Inspection Report
Annual Inspection
Census: 6
Capacity: 8
Deficiencies: 3
Aug 16, 2012
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but had deficiencies related to medication administration, medication storage, and resident file storage. Deficiencies were corrected during or immediately after the survey.
Severity Breakdown
Level 2: 2
Level 1: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Medication administration: The facility failed to ensure medications were administered properly, including review and reporting requirements. | Level 2 |
| Medication storage: Employee medications were found unsecured in the refrigerator; medications were not stored in locked areas as required. | Level 2 |
| Resident file storage: Resident files were not kept in a secured area; files of former residents were observed in an unlocked cabinet. | Level 1 |
Report Facts
Residents present: 6
Licensed beds: 8
Deficiency severity: 2
Deficiency severity: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eugenia D. Coleman | Administrator | Named in relation to medication administration and facility compliance |
Inspection Report
Annual Inspection
Census: 6
Capacity: 8
Deficiencies: 3
Aug 16, 2012
Visit Reason
This document is an annual State Licensure survey conducted on 8/16/2012 to assess compliance with state regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but had several deficiencies related to medication administration, medication storage, and resident file security. Specific issues included failure to maintain medications at a maintenance level requiring medical assessment, unsecured medications in the refrigerator, and unsecured resident files.
Severity Breakdown
Level 2: 2
Level 1: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure medications for 2 of 6 residents were at maintenance level and required medical assessment before administration. | Level 2 |
| Failed to ensure medications administered by a resident capable of self-administration were kept in a locked container; employee medications were unsecured in the kitchen refrigerator. | Level 2 |
| Failed to ensure resident files were kept in a secured area; files of former residents were observed in an unlocked cabinet in the living room. | Level 1 |
Report Facts
Residents reviewed: 6
Employee files reviewed: 5
Facility licensed capacity: 8
Current census: 6
Inspection Report
Annual Inspection
Census: 3
Capacity: 8
Deficiencies: 2
Jul 27, 2011
Visit Reason
This document is the result of an annual State Licensure survey conducted on 07/27/2011 to assess compliance with regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A. Two deficiencies were identified: one related to the medication plan not being facility specific, and another related to failure to ensure tuberculosis testing compliance for one resident.
Severity Breakdown
Level 1: 1
Level 2: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop and maintain a medication plan that was facility specific. | Level 1 |
| Failure to ensure one resident complied with tuberculosis testing requirements. | Level 2 |
Report Facts
Licensed capacity: 8
Resident census: 3
Severity 1 deficiencies: 1
Severity 2 deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Virginia D. Coleman | Administrator | Named in relation to medication plan deficiency and responsible for corrective actions |
Inspection Report
Annual Inspection
Census: 3
Capacity: 8
Deficiencies: 2
Jul 27, 2011
Visit Reason
This document is the result of an annual State Licensure survey conducted at the Garden Breeze Alzheimer Villa on 7/27/2011 to assess compliance with state regulations for residential facilities providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but was found deficient in developing a facility-specific medication plan and ensuring compliance with tuberculosis testing requirements for residents.
Severity Breakdown
Severity: 1: 1
Severity: 2: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to prepare a medication plan that was facility specific. | Severity: 1 |
| Failure to ensure 1 of 3 residents complied with tuberculosis testing requirements (NAC 441A.380). | Severity: 2 |
Report Facts
Resident files reviewed: 3
Employee files reviewed: 4
Licensed capacity: 8
Current census: 3
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