Inspection Reports for Las Vegas Alzheimers & Memory Care 2
3225 Brazos Street, Las Vegas, NV 89169, NV, 89169
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 1
Oct 28, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by one complaint at the facility, in accordance with Nevada Administrative Code (NAC), Chapter 449, Residential Facility for Groups.
Findings
The complaint was unsubstantiated due to lack of evidence after observations, interviews, and record reviews. However, one deficiency was identified related to inaccurate documentation in the Medication Administration Record (MAR) for one resident, where a medication was not initialed as administered.
Complaint Details
One complaint (#NV00074855) was investigated and found to be unsubstantiated due to lack of evidence.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure the Medication Administration Record (MAR) included accurate documentation for 1 of 10 residents; specifically, Clopidogrel 75 mg was not initialed as administered on 08/20/25. | Severity: 2 |
Report Facts
Residents present: 10
Sample size: 5
Complaints investigated: 1
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 2
Jan 27, 2025
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 01/27/2025, triggered by complaint #NV00072920.
Findings
The complaint was substantiated without deficiencies. However, two regulatory deficiencies were identified: failure to complete an incident report for a resident with a change of condition, and failure to retain resident records for at least five years after discharge.
Complaint Details
Complaint #NV00072920 was substantiated without deficiencies. The investigation included observation of grooming and physical appearance, resident interactions with staff, a tour of the facility, interviews with caregivers, residents, and the administrator, and record review of five resident files including the resident of concern.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure an incident report was completed for a resident who had a change of condition (Resident #1). | Severity: 2 |
| Failure to ensure resident records were retained for at least 5 years after discharge for Resident #1. | Severity: 2 |
Report Facts
Residents present: 10
Resident files reviewed: 5
Deficiency count: 2
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 1
Nov 4, 2024
Visit Reason
The inspection was conducted as a result of an Annual State Licensure survey combined with a complaint investigation at the facility on 11/04/2024.
Findings
The facility received a grade of A with no regulatory deficiencies identified from the complaint investigation, which was unsubstantiated. However, one deficiency was cited related to medication administration documentation inaccuracies for one resident.
Complaint Details
One complaint (Complaint #NV00072251) was investigated and found to be unsubstantiated after observation, interviews, and record review.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medication-in-charge caregiver failed to document medication administration on the Medication Administration Record (MAR) for Resident #8, despite medication being administered as ordered by the physician. | D |
Report Facts
Residents files reviewed: 10
Employee files reviewed: 3
Deficiency severity level: 1
Inspection Report
Re-Inspection
Census: 9
Capacity: 10
Deficiencies: 10
Jan 10, 2024
Visit Reason
This Statement of Deficiencies was generated as a result of a State Licensure mandatory grading resurvey conducted at the facility on 01/10/24, 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. The premises were found to be clean and well maintained, meals were nutritious and served appropriately, and medication administration and storage policies were in compliance with regulations.
Severity Breakdown
F: 4
D: 4
E: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Health & Sanitation - Maintain Interior/Exterior - NAC 449.209 | F |
| Service of Food-Nutritious Meals; Frequency - NAC 449.2175 | F |
| Bathrooms and Toilet Facilities - NAC 449.222 | F |
| Residents Requiring Use of Oxygen - NAC 449.2712 | D |
| Medication Administration - NRS 449.0302 - NAC 449.2742 | D |
| Medication/OTCS, Supplements, Change Order - NAC 449.2742 | D |
| Medication - Destruction - NAC 449.2742 | E |
| Administration of Medication Maintenance - NAC 449.2744 | D |
| Medication: Storage - NAC 449.2748 | F |
| Maintenance and Contents of Separate File - NAC 449.2749 | E |
Report Facts
Licensed beds: 10
Residents present: 9
Resident files reviewed: 5
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 10
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 to have multiple regulatory deficiencies including cleanliness issues with kitchen grease and mouse droppings, expired food items, lack of non-slip surfaces in showers, unsecured oxygen tanks, medication administration and storage errors, failure to destroy expired medications, and incomplete annual assessments for residents.
Severity Breakdown
Level 2: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Facility failed to ensure premises was well maintained; kitchen cabinets and cooktop had grease and mouse droppings. | Level 2 |
| Expired food items found in kitchen pantry and refrigerator, not suitable for residents. | Level 2 |
| Two of three bathroom showers lacked surfaces to inhibit falling and slipping. | Level 2 |
| Oxygen tank unsecured in resident's closet. | Level 2 |
| Ultimate User Agreement for medication administration was unsigned and undated for one resident. | Level 2 |
| Medication (Meclizine) was not on site for one resident. | Level 2 |
| Expired medications were not destroyed for three residents. | Level 2 |
| Medication Administration Record (MAR) was inaccurate for one resident. | Level 2 |
| Medications stored unsecured in refrigerator. | Level 2 |
| Annual Activities of Daily Living (ADL) assessments were not completed for two residents. | Level 2 |
Report Facts
Census: 9
Total Capacity: 10
Deficiencies cited: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Chan Tan | Administrator | Signed the report and plan of correction |
Inspection Report
Re-Inspection
Census: 8
Capacity: 10
Deficiencies: 2
Mar 9, 2023
Visit Reason
The inspection was a State Licensure voluntary grading resurvey conducted to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but was cited for two deficiencies: failure to destroy expired medication and failure to securely store medication in a locked refrigerator. Both deficiencies were corrected during the survey.
Severity Breakdown
2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to destroy expired medication of a resident, including morphine syringes and Tubersol, which had expired several months prior. | 2 |
| Failure to ensure medication was stored securely; medication was found in an unsecured refrigerator with a broken lock accessible to residents. | 2 |
Report Facts
Licensed beds: 10
Census: 8
Expired morphine syringes: 8
Expired medication dates: Morphine expired 06/11/22, Tubersol expired 07/28/22
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 5
Nov 22, 2022
Visit Reason
The inspection was conducted as an annual licensing and infection control survey of the residential facility for groups providing care for persons with Alzheimer's disease.
Findings
The facility was found deficient in multiple areas including failure to provide scheduled activities for residents, unsecured refrigerated medications, incomplete tuberculosis testing documentation for a newly admitted resident, unsecured chemicals accessible to residents, and the presence of broken equipment and debris in the backyard.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to provide activities in accordance with the activity calendar for all residents. | Severity: 2 |
| Refrigerated medications were not stored in a locked refrigerator and were accessible to residents. | Severity: 2 |
| Failure to ensure a two-step tuberculosis test was completed for a newly admitted resident. | Severity: 2 |
| Chemicals in the kitchen were not properly locked up and were accessible to residents. | Severity: 2 |
| Backyard was not free of debris and broken equipment, posing safety risks. | Severity: 2 |
Report Facts
Resident files reviewed: 10
Employee files reviewed: 4
Facility licensed beds: 10
Residents present: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris C. Tan | Administrator | Named as the administrator responsible for monitoring and corrective actions. |
Inspection Report
Re-Inspection
Census: 8
Capacity: 10
Deficiencies: 0
Apr 13, 2022
Visit Reason
This inspection was a State Licensure voluntary grading resurvey conducted at the facility 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. Guidance was provided on non-discrimination policies, privacy protection, cultural competency training, complaint policy, and gender identity/expression policy compliance.
Inspection Report
Complaint Investigation
Census: 10
Capacity: 10
Deficiencies: 1
Mar 17, 2022
Visit Reason
The inspection was conducted as a State Licensure Complaint Investigation survey triggered by a complaint regarding medication administration at the facility.
Findings
The facility failed to ensure medications were administered to a resident as ordered by the physician. Specifically, medications prescribed on 02/11/22 for Resident #1 were misplaced after delivery and not administered as ordered.
Complaint Details
Complaint #NV00065903 was substantiated with one allegation that the facility did not administer medications as ordered by the physician on 02/11/22.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to administer medications as ordered by the physician for Resident #1. | D |
Report Facts
Complaint number: 65903
Resident records reviewed: 4
Inspection Report
Annual Inspection
Census: 7
Capacity: 10
Deficiencies: 5
Nov 22, 2021
Visit Reason
The inspection was conducted as an annual State Licensure, infection control, and complaint investigation survey at the facility on 11/22/21.
Findings
The facility received a grade of B with several deficiencies identified including failure to implement proper infection control practices during COVID-19, improper storage of oxygen canisters, lack of annual physical examination for one resident, absence of an ultimate user agreement for medication administration for one resident, and missing documentation of a second step tuberculosis test for one resident. One complaint was investigated and found unsubstantiated.
Complaint Details
One complaint (#NV00064933) was investigated with one allegation that a resident was pushed out onto the porch with their belongings. The allegation was unsubstantiated based on interviews with the owner and a caregiver, observations, and record reviews.
Severity Breakdown
Level 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure infection control practices were implemented and maintained in response to the COVID-19 pandemic, including not checking temperatures or conducting screening questionnaires for health facilities inspectors prior to entry. | Level 2 |
| Oxygen canister was found unsecured in the corner of a resident room without a holder to prevent it from falling over. | Level 2 |
| Failed to ensure one resident had an annual physical examination documented. | Level 2 |
| Failed to ensure one resident had an ultimate user agreement for medication administration. | Level 2 |
| Failed to ensure one resident had a documented two-step tuberculosis test; second step was missing. | Level 2 |
Report Facts
Licensed capacity: 10
Current census: 7
Resident files reviewed: 7
Employee files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris C. Tan | Administrator | Named in relation to infection control deficiencies and oversight responsibilities |
Inspection Report
Renewal
Census: 9
Capacity: 10
Deficiencies: 13
Jul 13, 2016
Visit Reason
The inspection was conducted as an annual State Licensure survey for re-licensure of the facility.
Findings
The facility received a grade of D with multiple deficiencies identified including improper food storage, sanitation issues, lack of resident privacy, medication administration errors, unsecured medications, incomplete resident files, missing tuberculosis testing documentation, unsecured dangerous items, non-operational door alarms, and unsafe yard conditions.
Severity Breakdown
1: 2
2: 11
Deficiencies (13)
| Description | Severity |
|---|---|
| Improper storage of perishable foods; eggs stored outside refrigerator. | 2 |
| Sanitation not maintained; grease, dust, food debris, and broken equipment found. | 2 |
| Lack of visual privacy in resident bedroom due to missing window coverings. | 2 |
| Failure to post the July 2016 food menu. | 1 |
| No paper towels or cloth towels provided in bathrooms. | 2 |
| Incomplete or missing ultimate user agreements for medication administration for 5 residents. | 2 |
| Medications not administered as prescribed; missing physician orders for some medications. | 2 |
| Medications stored unsecured in kitchen cabinets including medications for discharged residents and staff. | 2 |
| Resident files stored unsecured in unlocked cabinets including outside the facility. | 1 |
| Missing tuberculosis testing documentation for 6 residents. | 2 |
| Dangerous items such as disposable razors found unsecured in resident bathroom. | 2 |
| Audible alarms for exit doors were not operational or turned off. | 2 |
| Front courtyard and backyard not maintained safely; broken wooden slats, broken sink, and hazards present. | 2 |
Report Facts
Residents reviewed: 9
Employee files reviewed: 4
Medication doses unaccounted: 39
Facility licensed beds: 10
Current census: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lalaine Villahermosa | Administrator | Named as Administrator and involved in findings and corrective actions |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 13
Jul 13, 2016
Visit Reason
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 and/or persons with Alzheimer's disease.
Findings
The facility received a grade of D with multiple deficiencies identified including issues with cleanliness and maintenance, improper food storage, lack of posted menus, privacy concerns, inadequate bathroom supplies, incomplete medication administration documentation, unsecured medication storage, unsecured resident files, missing tuberculosis documentation, non-operational exit door alarms, presence of dangerous items accessible to residents, and unsafe conditions in the outdoor yard areas.
Severity Breakdown
Severity: 1: 2
Severity: 2: 11
Deficiencies (13)
| Description | Severity |
|---|---|
| Facility failed to ensure premises were clean and well maintained, including grease and dust buildup in kitchen and backyard clutter. | Severity: 2 |
| Perishable foods were not refrigerated properly; eggs stored in kitchen cabinet due to full refrigerator. | Severity: 2 |
| Facility failed to post the July 2016 menu as required. | Severity: 1 |
| Failed to provide visual privacy in 1 of 6 bedrooms (Room #4) due to lack of window coverings. | Severity: 2 |
| No paper towels or cloth towels provided in facility bathrooms. | Severity: 2 |
| Ultimate user agreements for medication administration were incomplete or missing for 5 of 9 residents. | Severity: 2 |
| Medications were not administered as prescribed for 2 residents and lacked physician orders for 1 resident. | Severity: 2 |
| Medications were not stored in a locked area; unsecured medications found in kitchen cabinets including those of discharged residents and employees. | Severity: 2 |
| Resident files were not kept in a secure location; files found in unlocked cabinets including outside the facility. | Severity: 1 |
| Facility failed to ensure 6 of 9 residents had required tuberculosis testing and documentation. | Severity: 2 |
| Audible alarms for exit doors were not operational or turned off, compromising resident safety. | Severity: 2 |
| Dangerous items such as disposable razors were accessible to residents in a bathroom. | Severity: 2 |
| Outdoor yard areas were not maintained safely, including broken wooden slats, sharp pottery shards, loose tubing, hose on ground, and broken sink with sharp edges. | Severity: 2 |
Report Facts
Resident census: 9
Total licensed capacity: 10
Residents with incomplete ultimate user agreements: 5
Residents with missing tuberculosis documentation: 6
Unaccounted alprazolam tablets: 39
Inspection Report
Complaint Investigation
Census: 7
Deficiencies: 0
Feb 8, 2016
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding allegations of improper staffing at the facility.
Findings
The complaint was investigated through observation, interviews, and policy review, and the allegations were not substantiated. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00045076 alleged the facility was not staffed properly; the allegation was not substantiated.
Report Facts
Sample size: 3
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 1
Dec 10, 2015
Visit Reason
This inspection was a mandatory State Licensure grading re-survey conducted on 12/8/2015 to assess compliance with state regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility was found to have a repeat deficiency related to door alarms; specifically, one of four exit doors did not have an operational alarm when opened. The alarm for the laundry room exit door was turned off during the inspection, and a required sign reminding staff to keep the door alarm on was missing but later replaced.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 exit doors had installed alarms that operated when the door was opened. | Severity: 2 |
Report Facts
Licensed beds: 10
Residents present: 8
Repeat deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver #2 | Caregiver | Acknowledged the alarm was turned off and turned it back on |
| Administrator | Reported on the missing sign and replaced it during the inspection |
Inspection Report
Re-Inspection
Census: 8
Capacity: 10
Deficiencies: 1
Dec 8, 2015
Visit Reason
The inspection was a mandatory State Licensure grading re-survey conducted to evaluate compliance with regulations related to door alarms in a residential facility for persons with Alzheimer's disease.
Findings
The facility was cited for failing to ensure that operational alarms were installed on all exit doors, specifically one of four exit doors lacked an alarm. The deficiency was a repeat from the prior annual survey, and the facility received a grade of A.
Severity Breakdown
Severity 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 exit doors had installed alarms that operated when the door was opened. | Severity 2 |
Report Facts
Residents present: 8
Total licensed capacity: 10
Exit doors without alarms: 1
Deficiency repeat count: 1
Scope: 3
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 2
Aug 27, 2014
Visit Reason
Annual State Licensure survey conducted to assess compliance with regulatory requirements for a residential facility providing care to persons with Alzheimer's disease, Category 2 residents.
Findings
The facility received a grade of A. Deficiencies were identified related to Elder Abuse Training and Personnel File requirements, including failure to ensure employees had required training and documentation prior to employment.
Severity Breakdown
Level 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure 2 of 7 employees had Elder Abuse training prior to employment. | Level 2 |
| Failure to ensure 3 of 7 employees had pre-employment physicals and 1 of 7 employees completed required two-step tuberculosis screening. | Level 2 |
Report Facts
Employees reviewed: 7
Resident files reviewed: 10
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 2
Aug 27, 2014
Visit Reason
This annual State Licensure survey was conducted to assess compliance with state regulations for a Residential Facility for Group beds providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A. Deficiencies were identified related to Elder Abuse training and personnel file requirements, including failure to ensure some employees had Elder Abuse training prior to employment and missing documentation of pre-employment physicals and tuberculosis screening.
Severity Breakdown
2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 7 employees had Elder Abuse training prior to employment (Employee #4 and #7). | 2 |
| Failed to ensure 3 of 7 employees had pre-employment physicals and 1 of 7 employees completed a two-step tuberculosis screening (Employees #1, #2, #4, and #7). | 2 |
Report Facts
Employees reviewed: 7
Resident files reviewed: 10
Inspection Report
Complaint Investigation
Census: 9
Deficiencies: 1
Jul 16, 2014
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding staffing levels for residents with Alzheimer's Disease.
Findings
The facility was found to have only one caregiver for nine residents with Alzheimer's Disease, which did not meet regulatory requirements. The complaint was substantiated, and the owner acknowledged the staffing deficiency and agreed to comply with regulations.
Complaint Details
Complaint #NV00039739 contained one allegation that the facility only had one caregiver for nine residents with Alzheimer's Disease. The complaint was substantiated.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide enough caregiver staff to nine residents with Alzheimer's Disease. | Severity: 2 |
Report Facts
Census: 9
Severity level: 2
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Caregiver observed and interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 9
Deficiencies: 1
Jul 16, 2014
Visit Reason
This inspection was conducted as a complaint investigation triggered by complaint #NV00039739 regarding staffing levels at the facility.
Findings
The complaint was substantiated; the facility failed to provide enough caregiver staff for nine residents with Alzheimer's Disease, having only one caregiver present during a visit.
Complaint Details
Complaint #NV00039739 contained one allegation that the facility only had one caregiver for nine residents with Alzheimer's Disease. The allegation was substantiated.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure it provided enough caregiver staff to nine residents with Alzheimer's Disease. | 2 |
Report Facts
Census: 9
Severity level: 2
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 was the only caregiver present during the visit; no full name provided. |
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 4
Aug 23, 2013
Visit Reason
This visit was a State Licensure annual grading survey conducted to assess compliance with licensing requirements for a residential facility for persons with Alzheimer's disease.
Findings
The facility received a grade of B with several deficiencies identified including failure to ensure pre-employment physicals for employees, medication storage issues, unsecured dangerous items, and violation of the license agreement regarding low income beds.
Severity Breakdown
Severity: 2: 3
Severity: 1: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 7 employees complied with pre-employment physicals requirements. | Severity: 2 |
| Medication cabinet was unlocked with medication unsecured in caregiver's bedroom; repeat deficiency from prior survey. | Severity: 2 |
| Knives, matches, firearms, tools and other dangerous items were accessible to residents. | Severity: 2 |
| Facility violated license agreement by having 4 of 5 low income beds occupied by residents who did not qualify as low income. | Severity: 1 |
Report Facts
Employees reviewed: 7
Resident files reviewed: 10
Low income beds occupied by non-qualifying residents: 4
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