Inspection Reports for Pacifica Senior Living Spring Valley
8880 W Tropicana Ave, Las Vegas, NV 89147, Las Vegas, NV
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 16, 2025, found no deficiencies during a complaint investigation, with three complaints and one incident substantiated without deficient practice. Earlier inspections showed a pattern of deficiencies mainly related to medication management, care plan updates, food service sanitation, and staff training, including issues such as incomplete medication training, non-functional call bells, elopement risk supervision, and food safety concerns. Complaint investigations were mostly unsubstantiated, except for a few substantiated complaints without deficiencies and one substantiated complaint involving failure to update a care plan for a high elopement risk resident. Enforcement actions included a monetary penalty of $800 in 2016 and an immediate jeopardy related to air conditioning that was abated the same day; no recent fines or license actions were listed in the available reports. The facility’s inspection history shows some improvement in recent years, with the latest inspections showing fewer or no deficiencies compared to earlier years.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
9.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% worse than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
56 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 0
Date: Sep 16, 2025
Visit Reason
The inspection was conducted as a result of a complaint investigation and Facility Incident Report investigation at the facility on 09/16/2025, in accordance with Nevada Administrative Code (NAC), Chapter 449, Residential Facilities for Groups.
Complaint Details
Three complaints (#NV00074734, #NV00074609, and FRI #11645) were substantiated without deficient practice or deficiencies. One complaint (#NV00074714) was unsubstantiated with no regulatory deficiencies identified.
Findings
There were three complaints and one Facility Reported Incident investigated. Three complaints and one incident were substantiated without deficient practice, and one complaint was unsubstantiated. No regulatory deficiencies were identified during the investigation.
Report Facts
Complaints investigated: 3
Facility Reported Incidents investigated: 1
Sample size: 5
Inspection Report
Annual Inspection
Census: 55
Capacity: 72
Deficiencies: 13
Date: Apr 29, 2025
Visit Reason
The inspection was an annual State Licensure survey conducted on 04/29/2025 to assess compliance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups providing assisted living services for persons with Alzheimer's disease.
Findings
The facility received a grade of D with multiple deficiencies identified including failure to notify change of administrator, incomplete medication management training, non-functional call bells, incomplete person-centered care plans, missing physical exams, medication errors, improper medication storage and labeling, missing annual ADL assessments, non-functional audible door alarms, and insufficient Alzheimer's disease training for staff.
Deficiencies (13)
Failed to notify Bureau of Health Care Quality and Compliance of Change of Administrator within 10 days.
Failed to ensure annual 8-hour Medication Management training was completed for 1 of 9 employees.
Failed to ensure 1 of 15 residents had a functional call bell.
Failed to ensure Person Centered Care plan was reviewed and signed off for 1 of 15 residents.
Failed to ensure initial or annual physical exams were completed for 4 of 15 residents.
Failed to ensure medications were on site, properly labeled, and had physician orders for 6 of 15 residents.
Failed to destroy discontinued medications for 1 of 15 residents.
Failed to maintain accurate and complete Medication Administration Records for 12 of 15 residents.
Failed to ensure over-the-counter medications were labeled with physician's name for 2 of 15 residents.
Failed to complete annual Activities of Daily Living (ADL) assessment for 1 of 15 residents.
Failed to ensure audible alarms were functional on all exit doors leading outside.
Failed to ensure 3 hours of annual Alzheimer's disease training was completed for 4 of 9 employees.
Failed to ensure annual infection control training was completed for 1 of 8 unlicensed caregivers.
Report Facts
Residents files reviewed: 15
Employee files reviewed: 9
Medication errors: 6
Residents with missing physical exams: 4
Residents with missing ADL assessment: 1
Employees lacking Alzheimer's training: 4
Employees lacking Infection Control training: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stacey Sheats | Executive Director | Signed report and involved in education and oversight |
| Employee #8 | Administrator on site not properly notified to Bureau of Health Care Quality and Compliance | |
| Employee #9 | Resident Services Coordinator | Failed to complete annual Medication Management training |
| Employee #4 | Personal Care Attendant | Failed to complete annual Infection Control training |
| Employee #3 | Personal Care Attendant | Failed to complete annual Alzheimer's disease training |
| Employee #7 | Medication Technician | Failed to complete annual Alzheimer's disease training |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 1
Date: Jan 23, 2025
Visit Reason
The inspection was conducted as a result of a Facility Reported Incident (FRI) investigation concerning a resident elopement incident at Pacifica Senior Living Spring Valley.
Complaint Details
The complaint investigation was substantiated. The Facility Reported Incident #10837 involved Resident #1 who eloped multiple times due to lack of updated protective supervision in the care plan.
Findings
The facility failed to ensure that a person-centered care plan was updated to provide protective supervision for a high elopement risk resident at admission and after multiple elopements. The resident eloped three times, and the care plan was not updated until after the last incident.
Deficiencies (1)
Failure to update the person-centered care plan to ensure protective supervision for a resident with high elopement risk.
Report Facts
Census: 53
Sample size: 5
Facility Reported Incident count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cindy Aragon-Harris | RSD | Responsible for auditing person-centered care plans weekly and monthly to ensure protective supervision |
| Stacey Sheats | Acting Executive Director | Named as the facility representative and involved in the investigation |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 0
Date: May 29, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation completed on 05/29/2024 in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Complaint Details
One complaint (#NV00071068) was investigated and found to be unsubstantiated with no regulatory deficiencies identified.
Findings
The facility received a grade of A with one complaint investigated which was unsubstantiated. No regulatory deficiencies were identified following observations, interviews, and record reviews.
Report Facts
Sample size: 5
Complaints investigated: 1
Inspection Report
Annual Inspection
Census: 57
Capacity: 72
Deficiencies: 2
Date: Apr 9, 2024
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility on 04/09/2024 in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but was found deficient in two main areas: food service compliance related to improper glove use by dietary staff, and medication administration errors involving two residents where medications on site did not match physician orders or lacked proper discontinuation orders.
Deficiencies (2)
A dietary employee was observed handling soiled ware with disposable gloves and then handling sanitized ware without changing gloves or washing hands.
Two residents did not receive medication as prescribed: Resident #1 had Trazadone 100 mg on site instead of the prescribed 50 mg without a discontinuation order; Resident #6 lacked Acetaminophen 500 mg on site with no discontinuation order.
Report Facts
Resident files reviewed: 15
Employee files reviewed: 10
Facility licensed capacity: 72
Census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donald D. Trump | Executive Director | Signed as Laboratory Director's or Provider/Supplier Representative's signature on the report |
| Dietary Director | Named in plan of correction for food service deficiency | |
| Resident Services Director | Named in plan of correction for medication administration deficiencies | |
| E1 | Acknowledged Acetaminophen was not on site for Resident #6 |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Date: May 18, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 05/18/23, in accordance with Nevada Administrative Code (NAC), Chapter 449, Residential Facility for Groups.
Complaint Details
One Facility Reported Incident (FRI #8219) was investigated and verified with no deficient practice.
Findings
The investigation included observation of staff and resident interactions, interviews, clinical record reviews, and document review. One Facility Reported Incident (FRI #8219) was verified with no deficient practice. No regulatory deficiencies were identified and no further action was necessary.
Report Facts
Sample size: 2
Inspection Report
Annual Inspection
Census: 56
Capacity: 72
Deficiencies: 6
Date: Apr 4, 2023
Visit Reason
The inspection was conducted as an Annual State Licensure Survey, infection control survey, and Complaint Investigation at the facility on 04/04/23.
Complaint Details
One complaint (#NV00067928) was investigated and found to be unsubstantiated with no regulatory deficiencies identified.
Findings
The facility received a grade of A with no substantiated complaints. Several deficiencies were identified including expired food items in the kitchen, dust and black build-up in food service areas, unsecured toxic substances in the Memory Care Unit, and incomplete cultural competency training for some employees.
Deficiencies (6)
Expired containers of cottage cheese found in the walk-in cooler.
Dust build-up behind equipment on the cook's line and fan guard of the evaporator in the walk-in cooler.
Black build-up on the wall near the dish machine.
Fiberglass Reinforced Panels on the wall entering the ware washing area were separating and corner guards were in disrepair; dust build-up around ceiling air vents.
Toxic substances (Lysol spray and Bleach disinfectant cleaner) were accessible in an unsecured cabinet in the Memory Care dining room.
Six of ten employees lacked documented evidence of completed cultural competency training from an approved program.
Report Facts
Licensed capacity: 72
Census: 56
Employees reviewed: 10
Residents reviewed: 15
Employees non-compliant with cultural competency training: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donald Trump | Executive Director | Signed the report as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Annual Inspection
Census: 56
Capacity: 72
Deficiencies: 7
Date: Apr 4, 2023
Visit Reason
The inspection was conducted as an Annual State Licensure Survey, infection control survey, and Complaint Investigation at the facility on 04/04/23.
Complaint Details
One complaint (#NV00067928) was investigated and found to be unsubstantiated with no regulatory deficiencies identified.
Findings
The facility was found to have several deficiencies including expired food items in the kitchen, dust and maintenance issues in food service areas, unsecured toxic substances in the Memory Care Unit, and incomplete cultural competency training for some employees. One complaint was investigated and found unsubstantiated with no regulatory deficiencies identified.
Deficiencies (7)
Expired containers of cottage cheese found in the walk-in cooler.
Dust build-up behind equipment on the cook's line and fan guard of the evaporator in the walk-in cooler.
Black build-up on the wall near the dish machine.
Fiberglass Reinforced Panels on the wall entering the ware washing area were separating and corner guards were in disrepair.
Dust build-up around the ceiling air vents.
Toxic substances (Lysol spray and Bleach disinfectant cleaner) were accessible in an unsecured cabinet in the Memory Care dining room.
Six of ten employees lacked documented evidence of completed cultural competency training from an approved program.
Report Facts
Licensed capacity: 72
Census: 56
Employees reviewed: 10
Residents reviewed: 15
Severity 2 deficiencies: 7
Employees non-compliant with cultural competency training: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donald Trump | Executive Director | Named as Laboratory Director's or Provider/Supplier Representative's signature on the report. |
| Dietary Manager | Named in relation to corrective actions for kitchen and maintenance deficiencies. | |
| Maintenance Supervisor | Named in relation to corrective actions for kitchen and maintenance deficiencies and securing toxic substances. | |
| Business Office Manager | Confirmed lack of cultural competency training for certain employees. | |
| Executive Director | Responsible for scheduling cultural competency training. |
Inspection Report
Annual Inspection
Census: 50
Capacity: 72
Deficiencies: 4
Date: Apr 5, 2022
Visit Reason
This inspection was conducted as a result of an Annual State Licensure Survey, infection control survey, and Complaint Investigation at the facility on 04/05/22.
Complaint Details
Complaint #NV00065757 was substantiated with two allegations: 1) The facility failed to notify the family of a resident's change in condition, which was substantiated with deficiency; 2) Loss of resident's dentures was substantiated without deficiency as no facility negligence was found.
Findings
The facility was found to have multiple deficiencies including food service violations related to expired and unlabeled food items, failure to notify a resident's family of a change in condition, incomplete initial two-step TB testing for a resident, and lack of audible alarms on exit doors to courtyards. One complaint was substantiated regarding failure to notify family of a resident's condition change.
Deficiencies (4)
Expired and unlabeled food items found in walk-in cooler; grease and dust buildup in kitchen.
Failure to notify family of resident's change in condition.
Initial two-step Tuberculosis test not completed for one resident within required timeframe.
Audible alarm systems were not activated on all exit doors to courtyards.
Report Facts
Resident records reviewed: 15
Employee records reviewed: 10
Beds licensed: 72
Residents present: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donald Trump | Executive Director | Signed the inspection report. |
| Resident Services Director | Interviewed during complaint investigation and involved in corrective actions. |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 0
Date: Feb 2, 2022
Visit Reason
The inspection was conducted as a complaint investigation triggered by one complaint regarding the facility's lockdown during a COVID-19 outbreak.
Complaint Details
Complaint #NV00065579 with one allegation was substantiated without deficiencies. Allegation #1 regarding lockdown during COVID-19 outbreak was substantiated without deficiencies.
Findings
The complaint was substantiated without deficiencies; the facility was on lockdown allowing only medical professionals and staff into the facility. No regulatory deficiencies were identified.
Report Facts
Complaint count: 1
Sample size: 0
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 3
Date: Sep 16, 2021
Visit Reason
This inspection was conducted as a result of a complaint investigation at the facility on 09/16/21, triggered by complaint #NV00064790 with seven allegations regarding food handling and kitchen sanitation practices.
Complaint Details
Complaint #NV00064790 with seven allegations was investigated. Allegations #1 and #2 were substantiated, while allegations #3 through #7 were unsubstantiated based on observations, interviews, and documentation review.
Findings
The investigation substantiated two allegations related to improper handwashing and failure to utilize sanitizing buckets and test strips. Other allegations regarding kitchen cleanliness, dishwasher operation, documentation of cooking logs, honoring residents' food preferences, and proper food storage were unsubstantiated. Additionally, a regulatory deficiency unrelated to the complaint was identified concerning failure to document menu substitutions for special diets.
Deficiencies (3)
Facility staff entered the kitchen and touched food without handwashing.
Facility staff not utilizing sanitizing buckets and test strips.
Facility failed to document menu substitutions for residents with special diets.
Report Facts
Sample size: 9
Severity level: 2
Severity level: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donald Trump | Executive Director | Named as the facility representative signing the report |
| Dietary Manager | Interviewed regarding food preferences, special diets, and menu substitutions |
Notice
Deficiencies: 0
Date: Sep 9, 2016
Visit Reason
The document serves as a sanction notice informing the facility of intended 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 an initial monetary penalty of $800 for a deficiency at TAG 181.
Report Facts
Monetary penalty amount: 800
Penalty reduction percentage: 25
Days to pay penalty: 15
Days until sanctions effective: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minou Nelson | Health Facilities Inspector III | Signed the sanction notice |
Inspection Report
Annual Inspection
Census: 49
Capacity: 72
Deficiencies: 1
Date: Aug 23, 2016
Visit Reason
The inspection was conducted as an annual State Licensure survey of the facility on 08/23/2016 to assess compliance with licensing requirements.
Findings
The facility received a re-survey grade of A. One deficiency was identified related to the failure to ensure expired and not prescribed medications were destroyed properly for one resident.
Deficiencies (1)
Failure to ensure 1 of 5 resident's expired and not prescribed medications were destroyed as required by regulations.
Report Facts
Resident files reviewed: 5
Employee files reviewed: 5
Deficiencies cited: 1
Inspection Report
Re-Inspection
Census: 49
Capacity: 72
Deficiencies: 1
Date: Aug 23, 2016
Visit Reason
This document is a Statement of Deficiencies generated as a result of a grading resurvey State Licensure survey conducted on 8/23/16 at Pacifica Senior Living Spring Valley.
Findings
The facility received a re survey grade of A. The main deficiency identified was the failure to ensure that expired and not prescribed medications for one resident were destroyed according to regulations.
Deficiencies (1)
Failure to ensure 1 of 5 resident's expired and not prescribed medications were destroyed.
Report Facts
Licensed capacity: 72
Census: 49
Deficiencies cited: 1
Inspection Report
Annual Inspection
Census: 49
Capacity: 72
Deficiencies: 1
Date: Aug 23, 2016
Visit Reason
The inspection was conducted as an annual State Licensure survey of the facility on 08/23/2016 by the Nevada Division of Public and Behavioral Health.
Findings
The facility received a re-survey grade of A. One deficiency was identified related to medication destruction where expired and not prescribed medications were not properly destroyed as required.
Deficiencies (1)
The facility failed to ensure 1 of 5 resident's expired and not prescribed medications were destroyed as required by NAC 449.2742(9).
Report Facts
Deficiencies cited: 1
Licensed capacity: 72
Census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Rodriguez | Executive Director | Named as primary contact and signer of the report |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 72
Deficiencies: 2
Date: Aug 3, 2016
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 8/3/16 and completed on 8/16/16 regarding compliance with regulations at a residential facility for persons with Alzheimer's disease providing assisted living services.
Complaint Details
Complaint #NV00046507 was substantiated.
Findings
The facility failed to follow established practices regarding periodic resident assessments for 4 of 5 residents reviewed, and failed to ensure one resident received personal care according to the service plan. Deficiencies were substantiated related to employee compliance with written policies and medical care.
Deficiencies (2)
Facility failed to follow established practice regarding periodic resident assessment for 4 of 5 residents.
Facility failed to ensure 1 of 5 residents received personal care according to the service plan.
Report Facts
Licensed capacity: 72
Census: 49
Residents reviewed: 5
Residents with assessment deficiencies: 4
Residents with personal care deficiency: 1
Inspection Report
Complaint Investigation
Census: 49
Capacity: 72
Deficiencies: 1
Date: Aug 2, 2016
Visit Reason
The inspection was conducted as a complaint investigation on 8/2/2016 regarding an allegation that the facility was without air conditioning for rooms adjacent to and including room A5.
Complaint Details
Complaint #NV00046647 was substantiated. The allegation that the facility was without air conditioning for rooms adjacent to and including room A5 was confirmed. An immediate jeopardy was identified due to excessive temperatures and failure to protect residents, and was abated on the same day.
Findings
The facility failed to maintain temperatures within the allowable range of 68 to 82 degrees Fahrenheit, with temperatures reaching up to 90 degrees in some rooms. Residents, including those with Alzheimer's disease, were not relocated from overheated rooms. An immediate jeopardy was identified and abated the same day after portable air conditioners were placed and a plan to relocate residents was implemented. All air conditioning units were repaired and operational by 8/4/2016.
Deficiencies (1)
Facility failed to ensure temperatures did not exceed 82 degrees Fahrenheit, resulting in unsafe conditions for residents in multiple rooms due to malfunctioning air conditioning units.
Report Facts
Temperature readings: 90
Temperature readings: 89
Temperature readings: 87.4
Temperature readings: 82
Temperature readings: 85.5
Temperature readings: 86.6
Temperature readings: 87
Temperature readings: 86.7
Temperature readings: 83.8
Temperature readings: 84.3
Licensed capacity: 72
Census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Rodriguez | Executive Director | Named as the Administrator and Executive Director involved in the inspection and findings |
| Maintenance Director | Mentioned in relation to air conditioning repair and monitoring but no full name provided | |
| Resident Service Director | Mentioned as alerting staff to the air conditioning problem but no full name provided |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 72
Deficiencies: 0
Date: Jul 7, 2016
Visit Reason
The inspection was conducted as a Complaint Investigation and Licensure survey at PACIFICA SENIOR LIVING SPRING VALLEY on 7/7/2016.
Complaint Details
Complaint #NV00046224 alleging failure to protect a resident from elopement was not substantiated after investigation including door alarms, perimeter checks, staff supervision, and record reviews. Complaint #NV00046193 alleging a resident sat in feces for an hour before being changed was also not substantiated after walkthroughs, observations, and record reviews.
Findings
Two complaints were investigated and both were not substantiated. The facility was found to have operational safety measures and adequate supervision, with no regulatory deficiencies identified.
Report Facts
Licensed capacity: 72
Census: 52
Number of resident files reviewed: 5
Inspection Report
Annual Inspection
Census: 56
Capacity: 72
Deficiencies: 7
Date: Jun 6, 2016
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey and a complaint investigation conducted on 6/6/16 at a residential facility for elderly and disabled persons.
Complaint Details
Complaint #NV00046104 was substantiated regarding medication not administered as prescribed by the physician.
Findings
The facility was found deficient in several areas including personnel files for tuberculosis and background checks, kitchen compliance with food service permits, periodic physical examinations of residents, and medication administration. One complaint was substantiated regarding medication not administered as prescribed. The facility received a grade of B.
Deficiencies (7)
Personnel file lacked complete tuberculosis test documentation for one employee.
Personnel file lacked documented evidence of background check for one employee.
Kitchen failed to comply with standards; new range not completely under hood, outside dumpster lids open, gas can stored improperly.
Four residents did not have valid or timely pre-admission or annual physical examinations.
Medications were not administered as prescribed by a physician for two residents; medications not on-site for four residents.
Repeat deficiency: Medications not on-site confirmed for several residents.
Dangerous items such as knives, matches, firearms, and hazardous materials were accessible to residents in an Alzheimer's facility.
Report Facts
Number of residents present: 56
Total licensed capacity: 72
Number of employees reviewed: 15
Number of resident files reviewed: 15
Severity 1 deficiencies: 1
Severity 2 deficiencies: 5
Severity 3 deficiencies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Rodriguez | ED | Signed the report as Laboratory Director or Provider/Supplier Representative |
| Employee #8 | Business Office Manager with incomplete TB test documentation | |
| Employee #10 | Administrator/Executive Director | Lacked documented evidence of FBI and State background clearances |
| Employee #16 | Medication Technician | Acknowledged medication not listed on MAR and not administered |
| Employee #17 | Regional Nurse Consultant | Acknowledged missed medication doses and facility policy |
| Employee #14 | Resident Care Director | Acknowledged medication findings and confirmed medications not on-site |
| Employee #18 | Maintenance Director | Acknowledged dangerous items accessible to residents |
Inspection Report
Annual Inspection
Census: 56
Capacity: 72
Deficiencies: 6
Date: Jun 6, 2016
Visit Reason
This Statement of Deficiencies was generated as a result of an annual State Licensure survey and a complaint investigation conducted on 6/6/16 at Pacifica Senior Living Spring Valley.
Complaint Details
Complaint #NV00046104 was substantiated regarding a medication not administered as prescribed by the physician.
Findings
The facility was found deficient in multiple areas including incomplete tuberculosis testing for an employee, incomplete background checks, kitchen safety violations, missing or incomplete resident physical exams, medication administration errors, missing medications on-site, and unsafe storage of dangerous items accessible to residents.
Deficiencies (6)
Failed to ensure 1 of 15 employees met tuberculosis test requirements; incomplete TB test documentation for Employee #8.
Failed to ensure 1 of 15 employees met background check requirements; Employee #10 lacked current FBI and State background clearances.
Failed to ensure kitchen complied with NAC 446 standards; new range not completely under hood, open dumpster lids, gas can stored on top shelf in janitor's closet.
Failed to ensure 4 of 15 residents received valid or timely pre-admission or annual physical exams (Residents #2, #4, #13, #15).
Failed to ensure medications were administered as prescribed for 2 of 15 residents (Residents #5 and #12), and medications were missing on-site for 4 of 15 residents (Residents #1, #2, #3, #4).
Failed to ensure dangerous items were inaccessible to residents; hot fireplace glass accessible, unsecured razors and chemicals in resident bathing area, unsecured laundry detergent, unsecured sharps container accessible from patio.
Report Facts
Residents reviewed: 15
Employees reviewed: 15
Deficiency severity 1: 1
Deficiency severity 2: 4
Deficiency severity 3: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #8 | Business Office Manager | Incomplete tuberculosis test documentation |
| Employee #10 | Administrator/Executive Director | Incomplete background check documentation |
| Employee #16 | Medication Technician | Acknowledged medication not listed on MAR and not administered |
| Employee #17 | Regional Nurse Consultant | Acknowledged missed medication doses and administration errors |
| Employee #14 | Resident Care Director | Acknowledged missing medications on-site |
| Employee #18 | Maintenance Director | Acknowledged hot fireplace glass accessible to residents |
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