Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 47
Capacity: 72
Deficiencies: 3
Jan 29, 2025
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation at the facility on 01/29/2025.
Findings
The facility received a grade of A with one complaint substantiated without deficient practice. Several regulatory deficiencies were identified including issues with laundry sanitation, kitchen cleanliness, and infection control training for employees.
Complaint Details
One complaint (Complaint #NV00073184) was investigated and substantiated with no deficient practice found. The investigation included observations of call bell functioning, staffing, fall precautions, interviews, and record reviews.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Laundry room washing machine was not maintained in a sanitary condition, with slimy, green/brown substance and standing water inside the machine. | Severity: 2 |
| Floors under double basin sinks in both serving kitchens were heavily soiled with food, debris, and broken glass. | Severity: 2 |
| Five of eight employees failed to receive infection control training through a nationally recognized organization as required. | Severity: 2 |
Report Facts
Licensed capacity: 72
Census: 47
Employees lacking proper infection control training: 5
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Jul 8, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 07/08/24, in accordance with Nevada Administrative Code (NAC), Chapter 449, Residential Facility for Groups.
Findings
Two complaints were investigated and both were substantiated without deficient practice. The investigation included observations, interviews, clinical record reviews, and document reviews. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Two complaints were investigated: Complaint #NV00071378 and Complaint #NV00071559, both substantiated without deficient practice.
Report Facts
Sample size: 8
Employee files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health Services | Interviewed during complaint investigation | |
| Administrator | Interviewed during complaint investigation | |
| Charge Nurse | Interviewed during complaint investigation | |
| Director of Culinary Services | Interviewed during complaint investigation | |
| Administrative Assistant | Interviewed during complaint investigation |
Inspection Report
Re-Inspection
Census: 45
Capacity: 72
Deficiencies: 8
May 7, 2024
Visit Reason
This inspection was a State Licensure grading resurvey conducted in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the survey. The facility received a grade of A, indicating compliance with applicable regulations.
Severity Breakdown
D: 5
E: 2
F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Permits-Comply with NAC 446 on Food Service - Kitchens; storage of food; adequate supplies of food; permits; inspections. | D |
| Medication Administration - Responsibilities of administrator, caregiver and employees of facility regarding administration of medication. | E |
| Medication/OTCS, Supplements, Change Order - Administration of medication including over-the-counter medications and dietary supplements. | D |
| Medication - Destruction - Responsibilities for destruction of discontinued or expired medication in presence of a witness. | D |
| Administration of Medication Maintenance - Maintenance and contents of logs and records for medication administration. | D |
| Medication: Storage - Medication must be stored in a locked area that is cool and dry with protections against misuse. | F |
| Medication: Storage - Medication must be plainly labeled and kept in original container until administered. | D |
| IC Program Responsible Person and Designee - Designation of primary and secondary persons responsible for infection control. | E |
Report Facts
Licensed beds: 72
Census: 45
Resident files reviewed: 13
Employee files reviewed: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Penny Munn | Administrator | Signed as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Annual Inspection
Census: 45
Capacity: 72
Deficiencies: 7
Jan 17, 2024
Visit Reason
This inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for a Residential Facility for Groups.
Findings
The facility received a grade of C with multiple regulatory deficiencies identified, including issues with food service permits, medication administration, medication storage, and infection control program management.
Severity Breakdown
Severity: 2: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Dumpster enclosure was soiled with bird droppings, cardboard boxes and trash bags. | Severity: 2 |
| Facility failed to ensure an Ultimate User Agreement (UUA) was completed for 4 of 15 residents prior to administering medications. | Severity: 2 |
| Facility failed to ensure medications were administered as prescribed for multiple residents, including missing medications and improper administration. | Severity: 2 |
| Facility failed to ensure discontinued and expired medications were destroyed for 3 of 15 residents. | Severity: 2 |
| Facility failed to ensure physician orders were obtained prior to administering medications to 1 of 15 residents. | Severity: 2 |
| Facility failed to ensure medications were stored securely; medication cart was unsecured during observation. | Severity: 2 |
| Facility failed to designate primary and secondary persons responsible for infection control program. | Severity: 2 |
Report Facts
Licensed capacity: 72
Census: 45
Residents reviewed: 15
Employee files reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jenny Luna | Administrator | Signed the Statement of Deficiencies |
Inspection Report
Re-Inspection
Census: 35
Capacity: 72
Deficiencies: 8
May 1, 2023
Visit Reason
This inspection was a State Licensure mandatory grading resurvey conducted to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but had several deficiencies related to health and sanitation, food service permits, medication administration, Alzheimer’s care safety standards including non-activated audible alarms on courtyard doors, and cultural competency training requirements.
Severity Breakdown
F: 7
D: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Health & Sanitation - Maintain interior/exterior premises clean and well maintained. | F |
| Permits - Comply with NAC 446 on Food Service including obtaining necessary permits. | F |
| Medication Administration - Accuracy & Report: Ensure physician, pharmacist or RN reviews medication regimen every 6 months and reports are maintained. | D |
| Medication Administration - Caregiver assistance with medication administration must meet prescribed conditions. | F |
| Alzheimer's Care Standards - Audible alarms on doors leading to outside courtyard were installed but not activated. | F |
| Alzheimer's Care Standards - Knives, matches, firearms, tools and other dangerous items must be inaccessible to residents. | F |
| Alzheimer's Care Standards - Toxic substances must not be accessible to residents. | F |
| Cultural Competency Training - Facility must conduct cultural competency training for employees providing care. | F |
Report Facts
Licensed capacity: 72
Census: 35
Severity 2 Scope: 3
Percentage signed: 62
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Penny Munn | Administrator | Named as Administrator responsible for facility and cited in findings |
Inspection Report
Re-Inspection
Census: 35
Capacity: 72
Deficiencies: 8
May 1, 2023
Visit Reason
This inspection was a State Licensure mandatory grading resurvey conducted to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but had several deficiencies related to health and sanitation, food service permits, medication administration, Alzheimer's care safety standards including non-activated audible alarms on courtyard doors, and cultural competency training requirements.
Severity Breakdown
F: 7
D: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Health & Sanitation - Maintain interior/exterior and landscaping of the facility. | F |
| Permits - Comply with NAC 446 on Food Service including obtaining necessary permits. | F |
| Medication Administration - Ensure physician, pharmacist or registered nurse reviews medication regimen every 6 months and maintains reports. | D |
| Medication Administration - Caregivers assist in medication administration only under prescribed conditions. | F |
| Alzheimer's Care Standards - Audible alarm on door leading to courtyard was not activated. | F |
| Alzheimer's Care Standards - Knives, matches, firearms, tools and other dangerous items must be inaccessible to residents. | F |
| Alzheimer's Care Standards - Toxic substances must not be accessible to residents. | F |
| Cultural Competency Training - Facility must conduct cultural competency training for employees providing care. | F |
Report Facts
Licensed capacity: 72
Census: 35
Deficiency severity count: 7
Deficiency severity count: 1
Percentage of staff signed off on courtyard door alarm training: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Penny Munn | Administrator | Named as Administrator responsible for the facility and cited in findings related to alarm activation and medication administration |
Inspection Report
Annual Inspection
Census: 28
Capacity: 72
Deficiencies: 8
Feb 14, 2023
Visit Reason
This inspection was conducted as an annual State Licensure and infection control survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for a Residential Facility for Groups.
Findings
The facility was found to have multiple regulatory deficiencies including sanitation issues with dog feces in courtyards, expired food items and improper food storage, missing semi-annual medication regimen reviews for some residents, lack of signed Ultimate User Agreements for medication administration, absence of audible alarms on exit doors, unsecured sharp objects and toxic substances accessible to residents, and failure to comply with cultural competency training requirements for employees.
Severity Breakdown
Severity: 2: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Exterior of the facility was not well maintained with several piles of dog feces in courtyard areas. | Severity: 2 |
| Expired food items found in kitchen and dining areas; improper food storage with raw shrimp stored over cantaloupe; ware washed in hand sink and stored improperly. | Severity: 2 |
| Medication regimen was not reviewed every six months by a pharmacist, physician, or registered nurse for 2 of 10 sampled residents. | Severity: 2 |
| All 10 sampled residents lacked signed Ultimate User Agreements for medication administration. | Severity: 2 |
| Exit doors lacked audible alarms that activate when doors are opened. | Severity: 2 |
| Sharp objects such as scissors were accessible to residents in unlocked cupboards and offices. | Severity: 2 |
| Toxic substances including lotions, proxy spray cleaner, and liquid glue were accessible to residents in unlocked cupboards. | Severity: 2 |
| Facility failed to submit an application for cultural competency training program and 9 of 9 employees lacked required annual cultural competency training. | Severity: 2 |
Report Facts
Licensed capacity: 72
Census: 28
Expired food items: 5
Residents sampled for medication review: 10
Residents without medication review: 2
Residents without signed Ultimate User Agreement: 10
Employees without cultural competency training: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Penny Munn | Administrator | Acknowledged sanitary problem with dog feces and lack of medication review system; involved in monitoring compliance |
| Director of Plant Operations | Confirmed presence of dog feces and lack of audible alarms on exit doors | |
| Director of Health Services | Monitors medication review compliance and medication administration agreements | |
| Culinary Director | Monitors compliance with food storage and safety | |
| Senior Engagement Director | Monitors compliance with food storage and safety | |
| Nexus Program Director | Monitors compliance with food storage and safety and medication administration |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 1
Nov 16, 2022
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by Complaint #NV00067126, which included two substantiated allegations regarding understaffing and medication administration concerns.
Findings
The facility was found to be understaffed, failing to maintain the required one caregiver per six residents ratio during waking hours in the Alzheimer's endorsed facility. Additionally, medication administration issues were substantiated but without deficiencies. The facility received a grade of A.
Complaint Details
Complaint #NV00067126 with two allegations was substantiated. Allegation #1: The facility was understaffed and residents were at risk for falls. Allegation #2: Facility staff were not properly administering medications and computer screens containing Medication Administration Records were left unsecured; this was substantiated without deficiencies.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staffing of one caregiver for every six residents during residents' waking hours in an Alzheimer's endorsed facility. | Severity: 2 |
Report Facts
Census: 28
Sample size: 7
Number of substantiated complaints: 1
Staffing ratio: 6
Number of caregivers hired: 8
Severity level: 2
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Penny Munn | Administrator | Named as the Administrator in the report signature |
| Director of Health Care Services | Interviewed regarding medication administration and staffing issues |
Inspection Report
Original Licensing
Capacity: 72
Deficiencies: 0
Feb 14, 2022
Visit Reason
This inspection was conducted as an initial State Licensure and infection control survey for a facility requesting licensure for 72 Residential Facility for Groups beds for elderly and disabled and/or persons with Alzheimer's disease, Category II residents.
Findings
No regulatory deficiencies were identified during the survey. The facility was provided guidance on infection control, antidiscrimination policies, privacy protection, cultural competency training, and complaint policies. No further action is required.
Report Facts
Licensed beds: 72
Census: 0
Employee files reviewed: 6
Resident files reviewed: 1
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