Deficiencies per Year
12
9
6
3
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Re-Inspection
Census: 115
Capacity: 150
Deficiencies: 0
Jul 1, 2025
Visit Reason
This inspection was a mandatory grading resurvey conducted at the facility on 07/01/2025 in accordance with Nevada Administrative Code, Chapter 449, for Residential Facilities for Groups.
Findings
The facility was found to be in compliance with no deficiencies identified and received a grade of A. Thirteen resident records and six employee records were reviewed during the survey.
Report Facts
Resident records reviewed: 13
Employee records reviewed: 6
Inspection Report
Annual Inspection
Census: 112
Capacity: 150
Deficiencies: 8
Apr 15, 2025
Visit Reason
Annual State Licensure survey conducted to assess compliance with Nevada Administrative Code for Residential Facilities for Groups.
Findings
The facility received a grade of C with multiple regulatory deficiencies identified including failure to ensure annual elder abuse training for one employee, kitchen sanitation and equipment issues, incomplete CPR and mental illness training for several employees, improper medication administration documentation, improper oxygen tank storage, incomplete tuberculosis test documentation, and lack of infection control training for some staff.
Severity Breakdown
Level D: 3
Level E: 4
Level F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 10 employees received annual elder abuse training. | Level D |
| Kitchen and supportive dining services failed to comply with standards; dish machine rinse temperature too low, floors soiled and deteriorated. | Level E |
| Failed to ensure 1 of 10 employees received hands on/in-person CPR training within 30 days of hire. | Level D |
| Failed to ensure oxygen tanks were properly secured and appropriate signage was posted. | Level F |
| Failed to ensure six month medication reviews were signed off and reviewed by the Administrator for 13 of 25 residents. | Level F |
| Failed to ensure initial two step tuberculosis test was completed with documented read date for 1 of 25 residents. | Level D |
| Failed to ensure 5 of 10 employees completed eight hours of mental illness training within 60 days of hire. | Level E |
| Failed to ensure 3 of 10 employees received infection control training through a nationally recognized course. | Level E |
Report Facts
Resident records reviewed: 25
Employee records reviewed: 10
Facility licensed capacity: 150
Current census: 112
Medication reviews not signed off: 13
Oxygen tanks improperly stored: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heather Lankford | Executive Director | Signed the inspection report and involved in monitoring compliance. |
| Employee #8 | Failed to complete annual elder abuse training and initial mental illness training; lacked infection control training. | |
| Employee #6 | Failed to complete hands on CPR training and initial mental illness training. | |
| Employee #2 | Failed to complete initial mental illness training. | |
| Employee #7 | Failed to complete initial mental illness training and infection control training. | |
| Employee #5 | Failed to complete infection control training. | |
| Employee #9 | Health Services Director | Failed to complete initial mental illness training. |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Feb 12, 2025
Visit Reason
The inspection was conducted as a result of a Facility Reported Incident (FRI) investigation completed in the facility on 02/12/2025, in accordance with Nevada Administrative Code (NAC), Chapter 449, Residential Facilities for Groups.
Findings
One FRI was investigated and substantiated without deficient practice. The investigation included observation of staff to resident interaction, a tour of the facility, interviews with the Business Office Manager and Executive Director, and review of one resident record and facility policies. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
The Facility Reported Incident (FRI) 10236 was substantiated with no deficient practice.
Report Facts
Sample size: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Interviewed during the investigation | |
| Executive Director | Interviewed during the investigation |
Inspection Report
Renewal
Census: 113
Capacity: 150
Deficiencies: 0
Aug 6, 2024
Visit Reason
This inspection was a mandatory State Licensure grading resurvey conducted to assess compliance with Nevada Administrative Code, Chapter 449, for Residential Facilities for Groups.
Findings
The facility was found to be in compliance with no regulatory deficiencies identified and received a grade of A. The inspection included review of ten resident files and one employee record.
Report Facts
Licensed capacity: 150
Census: 113
Inspection Report
Annual Inspection
Census: 114
Capacity: 150
Deficiencies: 10
Apr 25, 2024
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation at the facility on 04/25/24.
Findings
The facility received a grade of D with multiple deficiencies including failure to provide adequate oversight for residents with complex needs, unsanitary conditions, inadequate laundry services, kitchen sanitation violations, lack of required medical exemption requests, incomplete medication reviews, missing annual ADL assessments, failure to obtain mental illness endorsement, and incomplete infection control training for designated staff.
Complaint Details
One complaint (#NV00070984) was substantiated without deficient practice after investigation including observations, interviews, and record reviews.
Severity Breakdown
Level 2: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight to ensure a resident with unmanageable behaviors and wounds received needed services (Resident #23). | Level 2 |
| Facility failed to maintain premises free from offensive odors, hazards, and dirt; Resident #23's room had urine odor, feces, and tripping hazards. | Level 2 |
| Laundry rooms not maintained; multiple washing machines out of service or leaking. | Level 2 |
| Kitchen and dining services failed to comply with food service standards including use of disposable cup in bulk sugar, grease buildup, and worn flooring. | Level 2 |
| Failure to submit medical exemption requests for residents with ileostomy and wounds/bedfast status. | Level 2 |
| Failure to obtain current physician review of physical and mental condition for Resident #23. | Level 2 |
| Failure to ensure six-month medication reviews were initialed and dated by the Administrator within 72 hours. | Level 2 |
| Failure to complete annual Activities of Daily Living (ADL) assessments for 5 sampled residents. | Level 2 |
| Facility failed to obtain endorsement to provide care for persons with mental illness despite admitting residents with such diagnoses. | Level 2 |
| Secondary infection control designee lacked documented evidence of required 15 hours infection control training. | Level 2 |
Report Facts
Licensed capacity: 150
Census: 114
Deficiency count: 10
Medication review date: Feb 24, 2024
Inspection date: Apr 25, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heather Lankford | Executive Director | Named as Administrator and Executive Director involved in oversight and plan of correction. |
| Employee #2 | Health Service Coordinator | Secondary infection control designee lacking required infection control training. |
Inspection Report
Complaint Investigation
Census: 108
Capacity: 150
Deficiencies: 1
Nov 14, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 2023-10-23 and completed offsite on 2023-11-14, in accordance with Nevada Administrative Code (NAC), Chapter 449, Residential Facility for Groups.
Findings
The investigation verified one complaint regarding failure to administer prescribed pain medication (Tramadol) to a resident as ordered by the physician. The facility failed to have the medication onsite and did not administer it on multiple occasions, resulting in resident pain. Documentation on the Medication Administration Record (MAR) was also inaccurate.
Complaint Details
Two complaints were investigated: Complaint #NV00069361 was unverified with no deficiencies identified; Complaint #NV00069580 was verified related to medication administration failures.
Severity Breakdown
Level 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medication ordered was not available and not administered as prescribed for a resident with pain. | Level 2 |
Report Facts
Licensed capacity: 150
Census: 108
Sample size: 5
Severity level: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sue McPherson | VP Reg Oakmont Mgr G | Signed as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Re-Inspection
Census: 76
Capacity: 150
Deficiencies: 6
Jun 14, 2023
Visit Reason
This Statement of Deficiencies was generated as a result of the mandatory grading resurvey conducted at the facility on 06/14/23, in accordance with Nevada Administrative Code, Chapter 449, Requirements for Residential Facilities for Groups.
Findings
The facility was licensed for 150 beds and had a census of 76 at the time of the survey. Four resident records and five employee records were reviewed. The facility received a grade of A with no regulatory deficiencies identified and no further action necessary.
Severity Breakdown
D: 4
F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Administrator's Responsibilities-Complete Rec - NAC 449.194 Responsibilities of administrator. | D |
| Personnel File - TB Screening - NAC 449.200 Personnel files. | D |
| Personnel File - 1st Aid & CPR - NAC 449.200 Personnel files. | D |
| Permits-Comply with NAC 446 on Food Service - NAC 449.217 Kitchens; storage of food; adequate supplies of food; permits; inspections. | F |
| Maintenance and Contents of Separate File - NAC 449.2749 Maintenance and contents of separate file for each resident; confidentiality of information. | D |
| Adults with Intellectual Disabilities - NAC 449.2762 Residential facility which offers or provides care for adults with intellectual disabilities or adults with related conditions: Application for endorsement; training for caregivers. | F |
Report Facts
Licensed beds: 150
Census: 76
Resident records reviewed: 4
Employee records reviewed: 5
Inspection Report
Re-Inspection
Census: 76
Capacity: 150
Deficiencies: 7
Jun 14, 2023
Visit Reason
The inspection was conducted as a mandatory grading resurvey in accordance with Nevada Administrative Code, Chapter 449, for Residential Facilities for Groups.
Findings
The facility received a grade of A with no regulatory deficiencies identified. Four resident records and five employee records were reviewed. Several deficiencies were noted with severity levels ranging from D to F, but no further action was necessary.
Severity Breakdown
D: 5
F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Administrator's Responsibilities-Complete Rec - NAC 449.194 Responsibilities of administrator. | D |
| Personnel File - TB Screening - NAC 449.200 Personnel files. | D |
| Personnel File - 1st Aid & CPR - NAC 449.200 Personnel files. | D |
| Permits-Comply with NAC 446 on Food Service - NAC 449.217 Kitchens; storage of food; adequate supplies of food; permits; inspections. | F |
| Maintenance and Contents of Separate File - NAC 449.2749 Maintenance and contents of separate file for each resident; confidentiality of information. | D |
| Maintenance and Contents of Separate File - NAC 449.2749 Maintenance and contents of separate file for each resident; confidentiality of information including evaluation of resident's ability to perform activities of daily living. | D |
| Adults with Intellectual Disabilities - NAC 449.2762 Residential facility which offers or provides care for adults with intellectual disabilities or adults with related conditions: Application for endorsement; training for caregivers. | F |
Report Facts
Licensed capacity: 150
Census: 76
Resident records reviewed: 4
Employee records reviewed: 5
Inspection Report
Annual Inspection
Census: 85
Capacity: 150
Deficiencies: 7
Apr 21, 2023
Visit Reason
The inspection was conducted as an annual State Licensure and infection control survey at the facility in accordance with Nevada Administrative Code, Chapter 449, Residential Facilities for Groups.
Findings
The facility was found to have multiple regulatory deficiencies including incomplete tuberculosis (TB) screenings for employees and residents, expired CPR certification for an employee, kitchen sanitation and maintenance violations, missing annual Activities of Daily Living assessments for a resident, incomplete intellectual disability training for employees, and incomplete employee files with missing required training documentation.
Severity Breakdown
Level 2: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure two-step tuberculosis (TB) screening was completed upon hire for 2 of 10 employees. | Level 2 |
| Failed to ensure cardiopulmonary resuscitation (CPR) training was completed every two years for 1 of 10 employees. | Level 2 |
| Failed to ensure kitchen and supportive dining services complied with NAC 446 standards, including improper storage of raw and cooked foods, strong sewer odor, stained cutting board, soiled can opener, rust-colored water leak, disrepair of microwave and refrigerator gasket, and dust buildup on air vents. | Level 2 |
| Failed to ensure tuberculosis (TB) testing was completed per requirement for 2 of 10 sampled residents. | Level 2 |
| Failed to ensure an annual Activities of Daily Living (ADL) assessment was completed for 1 of 20 sampled residents. | Level 2 |
| Failed to ensure four hours of intellectual disability training was completed within 60 days of hire for 8 of 10 employees. | Level 2 |
| Failed to ensure an employee file was onsite and available with all required documents for 1 of 10 employees, including medication management, intellectual disability, chronic illness, and cultural competency trainings. | Level 2 |
Report Facts
Number of employees reviewed: 10
Number of resident records reviewed: 20
Facility licensed capacity: 150
Current census: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nathalie Hoffenden | Executive Director | Signed the inspection report |
| Employee #7 | Failed two-step TB screening upon hire; completed TB screening after survey | |
| Employee #8 | Failed two-step TB screening upon hire; completed TB screening after survey | |
| Employee #9 | Had expired CPR certification; completed CPR training after survey | |
| Employee #10 | Employee file missing required training documentation; no longer employed |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 150
Deficiencies: 0
Jan 26, 2023
Visit Reason
The inspection was conducted as a complaint investigation in response to Complaint #NV00067308 at the facility on 01/26/23.
Findings
The complaint was unsubstantiated with no regulatory deficiencies identified. Observations, interviews, and record reviews were conducted, and no further action was necessary.
Complaint Details
Complaint #NV00067308 was investigated and found to be unsubstantiated with no regulatory deficiencies identified.
Report Facts
Sample size: 3
Facility licensed beds: 150
Category II residents: 120
Category II (Alzheimer's) residents: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Interim Executive Director | Interviewed during complaint investigation | |
| Health Services Director | Interviewed during complaint investigation | |
| Lead Caregiver | Interviewed during complaint investigation | |
| Business Office Manager | Interviewed during complaint investigation |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 150
Deficiencies: 0
Jul 26, 2022
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding allegations about improper placement of a resident and inadequate care leading to accelerated decline.
Findings
The complaint investigation found both allegations unsubstantiated. The resident was appropriately placed on the assisted living side, and no inadequate care or accelerated decline was observed. No regulatory deficiencies were identified.
Complaint Details
Complaint #NV00066465 with two allegations was investigated and found unsubstantiated. Allegation #1 regarding improper placement for additional fees was unsubstantiated based on cost review and physician confirmation. Allegation #2 regarding inadequate care and accelerated decline was unsubstantiated based on observations, physician assessments, and interviews.
Report Facts
Licensed capacity: 150
Census: 122
Sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Senior Business Office Director | Interviewed regarding resident billing and placement | |
| Health Services Director | Interviewed regarding resident care and condition | |
| Caregiver | Interviewed regarding resident care and condition | |
| Executive Director | Interviewed during investigation |
Loading inspection reports...



