Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 83
Capacity: 104
Deficiencies: 12
Apr 24, 2025
Visit Reason
The inspection was conducted as a result of a regrading State Licensure survey and complaint investigation triggered by two substantiated complaints regarding resident monitoring and verbal abuse.
Findings
The facility was found deficient in multiple areas including incomplete personnel and resident records, late or missing CPR/First Aid training, inadequate person-centered service plans especially for residents with dementia and fall risks, failure to protect residents from verbal abuse, late annual physical exams, medication administration errors including missing medications, unsecured resident medications, late tuberculosis testing, failure to display the correct facility grade placard, and incomplete dementia training for employees.
Complaint Details
Two complaints were investigated. Complaint #NV00073541 was substantiated regarding failure to monitor a resident with a history of falls. Complaint #NV00073767 was substantiated regarding a resident being verbally abusive to others. Other allegations related to hygiene and grooming were not substantiated.
Severity Breakdown
F: 2
E: 6
D: 4
C: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Administrator failed to ensure complete and accurate records for employees and residents. | D |
| Employees failed to obtain timely first aid and CPR training. | E |
| Person-centered service plans lacked interventions for resident behaviors and fall risks. | F |
| Person-centered service plans lacked interventions for dementia/memory loss for residents in memory care. | E |
| Resident verbally abusive to residents and staff without effective interventions. | D |
| Person-centered service plan lacked protective supervision for resident with fall risk. | D |
| Annual physical examinations were completed late for some residents. | D |
| Medications were not onsite or available for administration as prescribed for several residents. | E |
| Resident medications were unsecured in resident rooms without physician orders for self-administration. | F |
| Annual tuberculosis testing was not completed timely or refused by some residents. | E |
| Employees required to have dementia training within 40 hours and 90 days of hire lacked required training hours. | E |
| Facility failed to display the most recent D letter grade placard conspicuously in a public area. | C |
Report Facts
Facility licensed beds: 104
Current census: 83
Survey date: Apr 24, 2025
Resurvey fee: 600
Employees reviewed: 9
Residents reviewed: 12
Days late for Resident #1 annual physical: 54
Days late for Resident #10 annual physical: 42
Days late for Resident #6 annual TB test: 15
Days late for Resident #10 annual TB test: 46
Dementia training hours completed by Employee #3: 6.75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Care Manager/Medication Technician | Named in findings for incomplete personnel records, late CPR/First Aid training, and incomplete dementia training. |
| Employee #2 | Care Manager | Named in findings for incomplete personnel records, late CPR/First Aid training, and incomplete dementia training. |
| Employee #3 | Care Manager | Named in findings for incomplete dementia training. |
| Stacey Taylor | Administrator | Named as facility administrator responsible for compliance and interviewed regarding findings. |
Inspection Report
Annual Inspection
Census: 82
Capacity: 104
Deficiencies: 13
Jul 8, 2024
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with complaint investigations based on allegations of resident neglect and medication issues.
Findings
The facility was found deficient in multiple areas including failure to provide timely CPR/First Aid training for employees, neglect of a resident left in urine-soaked clothes, incomplete physical and annual examinations for residents, medication administration errors including missing medications and improper storage, failure to destroy discontinued medications, unsecured medications in resident rooms and medication carts, incomplete resident records including missing TB tests and ADL assessments, and inadequate dementia and cultural competency training for staff.
Complaint Details
Two complaints were investigated: Complaint #NV00070330 substantiated neglect of Resident #12 left in urine-soaked clothes; Complaint #NV00069769 substantiated medication availability issues for residents including missing as-needed pain medication and medications kept unsecured in resident rooms.
Severity Breakdown
Level 2: 12
Level 3: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to ensure timely CPR and First Aid training for 4 of 15 employees. | Level 2 |
| Resident #12 was neglected by being left in urine-soaked clothes for an undetermined amount of time. | Level 2 |
| Failure to ensure initial and annual physical examinations were completed timely for multiple residents. | Level 2 |
| Failure to ensure pharmacy medication reviews were completed every six months for Resident #7. | Level 2 |
| Failure to complete Ultimate User Agreements for Residents #18 and #20. | Level 2 |
| Failure to ensure medications and over-the-counter supplements were available and properly labeled for residents #3, #5, #6, #7, #14. | Level 2 |
| Failure to destroy discontinued medications for Resident #6. | Level 2 |
| Unsecured medications found in Resident #2 and #3 apartments and unlocked medication carts accessible to residents. | Level 3 |
| Failure to secure toxic substances such as hand sanitizer in the memory care unit. | Level 2 |
| Failure to ensure employees received required dementia training within 40 hours and 3 months of hire. | Level 2 |
| Failure to ensure annual TB tests were completed for residents #7, #12, #4, and #20. | Level 2 |
| Failure to ensure annual Activities of Daily Living (ADL) assessments were completed for residents #7, #5, #20 and initial ADL assessments for residents #10 and #19 were incomplete or undated. | Level 2 |
| Failure to ensure cultural competency training was completed timely for Employee #3. | Level 2 |
Report Facts
Licensed beds: 104
Current census: 82
Employees reviewed: 15
Residents reviewed: 20
Application fee for resurvey: 600
Deficiency severity counts: 13
Medication cart audits frequency: 1
Resident rounding frequency: 2
Dementia training hours required: 2
Dementia training hours required: 8
Cultural competency training hours: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stacey Taylor | Administrator | Named in relation to overall facility compliance and attestation of personnel record review |
| Employee #2 | Director of Health and Wellness | Failed to complete timely CPR/First Aid and dementia training |
| Employee #3 | Medication Technician | Failed to complete timely CPR/First Aid, dementia training, and cultural competency training |
| Employee #4 | Medication Technician | Failed to complete timely CPR/First Aid and dementia training |
| Employee #5 | Medication Technician | Failed to complete timely CPR/First Aid training |
| Employee #6 | Medication Technician | Failed to complete timely CPR/First Aid and dementia training |
| Employee #7 | Medication Technician | Failed to complete dementia training within 90 days |
| Employee #13 | Care Manager | Failed to complete timely CPR/First Aid and dementia training |
| Generations Program Manager | Interviewed regarding resident care and medication issues | |
| Resident Care Director | Interviewed regarding physical exams, medication reviews, and resident care |
Inspection Report
Re-Inspection
Census: 70
Capacity: 104
Deficiencies: 15
Jan 25, 2024
Visit Reason
This inspection was a grading re-survey State Licensure survey conducted to assess compliance with Nevada Administrative Code (NAC) Chapter 449 for a Residential Facility for Groups.
Findings
The facility was found to have multiple deficiencies including failure to secure oxygen tanks, medication administration issues such as missing medications and improper labeling, unsecured resident records, unsafe storage of toxic substances in the memory care unit, and incomplete dementia training for some employees. The facility received a grade of B.
Severity Breakdown
Level 2: 6
Level D: 7
Level F: 3
Level B: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to secure oxygen tanks in metal racks as required. | Level 2 |
| Medications missing or not properly labeled for residents. | Level 2 |
| Medication storage not compliant with regulations. | Level 2 |
| Resident records left unsecured, exposing confidential information. | Level 2 |
| Unsafe storage of toxic substances accessible to residents in memory care unit. | Level 2 |
| Failure to ensure required dementia training completed by employees within 90 days of hire. | Level 2 |
| Failure to provide required elder abuse training annually. | Level D |
| Personnel files missing required TB screening and First Aid/CPR certification documentation. | Level D |
| Kitchen equipment not clean or in good working condition. | Level F |
| Failure to ensure residents requiring oxygen meet admission criteria. | Level D |
| Failure to follow medication administration responsibilities and reporting. | Level B |
| Failure to maintain separate resident files securely with all required information. | Level D |
| Failure to meet Alzheimer's care standards for safety including securing dangerous items. | Level D |
| Failure to meet Alzheimer's care standards for safety including securing toxic substances. | Level D |
| Failure to ensure infection control personnel complete required training. | Level F |
Report Facts
Licensed beds: 104
Census: 70
Deficiency count: 16
Severity 2 deficiencies: 6
Severity D deficiencies: 7
Severity F deficiencies: 3
Severity B deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stacey Taylor | Administrator/Executive Director | Named as facility administrator and signatory on report |
| Employee #3 | Caregiver | Named in deficiency for lack of dementia training within 90 days |
| Employee #4 | Caregiver | Named in deficiency for lack of dementia training within 90 days |
Inspection Report
Annual Inspection
Census: 61
Capacity: 104
Deficiencies: 15
Sep 18, 2023
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation at the facility.
Findings
The facility was found deficient in multiple areas including timely elder abuse training, tuberculosis testing, first aid and CPR training, kitchen sanitation, resident safety, oxygen storage, medication administration and storage, dementia care training, and infection control program requirements. One complaint was substantiated involving resident injury due to caregiver horseplay.
Complaint Details
Complaint #NV00069002 was investigated. Allegation #1 that a resident was hit and knocked over by two caregivers horseplaying was substantiated. Allegations #2 and #3 were not substantiated due to lack of evidence.
Severity Breakdown
Severity: 2 Scope: 1: 7
Severity: 2 Scope: 2: 1
Severity: 2 Scope: 3: 4
Severity: 1 Scope: 2: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Employee #10 failed to complete annual elder abuse prevention training timely. | Severity: 2 Scope: 1 |
| Two employees failed to meet tuberculosis testing requirements; one had a late test and one lacked a current test. | Severity: 2 Scope: 1 |
| Two employees failed to obtain timely first aid and CPR training. | Severity: 2 Scope: 1 |
| Kitchen dry storage floor was unclean, food was not properly labeled or expired food removed, refrigerator temperature logs were incomplete, and dented cans were stored. | Severity: 2 Scope: 3 |
| Facility failed to provide a safe environment for a resident who was injured when two caregivers horseplayed causing the resident to fall and sustain injury. | Severity: 2 Scope: 1 |
| Oxygen tanks were found unsecured in resident rooms. | Severity: 2 Scope: 1 |
| Medication profile reviews for seven residents were not reviewed and initialed by the Administrator within 72 hours. | Severity: 1 Scope: 2 |
| One resident lacked a signed and dated Ultimate User Agreement for medication administration. | Severity: 2 Scope: 1 |
| Medications for four residents were not on-site or lacked proper labeling with administration instructions or physician name. | Severity: 2 Scope: 2 |
| Resident medications were not secured in rooms for two residents and unsecured medications were found in 10 resident rooms where residents self-administer medications. | Severity: 2 Scope: 3 |
| One resident's over-the-counter medications lacked labeling with resident's name and prescribing physician. | Severity: 2 Scope: 1 |
| Dangerous items such as curling iron, batteries, and hearing aid batteries were accessible to residents in the memory care unit. | Severity: 2 Scope: 1 |
| Seven employees lacked documented evidence of two hours of dementia training within 40 hours of employment. | Severity: 2 Scope: 3 |
| Facility failed to identify a secondary person responsible for the infection control program. | Severity: 2 Scope: 1 |
| Primary and secondary infection control persons lacked required 15 hours of infection control training. | Severity: 2 Scope: 3 |
Report Facts
Facility licensed beds: 104
Resident census: 61
Complaint investigated: 1
Employees sampled: 10
Residents sampled: 15
Inspection completion date: Sep 19, 2023
Resurvey application fee: 600
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stacey Taylor | Administrator/Executive Director | Named in relation to multiple findings including training, medication reviews, and infection control. |
| Business Office Director | Involved in personnel record reviews and compliance tracking. | |
| Building Services Director | Designated as infection control designee and involved in environmental safety. | |
| Executive Director | Confirmed findings and plans of correction. |
Inspection Report
Follow-Up
Capacity: 64
Deficiencies: 1
Apr 12, 2023
Visit Reason
This on-site follow-up initial State Licensure survey was conducted to assess compliance with Nevada Administrative Code 449 for Residential Facility for Groups and to evaluate the facility's request for licensure of additional beds.
Findings
The facility was found deficient for failing to provide a mattress for each bed as required by NAC 449.218. Specifically, 23 of the requested 104 beds did not have a bed at least 36 inches wide, and the facility lacked a vendor contract to supply additional beds when needed.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide a mattress for each bed; 23 of the requested 104 beds did not have a bed at least 36 inches wide, and no vendor contract was in place to supply additional beds as required. |
Report Facts
Licensed beds: 64
Requested additional beds: 40
Beds without mattress: 23
Rooms inspected: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stacey Taylor | Administrator/Executive Director | Named as facility representative and responsible for plan of correction |
Inspection Report
Original Licensing
Capacity: 104
Deficiencies: 12
Nov 1, 2022
Visit Reason
This inspection was an initial State Licensure survey conducted for licensure of a Residential Facility for Groups with 80 beds for elderly and disabled persons and 24 beds for persons with Alzheimer's disease, Category II residents.
Findings
The facility was found to have multiple regulatory deficiencies including failure to ensure employee pre-employment physicals, inaccurate advertising, maintenance issues, inadequate bedroom window size, lack of bedding and linens, insufficient bathroom supplies, safety hazards in the memory care unit, and lack of policies related to discrimination and resident rights.
Deficiencies (12)
| Description |
|---|
| Failure to ensure employees completed a physical examination prior to beginning work for 1 of 7 sampled employees. |
| Facility promotional website contained inaccurate statements about nursing and physical therapy services provided. |
| Exterior window seals on resident rooms and flooring in a resident dining area were not maintained. |
| Windows in 2 of 22 resident rooms in the Memory Care unit were less than 10 percent of the room size. |
| Facility failed to provide a mattress, sheets, blanket, pillow, and bedspread for each bed for 100 of 104 beds. |
| Facility failed to provide toilet paper, individual towels or paper towels, and soap dispenser or bar of soap in each resident room. |
| Memory care unit door into courtyard was not alarmed, posing a safety risk. |
| Memory care unit contained an electric fireplace capable of generating heat, posing a burn risk to residents. |
| Toxic soap was present in the memory care common area bathroom soap dispenser. |
| Facility failed to develop policies to prevent discrimination based on gender, sexual orientation, gender identity or expression, or HIV status. |
| Facility failed to develop policies on how to file, document, investigate, and resolve complaints related to discrimination. |
| Facility failed to develop policies to ensure residents are addressed by their preferred name and pronoun in accordance with their gender identity or expression. |
Report Facts
Beds requested for licensure: 104
Sampled employees: 7
Sampled resident records: 1
Resident rooms with insufficient window size: 2
Beds lacking mattress and bedding: 100
Memory Care rooms: 22
Beds set up with bedding: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stacey Taylor | Administrator/Executive Director | Named as Executive Director providing documentation and interview responses related to findings. |
| Employee #6 | Caregiver | Employee lacking documented pre-employment physical examination. |
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