Inspection Reports for Morningstar of Sparks
2360 WINGFIELD HILLS DR, SPARKS, NV 89436, SPARKS, NV
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
15.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
115% worse than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
87% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 97
Capacity: 112
Deficiencies: 10
Date: May 22, 2025
Visit Reason
This inspection was conducted as a regrading State Licensure survey of the facility on 05/22/2025, in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to have multiple regulatory deficiencies including issues with food storage temperatures, staff not wearing hair restraints in the kitchen, unsecured medications in resident rooms, lack of initial tuberculosis screening for a resident, and unsafe storage of dangerous and toxic items in the memory care unit. The facility received a grade of B.
Deficiencies (10)
Health and sanitation issues related to safe water and sewage disposal.
Kitchen equipment not maintained clean, sanitary, or in good working condition.
Refrigerator in memory care unit failed to maintain required temperature between 36 and 40 degrees Fahrenheit.
Inadequate storage and packaging of food.
Failure to ensure kitchen staff wore hair restraints as required.
Medications in resident rooms and facility were not securely stored, risking resident safety.
Failure to complete initial tuberculosis screening for a resident.
Unsafe storage of dangerous items such as scissors accessible to residents in memory care unit.
Toxic items such as lotion were accessible to residents in memory care unit.
Failure to properly implement policies concerning preferred names and pronouns.
Report Facts
Licensed beds: 112
Beds for assisted living: 80
Beds for Alzheimer's care: 32
Resident census: 97
Refrigerator temperature: 47
Resident rooms with unsecured medications: 3
Residents sampled for medication storage: 24
Residents self-administering medications: 15
Residents sampled for medication security: 9
Repeat deficiency date: Feb 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paula Allec | Executive Director | Signed the inspection report |
| Food Services Director | Named in findings related to refrigerator temperature and hair restraint violations | |
| Maintenance Director | Confirmed unsecured medications and unsafe items in resident rooms | |
| Wellness Director | Provided confirmation and verbalized medication security policies and safety rounds | |
| Assisted Living Coordinator | Confirmed presence of unsecured medications in resident rooms | |
| Reflections Coordinator | Responsible for daily rounding to ensure safety in memory care unit |
Inspection Report
Annual Inspection
Census: 97
Capacity: 112
Deficiencies: 9
Date: Feb 11, 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 received a grade of C with multiple deficiencies identified including unsafe water temperature, kitchen sanitation issues, expired food storage, lack of current CPR/first aid training for an employee, incomplete dementia care plans, medication storage issues, missing TB testing documentation, unsecured toxic substances in memory care, and failure to address residents by preferred names and pronouns.
Deficiencies (9)
Water temperature in the memory care unit was measured at 126 degrees Fahrenheit, exceeding the safe range of 115-120 degrees.
The high temperature dishwasher failed to reach the required 180 degrees for sanitization; refrigerators in memory care unit were above safe temperatures; staff did not wear hair restraints in the kitchen.
Expired food (ten 46-ounce cans of tomato juice) found in kitchen dry storage.
An employee lacked current first aid and CPR training; certification was expired beyond the two-year period.
Person-centered service plan for a resident with dementia lacked interventions addressing dementia care and safety.
Medications in two resident rooms were not safely stored or locked; medications in one resident's bathroom were unsecured.
Resident file lacked documented evidence of initial two-step tuberculosis testing upon admission.
Toxic substances including cleaning products and hand sanitizer were accessible to residents in the memory care unit.
Facility failed to develop policies ensuring residents were addressed by preferred names and pronouns in accordance with gender identity or expression; resident records lacked this documentation.
Report Facts
Facility licensed beds: 112
Resident census: 97
Expired food cans: 10
Employee files reviewed: 15
Resident files reviewed: 20
Dishwasher temperature: 130
Water temperature: 126
Refrigerator temperature: 44
Refrigerator temperature: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paula Allec | Administrator | Named as the facility administrator responsible for compliance and attestation of personnel records |
Inspection Report
Re-Inspection
Census: 91
Capacity: 112
Deficiencies: 9
Date: Jan 27, 2025
Visit Reason
This Statement of Deficiencies was generated as a result of a grading resurvey State Licensure survey conducted on 01/27/2025 at Morningstar of Sparks in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A with several regulatory deficiencies identified related to Elder Abuse Training, First Aid & CPR, Medication Administration, Medication Destruction, and Medication Administration Records. Deficiencies included failure to ensure medication profile reviews were initialed by the Administrator within 72 hours, medications not on-site for administration, failure to destroy discontinued medications, and inaccurate medication administration records.
Deficiencies (9)
Elder Abuse Training requirements not met as per NRS 449.093.
First Aid and CPR training requirements not met as per NAC 449.231.
Administrator failed to ensure medication profile reviews were initialed within 72 hours for 2 of 12 residents.
Failure to have medication (PDR Cream) on-site to administer as prescribed for 1 of 12 residents.
Failure to destroy discontinued medication for 1 of 12 residents.
Medication Administration Record (MAR) was inaccurate for 1 of 12 residents due to missing documentation of as needed medication.
Administration of Medication Restrictions not met as per NAC 449.2746.
Vital Signs-Glucose training/competency not met as per NAC 449.1985.
Weights training/consent requirements not met as per NAC 449.1985.
Report Facts
Licensed beds: 112
Census: 91
Residents reviewed: 12
Employee files reviewed: 8
Residents with medication profile review deficiencies: 2
Residents with medication on-site deficiency: 1
Residents with discontinued medication not destroyed: 1
Residents with inaccurate MAR: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paula Allec | Administrator | Named as Administrator responsible for medication review deficiencies and signature absence |
Inspection Report
Annual Inspection
Census: 86
Capacity: 112
Deficiencies: 8
Date: Sep 23, 2024
Visit Reason
The inspection was a grading resurvey State Licensure survey initiated on 09/03/2024 and completed on 09/23/2024, including investigation of one substantiated complaint regarding medication refill resulting in hospitalization.
Complaint Details
Complaint #NV00072150 was substantiated regarding a resident's medication not being refilled by the facility, resulting in severe symptoms requiring hospitalization.
Findings
The facility received a grade of C with multiple deficiencies including failure to ensure timely elder abuse training, CPR/first aid training, medication administration errors including a medication not refilled leading to hospitalization, lack of consent for weight measurements, incomplete training for vital signs measurement, and failure to destroy discontinued medications.
Deficiencies (8)
Failure to ensure 2 of 9 sampled employees received initial or annual elder abuse training timely.
Failure to ensure timely cardiopulmonary resuscitation (CPR) and first aid training for 1 of 9 sampled employees.
Failure to ensure medication profile reviews were reviewed and initialed by the Administrator within 72 hours for 2 of 12 residents.
Failure to ensure a medication was onsite to administer prescribed dosage and failure to refill medication for 2 of 13 residents, including one resident hospitalized due to medication omission.
Failure to destroy discontinued medication for 1 of 12 residents.
Failure to document written instructions indicating specific symptoms for which an as needed medication was to be administered for 1 of 12 residents.
Failure to provide training and competency assessment for 7 of 7 employees measuring resident vitals.
Failure to obtain resident or power of attorney consent to take weight measurement for 9 of 12 residents.
Report Facts
Facility licensed beds: 112
Census: 86
Complaint investigated: 1
Employees sampled: 9
Residents sampled: 12
Plan of Correction completion dates: Various dates between 10/02/2024 and 12/31/2024 for corrective actions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sal Gomez-Orozco | Executive Director | Named in relation to oversight and corrective actions for multiple deficiencies including elder abuse training, medication administration, and staff training. |
| Business Office Manager | Involved in reviewing onboarding checklists, training compliance, and providing personnel checklists during inspection. | |
| Wellness Director | Involved in medication administration issues, training, and corrective actions. |
Inspection Report
Annual Inspection
Census: 103
Capacity: 112
Deficiencies: 13
Date: Feb 13, 2024
Visit Reason
This inspection was an annual State Licensure survey conducted in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of D with multiple deficiencies including failure to ensure elder abuse training, kitchen sanitation issues, incomplete first aid and CPR training, missing nondiscrimination statements, untimely physical exams, medication administration errors, lack of consent for weight measurements, missing physician placement determinations, lack of infection control training, incomplete medication administration records, lack of mental illness endorsement, and inadequate training for vital signs measurement.
Deficiencies (13)
Failed to ensure 1 of 10 sampled employees received initial elder abuse training prior to beginning work and annually thereafter.
Kitchen and supportive dining services failed to comply with NAC 446 standards including dishmachine issues, mold-like buildup, soiled floors and surfaces, and repeat deficiencies in Memory Care kitchens.
Failed to ensure first aid and CPR training was received within 30 days of employment for 2 of 8 sampled employees.
Facility lacked a statement of nondiscrimination regarding admission and complaint contact information for all 20 sampled residents.
Failed to ensure initial and/or annual general physical examinations were completed timely for 3 of 20 sampled residents.
Failed to ensure medication profile review was reviewed and initialed by the Administrator within 72 hours for 1 of 20 sampled residents.
Failed to ensure medications had change labels and medication was available on-site for 4 of 20 sampled residents; tuberculosis testing administered without physician order affecting all residents.
Failed to obtain resident or power of attorney consent to take resident weight measurements for all 20 sampled residents.
Failed to obtain completed Physician Placement Determination Statement for 2 of 20 sampled residents.
Primary infection control staff lacked required infection control training.
Medication Administration Record was inaccurate and medication administration was not properly documented for 1 of 20 residents.
Facility failed to obtain required endorsement to care for a resident with mental illness for 1 of 20 sampled residents.
Failed to ensure 3 of 3 sampled Medication Care Managers were trained in use of blood pressure monitors and oximetry; lacked physician orders and competency evaluation affecting all Medication Care Managers.
Report Facts
Licensed beds: 112
Current census: 103
Resident files reviewed: 20
Employee files reviewed: 10
Resurvey fee: 600
Deficiency severity counts: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Salvador Gomez-Orozco | Executive Director | Signed report and attested to accuracy of Personnel Checklist Form |
| Employee #4 | Failed to receive initial elder abuse training prior to employment | |
| Employee #6 | Failed to receive first aid and CPR training within 30 days of employment | |
| Employee #8 | Lacked documented evidence of first aid and CPR certification | |
| Employee #1 | Administrator | Lacked required infection control training |
| Employee #2 | Wellness Director | Lacked required infection control training and confirmed administering TB tests without physician order |
| Employee #3 | Medication Care Manager | Lacked documented training and competency evaluation for taking resident vitals |
| Employee #11 | Medication Care Manager | Lacked documented training and competency evaluation for taking resident vitals |
| Med Care Manager | Confirmed medication label errors and missing physician orders for medications |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 112
Deficiencies: 7
Date: Aug 10, 2023
Visit Reason
The inspection was conducted as a result of a grading resurvey State Licensure survey and complaint investigations in accordance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.
Complaint Details
The visit was complaint-related as indicated by the report stating it was generated from a grading resurvey and complaint investigations.
Findings
The facility received a grade of B with multiple deficiencies identified including failure to ensure elder abuse training for employees, kitchen sanitation issues, unsecured oxygen tanks, medication administration errors, and safety concerns in the memory care unit related to dangerous and toxic items accessibility.
Deficiencies (7)
Administrator failed to ensure 3 of 12 sampled employees received initial elder abuse training prior to beginning work and annually thereafter.
Facility failed to ensure kitchen and supportive dining services complied with health standards; refrigerators not holding proper temperature, food debris accumulation, and maintenance issues.
Oxygen tanks were unsecured in resident rooms, posing safety risks.
Failed to ensure discontinued medication was destroyed and not stored with active medications for Resident #4.
Medication Administration Record (MAR) was inaccurate for Resident #4; missing current medication order.
Dangerous items such as push pins and butter knives were accessible to residents in memory care unit rooms.
Toxic substances such as toothpaste and soap were accessible to residents in memory care unit rooms.
Report Facts
Beds licensed for assisted living: 80
Beds licensed for Alzheimer's disease residents: 32
Resident census: 73
Employees reviewed: 12
Residents reviewed: 9
Severity 2 deficiencies: 4
Severity 1 deficiencies: 1
Inspection Report
Annual Inspection
Census: 68
Capacity: 112
Deficiencies: 16
Date: Feb 9, 2023
Visit Reason
This Statement of Deficiencies was generated as a result of an annual State Licensure survey and complaint investigation conducted at the facility on 02/09/23.
Complaint Details
Complaint #NV00067725 with allegations of medication technicians pre-popping pills, call lights not answered, resident death while caregiver distracted, and morphine theft were investigated and not substantiated due to lack of evidence.
Findings
The facility received a grade of D with multiple deficiencies identified including unsecured dangerous items and toxic substances in memory care rooms, failure to post required nondiscrimination statements and complaint contact information, incomplete medication management training for some employees, missing annual physician placement determination statements for several residents, failure to submit waivers for residents receiving 24-hour skilled nursing care, unsecured oxygen tanks, discrepancies in liquid narcotic medication reconciliation, and incomplete documentation for PRN medication administration and annual assessments.
Deficiencies (16)
Facility failed to ensure dangerous items were inaccessible to residents in memory care unit for 3 of 19 occupied rooms.
Facility failed to ensure toxic substances were inaccessible to residents in memory care unit for 4 of 19 occupied rooms.
Facility failed to post a current nondiscrimination statement prominently and on website.
Facility failed to post State contact information for discrimination complaints.
Two employees who administered medication did not receive required annual medication management training.
Two employees who administered medication did not receive required annual elder abuse training.
Facility failed to obtain initial and/or annual Physician Placement Determination Statements for 6 of 15 sampled residents.
Facility failed to ensure residents receiving skilled nursing services were not allowed to remain without submitting waivers to State Agency.
Facility failed to ensure oxygen tanks were secured in approved receptacles.
Facility failed to have a plan in place to reconcile liquid narcotic medications for 1 of 14 hospice residents; discrepancy found in morphine medication bottle.
Facility failed to ensure a resident admitted for six months or greater had medication review for accuracy and appropriateness.
Facility failed to ensure PRN medications were only administered to residents able to verbalize need or had written instructions specifying symptoms for administration for 13 of 13 hospice residents with cognitive deficits.
Facility failed to ensure an annual Activities of Daily Living (ADL) assessment was completed for 1 of 15 sampled residents.
Facility failed to ensure two employees met tuberculosis testing requirements.
Facility failed to ensure resident bedroom doors were equipped with single motion locks.
Facility failed to ensure dryer lint trap was free from excessive lint.
Report Facts
Facility licensed capacity: 112
Current census: 68
Resurvey application fee: 600
Number of resident files reviewed: 15
Number of employee files reviewed: 20
Residents missing Physician Placement Determination Statements: 6
Residents receiving skilled nursing without waiver: 14
Employees missing annual medication management training: 2
Employees missing annual elder abuse training: 2
Employees missing annual TB test: 2
Residents missing annual ADL assessment: 1
Hospice residents with PRN medication lacking specific symptom instructions: 13
Inspection Report
Complaint Investigation
Census: 69
Capacity: 112
Deficiencies: 0
Date: Oct 3, 2022
Visit Reason
The inspection was conducted as a result of a State Licensure complaint investigation regarding an allegation that the facility does not isolate COVID-19 positive residents.
Complaint Details
Complaint #NV00067019 alleged the facility does not isolate COVID-19 positive residents; this allegation was not substantiated due to lack of evidence.
Findings
The complaint could not be substantiated due to lack of evidence. Observations, interviews, and policy reviews were conducted, and no regulatory deficiencies were identified. The facility received a grade of A and no further action was necessary.
Report Facts
Licensed beds: 112
Complaint count: 1
Inspection Report
Re-Inspection
Census: 65
Capacity: 112
Deficiencies: 0
Date: Jun 30, 2022
Visit Reason
This document is a Statement of Deficiencies generated as a result of a grading re-survey State Licensure survey conducted at the facility on 06/30/22 in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during this re-survey. The facility is licensed for 112 beds with 80 beds for assisted living services and 32 beds for persons with Alzheimer's disease. Five resident files and six employee files were reviewed.
Report Facts
Licensed beds: 112
Current census: 65
Resident files reviewed: 5
Employee files reviewed: 6
Inspection Report
Annual Inspection
Census: 62
Capacity: 112
Deficiencies: 12
Date: Jan 24, 2022
Visit Reason
This inspection was an annual State Licensure survey conducted in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a D grade with multiple deficiencies including failure to ensure annual caregiver training, maintenance issues with the building exterior, failure to post monthly activity calendars, incomplete annual physical exams for residents, medication administration inaccuracies, failure to destroy discontinued medications, incomplete tuberculosis testing, unsafe storage of toxic substances in memory care, and lack of required dementia care training for employees.
Deficiencies (12)
Failed to ensure 3 of 10 sampled employees completed annual caregiver training in 2021.
Failed to ensure wooden window frames were not cracked and crumbling, wood siding was secured, and lint was removed from dryer vent exterior.
Failed to post a monthly activities calendar for residents; only daily activities were posted.
Failed to ensure annual physical examination with review of systems was completed for 2 of 15 sampled residents.
Failed to ensure six-month pharmacy medication reviews were reviewed and signed by the Administrator for 51 of 62 residents.
Failed to ensure medication change labels were affixed and PRN medications were onsite per physician orders for sampled residents.
Failed to ensure discontinued medications were destroyed in a timely manner for 2 of 15 residents.
Failed to ensure Medication Administration Records (MAR) were accurate for 2 of 15 residents.
Failed to ensure tuberculosis testing was completed and documented according to regulations for 2 of 15 residents.
Failed to ensure residents were safe from toxic substances in memory care unit; toxic items were accessible to a resident.
Failed to ensure 7 of 10 sampled employees completed required annual dementia care training.
Failed to ensure a resident with dementia had a dated standard placement determination prior to admission.
Report Facts
Facility licensed capacity: 112
Current census: 62
Employees sampled: 10
Residents sampled: 15
Deficiencies cited: 12
Annual caregiver training non-compliance: 3
Employees lacking dementia training: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Salvador Gomez-Orozco | Executive Director | Named as facility representative and confirmed multiple findings including training and medication review deficiencies |
Notice
Deficiencies: 1
Date: May 19, 2016
Visit Reason
The document serves as a sanction notice informing the facility of imposed sanctions and monetary penalties due to deficiencies found during regulatory oversight.
Findings
The Division of Public and Behavioral Health is imposing sanctions based on the severity and scope of deficiencies, including a monetary penalty of $400 for a deficiency at TAG Y 0878 with a severity level of three and scope level of two or less.
Deficiencies (1)
Deficiency at TAG Y 0878 with a severity level of three and scope level of two or less
Report Facts
Monetary penalty amount: 400
Penalty reduction percentage: 25
Working days until sanctions effective: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minou Nelson | Health Facilities Inspector III | Signed the sanction notice |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 1
Date: Apr 19, 2016
Visit Reason
The inspection was conducted as a complaint investigation triggered by complaint #NV00045659 regarding resident medications not being given as prescribed.
Complaint Details
Complaint #NV00045659 was substantiated. The allegation that resident medications were not given as prescribed was confirmed.
Findings
The facility failed to ensure medications were on site and administered as prescribed for one resident, resulting in harm due to missed seizure medication doses over several days. The complaint was substantiated with evidence from medication administration records, hospital records, and staff interviews.
Deficiencies (1)
Failure to ensure medications were on site and administered as prescribed for Resident #2, leading to missed doses and harm.
Report Facts
Census: 63
Sample size: 5
Sample size: 5
Dates of missed medication: 4
Severity: 3
Scope: 1
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 1
Date: Apr 19, 2016
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by complaint #NV00045659 regarding resident medications not being given as prescribed.
Complaint Details
Complaint #NV00045659 was substantiated. The allegation that resident medications were not given as prescribed was confirmed.
Findings
The facility failed to ensure medications were on site and administered as prescribed for one resident, leading to a seizure and hospitalization. The investigation substantiated the complaint that medications were not given as prescribed due to delays in medication delivery and lack of follow-through by staff.
Deficiencies (1)
Failure to ensure medications were on site and administered as prescribed for Resident #2, resulting in missed doses and a seizure.
Report Facts
Census: 63
Sample size: 5
Sample size: 5
Missed medication doses: 4
Missed medication doses: 7
Fine amount: 225
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 26, 2015
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #NV00041144 regarding an allegation that the facility failed to prevent a resident fall.
Complaint Details
Complaint #NV00041144 contained one allegation that the facility failed to prevent a resident fall. The allegation was not substantiated.
Findings
The complaint was not substantiated after review of the resident's file and interviews with facility directors. No regulatory deficiencies were identified.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed during complaint investigation | |
| Memory Care Director | Interviewed during complaint investigation | |
| Wellness Director | Interviewed during complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 112
Deficiencies: 0
Date: Nov 5, 2014
Visit Reason
The inspection was conducted as a complaint investigation initiated by the Division of Public and Behavioral Health on 11/5/14 regarding an allegation of quality of care related to resident safety and falls.
Complaint Details
Complaint #NV00040878 contained one allegation regarding quality of care related to resident safety/falls. The allegation was not substantiated through record review, document review, and interviews.
Findings
The investigation included interviews and record reviews which confirmed the facility followed approved policies and procedures for resident falls, with no pattern of falls identified. The allegation was not substantiated and no regulatory deficiencies were found.
Report Facts
Licensed capacity: 112
Inspection Report
Annual Inspection
Census: 62
Capacity: 112
Deficiencies: 4
Date: Aug 20, 2014
Visit Reason
The inspection was conducted as an annual State Licensure grading survey combined with a Complaint Investigation initiated by the Division of Public and Behavioral Health on 8/20/14.
Complaint Details
Complaint #NV00039603 contained seven allegations. The complaint was substantiated. Allegations included failure to document incident reports, missing medications, administration of discontinued medications, failure to destroy medications, medications left on cart after resident death, medication errors, and MAR errors.
Findings
The facility received a grade of A. The complaint contained seven allegations, of which some were substantiated and others were not. Deficiencies were identified related to medication administration, medication destruction, and kitchen food service compliance.
Deficiencies (4)
Facility failed to ensure the kitchen complied with standards of NAC 446, including multiple badly dented cans in dry storage, improper hand washing by kitchen staff, and food stored improperly.
Facility failed to destroy medications after they were discontinued for Residents #1 and #2.
Medication administration records (MAR) were inaccurate for 5 of 15 MARs inspected.
Facility admitted a resident with a chronic illness without a chronic illness endorsement on license.
Report Facts
Licensed beds: 112
Census: 62
Resident files reviewed: 15
Employee files reviewed: 15
Medication Administration Records (MAR) inspected: 15
Severity 1 deficiencies: 1
Severity 2 deficiencies: 3
Inspection Report
Annual Inspection
Census: 62
Capacity: 112
Deficiencies: 4
Date: Aug 20, 2014
Visit Reason
The inspection was conducted as an annual State Licensure grading survey combined with a complaint investigation initiated by the Division of Public and Behavioral Health on 8/20/14.
Complaint Details
Complaint #NV00039603 contained seven allegations related to incident reporting, missing medications, administration of discontinued medications, medication destruction, medication errors, and MAR errors. Six allegations were not substantiated; the MAR errors allegation was substantiated.
Findings
The facility received a grade of A. The complaint investigation substantiated one allegation related to MAR errors. Deficiencies were identified including food service permit violations, failure to destroy discontinued medications, inaccurate medication administration records, and admission of a resident with chronic illness without proper endorsement.
Deficiencies (4)
Multiple badly dented cans of food found in dry storage and poor kitchen hygiene including staff not washing hands between handling soiled and sanitized ware, soda syrup lines stored on floor, soiled soda dispenser heads, uncovered ice cream in freezer, and food stored on milk crates.
Failure to destroy discontinued medications for Resident #1 and #2; medications remained on medication cart past discontinuation date.
Medication Administration Record (MAR) errors for 5 residents including missing signatures, inaccurate documentation of medication changes, and inconsistent administration times.
Admission of a resident with a chronic illness (cancer) without a chronic illness endorsement on the facility license.
Report Facts
Licensed beds: 112
Census: 62
Resident files reviewed: 15
Employee files reviewed: 15
Severity 2 deficiencies: 3
Severity 1 deficiencies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Technician | Interviewed regarding medication administration and destruction findings; agreed to findings. | |
| Wellness Director | Stated Resident #7 was actively being treated for cancer. |
Inspection Report
Plan of Correction
Capacity: 112
Deficiencies: 5
Date: Mar 25, 2014
Visit Reason
This document is a plan of correction submitted following a required grading re-survey conducted from 2013-11-25 to 2014-03-25 for a residential care facility licensed for 112 beds.
Findings
The facility received a grade of B with deficiencies related to personnel files, tuberculosis testing compliance, medication administration, resident file maintenance, and safety regarding toxic substances. Several deficiencies were repeat findings from a prior 2013 survey.
Deficiencies (5)
Failed to ensure 3 of 5 employees met tuberculosis testing requirements.
Failed to ensure 1 of 6 residents received medications as prescribed and failed to indicate medication changes on containers.
Failed to ensure medication administration records were accurate for 1 of 6 residents.
Failed to maintain separate resident files with confidentiality and required documentation.
Failed to ensure toxic substances were inaccessible; carpet cleaner found unlocked in memory care unit.
Report Facts
Licensed capacity: 112
Employees reviewed: 5
Resident files reviewed: 6
Deficiency repeat: 3
Inspection Report
Re-Inspection
Capacity: 112
Deficiencies: 5
Date: Mar 25, 2014
Visit Reason
This document is a required grading re-survey conducted from 2013-11-25 to 2014-03-25 as a State Licensure survey to assess compliance and deficiencies at Morningstar of Sparks, an assisted living facility.
Findings
The facility received a re-survey grade of B with multiple deficiencies identified including failure to meet tuberculosis testing requirements for employees and residents, medication administration errors, inaccurate medication administration records, and unsafe storage of toxic substances in the memory care unit.
Deficiencies (5)
Failed to ensure 3 of 5 employees met tuberculosis testing requirements with insufficient time between test steps.
Failed to ensure 1 of 6 residents received medications as prescribed and failed to indicate medication change on container.
Medication administration record (MAR) was inaccurate for 1 of 6 residents, missing tablet amounts for multiple medications.
Failed to ensure 5 of 6 residents complied with tuberculosis testing requirements with insufficient time between test steps or missing documentation.
Failed to ensure carpet cleaner was inaccessible in the memory care unit; found unlocked in storage cabinet.
Report Facts
Licensed capacity: 112
Employees reviewed: 5
Resident files reviewed: 6
Repeat deficiencies: 3
Inspection Report
Complaint Investigation
Capacity: 112
Deficiencies: 2
Date: Jan 6, 2014
Visit Reason
This inspection was conducted as a complaint investigation initiated by the Division of Public and Behavioral Health on 7/23/2013 regarding allegations of Safe Physical Environment and Quality of Care at Morningstar of Sparks.
Complaint Details
Complaint #NV00036187 was substantiated regarding Safe Physical Environment and Quality of Care. The complaint investigation was initiated on 7/23/2013 and concluded on 1/6/2014.
Findings
The facility was found to have deficiencies related to maintenance and supervision. Specifically, a bathroom toilet in Resident #1's room was not repaired timely, leading to a water leak and a resident fall. Additionally, the facility failed to provide adequate protective supervision to Resident #1, who had a history of falls and dementia, resulting in injury and hospitalization.
Deficiencies (2)
Failed to ensure the bathroom toilet in Resident #1's room was repaired and well-maintained, resulting in a water leak and resident fall.
Failed to provide protective supervision to Resident #1, contributing to a fall and injury.
Report Facts
Total licensed capacity: 112
Date of resident fall incident: Jun 26, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Reported Resident #1's fall and observed resident limping with hip pain. | |
| Employee #2 | Documented Resident #1's fall and was called for additional assistance. | |
| Employee #5 | Maintenance employee who repaired Resident #1's toilet and investigated water leak. |
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