Inspection Reports for Grand Montecito Memory Care
6660 Grand Montecito Pkwy, Las Vegas, NV 89149, United States, NV, 89149
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
11.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% worse than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
80% occupied
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 37
Capacity: 46
Deficiencies: 12
Date: Jul 14, 2025
Visit Reason
This inspection was a mandatory State Licensure grading resurvey conducted at the facility to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility received a grade of A but had several regulatory deficiencies related to food service permits, supervision and treatment of residents, medication administration, resident admission policies, maintenance of resident files, tuberculosis testing, and Alzheimer's care safety standards.
Deficiencies (12)
Permits-Comply with NAC 446 on Food Service - Kitchens; storage of food; adequate supplies of food; permits; inspections.
Supervision and Treatment of Residents - Ensure staff collaborate with residents, families, and healthcare providers to develop and review person-centered service plans annually.
Written Policy on Admissions - Facility shall not admit or allow to remain persons who are bedfast, require restraint, confinement in locked quarters, or skilled nursing/medical supervision 24/7.
Medical Care of Resident After Illness - Obtain general physical examination results before admission and annually or more frequently if condition changes.
Medication Administration-Report Received - Notify resident's healthcare provider of concerns within 72 hours; report reviewed and initialed by administrator.
Medication/OTCS, Supplements, Change Order - Medications must be administered per physician orders; failure to have medication onsite caused missed dose for Resident #2.
Medication - Resident Refusal - Notify healthcare provider within 12 hours if resident refuses or misses medication dose.
Administration of Medication Maintenance - Maintain accurate medication administration records including documentation of administration and refusals; failure to document administration for Resident #1.
Maintenance and Contents of Separate File - Maintain locked, confidential resident files with required medical and assessment information; failed to document required TB testing for Resident #5.
Maintenance and Contents of Separate File - Annual evaluation of resident's ability to perform activities of daily living required.
Alzheimer's Care Standards for Safety - Install operational alarms or technology on all exit doors for residents with Alzheimer's or dementia.
Alzheimer's Care Standards for Safety - Ensure all toxic substances are not accessible to residents.
Report Facts
Licensed capacity: 46
Census: 37
Residents files reviewed: 5
Severity 2 deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marjolijn Kirby | Administrator | Signed report and involved in oversight |
| Memory Care Director | Acknowledged medication administration issues and TB testing deficiencies | |
| Executive Director | Involved in medication administration corrective actions and monitoring compliance | |
| Medication Technician | Acknowledged medication administration documentation issues |
Inspection Report
Annual Inspection
Census: 33
Capacity: 46
Deficiencies: 11
Date: Apr 16, 2025
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility in accordance with Nevada Administrative Code, Chapter 449, Residential Facilities for Groups.
Findings
The facility was found deficient in multiple areas including food safety violations in the kitchen, failure to develop person-centered care plans, lack of medical exemptions for wound care, missing initial and annual physical examinations, incomplete medication administration and reviews, missing tuberculosis testing, incomplete activities of daily living assessments, lack of audible door alarms on exit doors, and unsecured toxic substances accessible to residents.
Deficiencies (11)
Food safety violations including improper cooling of beef soup, improper storage of raw sausage above cooked foods, lack of certified food protection manager, and unsanitary kitchen conditions.
Failure to develop a Person Centered Care Plan for one resident.
Failure to obtain medical exemption for a resident receiving wound care.
Failure to ensure residents received initial and annual physical examinations as required.
Failure to ensure Administrator reviewed and initialed medication reviews within required timeframes.
Failure to ensure medications were on site and administered per physician orders; missing medications and documentation.
Failure to notify physician within 12 hours after a resident missed medication dose.
Failure to ensure residents were tested for tuberculosis prior to admission and annually.
Failure to complete initial and annual Activities of Daily Living assessments for residents.
Failure to ensure all exterior doors had audible alarms to alert staff when doors were opened.
Failure to secure toxic substances in cabinets accessible to residents in the memory care unit.
Report Facts
Licensed capacity: 46
Census: 33
Severity 2 deficiencies: 8
Severity F deficiencies: 7
Severity D deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marjolijn M Kirby | Administrator | Signed the inspection report and involved in corrective actions |
| Environmental Services Director | Acknowledged lack of audible door alarms and unsecured toxic substances | |
| Wellness Director/Memory Care Director | Acknowledged missing care plans, medication issues, and physical exams | |
| Medication Technician Employee #8 | Acknowledged missing medications and medication administration issues | |
| Medication Technician Employee #9 | Acknowledged missing medications |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Date: Aug 13, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 08/13/2024, triggered by one substantiated complaint regarding resident care.
Complaint Details
One complaint was investigated and substantiated (Complaint #NV0007195). The complaint involved failure to notify the responsible party of a resident's fall and hospital transfer.
Findings
The facility failed to notify a resident's responsible party after a fall and hospital transfer for one of five sampled residents. The investigation included observations, interviews, and record reviews confirming the lack of notification.
Deficiencies (1)
Facility failed to notify a resident's responsible party after a fall and hospital transfer for Resident #1.
Report Facts
Census: 31
Sample size: 5
Complaints investigated: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marjolijn Kirby | Administrator | Signed the inspection report |
| Wellness Director | Interviewed and confirmed failure to notify responsible party | |
| Executive Director | Interviewed and confirmed lack of documented notification | |
| Business Office Manager | Interviewed during complaint investigation | |
| Health Services Director | Re-educated staff on incident reporting and notification procedures |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 0
Date: Jun 26, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 06/26/24 in accordance with Nevada Administrative Code (NAC), Chapter 449, Residential Facility for Groups.
Complaint Details
One complaint (NV00071255) was investigated and found to be unsubstantiated.
Findings
The investigation included observations, interviews, and clinical record reviews. The complaint was unsubstantiated, no regulatory deficiencies were identified, and no further action was necessary.
Report Facts
Sample size: 6
Complaints investigated: 1
Inspection Report
Complaint Investigation
Census: 33
Capacity: 46
Deficiencies: 2
Date: May 9, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation survey triggered by Complaint #NV00071073, which was substantiated.
Complaint Details
Complaint #NV00071073 was substantiated based on observations and interviews regarding water temperatures and trash management issues.
Findings
The facility failed to ensure hot water was available in 2 of 6 resident rooms and failed to maintain the exterior premises free of trash and debris, including overflowing dumpsters. Interviews and observations confirmed these deficiencies.
Deficiencies (2)
Failed to ensure hot water was available in 2 of 6 resident rooms (Rooms #126 and #127).
Failed to ensure the exterior of the building was free of trash and debris, including overflowing dumpsters.
Report Facts
Licensed capacity: 46
Census: 33
Sample size: 6
Hot water temperature: 95
Severity level: 2
Dumpster overflow count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marjolijn Kirby | Administrator | Re-educated Maintenance Director on hot water temperatures and garbage management |
| Maintenance Director | Confirmed hot water temperature issues and trash overflow; re-educated by Administrator | |
| Kitchen Staff | Reported issues with trash overflowing due to irregular pickup | |
| Caregiver | Indicated trash would overflow on occasion | |
| Executive Director | Indicated issues with trash pickup on a regular basis |
Inspection Report
Annual Inspection
Census: 33
Capacity: 46
Deficiencies: 5
Date: Apr 23, 2024
Visit Reason
This inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code, Chapter 449, Residential Facilities for Groups.
Findings
The facility was found to have multiple regulatory deficiencies including failure to ensure annual tuberculosis testing for one employee, expired food items and improper food storage temperatures in the kitchen, lack of six-month medication reviews for four residents, and incomplete or unapproved cultural competency training for seven employees. The facility received a grade of B.
Deficiencies (5)
Failed to ensure tuberculosis testing was completed annually for 1 of 10 employees (Employee #2).
Expired food items found in walk-in cooler and refrigerated juice dispenser temperature was approximately 85°F with multiple juice containers.
Grease and debris build-up on cook's line around salamander broiler and under grill and griddle.
Failed to ensure six-month medication review and recommendations were reviewed and signed by physician for 4 of 10 sampled residents.
Failed to ensure Cultural Competency training was completed from an approved program within 30 days of hire for 7 of 10 employees.
Report Facts
Resident files reviewed: 10
Employee files reviewed: 10
Expired lime juice cartons: 1
Expired liquid egg white cartons: 6
Residents lacking six-month medication review: 4
Employees lacking approved cultural competency training: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marjolijn Kirby | Administrator | Signed the report and involved in oversight |
| Employee #2 | Caregiver | Failed annual TB screening |
| Memory Care Director | Re-educated on medication administration accuracy and responsible for quarterly audits | |
| Business Office Manager | Re-educated on employee TB screening and cultural competency training; responsible for audits | |
| Executive Director | Confirmed deficiencies and re-educated staff; responsible for monitoring compliance |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 2
Date: Feb 12, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 02/12/2024, triggered by Complaint #NV00070163 which was unverified.
Complaint Details
Complaint #NV00070163 was investigated but could not be verified. No regulatory deficiencies related to the complaint were identified.
Findings
No regulatory deficiencies were identified related to the complaint itself. However, deficiencies were found related to failure to ensure annual Elder Abuse Training and annual Alzheimer's/Dementia training for 3 of 5 sampled employees.
Deficiencies (2)
Failure to ensure annual Elder Abuse Training was completed for 3 of 5 sampled employees.
Failure to ensure three hours of annual Alzheimer's training was completed by 3 of 5 employees.
Report Facts
Sample size: 5
Employees lacking training: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Caregiver | Lacked evidence of current annual Elder Abuse and Alzheimer's training |
| Employee #2 | Caregiver | Lacked evidence of current annual Elder Abuse and Alzheimer's training |
| Employee #3 | Medication Technician | Lacked evidence of current annual Elder Abuse and Alzheimer's training; no longer employed |
| Marjolijn Kirby | Administrator | Acknowledged lack of training documentation for Employees #1, #2, and #3 |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 0
Date: Jun 26, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by two complaints received by the facility.
Complaint Details
Two complaints were investigated: Complaint #NV00068600 and Complaint #NV00068739. Neither complaint was substantiated and no regulatory deficiencies were found.
Findings
No regulatory deficiencies were identified during the investigation. Both complaints could not be verified after observations, interviews, and record reviews.
Report Facts
Sample size: 5
Complaints investigated: 2
Inspection Report
Annual Inspection
Census: 36
Capacity: 46
Deficiencies: 2
Date: Apr 24, 2023
Visit Reason
The inspection was conducted as an annual and infection control State Licensure survey in accordance with Nevada Administrative Code, Chapter 449, Residential Facilities for Groups.
Findings
The facility received a grade of A but had regulatory deficiencies including failure to comply with food service standards such as dietary staff not wearing hair restraints and dust build-up in kitchen ventilation, and failure to secure cleaning products in the dining area accessible to residents.
Deficiencies (2)
Dietary staff member working in the kitchen was not wearing a hair restraint; dust build-up in the duct of the ventilation hood above the dish machine.
Cabinet containing cleaning products was unsecured and accessible to residents in the dining area.
Report Facts
Licensed beds: 46
Resident census: 36
Employee files reviewed: 6
Resident files reviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Aragon | Administrator | Named in relation to ensuring vents are free of dust and securing chemicals |
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