Inspection Report
Annual Inspection
Census: 46
Capacity: 57
Deficiencies: 6
Aug 5, 2025
Visit Reason
The inspection was an annual State Licensure survey conducted in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility was found deficient in several areas including failure to ensure annual Elder Abuse training for one employee, kitchen and dining service sanitation issues, lack of audible alarm on one exit door in the Memory Care Neighborhood, and incomplete Alzheimer's disease and Cultural Competency training for certain employees. Corrective actions and plans were provided for each deficiency.
Severity Breakdown
D: 5
E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure Elder Abuse training was completed annually for 1 of 8 employees (Employee #5). | D |
| Failure to comply with NAC 446 on Food Service including biofilm build-up on ice machine, soiled ventilation hood filters, and heavily littered dumpster enclosure. | E |
| One of three exit doors to the Memory Care Neighborhood Zen Garden did not have a functional audible alarm. | D |
| Failure to ensure Alzheimer's disease training was completed for 1 of 8 employees (Employee #3). | D |
| Failure to ensure three hours of Alzheimer's disease training was completed annually for 2 of 8 employees (Employees #4 and #5). | D |
| Failure to ensure Cultural Competency training was completed for 1 of 8 employees (Employee #1). | D |
Report Facts
Licensed beds: 57
Resident census: 46
Employees reviewed: 8
Resident files reviewed: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Graham | Executive Director | Named as person responsible for plan of correction and signed report |
| Employee #5 | Failed to complete annual Elder Abuse training and Alzheimer's disease training; resigned 8/11/2025 | |
| Employee #3 | Medication Technician | Failed to complete Alzheimer's disease training |
| Employee #4 | Medication Technician | Failed to complete required Alzheimer's disease training hours |
| Employee #1 | Executive Director | Failed to complete Cultural Competency training |
Inspection Report
Renewal
Census: 38
Capacity: 57
Deficiencies: 0
Oct 21, 2024
Visit Reason
This inspection was a voluntary grading State Licensure resurvey conducted to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A with no regulatory deficiencies identified. No further action was necessary.
Report Facts
Licensed beds: 57
Census: 38
Inspection Report
Annual Inspection
Census: 36
Capacity: 57
Deficiencies: 6
Aug 20, 2024
Visit Reason
Annual State Licensure survey conducted to assess compliance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to have multiple regulatory deficiencies including food service violations, medication administration errors, incomplete resident tuberculosis testing documentation, unsecured toxic substances in Alzheimer's unit, and incomplete cultural competency training for several employees.
Severity Breakdown
Severity: 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Kitchen and dining services failed to comply with NAC 446 standards including moldy strawberries, expired half & half, grease buildup on ventilation hoods, and lack of paper towels at hand washing sink. | Severity: 2 |
| Medication containers lacked change order labels for 1 of 15 residents, failing to reflect physician order changes. | Severity: 2 |
| Medication administered at incorrect dose for 1 of 10 residents. | Severity: 2 |
| Resident file lacked documented evidence of two-step or QuantiFERON TB test prior to admission for 1 of 10 sampled residents. | Severity: 2 |
| Toxic substances were unsecured in the Alzheimer's unit kitchen, accessible to residents. | Severity: 2 |
| Five of nine employees failed to complete required Cultural Competency training or completed training from unapproved courses. | Severity: 2 |
Report Facts
Licensed beds: 57
Resident census: 36
Employees missing Cultural Competency training: 5
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 4
Jun 24, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation and a Facility Reported Incident (FRI) at the facility on 06/24/24, triggered by substantiated complaint #NV00071209 and FRI #9883.
Findings
The facility failed to notify the proper State agency regarding a gastrointestinal illness outbreak affecting 5 of 9 sampled residents and failed to notify residents' responsible parties of changes in condition. Additionally, the facility did not ensure required infection control training was completed by designated employees and unlicensed caregivers.
Complaint Details
Complaint #NV00071209 was substantiated. The complaint involved failure to notify the State agency of a gastrointestinal illness outbreak and failure to notify responsible parties of residents' changes in condition.
Severity Breakdown
Severity: 2 Scope: 3: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to notify the proper State agency regarding Gastrointestinal Illness for 5 of 9 sampled residents. | Severity: 2 Scope: 3 |
| Failed to notify residents' responsible parties of a change in condition for 5 of 9 sampled residents. | Severity: 2 Scope: 3 |
| Failed to ensure primary and secondary infection control designees completed required initial 15 hours of infection control training from nationally recognized organizations. | Severity: 2 Scope: 3 |
| Failed to ensure 3 of 3 sampled unlicensed employees received annual infection control training through a nationally recognized course. | Severity: 2 Scope: 3 |
Report Facts
Census: 35
Sample size: 9
Sample size: 5
Residents affected by illness: 5
Residents experiencing symptoms: 12
Training hours required: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Graham | Executive Director | Named as primary infection control designee and involved in findings related to infection control training and notification failures |
| Wellness Director | Named as secondary infection control designee and involved in findings related to infection control training and notification failures | |
| Care Specialist | Interviewed during investigation; specific names not provided | |
| Medical Technician | Interviewed during investigation; specific names not provided | |
| Employee #1 | Executive Director | Lacked documented evidence of required infection control training |
| Employee #2 | Wellness Director | Lacked documented evidence of required infection control training |
| Employee #3 | Care Specialist | Lacked documented evidence of annual infection control training |
| Employee #4 | Medication Technician | Lacked documented evidence of annual infection control training |
| Employee #5 | Care Specialist | Lacked documented evidence of annual infection control training |
Inspection Report
Original Licensing
Capacity: 57
Deficiencies: 0
Aug 17, 2023
Visit Reason
This inspection was conducted as an initial state licensure survey for a Residential Facility for Groups requesting licensure for 57 beds for Assisted Living, elderly and disabled and/or persons with Alzheimer's Category II residents.
Findings
No regulatory deficiencies were identified during the survey. The facility was approved for licensure on 2023-08-23 with no further action necessary.
Report Facts
Licensed beds: 57
Census: 0
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