Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Jul 8, 2025
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 07/08/25, in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
Two complaints were investigated: one was substantiated without deficient practice and the other was unsubstantiated. No regulatory deficiencies were identified and no further action was needed.
Complaint Details
Two complaints were investigated: Complaint #NV00074381 was substantiated without deficient practice and Complaint #NV00074534 was unsubstantiated. No regulatory deficiencies were identified.
Report Facts
Sample size: 5
Complaints investigated: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver | Interviewed during the complaint investigation | |
| Wellness Director | Interviewed during the complaint investigation | |
| Reflections Coordinator | Interviewed during the complaint investigation | |
| Administrator | Interviewed during the complaint investigation |
Inspection Report
Original Licensing
Capacity: 93
Deficiencies: 6
Oct 3, 2024
Visit Reason
This inspection was an initial State Licensure survey conducted for licensure application of a Residential Facility for Groups with Alzheimer's endorsement, requesting licensure for 93 beds including 63 Category II Non-Alzheimer's beds and 30 Category II Alzheimer's beds.
Findings
The facility was found non-compliant with numerous Nevada Administrative Code (NAC) and Nevada Revised Statutes (NRS) requirements, including failure to provide required policies on resident admission criteria, medication administration, discharge procedures, confidentiality, and resident rights. The environment was also not compliant with safety standards for Alzheimer's care, including lack of pull cords, inadequate secured outdoor space, unsecured patio furniture, and absence of audible alarms on exits.
Deficiencies (6)
| Description |
|---|
| Failure to provide policies on handling resident money/property, admission criteria for residents with specific medical conditions, medication administration, discharge procedures, confidentiality, and resident rights. |
| No functioning washer and dryer in the Memory Care unit and lack of bedroom furniture or storage space of at least 10 square feet in resident rooms. |
| No pull cords present in all resident and common area bathrooms. |
| Alzheimer's residents had access to a second-floor patio with insufficient square footage for 30 residents and no documented supervision or staffing plan. |
| Outdoor tables and chairs in Memory Care patio were not secured, creating a hazard for residents. |
| No audible alarms on any exits of the Alzheimer's unit; audible alarm on secure courtyard exit door may be deactivated during daylight hours. |
Report Facts
Licensed beds: 93
Census: 0
Alzheimer's patio square footage: 27
Completion date for corrective actions: Oct 7, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul Ortega | Administrator | Named as the Administrator who acknowledged missing documentation and confirmed inability to provide required policies. |
| Maintenance Director | Confirmed lack of pull cords, absence of audible alarms, and unsecured patio furniture during inspection. |
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