Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 128
Deficiencies: 0
Jan 21, 2025
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 01/21/25, in accordance with Nevada Administrative Code (NAC), Chapter 449, Residential Facility for Groups.
Findings
The complaint was unsubstantiated with no regulatory deficiencies identified. Observations, interviews, and record reviews were conducted, and the facility received a grade of A. No further action was necessary.
Complaint Details
One complaint (NV00072946) was investigated and found to be unsubstantiated.
Report Facts
Sample size: 6
Complaints investigated: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wellness Director | Interviewed during the complaint investigation. | |
| Memory Care Director | Interviewed during the complaint investigation. | |
| Resident Care Coordinator | Interviewed during the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 2
Nov 16, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by two substantiated complaints regarding resident care and medication administration at the facility.
Findings
The facility failed to notify a resident's responsible party after multiple falls and did not complete required incident reports or alert charting. Additionally, the facility failed to provide evidence of a medication release form for a discharged resident. A mandatory Med Tech meeting was held to address these issues and reinforce policies.
Complaint Details
Two complaints were investigated: Complaint #NV00072404 and Complaint #NV00072534, both substantiated. The investigation included observations, interviews with staff and residents, and record reviews.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to notify a resident's responsible party after a fall and incomplete incident reporting and alert charting. | Level D |
| Failure to maintain and provide a medication release form listing medications given to a resident upon discharge. | Level D |
Report Facts
Sample size: 5
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Hernandez | Sr. Executive Director | Signed the report and involved in corrective actions |
| Health Services Director | Interviewed and involved in corrective actions | |
| Administrator | Interviewed and acknowledged deficiencies |
Inspection Report
Annual Inspection
Census: 115
Capacity: 140
Deficiencies: 2
Oct 2, 2024
Visit Reason
The inspection was conducted as a result of an annual State Licensure and complaint investigation surveys at the facility on 10/02/24, including review of two complaints.
Findings
The facility received a grade of A with two complaints investigated—one substantiated without deficient practice and one unsubstantiated. Two regulatory deficiencies were identified: failure to submit a wound care and bedfast waiver for one resident, and failure to secure sharp objects in the memory care unit.
Complaint Details
Two complaints were investigated: Complaint #NV00072213 was substantiated with no deficient practice; Complaint #NV00072006 was unsubstantiated with no regulatory deficiencies identified.
Severity Breakdown
Level 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure a wound care and bedfast waiver was submitted to retain one resident with a Stage IV coccyx wound and bedfast status. | Level 2 |
| Failure to ensure sharp objects, specifically a steak knife, were secured inside the memory care unit. | Level 2 |
Report Facts
Resident files reviewed: 25
Employee files reviewed: 8
Total licensed beds: 140
Assisted living beds for Alzheimer's disease: 30
Complaints investigated: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Hernandez | Sr. Executive Director | Signed the report and acknowledged findings |
| Claire Walton | Approved Medical Exemption for wound and Bedfast Waiver on 10/09/2024 | |
| Assistant Maintance Director | Acknowledged the steak knife was not secured in the memory care unit | |
| Memory Care Director | Held in-service with Memory Care team members regarding securing knives | |
| Executive Director | Acknowledged unsecured steak knife and participated in staff training |
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 0
Mar 14, 2024
Visit Reason
The inspection was conducted as a result of a Complaint State Licensure survey at the facility on 03/14/24, triggered by one complaint investigation.
Findings
The complaint #NV00070439 was verified without deficient practice. The investigation included observations, interviews with staff and residents, and record reviews. No deficiencies were identified.
Complaint Details
One complaint was investigated and verified without deficient practice.
Report Facts
Sample size: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed during complaint investigation | |
| Health Services Director | Interviewed during complaint investigation | |
| Medication Technicians | Interviewed during complaint investigation |
Inspection Report
Annual Inspection
Census: 128
Capacity: 170
Deficiencies: 7
Oct 18, 2023
Visit Reason
The inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but had several regulatory deficiencies including expired food items, mold and grease build-up in kitchen equipment, medication not available on-site as prescribed, and unsecured toxic substances in the memory care unit.
Severity Breakdown
2: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Expired concentrated apple juice found in juice dispenser. | 2 |
| Black mold build-up inside ice machine in the bar. | 2 |
| Grease and debris build-up behind cook's line equipment and on ventilation hood filters. | 2 |
| Missing filter and heavy dust build-up on ventilation hood above double oven. | 2 |
| Dumpster enclosure littered with leaves and debris; grease rendering receptacle heavily soiled with grease build-up. | 2 |
| Medication (Albuterol) not available on-site for Resident #14 as prescribed by physician. | 2 |
| Toxic substances (insect spray) unsecured in bathroom cabinet in memory care unit room 148. | 2 |
Report Facts
Resident files reviewed: 26
Employee files reviewed: 10
Total licensed beds: 170
Current census: 128
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Hernandez | Sr. Executive Director | Signed the inspection report |
| Fernando | Executive Chef | Named in corrective actions related to kitchen deficiencies |
| Traditions Director | Responsible for ensuring cabinets are secured in memory care unit | |
| Assisted Living Coordinator | Acknowledged medication deficiency for Resident #14 |
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 0
Jun 29, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated at the facility on 06/29/23 and finalized on 07/18/23, in accordance with Nevada Administrative Code, Chapter 449, Requirements for Residential Facilities for Groups.
Findings
There were no regulatory deficiencies identified during the investigation. The complaint #NV00068686 was unverified and no action was necessary.
Complaint Details
One complaint was investigated: Complaint #NV00068686, which was unverified after review including interviews, clinical record review, personnel record review, and policy review.
Report Facts
Census: 120
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 0
May 24, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation and a facility reported incident investigation initiated on 05/11/23 and finalized on 05/24/23.
Findings
The investigation included observations, interviews, clinical record reviews, and document reviews. Both the complaint and the facility reported incident were verified with no deficient practices. No regulatory deficiencies were identified and no action was necessary.
Complaint Details
One complaint (#NV00068371) and one facility reported incident (#8218) were investigated and both were verified with no deficient practice.
Report Facts
Sample size: 3
Sample size: 1
Number of residents interviewed: 16
Facility grade: A
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 18, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated at the facility on 10/17/23 and completed on 10/18/23.
Findings
One complaint was investigated and substantiated without any deficient practice. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00067474 was substantiated with no deficient practice. The investigation included interviews with Medication Technicians, Transitions Director, and the Administrator, as well as record and document reviews.
Report Facts
Sample size: 5
Number of complaints investigated: 1
Inspection Report
Annual Inspection
Census: 133
Capacity: 140
Deficiencies: 6
Oct 19, 2022
Visit Reason
The inspection was conducted as an annual State licensure and Infection Control survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility received a grade of A. A regulatory deficiency was identified related to food service compliance with NAC 446, including critical and major violations such as improper storage of raw chicken and beef, use of plastic bowls in bulk containers, biofilm buildup on the ice machine, and soiled kitchen equipment.
Severity Breakdown
Critical: 1
Major: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Raw chicken was stored above and on the same pan as raw beef in the walk-in cooler. | Critical |
| Plastic bowls were used to scoop flour and sugar and stored in the bulk containers. | Major |
| Pink grime/biofilm build-up on the interior plastic shield of the ice machine. | Major |
| Blade of the deli slicer was soiled with food debris. | Major |
| Can opener was soiled with food debris and metal shavings. | Major |
| Cook's line ventilation hood filters were soiled with grease build-up above the grill. | Major |
Report Facts
Resident records reviewed: 25
Employee records reviewed: 10
Facility licensed beds: 140
Census: 133
Severity level: 2
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Hernandez | Executive Director | Signed as Laboratory Director's or Provider/Supplier Representative |
| Fernando | Executive Chef | Named in plan of correction to oversee cleaning of ice machine |
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