Inspection Reports for Gentle Spring Care Home
6418 Spring Meadow Dr, Las Vegas, NV 89103, NV, 89103
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 0
Jun 2, 2025
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by two complaints received regarding the facility.
Findings
Both complaints investigated were found to be unsubstantiated with no regulatory deficiencies identified. The investigation included observations, interviews, and record reviews.
Complaint Details
Two complaints were investigated: Complaint #NV00073488 and Complaint #NV00073487. Both were unsubstantiated with no regulatory deficiencies identified.
Report Facts
Complaints investigated: 2
Sample size: 2
Inspection Report
Re-Inspection
Census: 8
Capacity: 10
Deficiencies: 9
Apr 22, 2025
Visit Reason
This inspection was a State Licensure mandatory grading resurvey conducted in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facilities for Groups.
Findings
The facility received a grade of A with one regulatory deficiency identified related to personnel files and background checks. Additional deficiencies were noted in health and sanitation, kitchen equipment, residents requiring oxygen, medication administration, medication storage, and medication record accuracy. The medication administration record for one resident was incomplete, representing a subsequent deficiency from the prior annual survey.
Severity Breakdown
F: 4
D: 5
Deficiencies (9)
| Description | Severity |
|---|---|
| Personnel files did not have all required background check documentation before hire date. | F |
| Health and sanitation issues including odors, hazards, insects, and dirt accumulation. | D |
| Kitchen equipment was not clean or in good working condition. | F |
| Residents requiring oxygen were not properly monitored and equipment not maintained as required. | D |
| Medication administration responsibilities not fully met by caregivers. | D |
| Over-the-counter medication administration not properly documented or approved. | F |
| Medication destruction procedures not properly followed. | D |
| Medication administration record (MAR) was incomplete and inaccurate for one resident, including missing documentation of PRN medication administration and duplicate entries. | D |
| Medication storage was not secure or properly maintained. | F |
Report Facts
Licensed beds: 10
Resident census: 8
Residents reviewed: 5
Employee files reviewed: 1
Severity 2 deficiency: 1
Inspection Report
Complaint Investigation
Census: 8
Deficiencies: 5
Feb 18, 2025
Visit Reason
The inspection was conducted as a result of a Complaint Investigation survey triggered by four complaints at the facility.
Findings
The facility was found to have multiple deficiencies including failure to maintain cleanliness (refrigerator), failure to provide special diets as ordered, failure to track resident activities of daily living (ADLs) for non-Medicaid residents, failure to obtain written authorization for handling resident funds, and failure to maintain hospice care records for a resident receiving dialysis.
Complaint Details
Four complaints were investigated; all were substantiated. Complaint #NV00073232, #NV00073100, #NV00073026, and #NV00073025 were substantiated.
Severity Breakdown
2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure the refrigerator was clean and well maintained with debris and grime found inside. | 2 |
| Facility failed to ensure a renal diet was provided for 1 of 5 residents as ordered by a physician. | 2 |
| Facility failed to comply with policies regarding monitoring and tracking resident Activities of Daily Living (ADLs) for 1 of 4 residents, especially non-Medicaid residents. | 2 |
| Facility failed to ensure written authorization was obtained for 1 of 5 residents to handle the resident's money, and policy was not followed. | 2 |
| Facility failed to maintain health and/or home health records for 1 of 5 residents receiving hospice care, including dialysis records and plan of care. | 2 |
Report Facts
Complaints investigated: 4
Sample size: 5
Census: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Sowers | Administrator | Named in relation to findings and corrective actions. |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 9
Dec 19, 2024
Visit Reason
The inspection was conducted as an annual State licensure survey combined with a complaint investigation at the facility.
Findings
The facility received a grade of D with multiple deficiencies identified including failure to ensure background checks for employees, sanitary hazards in bathrooms, broken kitchen equipment, unsecured oxygen tanks, medication administration errors, expired medications not destroyed, incomplete medication administration records, and unsecured medication storage.
Complaint Details
One complaint (#NV00072085) was substantiated with no deficient practice after investigation including interviews and record review.
Severity Breakdown
Level 2: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure 4 of 5 employees had background check clearance through the Nevada Automated Background Check System for this facility. | Level 2 |
| Facility bathrooms were not free of sanitary hazards; signs posted incorrectly and wastebaskets uncovered with discarded materials. | Level 2 |
| Kitchen equipment including oven and dishwasher were not in working order; repeat deficiency. | Level 2 |
| Oxygen tanks were unsecured in resident room where oxygen was in use. | Level 2 |
| Failed to ensure an Ultimate User Agreement was completed and signed for 1 of 9 residents prior to medication administration. | Level 2 |
| Medications were not administered as prescribed for 2 of 9 residents; medications missing on site for 2 residents; medication packages lacked proper labeling for 2 residents. | Level 2 |
| Failed to destroy expired medications; expired medications found on site without destruction. | Level 2 |
| Medication Administration Records were incomplete and inaccurate for all 9 residents; medication administration not documented for certain dates. | Level 2 |
| Medications were not stored securely; medication closet open and medications found unsecured in resident rooms and kitchen refrigerator. | Level 2 |
Report Facts
Facility licensed beds: 10
Resident census: 9
Employees reviewed: 5
Resident files reviewed: 9
Deficiency severity Level 2 count: 9
Inspection Report
Complaint Investigation
Census: 10
Capacity: 10
Deficiencies: 2
Jul 17, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation survey triggered by Complaint #NV00071344, substantiated during the visit.
Findings
The facility was found to have regulatory deficiencies including the improper restraint of a resident in bed and failure to ensure a resident with incontinence was kept clean and dry. The investigation included observations, interviews, and record reviews.
Complaint Details
Complaint #NV00071344 was substantiated. The investigation included observation of residents, interviews with staff and residents, and record review including incident reports.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident was not restrained in bed; resident was tied to a recliner with sheets to prevent getting out of bed. | Severity: 2 |
| Facility failed to ensure a resident with manageable bowel incontinence was kept clean and dry following a bowel movement. | Severity: 2 |
Report Facts
Number of residents present: 10
Total licensed capacity: 10
Sample size: 5
Number of complaints investigated: 1
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 4
Jan 25, 2024
Visit Reason
The inspection was conducted as an annual State Licensure survey to assess compliance with Nevada Administrative Code (NAC) Chapter 449 for a Residential Facility for Groups.
Findings
The facility received a grade of A but was found deficient in maintaining the interior and exterior cleanliness, kitchen equipment functionality, medication destruction, and medication administration record accuracy. Several corrective actions were planned with specified correction dates.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure the interior and exterior of the facility was well maintained, including a leaking toilet and detached shower drain cover with dust accumulation on the air vent. | Severity: 2 |
| Facility failed to ensure kitchen equipment was clean and functional; refrigerator was not working and contained spoiled food. | Severity: 2 |
| Facility failed to ensure medications were destroyed for 2 of 8 residents and one discharged resident. | Severity: 2 |
| Facility failed to ensure medication administration records were accurate for 1 of 8 residents. | Severity: 2 |
Report Facts
Licensed beds: 10
Resident census: 8
Deficiencies cited: 4
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 0
Jan 30, 2023
Visit Reason
The inspection was conducted as an annual state licensure and infection control survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A with no regulatory deficiencies identified. Ten resident files and three employee files were reviewed, and no further action was necessary.
Report Facts
Resident files reviewed: 10
Employee files reviewed: 3
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 1
Feb 3, 2022
Visit Reason
The inspection was an annual state licensure and infection control survey conducted in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but was found deficient in medication storage practices, specifically failing to separate medications for external use from oral medications for five of ten sampled residents.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure medications for external use were separated from oral medications for Residents #4, #5, #7, #8, and #10. | E |
Report Facts
Residents with medication storage deficiency: 5
Resident files reviewed: 10
Employee files reviewed: 4
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 0
Jul 2, 2021
Visit Reason
This inspection was conducted as an annual state licensure and infection control 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 was provided guidance on compliance with nondiscrimination, privacy, cultural competency, and complaint policies.
Report Facts
Resident files reviewed: 9
Employee files reviewed: 4
Inspection Report
Annual Inspection
Census: 7
Capacity: 10
Deficiencies: 3
Aug 4, 2020
Visit Reason
The inspection was conducted as a result of a COVID-19 focused infection control survey combined with the annual State Licensure survey for the facility.
Findings
The facility received a grade of A. Deficiencies were identified related to visitor COVID-19 screening procedures, staff training on PPE, medication documentation, and completion of initial activities of daily living screenings for residents.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Administrator did not ensure visitors were screened for COVID-19 according to CDC guidelines and staff were not trained on proper PPE use. | Level 2 |
| Medication (Vitamin D) for Resident #1 was administered but not documented on the Medication Administration Record (MAR). | Level 2 |
| Facility failed to complete initial activities of daily living (ADL) screenings for Resident #7 and Resident #2. | Level 2 |
Report Facts
Facility licensed capacity: 10
Census: 7
Medication errors: 1
Residents without initial ADL screening: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Sowers | Administrator | Named in relation to oversight deficiencies and responsible for plan of correction |
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 0
Jun 6, 2019
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility 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: 8
Capacity: 10
Deficiencies: 6
May 5, 2016
Visit Reason
This annual State Licensure survey was conducted to assess compliance with state regulations for a residential facility for elderly and disabled persons and/or persons with mental illnesses and chronic illnesses.
Findings
The facility received a grade of B with several deficiencies identified including offensive odors in resident rooms, inadequate separation of laundry and food storage areas, improper storage of chemicals near food, admission of residents requiring locked quarters without proper confinement, admission of a resident with an ileostomy requiring care by another person, and medication labeling issues for one resident.
Severity Breakdown
2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility premises were not kept free from offensive odors, evidenced by a strong urine smell in Resident #6's bedroom. | 2 |
| Laundry room was not separate from food storage area; pantry accessed through laundry room with no door separation. | 2 |
| Laundry chemicals were stored on the floor next to pantry food items. | 2 |
| Facility retained two residents requiring locked quarters without proper confinement. | 2 |
| Facility admitted a resident with an ileostomy requiring care by another person, which is not permitted. | 2 |
| Medication for Resident #7 was not labeled with directions for administration as required. | 2 |
Report Facts
Licensed capacity: 10
Census: 8
Deficiency count: 6
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 6
May 5, 2016
Visit Reason
This annual State Licensure survey was conducted on 5/5/2016 to assess compliance with state regulations for the facility licensed for residential care of elderly and disabled persons.
Findings
The facility received a grade of B with multiple deficiencies identified including offensive odors, improper separation of laundry and food storage areas, improper chemical storage, retention of residents requiring locked quarters, admission of a resident with an ileostomy requiring professional care, and medication labeling issues.
Severity Breakdown
Level 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to ensure premises were free from offensive odors, specifically urine odor in Resident #6's room due to use of uncovered urine collection containers. | Level 2 |
| Laundry room and food pantry were not separated; access to pantry was through laundry room without a door. | Level 2 |
| Laundry chemicals were stored on the floor next to pantry food items, violating chemical storage regulations. | Level 2 |
| Facility retained two residents (Residents #4 and #5) who required confinement in locked quarters, which is not permitted. | Level 2 |
| Facility admitted Resident #1 with an ileostomy requiring care by another person without proper documentation of capability or physician clearance. | Level 2 |
| Medication for Resident #7 was not labeled with directions for administration; a Patient Starter Kit lacked patient name and pharmacy instructions. | Level 2 |
Report Facts
Licensed beds: 10
Residents present: 8
Deficiency severity counts: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver #2 | Reported on Resident #5 wandering behavior and medication administration for Resident #7 | |
| Administrator | Acknowledged findings related to offensive odors and separation of laundry and food storage |
Inspection Report
Complaint Investigation
Census: 9
Deficiencies: 0
Dec 1, 2015
Visit Reason
The inspection was conducted as a result of a complaint investigation at Gentle Spring Care Home on December 1, 2015, triggered by allegations regarding resident care and facility conditions.
Findings
The investigation included observations, interviews, and record reviews. No regulatory deficiencies were identified, and the complaint allegations were not substantiated.
Complaint Details
Complaint #NV00044369 included allegations that a resident was not provided a soft foods diet and choked, a resident was left soiled in incontinence briefs for extended periods, staff were unqualified, and the facility had bed bugs. None of these allegations were substantiated.
Report Facts
Sample size: 6
Number of complaints investigated: 1
Inspection Report
Complaint Investigation
Census: 9
Deficiencies: 0
Oct 8, 2015
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding allegations of bedbugs and roaches, a resident with a non-healing foot wound due to facility neglect, and a resident not receiving proper food.
Findings
The investigation included tours, observations, interviews, and record reviews. The complaint allegations could not be substantiated, and no regulatory deficiencies were identified.
Complaint Details
Complaint #NV00044041 with allegations of bedbugs and roaches, a non-healing foot wound due to neglect, and improper food provision were investigated and found unsubstantiated.
Report Facts
Sample size: 1
Inspection Report
Complaint Investigation
Census: 10
Capacity: 10
Deficiencies: 1
Sep 17, 2015
Visit Reason
The inspection was conducted as a complaint investigation initiated by the Division of Public and Behavioral Health on 9/17/15 due to one complaint alleging an employee was missing a State and FBI background check.
Findings
The facility was found to have failed to ensure 1 out of 4 employees met the background check requirements under NRS 449. Specifically, Employee #2 lacked documented evidence of State and FBI background check results. The complaint was substantiated.
Complaint Details
Complaint #NV00044020 contained one allegation that an employee was missing a State and FBI background check. The complaint was substantiated.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personnel File - Background Check: Facility failed to ensure 1 out of 4 employees met background check requirements under NRS 449. | Severity: 2 |
Report Facts
Employees reviewed: 4
Complaint count: 1
Inspection Report
Complaint Investigation
Census: 10
Capacity: 10
Deficiencies: 1
Sep 17, 2015
Visit Reason
The inspection was conducted as a complaint investigation triggered by complaint #NV00044020 regarding an allegation of an employee missing a State and FBI background check.
Findings
The facility was found to have one substantiated complaint where 1 out of 4 employee files reviewed lacked documented evidence of State and FBI background checks as required by regulations.
Complaint Details
Complaint #NV00044020 contained one allegation which was substantiated. The allegation was that an employee was missing a State and FBI background check.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 1 out of 4 employees met the requirements for background checks under NRS 449; Employee #2's file lacked documented evidence of State and FBI background check results. | Severity: 2 |
Report Facts
Number of employees reviewed: 4
Number of complaints investigated: 1
Inspection Report
Annual Inspection
Census: 7
Capacity: 10
Deficiencies: 5
Apr 24, 2015
Visit Reason
This inspection was an annual State Licensure survey conducted by the Division of Public and Behavioral Health to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of B with multiple deficiencies identified including failure to maintain clean and well-maintained premises, inadequate CPR training for an employee, failure to destroy medications after resident expiration, unsecured medication storage, and failure to keep medications in original containers.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure the interior and exterior of the facility was clean and maintained, including discarded mattress, overgrowth of weeds, uncoiled hose, broken appliances, standing water, and worn mattress. | Severity: 2 |
| Facility failed to ensure 1 of 5 employees had acceptable certified pulmonary resuscitation (CPR) training; CPR card issued online without evidence of hands-on training. | Severity: 2 |
| Facility failed to destroy medications after a resident had expired; medication was found in caregiver bedroom after resident expired. | Severity: 2 |
| Facility failed to ensure medications were stored and secured in a locked area; unsecured medications found in multiple locations including resident rooms, bathroom, medication cabinet, and refrigerator. | Severity: 2 |
| Facility failed to keep medications belonging to 1 of 7 residents in their original container; medications found in a cup on bedside table. | Severity: 2 |
Report Facts
Resident census: 7
Total licensed capacity: 10
Employee files reviewed: 5
Resident files reviewed: 7
Severity 2 deficiencies: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #5 | Named in CPR training deficiency; hired 4/15/14 with CPR card issued online without hands-on training | |
| Caregiver #3 | Acknowledged placing medications in resident's room while resident was out for an appointment | |
| House Manager | Acknowledged multiple observations including facility maintenance issues and CPR training deficiency |
Inspection Report
Complaint Investigation
Census: 7
Capacity: 10
Deficiencies: 0
Apr 24, 2015
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #NV00042050, which contained three allegations regarding staff communication, meal preferences, and resident phone use.
Findings
The investigation found that none of the three allegations could be substantiated after interviews with staff and residents and observations of facility operations.
Complaint Details
Complaint #NV00042050 contained three allegations: 1) Facility caregiver staff could not communicate effectively in English with residents; 2) Facility failed to provide meals that met residents' food preferences; 3) Facility staff did not allow residents use of the facility phone. None of these allegations were substantiated.
Report Facts
Licensed capacity: 10
Census: 7
Number of allegations: 3
Inspection Report
Complaint Investigation
Census: 9
Deficiencies: 2
Jul 29, 2014
Visit Reason
The inspection was conducted as a complaint investigation based on complaint #NV00039848 regarding quality of care related to resident safety and falls.
Findings
The investigation substantiated the complaint about resident safety/falls and identified deficiencies including failure to provide bedrooms for caregivers living at the facility and failure to obtain emergency medical services promptly after a resident's fall.
Complaint Details
Complaint #NV00039848 contained one allegation regarding quality of care related to resident safety/falls. The complaint was substantiated.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure 2 of 2 caregivers who live at the facility had a bedroom. | Severity: 2 |
| Facility failed to ensure emergency medical services were obtained for a resident following an injury in a timely manner. | Severity: 2 |
Report Facts
Census: 9
Sample size: 2
Time delay: 8
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