Deficiencies per Year
12
9
6
3
0
Severe
High
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 133
Capacity: 156
Deficiencies: 5
Jul 9, 2025
Visit Reason
The inspection was conducted as an annual State Licensure and Complaint Investigation survey in accordance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.
Findings
The facility received a grade of A with one complaint investigated and found unsubstantiated. Several regulatory deficiencies were identified including failure to complete annual tuberculosis screenings for employees and a resident, failure to complete background checks every five years for an employee, failure to maintain kitchen cleanliness, and failure to ensure medications administered as needed had proper written instructions.
Complaint Details
One complaint (Complaint #NV00074013) was investigated and found unsubstantiated with no regulatory deficiencies identified.
Severity Breakdown
Level 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure annual tuberculosis screening was completed for 2 of 10 employees. | Level 2 |
| Failed to ensure a background check was completed every five years for 1 of 10 employees. | Level 2 |
| Failed to ensure kitchen and supportive dining services complied with NAC 446 standards; heavy grease and debris buildup on cook's line equipment and soiled floor under beverage table. | Level 2 |
| Failed to ensure resident physician orders for medications administered as needed included written instructions indicating symptoms for administration and did not require staff assessment to determine medication amount for 3 of 25 sampled residents. | Level 2 |
| Failed to ensure 1 of 25 sampled residents received an annual tuberculosis test. | Level 2 |
Report Facts
Number of employees reviewed: 10
Number of resident files reviewed: 26
Number of sampled residents for medication review: 25
Facility licensed capacity: 156
Facility census at time of survey: 133
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Trudy Andrews | Executive Director | Named as Executive Director responsible for oversight and signing the report |
Inspection Report
Complaint Investigation
Census: 144
Deficiencies: 0
Feb 5, 2025
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 02/05/2025.
Findings
No regulatory deficiencies were identified during the investigation. The complaint #NV00072991 was not substantiated after observations, interviews, and document reviews.
Complaint Details
One complaint was investigated (Complaint #NV00072991) and it was not substantiated.
Report Facts
Complaint investigated: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| food service director | Interviewed during complaint investigation | |
| assistant food service director | Interviewed during complaint investigation | |
| food service staff | Interviewed during complaint investigation |
Inspection Report
Re-Inspection
Census: 133
Capacity: 136
Deficiencies: 0
Sep 26, 2024
Visit Reason
This Statement of Deficiencies was generated as a result of a mandatory regrading survey completed at the facility on 09/26/24, in accordance with Nevada Administrative Code (NAC) Chapter 449, Residential Facility for Groups.
Findings
The facility received a grade of A with no deficiencies identified during the survey. Eleven resident files and four employee files were reviewed.
Report Facts
Resident files reviewed: 11
Employee files reviewed: 4
Inspection Report
Complaint Investigation
Census: 133
Capacity: 156
Deficiencies: 0
Sep 26, 2024
Visit Reason
The inspection was conducted due to a bed increase request and complaint investigation surveys at the facility on 09/26/24.
Findings
Two complaints were investigated: one was substantiated without deficient practice, and the other was unsubstantiated. No regulatory deficiencies were identified during the investigation, which included observations, interviews, and record reviews.
Complaint Details
Two complaints were investigated: Complaint #NV00072096 was substantiated with no deficient practice, and Complaint #NV00072015 was unsubstantiated. No regulatory deficiencies were identified.
Report Facts
Licensed beds: 156
Current census: 133
Sample size: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver | Interviewed during complaint investigation | |
| Medication Technicians | Interviewed during complaint investigation | |
| Food Services Manager | Interviewed during complaint investigation | |
| Executive Director | Interviewed during complaint investigation |
Inspection Report
Annual Inspection
Census: 133
Capacity: 136
Deficiencies: 11
Jul 18, 2024
Visit Reason
This inspection was an annual State Licensure survey conducted to assess compliance with Nevada Administrative Code (NAC) Chapter 449 for a Residential Facility for Groups providing assisted living services.
Findings
The facility was found deficient in multiple areas including caregiver training (medication management, elder abuse, infection control), personnel file requirements (TB screening, background checks), food service compliance, safety requirements in the Alzheimer's unit, medication administration accuracy, maintenance of resident files, and documentation of residents' preferred pronouns. The facility received a grade of D.
Severity Breakdown
Level 2: 10
Level 1: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure Medication Management training was completed annually for 1 of 10 employees (Employee #5). | Level 2 |
| Failed to ensure Elder Abuse training was completed upon hire and annually for 2 of 10 employees (Employee #1 and Employee #4). | Level 2 |
| Failed to ensure two-step tuberculosis (TB) screening was completed upon hire for 1 of 10 employees (Employee #6). | Level 2 |
| Failed to ensure background check was completed for 1 of 10 employees (Employee #10). | Level 2 |
| Failed to ensure kitchen and dining services complied with NAC 446 standards including food held past safe date, employees not wearing hairnets, and grime build-up on ice machine. | Level 2 |
| Failed to ensure auditory notification system was working in the Alzheimer's unit; residents were not provided pendants. | Level 2 |
| Failed to ensure six month pharmacy reviews were reviewed and signed off by the Administrator for 11 of 25 residents. | Level 2 |
| Failed to ensure medications were onsite for 3 of 25 residents (Residents #2, #15, and #23) and lacked documented discontinue orders. | Level 2 |
| Failed to obtain a Physician Placement Determination upon admission for 1 of 25 residents (Resident #16). | Level 2 |
| Failed to document preferred pronoun, gender expression, and sexual orientation for 25 of 25 residents. | Level 1 |
| Failed to ensure Infection Control training was completed for 4 of 10 employees (Employees #2, #4, #5, and #7). | Level 2 |
Report Facts
Residents reviewed: 25
Employee files reviewed: 10
Deficiencies cited: 11
Facility licensed capacity: 136
Current census: 133
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Trudy Andrews | Administrator | Named as responsible for compliance and signing report |
| Employee #5 | Assisted Living Manager | Failed to complete annual Medication Management and Infection Control training |
| Employee #1 | Medication Technician | Failed to complete Elder Abuse training upon hire |
| Employee #4 | Memory Care Manager | Failed to complete annual Elder Abuse and Infection Control training |
| Employee #6 | Wellness Director | Failed to complete two-step TB screening upon hire |
| Employee #10 | Caregiver | Failed to complete background check |
| Employee #2 | Caregiver | Failed to complete Infection Control training annually |
| Employee #7 | Medication Technician | Failed to complete Infection Control training annually |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 136
Deficiencies: 1
Nov 20, 2023
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received, in accordance with Nevada Administrative Code, Chapter 449, Requirements for Residential Facilities for Groups.
Findings
The facility was found to be over its licensed capacity with 141 residents present versus a licensed capacity of 136 beds. The complaint investigated was unverified. Observations, interviews, and document reviews were conducted, and the facility received a grade of A.
Complaint Details
One complaint was investigated (Complaint #NV00069683) and was unverified.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure the number of residents did not exceed the licensed capacity, with 141 residents present exceeding the licensed 136 beds. | Severity: 2 |
Report Facts
Licensed beds: 136
Residents present: 141
Sample size: 15
Occupants in assisted living units: 113
Occupants in memory care units: 28
Category II residents licensed: 106
Category II Alzheimer's residents licensed: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Trudy Andrews | Administrator | Signed as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 136
Deficiencies: 0
Oct 17, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 2023-09-28 and finalized on 2023-10-17, in accordance with Nevada Administrative Code, Chapter 449, Requirements for Residential Facilities for Groups.
Findings
No regulatory deficiencies were identified during the investigation. The complaint was unverified and no action was necessary. The investigation included facility tours, observations, interviews, and record reviews.
Complaint Details
One complaint was investigated: Complaint #NV00069194 could not be verified. No regulatory deficiencies were identified.
Report Facts
Sample size: 4
Sample size: 3
Rooms observed: 12
Residents interviewed: 10
Family members interviewed: 2
Housekeepers interviewed: 1
Caregivers interviewed: 5
Inspection Report
Re-Inspection
Census: 133
Capacity: 136
Deficiencies: 0
Aug 31, 2023
Visit Reason
This inspection was a State Licensure mandatory grading resurvey conducted at the facility on 08/31/2023 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. Multiple areas including personnel files, laundry and linen services, food service permits, medication storage, and Alzheimer's care standards were reviewed with no further action needed.
Report Facts
Licensed beds: 136
Census: 133
Inspection Report
Annual Inspection
Census: 133
Capacity: 136
Deficiencies: 6
Jul 19, 2023
Visit Reason
This inspection was conducted as an annual State Licensure survey 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 missing pre-employment physicals for employees, unsanitary laundry conditions, food safety violations in the kitchen, unsecured medications and sharp objects in resident rooms, and unsecured toxic substances. The facility received a grade of C.
Severity Breakdown
Severity: 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 10 employees had a signed and dated pre-employment physical examination. | Severity: 2 |
| Laundry room was not kept in a sanitary manner with heavy lint build-up behind washers and dryers and lint traps not cleaned daily. | Severity: 2 |
| Kitchen and supportive dining services failed to comply with food safety standards including expired food, improper food storage, and inadequate dishwashing temperatures. | Severity: 2 |
| Medications were unsecured in 2 of 3 sampled resident rooms with broken cabinet locks. | Severity: 2 |
| Sharp objects were unsecured in 1 of 3 sampled resident rooms with broken cabinet locks. | Severity: 2 |
| Toxic substances were unsecured in 3 of 3 sampled resident rooms with broken cabinet locks. | Severity: 2 |
Report Facts
Employees missing pre-employment physicals: 2
Resident census: 133
Total licensed capacity: 136
Expired food items: 3
Dishwasher final rinse temperature: 105
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Trudy Andrews | Administrator | Acknowledged missing pre-employment physicals and oversaw compliance processes. |
| Memory Care Director | Acknowledged unsecured medications, sharp objects, toxic substances, and lint build-up issues. | |
| Maintenance Director | Acknowledged lint build-up in laundry and responsibility for cleaning. | |
| Food Service Director | Responsible for ensuring no expired food and cleanliness of kitchen equipment. |
Inspection Report
Complaint Investigation
Census: 132
Capacity: 136
Deficiencies: 0
Feb 21, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 02/21/23 in accordance with Nevada Administrative Code Chapter 449.
Findings
No regulatory deficiencies were identified during the investigation. The complaint could not be substantiated after observations, interviews, and record reviews. No further action was necessary.
Complaint Details
One complaint (Complaint #NV00067583) was investigated and could not be substantiated.
Report Facts
Sample size: 5
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