Deficiencies (last 3 years)
Deficiencies (over 3 years)
17.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
144% worse than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
140 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 0
Aug 18, 2025
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated at the facility on 08/18/25 in accordance with Nevada Administrative Code Chapter 449.
Findings
One complaint was investigated and found to be unsubstantiated. Observations, interviews, and record reviews were conducted, and no regulatory deficiencies were identified. No further action was required.
Complaint Details
One complaint (NV00074653) was investigated and determined to be unsubstantiated.
Report Facts
Sample size: 5
Facility grade: A
Inspection Report
Complaint Investigation
Census: 142
Capacity: 158
Deficiencies: 11
May 21, 2025
Visit Reason
The inspection was conducted as a result of a mandatory State Licensure grading resurvey and a complaint investigation related to the facility's compliance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility received a grade of B with multiple deficiencies identified, including failure to ensure annual caregiver and elder abuse training for employees, missing annual physical exams and TB tests for residents, and improper insulin administration for a resident. One complaint was substantiated regarding insulin not being maintained at a maintenance level.
Complaint Details
Complaint #NV00073954 was substantiated. The complaint investigation included observation of insulin storage and administration practices, interviews with staff, and record reviews. The finding was that insulin was administered using a sliding scale, which is not considered maintenance-level medication.
Severity Breakdown
Level F: 6
Level D: 5
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure 5 of 6 sampled employees completed annual caregiver training. | Level F |
| Failed to ensure 5 of 6 sampled employees completed annual elder abuse training. | Level F |
| Personnel files missing TB screening documentation. | Level D |
| Personnel files missing First Aid and CPR certification. | Level D |
| Failed to comply with food service permits and inspections. | Level F |
| Resident's insulin was administered using a sliding scale, not considered maintenance-level medication. | Level D |
| Failed to ensure 7 of 10 sampled residents received annual physical examinations. | Level F |
| Several resident files lacked evidence of required TB tests. | Level F |
| Failed to ensure operational alarms or technology for notifying staff when doors are opened for Alzheimer's care safety. | Level F |
| Failed to provide required cultural competency training documentation for employees. | Level D |
| Failed to conduct annual assessments and physical examinations of residents as required. | Level D |
Report Facts
Licensed capacity: 158
Census: 142
Employees sampled: 6
Residents sampled: 10
Deficiency severity counts: 6
Deficiency severity counts: 5
Inspection Report
Annual Inspection
Census: 156
Capacity: 158
Deficiencies: 11
Mar 18, 2025
Visit Reason
The inspection was conducted as an annual State Licensure survey of the assisted living facility to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility was found deficient in multiple areas including caregiver training, elder abuse training, tuberculosis screening, CPR and first aid certification, annual physical examinations for residents, maintenance of door alarms in the memory care unit, cultural competency training, and documentation of residents' preferred pronouns and gender identity. Several deficiencies were rated at severity level 2 or higher, with one severity level F deficiency related to kitchen sanitation and resident care.
Severity Breakdown
Level 1: 1
Level 2: 9
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 10 sampled employees completed eight hours of initial caregiver training. | Level 2 |
| Failure to ensure annual elder abuse training was completed for 2 of 10 employees. | Level 2 |
| Failure to ensure initial two-step tuberculosis (TB) test and physical examination upon hire for 2 of 10 sampled employees. | Level 2 |
| Failure to ensure initial CPR and first aid training for 2 of 10 sampled employees. | Level 2 |
| Failure to comply with kitchen sanitation standards including expired food, soiled surfaces, and non-operational dipper well. | Level 2 |
| Failure to ensure 3 of 25 residents received an annual physical examination. | Level 2 |
| Failure to ensure initial two-step TB test and annual TB tests for multiple residents. | Level 2 |
| Failure to ensure a functional audible alarm on a door leading to the memory care unit courtyard. | Level 2 |
| Failure to ensure 4 of 10 sampled employees completed cultural competency training within 90 days of hire. | Level 2 |
| Lack of updated policies and documentation addressing residents' preferred pronouns, gender expression, and sexual orientation for all residents. | Level 1 |
| Failure to ensure an annual placement assessment by a physician for 1 of 25 sampled residents. | Level 2 |
Report Facts
Residents present: 156
Total licensed capacity: 158
Employees sampled: 10
Residents sampled: 25
Facility grade: Facility received a grade of D
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Masich | Executive Director | Signed the report |
| Employee #3 | Caregiver | Named in deficiencies for caregiver training, elder abuse training, and cultural competency training |
| Employee #4 | Caregiver | Named in deficiencies for elder abuse training and CPR/first aid training |
| Employee #9 | Caregiver | Named in deficiencies for TB screening and cultural competency training |
| Employee #10 | Caregiver | Named in deficiencies for TB screening, CPR/first aid training, and cultural competency training |
| Employee #8 | Wellness Director | Named in deficiency for cultural competency training |
Inspection Report
Complaint Investigation
Census: 153
Deficiencies: 0
Feb 25, 2025
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 2025-01-28 and completed on 2025-02-25, in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
One complaint was investigated and found to be unsubstantiated. The investigation included observations, interviews, clinical record reviews, and document reviews. No regulatory deficiencies were identified and no further action was required.
Complaint Details
One complaint (NV00072932) was investigated and determined to be unsubstantiated.
Report Facts
Sample size: 3
Facility grade: A
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregivers | Interviewed during complaint investigation | |
| Kitchen staff | Interviewed during complaint investigation | |
| Administrator | Interviewed during complaint investigation | |
| Memory Care Coordinator | Interviewed during complaint investigation | |
| Wellness Director | Interviewed during complaint investigation | |
| Home Health agency representatives | Interviewed during complaint investigation |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 158
Deficiencies: 1
Nov 18, 2024
Visit Reason
The inspection was conducted due to a bed increase request and a complaint investigation regarding infection control practices related to Norovirus at the facility.
Findings
The facility failed to notify the proper State agency regarding a suspected Norovirus outbreak affecting six sampled residents. The complaint was substantiated, and deficiencies were identified related to infection control and reporting policies.
Complaint Details
Complaint #NV00072664 was substantiated. The investigation included observation of infection control practices, interviews with residents, caregivers, Wellness Director, and Administrator, and review of records and policies. The facility did not notify the county health department about the suspected Norovirus outbreak despite symptoms in six residents.
Severity Breakdown
Severity: 2 Scope: 3: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify the proper State agency regarding Norovirus in the facility for 6 sampled residents. | Severity: 2 Scope: 3 |
Report Facts
Bed increase: 22
Sample size: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Masich | Executive Director | Verified the facility did not contact the county health department regarding the illness. |
| Wellness Director | Indicated residents with Norovirus symptoms were immediately transferred to acute care hospital but county health department was not notified. |
Inspection Report
Complaint Investigation
Census: 136
Deficiencies: 1
Nov 14, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 2024-10-16 and completed on 2024-11-14, following Nevada Administrative Code requirements for Residential Facilities for Groups.
Findings
The facility failed to ensure timely response to the auditory call system for 1 of 5 sampled residents, resulting in delayed assistance to Resident #1 who experienced a stroke. The investigation found response times of 26 and 12 minutes, exceeding the facility's expected 10-minute response time.
Complaint Details
One complaint (#NV00072077) was substantiated regarding delayed response to a resident's call pendant. The complaint involved Resident #1 who pressed the call pendant twice on 07/19/24 and experienced delayed assistance leading to a stroke diagnosis. The facility acknowledged the response times were not timely and not per policy.
Severity Breakdown
Level 3: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the auditory call system was responded to in a timely manner for Resident #1, resulting in delayed assistance during a medical emergency. | Level 3 |
Report Facts
Census: 136
Response time to first call: 26
Response time to second call: 12
Complaint count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Masich | Executive Director | Signed the report and acknowledged response time issues |
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 2
Sep 5, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation survey triggered by complaint #NV00071699, which was substantiated.
Findings
The facility failed to report an allegation of abuse to Adult Protective Services (APS) concerning Resident #1, and failed to properly destroy discontinued medications for the resident. The investigation included interviews and record reviews, revealing multiple instances where APS notification was not documented and discontinued medications were improperly handled.
Complaint Details
Complaint #NV00071699 was substantiated. The complaint involved allegations of abuse and failure to report to APS. The investigation included interviews with facility staff and review of resident records and policies.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report an allegation of abuse to Adult Protective Services (APS) as required by Nevada Revised Statutes. | Severity: 2 |
| Failure to destroy discontinued medications for Resident #1 according to regulatory requirements. | Severity: 2 |
Report Facts
Sample size: 5
Discontinued medications: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Masich | Executive Director | Signed as Laboratory Director's or Provider/Supplier Representative's Signature on the report |
Inspection Report
Re-Inspection
Census: 140
Deficiencies: 12
May 30, 2024
Visit Reason
This inspection was conducted as a mandatory grading resurvey of the facility in accordance with Nevada Administrative Code, Chapter 449, Requirements for Residential Facilities for Groups.
Findings
The facility received a new grade of A with no regulatory deficiencies identified. No action is necessary.
Severity Breakdown
E: 1
F: 4
I: 1
D: 6
Deficiencies (12)
| Description | Severity |
|---|---|
| Personnel File - 1st Aid & CPR certification must be included for caregivers. | E |
| Laundry and linen services must be provided and maintained in a sanitary manner with proper equipment and separation from food areas. | F |
| Permits must comply with NAC 446 on Food Service for facilities with more than 10 residents. | F |
| Facility must comply with State Fire Marshal regulations and local ordinances regarding fire safety. | F |
| Supervision and treatment of residents must include collaboration with residents, families, and qualified healthcare providers to develop and review person-centered service plans. | I |
| Medical care of residents after illness requires obtaining physical exam results and following healthcare provider instructions. | D |
| Administration of medication must follow written orders and proper documentation, including changes and refusals. | D |
| Maintenance and contents of separate resident files must be kept confidential, locked, and retained for at least 5 years. | D |
| Alzheimer's care standards require safety measures including restricting access to toxic substances. | D |
| Cultural competency training must be conducted annually for employees providing care, with documentation maintained. | D |
| Infection control training of at least 15 hours is required for designated persons, with certificates maintained for 3 years. | D |
| Unlicensed caregivers must annually complete evidence-based infection control training and provide proof of completion. | F |
Report Facts
Census: 140
Sample size: 5
Sample size: 5
Training hours: 15
Training timeframe: 3
Retention period: 5
Retention period: 3
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 0
Apr 16, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 04/16/2024, in accordance with Nevada Administrative Code Chapter 449.
Findings
One complaint was investigated and found to be unsubstantiated. No regulatory deficiencies were identified and no further action was needed.
Complaint Details
One complaint (#NV00070750) was investigated and determined to be unsubstantiated after observation, interviews, and record review.
Report Facts
Sample size: 4
Sample size: 4
Complaints investigated: 1
Inspection Report
Annual Inspection
Census: 130
Capacity: 158
Deficiencies: 14
Mar 5, 2024
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility received a grade of D with multiple deficiencies identified including medication administration errors, failure to notify physicians of missed medications, incomplete resident assessments, unsecured toxic substances, lack of cultural competency and infection control training for staff, inadequate laundry and kitchen sanitation, failure to ensure annual physical exams for residents, and insufficient supervision of a combative resident.
Severity Breakdown
Level D: 9
Level E: 1
Level F: 3
Level I: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failure to ensure medications were on site and administered per physician's orders for multiple residents. | Level D |
| Failure to notify physician after resident missed medications as required. | Level D |
| Failure to complete annual tuberculosis test for one resident. | Level D |
| Failure to complete assessment or service plan upon admission and after change in condition for one resident with aggressive behaviors. | Level D |
| Failure to secure toxic substances from residents in memory care unit. | Level D |
| Failure to provide initial cultural competency training to two employees. | Level D |
| Failure to ensure primary and secondary infection control designees completed required infection control training. | Level D |
| Failure to ensure eight employees completed required infection control training through a nationally recognized course. | Level F |
| Failure to ensure five employees received in-person CPR and first aid training; training was completed online instead. | Level E |
| Laundry and linen services not maintained in sanitary manner; excessive lint in dryers and mildew in washing machine. | Level F |
| Kitchen and food storage areas failed to comply with standards; expired foods found, biofilm in ice machine, grease and debris on equipment and floors. | Level F |
| Failure to ensure annual inspection of fire extinguisher; one extinguisher was last inspected in 2022. | Level D |
| Failure to provide protective supervision for a resident with aggressive behaviors and to protect other residents from harm. | Level I |
| Failure to ensure annual physical examination was completed for one resident. | Level D |
Report Facts
Residents reviewed: 26
Employee files reviewed: 10
Medications missing: 4
Missed medication notifications: 2
Employees lacking cultural competency training: 2
Employees lacking infection control training: 8
Employees lacking in-person CPR training: 5
Facility licensed capacity: 158
Current census: 130
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Masich | Executive Director | Signed report and involved in corrective actions |
| Wellness Director | Involved in medication services, infection control, TB testing, and resident care plans | |
| Memory Care Director | Involved in medication services, supervision of aggressive resident, and securing toxic substances | |
| Maintenance Director | Responsible for infection control training and fire extinguisher inspections | |
| Business Office Manager | Acknowledged lack of cultural competency and infection control training for employees | |
| Resident Service Coordinator | Involved in resident care coordination and annual physical exam scheduling |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 158
Deficiencies: 0
Nov 1, 2023
Visit Reason
The inspection was conducted as a result of a Complaint Investigation initiated on 11/01/2023 and finalized on 11/16/2023, following two complaints received by the facility.
Findings
Two complaints were investigated but could not be verified, and no regulatory deficiencies were identified. The investigation included observations, interviews with staff and family members, clinical record reviews, and document reviews.
Complaint Details
Two complaints (#NV00069553 and #NV00069680) were investigated and found unverified with no regulatory deficiencies identified. The investigation involved observations of residents and staff, interviews with multiple personnel and family members, clinical record reviews of eight residents, and document reviews including grievance procedures and staffing schedules.
Report Facts
Licensed capacity: 158
Census: 129
Sample size: 8
Staff: 9
Residents in Memory Care Unit: 39
Staffing ratio: 4.3
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