Inspection Report
Complaint Investigation
Census: 84
Capacity: 150
Deficiencies: 3
Jun 23, 2025
Visit Reason
The inspection was conducted as a mandatory re-grading and complaint investigation survey following four complaints received by the facility.
Findings
The facility received a grade of A with no regulatory deficiencies identified related to the complaints investigated. However, deficiencies were found related to personnel files, including missing annual tuberculosis testing, outdated CPR training, and incomplete infection control training for some employees.
Complaint Details
Four complaints were investigated: three were unsubstantiated with no regulatory deficiencies identified, and one was substantiated without deficiency.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure a tuberculosis (TB) test was completed annually for 1 of 5 sampled employees (Employee #6). | Level 2 |
| Failed to ensure cardiopulmonary resuscitation (CPR) training was completed every two years for 1 of 5 sampled employees (Employee #7). | Level 2 |
| Failed to ensure infection control training was completed annually for 1 of 5 sampled employees (Employee #5) and upon hire for 1 of 5 sampled employees (Employee #7). | Level 2 |
Report Facts
Complaints investigated: 4
Employees sampled: 5
Resident files reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alex Betancourt | Executive Director | Signed the inspection report. |
Inspection Report
Annual Inspection
Census: 70
Capacity: 150
Deficiencies: 7
Jan 15, 2025
Visit Reason
The inspection was conducted as an annual State Licensure and complaint survey in accordance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.
Findings
The facility received a grade of C with multiple regulatory deficiencies identified including missing physical exams and TB screenings for employees, incomplete CPR training, kitchen sanitation issues, missing annual physical exams for residents, medication administration errors, missing cultural competency and infection control training for staff.
Complaint Details
Two complaints were investigated and both were unsubstantiated with no regulatory deficiencies identified.
Severity Breakdown
Level 2: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure a physical exam was completed for 1 of 10 employees and annual tuberculosis (TB) screening was completed for 4 of 10 employees. | Level 2 |
| Failed to ensure cardiopulmonary resuscitation (CPR) training was completed every two years for 3 of 10 employees. | Level 2 |
| Failed to ensure the kitchen and supportive dining services complied with NAC 446 standards including dishwasher temperature and sanitizer levels, staff hair restraint, ice machine cleanliness, and equipment maintenance. | Level 2 |
| Failed to ensure 2 of 20 residents received an annual physical examination. | Level 2 |
| Failed to ensure medications were administered per physician orders for 1 of 20 sampled residents, including incorrect calcium dosage and missing written instructions for PRN medications. | Level 2 |
| Failed to ensure Cultural Competency training was completed within 90 days of hire for 1 of 10 employees. | Level 2 |
| Failed to ensure infection control training was completed for 4 of 10 unlicensed caregivers. | Level 2 |
Report Facts
Licensed capacity: 150
Census: 70
Complaints investigated: 2
Employees reviewed: 10
Residents reviewed: 20
Deficiency severity counts: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Administrator | Failed to complete physical exam |
| Employee #2 | Personal Care Attendant | Missing annual TB screening, CPR training, infection control training |
| Employee #3 | Personal Care Attendant | Missing cultural competency training and infection control training |
| Employee #4 | Medication Technician | Missing infection control training |
| Employee #5 | Medication Technician | Missing annual TB screening and infection control training |
| Employee #7 | Personal Care Attendant | Missing annual TB screening and CPR training |
| Employee #10 | Resident Care Coordinator | Missing annual TB screening and CPR training |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 0
Oct 1, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by three complaints received regarding the facility.
Findings
The investigation included observations, interviews, and record reviews. No regulatory deficiencies were identified and all three complaints were unsubstantiated. No further action was necessary.
Complaint Details
Three complaints were investigated: Complaint #NV00071972, Complaint #NV00072288, and Complaint #NV00072347. All were found unsubstantiated with no regulatory deficiencies identified.
Report Facts
Complaints investigated: 3
Sample size: 5
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 1
Jun 18, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation and a Facility Reported Incident (FRI) at Pacifica Senior Living San Martin on 06/18/2024.
Findings
The facility received a grade of A. One complaint was substantiated with deficiencies related to failure to provide residents with toilet paper, while one FRI was substantiated with no deficient practice. The investigation included observations, interviews, and document reviews.
Complaint Details
Complaint #NV00071070 was substantiated. FRI #9910 was substantiated with no deficient practice.
Severity Breakdown
1: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide residents with toilet paper; residents were told to purchase their own due to budget constraints. | 1 |
Report Facts
Census: 104
Sample size: 6
Severity: 1
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Torrey Donner | Executive Director | Signed the report and involved in monitoring purchasing application for toilet paper |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 1
Aug 17, 2023
Visit Reason
This inspection was conducted as a result of a State Licensure complaint investigation triggered by two complaints at the facility.
Findings
The investigation found no regulatory deficiencies related to the complaints themselves, but identified one deficiency where the facility failed to discharge a resident after a significant change in condition and did not provide notice or attempt to increase the level of care prior to 06/21/23.
Complaint Details
Two complaints were investigated: Complaint #NV00069199 and Complaint #NV00069004. Both complaints could not be verified and no regulatory deficiencies were identified related to them.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure discharge of a resident after a significant change of condition and failure to provide notice or increase level of care as required. | Severity: 2 |
Report Facts
Sample size: 5
Complaints investigated: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Torrey Donner | Executive Director | Signed as Laboratory Director's or Provider/Supplier Representative's Signature |
| Resident Services Director | Interviewed and reported on resident condition and family communications | |
| Administrator | Interviewed and reported on resident behavior and facility actions |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Apr 26, 2023
Visit Reason
The inspection was conducted as a result of a State Licensure complaint investigation at the facility on 04/26/23.
Findings
No regulatory deficiencies were identified. The complaint investigated could not be verified after observation, interviews, and record reviews.
Complaint Details
One complaint (#NV00068307) was investigated but could not be verified.
Report Facts
Sample size: 5
Inspection Report
Annual Inspection
Census: 107
Capacity: 150
Deficiencies: 6
Jan 10, 2023
Visit Reason
The inspection was conducted as a result of an annual, complaint investigation, and infection control State Licensure survey at the facility.
Findings
The facility received a grade of B. One complaint with six allegations was substantiated without deficiency. Several regulatory deficiencies were identified including issues with kitchen sanitation, medication administration, Alzheimer's care unit compliance, and cultural competency training.
Complaint Details
One complaint (#NV00067134) with six allegations was investigated and substantiated without deficiency. Allegations included issues with washers and dryers, food order wait times, meal service times, condiment availability, call button operation, and room cleanliness. All were found unsubstantiated based on observations and interviews.
Severity Breakdown
Severity: 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Kitchen and supportive dining services failed to comply with NAC 446 standards including water pooling on floor, non-operational hand washing sinks, floor staining, debris buildup, ice buildup in walk-in cooler and freezer, peeling ceiling, and wall gaps. | Severity: 2 |
| Failed to perform medication reviews every six months for 1 of 25 residents (Resident #14). | Severity: 2 |
| Failed to ensure a current and correct Ultimate User Agreement for medication administration was obtained for 1 of 25 residents (Resident #9). | Severity: 2 |
| Failed to ensure medications were on-site per physician's order for 2 of 25 residents (Resident #13 and #14). | Severity: 2 |
| Failed to maintain a safe and secure unit for persons with Alzheimer's disease or related dementia and failed to ensure residents with dementia, sundowning, and wandering behaviors were not retained for 2 of 25 residents (Resident #19 and #22). | Severity: 2 |
| Failed to post a non-discrimination sign and submit or provide evidence of a cultural competency training program for employees. | Severity: 2 |
Report Facts
Resident files reviewed: 25
Employee files reviewed: 10
Complaint allegations: 6
Deficiency repeat count: 3
Residents sampled: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Morris | LPN, RDO | Laboratory Director's or Provider/Supplier Representative's signature on the report. |
Inspection Report
Complaint Investigation
Capacity: 150
Deficiencies: 0
Oct 13, 2022
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 09/12/22 and completed on 10/13/22, concerning seven allegations related to resident care and facility operations.
Findings
The investigation found all seven allegations unsubstantiated, including claims of bullying, failure to conduct hourly checks, failure to report falls, unauthorized room entry, delayed call bell response, fire exit door malfunction, and theft of resident property. No regulatory deficiencies were identified.
Complaint Details
Complaint #NV00066893 with seven allegations was investigated and found unsubstantiated. Allegations included bullying, failure to conduct hourly checks, failure to report falls, unauthorized room entry, delayed call bell response, fire exit door issues, and theft of resident property. The theft allegation was previously substantiated in an earlier investigation dated 08/18/22, but no new deficiencies were found in this investigation.
Report Facts
Licensed capacity: 150
Sample size: 5
Number of allegations: 7
Inspection Report
Complaint Investigation
Capacity: 150
Deficiencies: 0
Oct 13, 2022
Visit Reason
The inspection was conducted as a complaint investigation initiated on 2022-09-12 and completed on 2022-10-13, in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
Seven allegations were investigated and all were found to be unsubstantiated except for a previously substantiated deficiency related to theft of a resident's property. No regulatory deficiencies were identified during this investigation.
Complaint Details
Complaint #NV00066893 involved seven allegations including bullying, failure to conduct hourly checks, failure to report falls, unauthorized room entry, delayed call bell response, stuck fire exit door, and stolen resident property. All allegations were unsubstantiated except the theft allegation which was substantiated previously on 2022-08-18.
Report Facts
Licensed capacity: 150
Sample size: 5
Number of allegations: 7
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 1, 2022
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding an allegation of theft of a resident's personal property at the facility.
Findings
The facility failed to complete an investigation for the allegation of theft of a resident's property and did not follow its grievance policy for 1 of 5 sampled residents. The complaint was substantiated with a severity level of 2 and scope of 1.
Complaint Details
Complaint #NV00066468 with one allegation was substantiated. The allegation involved a resident's property reported as stolen and the facility's failure to follow policies and procedures related to the theft.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to follow policies and procedures related to theft of resident property. | Severity: 2 |
Report Facts
Sample size: 5
Complaints investigated: 1
Deficiency severity: 2
Scope: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Morris | Regional Director of Operations | Signed the report |
| Business Office Manager | Reported awareness of missing property and facility policies but no full name provided |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 150
Deficiencies: 5
May 10, 2022
Visit Reason
The inspection was conducted as a result of a mandatory grading resurvey and complaint investigation triggered by complaint #NV00065879 with 12 allegations at the facility.
Findings
The facility received a grade of A. One complaint was substantiated involving failure to respond timely to a resident's call bell and intermittent call alert system functionality. Other allegations were unsubstantiated. Deficiencies were identified related to administrator oversight, food service permits, call bell response times, and medication administration including lack of physician order for cannabidiol (CBD) oil.
Complaint Details
Complaint #NV00065879 with 12 allegations was investigated. Four allegations were substantiated including failure to respond timely to call bell and intermittent call alert system. Other allegations such as unauthorized charges, misdelivered packages, and lack of incident reports were unsubstantiated.
Severity Breakdown
F: 3
J: 1
D: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure a resident's call bell was responded to in a timely manner and the call alert system was functional. | F |
| Administrator failed to provide oversight to ensure compliance with regulations. | F |
| Failure to comply with food service permits and inspections requirements. | F |
| Failure to ensure medical care of resident after illness including notification and arrangements for physician services. | J |
| Failure to obtain physician's order for over-the-counter medication (CBD oil) for a resident. | D |
Report Facts
Complaint allegations: 12
Sample size: 8
Call bell response times: 14
Resident census: 110
Total licensed capacity: 150
Fine amount: 1500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dwight Aalgaard | Administrator | Named in relation to findings on call bell response times, call alert system issues, and medication order deficiencies |
Inspection Report
Re-Inspection
Census: 108
Capacity: 132
Deficiencies: 2
Jan 25, 2016
Visit Reason
This inspection was conducted as a State Licensure resurvey of an assisted living facility providing services to elderly or disabled persons, to verify compliance with regulatory standards.
Findings
The facility received a grade of A but was cited for deficiencies related to food service permits and diabetes care. Major violations included uncovered food in the walk-in freezer and failure to ensure glucose testing supplies were accessible to a resident with diabetes.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Food (sausage patties and french fries) uncovered/unprotected in the walk-in freezer. | Severity: 2 |
| Glucose testing supplies and syringes were not accessible to a resident who cannot test without assistance. | Severity: 2 |
Report Facts
Licensed beds: 132
Resident census: 108
Deficiency severity: 2
Inspection Report
Annual Inspection
Census: 108
Capacity: 132
Deficiencies: 2
Jan 25, 2016
Visit Reason
This document is a State Licensure resurvey conducted on 1/25/2016 to assess compliance with regulatory standards for an assisted living facility.
Findings
The facility received a grade of A but was found deficient in food service permit compliance and diabetes resident care. Specifically, uncovered food was found in the kitchen freezer, and glucose testing supplies were accessible to a resident who requires assistance.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Food (sausage patties and french fries) uncovered/unprotected in the walk-in freezer. | Severity: 2 |
| Failed to ensure glucose testing supplies and syringes were not accessible by a resident who cannot test without assistance (Resident #4). | Severity: 2 |
Report Facts
Licensed beds: 132
Resident census: 108
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Services Director | Indicated Resident #4 had insulin discontinued and home health services monitor glucose | |
| Executive Director | Reported Resident #4 had insulin discontinued and supplies removed from room | |
| Maintenance Director | Acknowledged observation of glucose testing supplies in resident's room |
Inspection Report
Annual Inspection
Census: 108
Capacity: 132
Deficiencies: 7
Nov 10, 2015
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with regulatory standards for an assisted living facility providing services to elderly or disabled persons.
Findings
The facility received a grade of B with multiple deficiencies identified including issues with food service permits, oxygen equipment storage, diabetes care, physical examinations, medication storage, and tuberculosis documentation. Several deficiencies were repeated from prior surveys.
Severity Breakdown
Severity: 2: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Multiple dented cans (beans, apple pie filling, and pudding) observed in dry storage. | Severity: 2 |
| Multiple foods (roast beef, osso, turkey, and beans) uncovered/unprotected in the walk-in refrigerator. | Severity: 2 |
| Oxygen tanks were unsecured in resident rooms (#226 and #103). | Severity: 2 |
| Resident #7's glucose testing was not performed without assistance as required. | Severity: 2 |
| Two residents (#4 and #17) lacked documented annual physical exams. | Severity: 2 |
| Medications were found unlocked in resident rooms, including over-the-counter and prescription drugs. | Severity: 2 |
| Facility failed to ensure 4 out of 25 sampled residents met tuberculosis testing requirements. | Severity: 2 |
Report Facts
Residents' files reviewed: 25
Employee files reviewed: 15
Residents present: 108
Licensed capacity: 132
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Owerson | Executive Director | Signed the statement of deficiencies and plan of correction |
Inspection Report
Annual Inspection
Census: 108
Capacity: 132
Deficiencies: 6
Nov 10, 2015
Visit Reason
This annual State Licensure survey was conducted to assess compliance with state regulations for assisted living services at Pacifica Senior Living San Martin.
Findings
The facility was found to have multiple deficiencies including food service permit issues, unsecured oxygen tanks, improper glucose testing assistance, missing annual physical exams, unsecured medication storage, and incomplete tuberculosis testing documentation.
Severity Breakdown
Severity: 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Kitchen failed to comply with NAC 446 standards; multiple dented cans in dry storage and uncovered foods in walk-in refrigerator. | Severity: 2 |
| Oxygen tanks were unsecured in resident rooms, a repeat deficiency from prior year. | Severity: 2 |
| Facility failed to ensure glucose testing was performed by resident without assistance for 1 of 25 sampled residents (Resident #7). | Severity: 2 |
| Two residents (Resident #4 and #17) lacked documented evidence of annual physical exams. | Severity: 2 |
| Medications were found unlocked in resident rooms, including prescription and over-the-counter drugs. | Severity: 2 |
| Four residents (Resident #3, #4, #16, #17) lacked required tuberculosis testing documentation. | Severity: 2 |
Report Facts
Resident files reviewed: 25
Employee files reviewed: 15
Residents with missing annual physical exams: 2
Residents with missing TB documentation: 4
Unsecured oxygen tanks found: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Observed and acknowledged unsecured oxygen tanks and unlocked medications in resident rooms | |
| Health Services Director | Provided information on Resident #7's medication management and lack of documentation for physical exams and TB tests |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 28, 2015
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #NV00044273, which included allegations regarding medication administration, resident placement appropriateness, and response times to call bells.
Findings
The complaint allegations were investigated through observations, interviews, and record reviews, and none of the allegations were substantiated. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00044273 included three allegations: failure to ensure a resident received medications as prescribed, failure to ensure appropriate resident placement, and failure to respond to call bells in a timely manner. All allegations were found unsubstantiated.
Inspection Report
Annual Inspection
Census: 105
Capacity: 132
Deficiencies: 3
Dec 11, 2014
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 12/11/2014 to assess compliance with regulations for a residential facility for elderly and disabled persons.
Findings
The facility was found deficient in providing meals for a special diet for one resident, securing oxygen tanks in resident rooms, and ensuring employees completed required chronic illness training within 60 days of hire. The facility received a grade of A.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure meals for a special diet were provided for one resident (Resident #26) with gluten allergy. | Level 2 |
| Oxygen tanks were not secured in 2 out of 31 resident rooms (Rooms #258, #264, and #101). | Level 2 |
| Facility failed to ensure 3 out of 14 sampled employees had minimum 4 hours chronic illness training within 60 days of hire. | Level 2 |
Report Facts
Resident census: 105
Total licensed capacity: 132
Number of resident files reviewed: 25
Number of employee files reviewed: 14
Number of resident rooms with unsecured oxygen tanks: 3
Number of employees lacking required training: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding gluten free food availability | |
| Dining Services Manager | Responsible for gluten free food restocking | |
| Executive Director | Oversight of gluten free food and oxygen user compliance | |
| Maintenance Director | Informed about unsecured oxygen tanks | |
| Business Office Manager | Unable to provide evidence of chronic illness training completion |
Inspection Report
Annual Inspection
Census: 105
Capacity: 132
Deficiencies: 3
Dec 11, 2014
Visit Reason
This annual State Licensure survey was conducted to assess compliance with regulatory requirements for the facility licensed as a Residential Facility for Group beds for elderly and disabled persons.
Findings
The facility received a grade of A but had deficiencies including failure to consistently provide gluten-free meals for a resident with a documented allergy, unsecured oxygen tanks in resident rooms, and inadequate chronic illness training for some employees.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure meals for a special diet were provided for 1 resident with gluten allergy; gluten free food was not consistently available and no physician order was included. | Severity: 2 |
| Oxygen tanks were not secured in 3 resident rooms (#101, #258, #264). | Severity: 2 |
| Three employees (#4, #8, #10) lacked documented evidence of completing minimum 4 hours chronic illness training within 60 days of hire. | Severity: 2 |
Report Facts
Resident files reviewed: 25
Employee files reviewed: 14
Unsecured oxygen tanks observed: 3
Employees lacking timely chronic illness training: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #4 | Lacked documented evidence of chronic illness training within 60 days of hire | |
| Employee #8 | Lacked documented evidence of chronic illness training within 60 days of hire | |
| Employee #10 | Lacked documented evidence of chronic illness training within 60 days of hire |
Inspection Report
Re-Inspection
Census: 79
Capacity: 132
Deficiencies: 1
Mar 5, 2014
Visit Reason
This document is a required grading re-survey conducted by the Division of Public and Behavioral Health to assess compliance with state licensure regulations.
Findings
The facility was found deficient in maintaining proper personnel files, specifically regarding background checks for employees. Several employees had undetermined or rejected State and FBI background checks, with the facility in the process of resubmitting fingerprints and awaiting results.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure 3 of 6 employees met background check requirements of NRS 449. | Severity: 2 |
Report Facts
Facility licensed capacity: 132
Census at time of survey: 79
Deficiency scope: 3
Inspection Report
Re-Inspection
Census: 79
Capacity: 132
Deficiencies: 1
Mar 5, 2014
Visit Reason
This document is a required grading re-survey conducted on 3/5/2014 to evaluate compliance with state licensure regulations for Willow Creek at San Martin.
Findings
The facility received a re-survey grade of A. However, deficiencies were identified related to personnel files, specifically failure to ensure that 3 of 6 employees met background check requirements as mandated by NRS 449.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 3 of 6 employees met background check requirements of NRS 449, including undetermined or rejected State and FBI background checks. | 2 |
Report Facts
Licensed capacity: 132
Census: 79
Employees reviewed: 6
Residents reviewed: 7
Deficiency scope: 3
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