Inspection Reports for Las Vegas Alzheimers & Memory Care 1
3224 Brazos Street, Las Vegas, NV 89169, NV, 89169
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Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 1
Jul 15, 2025
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding the facility's temperature control, specifically allegations that the temperature exceeded regulatory limits.
Findings
The facility failed to maintain temperatures below 82 degrees Fahrenheit throughout the home, with observed temperatures reaching as high as 90 degrees. The air conditioning unit was malfunctioning but was repaired with a new compressor installed on 07/22/25.
Complaint Details
One complaint (#NV00074690) was substantiated regarding elevated temperatures in the facility. The investigation included observations, interviews, clinical record review, and document review related to air conditioning repairs.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain temperatures below 82 degrees Fahrenheit throughout the home. | F |
Report Facts
Temperature readings: 90
Census: 10
Sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tolentino Tan | Administrator | Acknowledged elevated temperatures and the need for air conditioning repair |
Inspection Report
Complaint Investigation
Census: 7
Deficiencies: 3
Jan 14, 2025
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 01/14/25, in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The investigation substantiated one complaint without deficient practice. However, regulatory deficiencies were identified related to failure to maintain documentation of pressure ulcer care, failure to submit a medical exemption request for a resident with pressure ulcers, and failure to complete incident reports for changes in resident condition.
Complaint Details
One complaint (#NV00072919) was investigated and substantiated without deficient practice.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to maintain documentation of care for pressure ulcers for 1 of 2 residents (Resident #1). | Severity: 2 |
| Failed to ensure a medical exemption for pressure ulcers was submitted to the Bureau to retain 1 of 2 sampled residents (Resident #1). | Severity: 2 |
| Failed to ensure incident reports were completed for 1 of 2 residents who had a change of condition (Resident #1). | Severity: 2 |
Report Facts
Sample size: 2
Complaint count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tolentino Tan | Administrator | Administrator confirmed findings related to pressure ulcers and incident reports |
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 0
Nov 18, 2024
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
The facility received a grade of A with no regulatory deficiencies identified. Eight resident files and five employee files were reviewed, and no further action was necessary.
Report Facts
Resident files reviewed: 8
Employee files reviewed: 5
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 5
Nov 14, 2023
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility was found deficient in several areas including inadequate supplies of fresh food, missing signed medication administration agreements, medication not on site as ordered, unsecured toxic substances, and lack of cultural competency training for an employee. The facility received a grade of B.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure a two day supply of fresh fruits and vegetables were available for 9 residents. | Severity: 2 |
| Failed to ensure 1 of 9 residents had a signed ultimate user agreement authorizing medication administration. | Severity: 2 |
| Failed to ensure medication (Ondansetron) was on site for 1 of 9 residents as ordered. | Severity: 2 |
| Failed to ensure toxic substances were secured; dishwasher detergent, multi-purpose cleaner, and dish soap were unsecured in kitchen cabinet. | Severity: 2 |
| Failed to ensure 1 of 4 employees received cultural competency training. | Severity: 2 |
Report Facts
Residents present: 9
Licensed capacity: 10
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tolentino I. Tan | Administrator | Named as administrator responsible for corrective actions |
| Employee #1 | Caregiver | Identified as employee lacking cultural competency training |
Inspection Report
Re-Inspection
Census: 10
Capacity: 10
Deficiencies: 3
Feb 27, 2023
Visit Reason
This inspection was a State Licensure mandatory grading resurvey conducted in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A with several deficiencies identified related to safety and maintenance, including unsecured construction debris in the backyard, lack of audible alarm on the front door, and accessible sharp objects. Other areas such as personnel files, medical care, medication administration, and training were found compliant with no deficiencies.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure the exterior of the building was free of debris and items harmful to residents; construction equipment including broken wood, drywall, and chemicals were accessible in the backyard. | Level 2 |
| Facility failed to ensure an audible alarm was present on the front door which led out of the home. | Level 2 |
| Facility failed to ensure sharp objects were not accessible to residents; scissors were unsecured and accessible in the open kitchen drawer. | Level 2 |
Report Facts
Licensed beds: 10
Resident census: 10
Severity 2 deficiencies: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tolentino I. Tan | Administrator | Named in relation to findings and plan of correction |
| Managing employee | Involved in corrective actions for alarm and sharp objects deficiencies |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 17
Nov 1, 2022
Visit Reason
The inspection was conducted as a result of a State Licensure Annual Grading and Complaint Investigation survey at the facility on 11/01/22, including investigation of two substantiated complaints.
Findings
The facility received a grade of D with multiple deficiencies including failure to notify guardians of resident condition changes, incomplete elder abuse and dementia training for employees, incomplete tuberculosis testing and physical exams for residents, medication administration errors, unsafe environment hazards, and lack of cultural competency training.
Complaint Details
Two complaints were investigated: Complaint #NV00066968 with three substantiated allegations related to resident falls, wounds, and failure to notify guardians; Complaint #NV00067119 with two substantiated allegations related to serious wounds requiring hospital debridement and failure to notify guardian.
Severity Breakdown
Level 2: 16
Deficiencies (17)
| Description | Severity |
|---|---|
| Failure to report a resident's fall, decline in condition, and open wounds to the resident's guardian. | Level 2 |
| Failure to ensure elder abuse training was completed for 1 of 5 employees. | Level 2 |
| Failure to ensure two-step tuberculosis (TB) test was completed upon hire for 2 of 5 employees and physical exam was missing for 1 of 5 employees. | Level 2 |
| Failure to ensure background check was completed upon hire for 1 of 5 employees. | Level 2 |
| Failure to ensure CPR training was completed within 30 days of hire for 1 of 5 employees. | Level 2 |
| Failure to ensure the exterior of the building was free of debris and construction equipment accessible to residents. | Level 2 |
| Failure to notify a resident's guardian upon a change of condition including falls and pressure sores for 1 of 10 residents. | Level 2 |
| Failure to ensure annual physical exam was completed for 1 of 10 residents. | Level 2 |
| Failure to ensure medication review was completed every six months for 1 of 10 residents. | Level 2 |
| Failure to ensure physician's orders for medications were followed and medications were available for 7 of 10 residents. | Level 2 |
| Failure to ensure Medication Administration Record (MAR) accurately documented all medications prescribed for 1 of 10 residents. | Level 2 |
| Failure to ensure medications were properly labeled for 1 of 10 residents. | Level 2 |
| Failure to ensure tuberculin (TB) testing was provided per requirement for 6 of 10 residents. | Level 2 |
| Failure to ensure an audible alarm was present on the front door which led out of the home. | Level 2 |
| Failure to ensure kitchen drawers containing knives and a cabinet containing cleaning chemicals were locked and inaccessible to residents. | Level 2 |
| Failure to ensure two hours of Alzheimer's training was completed within 40 hours of start date for 1 of 5 employees. | Level 2 |
| Failure to submit a cultural competency course/training program and failure to ensure cultural competency training for 2 of 5 employees. | Level 2 |
Report Facts
Deficiencies cited: 16
Facility licensed beds: 10
Resident census: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Chan Tan | Administrator | Named in relation to findings about failure to provide documented training and failure to notify guardians. |
| Employee #1 | Failed to complete elder abuse training, two-step TB test, CPR training, Alzheimer's training, and cultural competency training. | |
| Employee #5 | Failed to complete two-step TB test, background check, and cultural competency training. |
Inspection Report
Re-Inspection
Census: 10
Capacity: 10
Deficiencies: 0
Apr 13, 2022
Visit Reason
This inspection was a State Licensure voluntary grading resurvey conducted in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A with no regulatory deficiencies identified. Guidance was provided on nondiscrimination policies, privacy protections, cultural competency training, and complaint policies.
Report Facts
Resident files reviewed: 5
Employee files reviewed: 1
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 5
Dec 3, 2021
Visit Reason
The inspection was conducted as an annual grading and infection control survey of the facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility received a grade of B with several deficiencies identified including failure to ensure annual tuberculosis testing for some employees and residents, failure to post required signage about the designated representative, medication labeling issues, and failure to complete annual Activities of Daily Living assessments for one resident.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure annual tuberculosis (TB) testing was completed for 1 of 4 employees (Employee #3). | Severity: 2 |
| Failed to post signage indicating the designated representative in the absence of the Administrator. | Severity: 2 |
| Failed to ensure a medication was labeled with a resident's name and directions for use; a bottle labeled Quetiapine lacked this information. | Severity: 2 |
| Failed to ensure tuberculosis (TB) testing was completed annually for 4 of 10 residents (Residents #3, #5, #6, and #9). | Severity: 2 |
| Failed to ensure an Activities of Daily Living (ADL) assessment was completed annually for 1 of 10 residents (Resident #8). | Severity: 2 |
Report Facts
Number of resident files reviewed: 10
Number of employee files reviewed: 4
Facility grade: B
Inspection Report
Abbreviated Survey
Census: 10
Capacity: 10
Deficiencies: 1
Nov 19, 2020
Visit Reason
The inspection was a COVID-19 focused infection control survey conducted to assess the facility's compliance with infection control practices during the pandemic.
Findings
The facility had implemented several infection control measures including screening, social distancing, and sanitization; however, staff were not fit-tested or medically cleared to wear N95 respirators as recommended, representing a regulatory deficiency.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Administrator failed to ensure staff were fit-tested and medically cleared to wear N95 respirators as required for safe infection control practices during the COVID-19 pandemic. | Severity: 2 |
Report Facts
Licensed beds: 10
Residents present: 10
N95 masks: 24
Gloves: 400
Surgical masks: 100
Hand sanitizer bottles: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tolentino I. Tan | Administrator | Named in relation to failure to ensure staff fit-testing for N95 respirators |
Inspection Report
Re-Inspection
Deficiencies: 0
May 29, 2018
Visit Reason
This document is a Statement of Deficiencies generated as a result of a re-grading survey initiated at the facility on May 29, 2018, conducted under Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a re-survey grade of A and no deficiencies were identified during this inspection.
Notice
Deficiencies: 2
May 9, 2016
Visit Reason
The document notifies the facility administrator of sanctions and monetary penalties imposed by the Division of Public and Behavioral Health due to deficiencies found at the facility.
Findings
The notice states that monetary penalties totaling $2000.00 are being imposed for deficiencies at TAG 851 and TAG 856, with severity level four for each deficiency. The notice outlines the appeal process, payment instructions, and potential penalty reductions.
Severity Breakdown
Severity level four: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Deficiency at TAG 851 | Severity level four |
| Deficiency at TAG 856 | Severity level four |
Report Facts
Monetary penalties: 2000
Initial penalty per deficiency: 1000
Penalty reduction: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Minou Nelson | Health Facilities Inspector III | Signed the sanction notice |
| Kyle Devine | Bureau Chief | Referenced as Bureau Chief in the sanction notice |
Inspection Report
Complaint Investigation
Census: 10
Capacity: 10
Deficiencies: 2
May 6, 2016
Visit Reason
The inspection was conducted as a complaint investigation initiated on 5/6/16 regarding allegations of misappropriation of property at a residential facility for elderly and disabled persons.
Findings
The investigation substantiated the complaint of misappropriation of property. The facility failed to obtain documented permission from one resident to handle their personal money and did not maintain accurate records of residents' money transactions.
Complaint Details
Complaint #NV00045551 was substantiated. The allegation of misappropriation of property was substantiated.
Severity Breakdown
Level 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to obtain documented permission from 1 of 10 residents to handle the resident's personal money. | Level 2 |
| Facility failed to ensure accurate records were kept for residents whose money was deposited with the facility, including withdrawals and receipts. | Level 2 |
Report Facts
Residents present: 10
Total licensed capacity: 10
Complaints investigated: 1
Inspection Report
Complaint Investigation
Census: 10
Capacity: 10
Deficiencies: 2
May 6, 2016
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 5/6/16 regarding allegations of misappropriation of property at the facility.
Findings
The investigation substantiated the complaint of misappropriation of property. Deficiencies were found related to failure to obtain documented permission to handle a resident's money and failure to maintain accurate records of residents' money deposited with the facility.
Complaint Details
Complaint #NV00045551 was substantiated. The allegation of misappropriation of property was substantiated.
Severity Breakdown
2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to obtain documented permission from 1 of 10 residents to hold the resident's personal money. | 2 |
| Facility failed to ensure accurate records were kept for residents whose money was deposited with the facility, including missing beginning monthly balance and lack of resident acknowledgement for purchases. | 2 |
Report Facts
Residents present: 10
Licensed capacity: 10
Complaints investigated: 1
Sample size: 1
Inspection Report
Complaint Investigation
Capacity: 10
Deficiencies: 3
Mar 15, 2016
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 2016-02-23 regarding the facility's failure to timely call 911 or the coroner after the death of a resident.
Findings
The facility was found to have failed to call 911 or emergency medical services timely after a resident experienced difficulty breathing and died. Caregivers did not attempt CPR and did not call 911, instead notifying the facility manager who also delayed calling emergency services. The resident's body was not removed until approximately 12 hours after death.
Complaint Details
Complaint #NV00045410 was substantiated. The allegation that the facility failed to call 911 or the coroner timely after the death of a resident was substantiated.
Severity Breakdown
Level 2: 1
Level 4: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure 911 or the coroner was called timely following the death of a resident. | Level 2 |
| Facility failed to ensure emergency medical services were obtained for a resident who experienced difficulty breathing and later stopped breathing. | Level 4 |
| Facility failed to ensure caregivers attempted cardiopulmonary resuscitation (CPR) on a resident after observing difficulty breathing and death. | Level 4 |
Report Facts
Total licensed beds: 10
Resident age: 89
Time delay: 12
Date of resident admission: Apr 10, 2013
Date of incident: Jan 24, 2016
Date caregiver called facility manager: Jan 24, 2016
Date facility manager called 911: Jan 25, 2016
CPR training expiration date caregiver #1: Oct 15, 2016
CPR training expiration date caregiver #2: Jun 10, 2017
Inspection Report
Complaint Investigation
Capacity: 10
Deficiencies: 3
Feb 23, 2016
Visit Reason
This complaint investigation was initiated due to an allegation that the facility failed to call 911 or the coroner timely after the death of a resident.
Findings
The investigation substantiated the complaint that the facility failed to ensure emergency medical services were obtained timely after a resident experienced difficulty breathing and later died. The facility also failed to ensure caregivers attempted CPR and failed to call 911 promptly. The administrator conducted training and staff meetings to address these issues.
Complaint Details
Complaint #NV00045410 was substantiated. The allegation that the facility failed to call 911 or the coroner timely after the death of a resident was substantiated.
Severity Breakdown
Level 2: 1
Level 4: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to call 911 or the coroner timely after the death of a resident. | Level 2 |
| Facility failed to ensure emergency medical services were obtained for a resident who experienced difficulty breathing and later stopped breathing. | Level 4 |
| Facility failed to ensure caregivers attempted cardiopulmonary resuscitation (CPR) on a resident after observing difficulty breathing and later stopped breathing. | Level 4 |
Report Facts
Licensed capacity: 10
Resident age: 89
Dates of CPR training: Oct 15, 2014
Dates of CPR training: Jun 10, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lalana Millahumosa | Administrator | Administrator named in findings and corrective actions |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 5
Jan 13, 2016
Visit Reason
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 B with multiple deficiencies identified related to caregiver training, elder abuse training, and safety issues including dangerous items accessible to residents, unsecured yard gate, and toxic substances accessible to residents.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 6 employees had annual care giving training for 2015 (Employee #6). | Severity: 2 |
| Failed to ensure 2 of 6 employees had Elder Abuse training for 2015 (Employees #1 and #6). | Severity: 2 |
| Facility failed to ensure dangerous items (push pins, nail clippers, key pins) were inaccessible to residents. | Severity: 2 |
| Facility failed to ensure a gate leading to an unsecured storage area was locked. | Severity: 2 |
| Facility failed to ensure toxic substances (aerosol air freshener and household cleaner) were inaccessible to residents. | Severity: 2 |
Report Facts
Census: 9
Total Capacity: 10
Employees reviewed: 6
Resident files reviewed: 9
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 5
Jan 13, 2016
Visit Reason
This inspection was conducted as an annual State Licensure survey to assess compliance with regulatory requirements for the residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of B with several deficiencies identified including failure to ensure annual caregiver training, elder abuse training, and safety measures related to dangerous items, fencing, and toxic substances accessibility.
Severity Breakdown
2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 6 employees had annual caregiving training for 2015. | 2 |
| Failed to ensure 2 of 6 employees had Elder Abuse training for 2015. | 2 |
| Failed to ensure dangerous items such as push pins, nail clippers, and key pins were inaccessible to residents. | 2 |
| Failed to ensure a gate leading to an unsecured storage area was locked. | 2 |
| Failed to ensure toxic substances were not accessible to residents; aerosol can and household cleaner found in resident bathroom. | 2 |
Report Facts
Number of resident files reviewed: 9
Number of employee files reviewed: 6
Facility grade: B
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #6 | Caregiver | Named in findings for lack of annual caregiving and elder abuse training |
| Employee #1 | Caregiver | Named in findings for lack of elder abuse training |
Inspection Report
Renewal
Census: 10
Capacity: 10
Deficiencies: 2
Feb 17, 2015
Visit Reason
This State Licensure re-grading survey was conducted to assess compliance with licensing requirements for a residential facility providing care to persons with Alzheimer's disease, Category 2 residents.
Findings
The facility received a grade of A but was found to have deficiencies related to health and sanitation, specifically the presence of insects and rodents in the kitchen and dining areas. These deficiencies were repeat findings from the previous annual survey.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure premises were free from insects and rodents; insect traps found with dead insects and a cockroach observed in the kitchen area. | Severity: 2 |
| Facility failed to maintain interior and exterior premises; food particles and dead insects observed in dining and pantry areas. | Severity: 2 |
Report Facts
Facility licensed beds: 10
Census: 10
Severity: 2
Scope: 3
Inspection Report
Renewal
Census: 10
Capacity: 10
Deficiencies: 2
Feb 17, 2015
Visit Reason
This Statement of Deficiencies was generated as a result of a State Licensure re-grading survey conducted on 2/17/15 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 to have deficiencies related to health and sanitation, specifically failure to keep the premises free from insects and rodents, and failure to maintain the interior of the facility well. These deficiencies were repeat findings from the previous annual survey.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure it was free from insects; cockroach observed in kitchen area despite ongoing exterminator treatment. | Severity: 2 |
| Facility failed to ensure the interior was well maintained; food particles and dead insects observed on floors and in cabinets. | Severity: 2 |
Report Facts
Facility licensed beds: 10
Census: 10
Repeat deficiencies: 2
Severity level: 2
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver #2 observed cockroach and confirmed ongoing exterminator treatment | ||
| Employee #3 acknowledged floors required sweeping and that cleaning would help mitigate cockroach situation |
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