Inspection Reports for Skyline Estates
2907 N. MOUNTAIN ST., CARSON CITY, NV 89703, CARSON CITY, NV
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 21, 2025, identified deficiencies related to administrator oversight, medication management, and employee training in dementia and cultural competency. Earlier inspections showed a pattern of similar issues, including medication administration errors, incomplete training, unsecured toxic substances, and staffing concerns, with no enforcement actions or fines listed in the available reports. Complaint investigations mostly resulted in unsubstantiated findings, except for one substantiated issue regarding failure to complete Serious Occurrence Reports. The main themes across reports involved medication management and staff training deficiencies. The facility’s inspection history shows persistent challenges without a clear trend of improvement or worsening over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
21.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
207% worse than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
87% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 52
Capacity: 60
Deficiencies: 9
Date: Apr 21, 2025
Visit Reason
This inspection was a State Licensure grading resurvey conducted due to the facility receiving a grade of C or D on a prior inspection, requiring a resurvey application and fee.
Findings
The facility failed to provide adequate oversight by the administrator, maintain a medication management plan, ensure proper medication administration and destruction, maintain accurate medication records, and provide required dementia and cultural competency training to employees. Several deficiencies were repeat findings from the previous annual survey.
Deficiencies (9)
Administrator failed to provide oversight and direction to staff impacting service delivery to all residents.
Facility lacked a Medication Plan and failed to ensure caregivers were trained on medication management.
Medications were not available on-site as prescribed for one resident.
Discontinued medications were not destroyed properly for one resident.
Medication Administration Records (MAR) lacked accurate documentation for four residents.
Two employees failed to complete required dementia training within 40 hours of hire.
One employee failed to complete required eight hours of dementia training within three months of hire.
One employee failed to complete required three hours of annual dementia training by anniversary date.
Three employees failed to complete cultural competency training within required 90 days of hire.
Report Facts
Licensed capacity: 60
Current census: 52
Medication administration errors: 4
Employees sampled: 9
Employees non-compliant with dementia training within 40 hours: 2
Employees non-compliant with dementia training within 3 months: 1
Employees non-compliant with annual dementia training: 1
Employees non-compliant with cultural competency training: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristy Lavey | Executive Director | Named as facility Executive Director responsible for oversight and training |
| Employee #7 | Resident Assistant/Medication Technician | Failed to complete dementia training within 40 hours and 3 hours annual training; terminated 04/25/2025 |
| Employee #8 | Resident Assistant | Failed to complete dementia training within 40 hours and 8 hours within 3 months |
| Wellness Director | Involved in medication management and training; caught medication order error | |
| Business Office Manager | Provided personnel files and training documentation during inspection |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 60
Deficiencies: 11
Date: Sep 16, 2024
Visit Reason
This Statement of Deficiencies was generated as a result of a regrading State Licensure survey and Complaint investigation conducted at the facility on 09/16/2024. The investigation included two complaints regarding resident care and facility conditions.
Complaint Details
Two complaints were investigated. Complaint #NV00071843 had two allegations: Allegation #1 regarding a resident left outside resulting in sunburn was unsubstantiated; Allegation #2 regarding failure to complete Serious Occurrence Reports for hospitalizations was substantiated. Complaint #NV00071731 with multiple allegations including falls, broken blinds, hygiene issues, unauthorized bathroom use, mold, missing belongings, medication errors, and privacy violations were all unsubstantiated due to lack of evidence.
Findings
The facility was found deficient in multiple areas including failure to complete Serious Occurrence Reports, inadequate staff training and supervision, medication administration errors, improper medication storage, and incomplete employee training on dementia care and cultural competency. Several allegations from complaints were substantiated while others were not due to lack of evidence.
Deficiencies (11)
Administrator failed to provide oversight and direction for employees to provide necessary services and protective supervision to residents.
Administrator failed to ensure a resident's record was complete including a Serious Occurrence Report for an overnight hospital stay.
Facility failed to ensure 7 of 15 sampled employees received required caregiver training including Tier 2 dementia training within 60 days of hire and annually thereafter.
Facility failed to ensure discontinued medication was destroyed properly for 1 of 6 sampled residents.
Medication Administration Records were inaccurate for 2 of 6 sampled residents, reflecting discontinued medications.
Facility failed to ensure written instructions indicating specific symptoms for PRN medications were documented for 2 of 6 sampled residents.
Medication storage was not secure; nicotine inhalers were found unsecured in a common area.
Facility failed to ensure 4 of 15 sampled employees completed at least 2 hours of dementia training within 40 hours of hire.
Facility failed to ensure 4 of 15 sampled employees completed at least 8 hours of dementia training within 3 months of hire.
Facility failed to ensure 9 of 15 sampled employees completed at least 3 hours of continuing education in dementia care by their hire anniversary date.
Facility failed to ensure cultural competency training was completed timely for 5 of 15 sampled employees required to obtain it.
Report Facts
Licensed capacity: 60
Census: 57
Employee files reviewed: 15
Resident files reviewed: 6
Severity 2 deficiencies: 11
Resurvey fee: 600
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristy Lavey | Executive Director | Signed report and named in plan of correction and training oversight |
| Wellness Director | Interviewed regarding Serious Occurrence Reports, medication errors, and training | |
| Medication Technician | Interviewed regarding medication administration and storage deficiencies | |
| Business Office Manager | Provided personnel checklists and attestation of compliance for employee training |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 60
Deficiencies: 13
Date: Jun 18, 2024
Visit Reason
This Statement of Deficiencies was generated as a result of a regrading State Licensure survey and Complaint investigation conducted at the facility on 06/18/2024. Four complaints were investigated regarding medication administration, staff behavior, care timeliness, and facility conditions.
Complaint Details
Four complaints were investigated. Complaint #NV00070947 regarding medication administration record issues and medication availability was not substantiated. Complaint #NV00070692 alleging staff yelling, call light delays, medication errors, and verbal abuse was not substantiated due to lack of evidence. Complaint #NV00071153 alleging medication and care delays, call light response issues, and staff neglect was not substantiated. Complaint #NV00071299 alleging failure to maintain safe and comfortable temperature was not substantiated.
Findings
The facility was licensed for 60 beds with a census of 52 at the time of survey. Multiple deficiencies were identified including failure to provide adequate oversight by the administrator, caregiver training deficiencies, medication administration errors, improper oxygen tank storage, inaccurate medication records, and incomplete cultural competency and dementia training for staff. Several complaints were not substantiated.
Deficiencies (13)
Administrator failed to provide oversight and direction for employees to provide necessary services and protective supervision to residents.
Facility failed to ensure 3 of 9 sampled employees received required Tier 2 caregiver training within 60 days of hire and annually thereafter.
Facility failed to ensure annual elder abuse training was completed as required.
Oxygen tanks were not secured in 1 of 7 rooms with residents using oxygen.
Facility failed to ensure medical care and physical examinations were obtained and followed as required.
Medication administration reports were not reviewed and initialed by the administrator within 72 hours of receiving a report.
Medication administration errors including inaccurate Medication Administration Records (MAR) for 2 of 10 sampled residents.
Facility failed to maintain separate resident files with required documentation and confidentiality.
Facility failed to ensure employees received required dementia training: at least 2 hours within 40 hours of hire for 1 employee.
Facility failed to ensure employees received at least 8 hours of dementia training within 3 months of hire for 2 employees.
Facility failed to ensure employees received at least 3 hours of annual dementia training by anniversary date for 2 employees.
Facility failed to ensure cultural competency training was completed timely for 4 of 9 sampled employees within 30 days of hire.
Facility failed to ensure infection control required training was completed within 3 months and annually thereafter.
Report Facts
Licensed beds: 60
Census: 52
Complaints investigated: 4
Deficiency severity Level 2 count: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristy Lavey | Executive Director | Named as facility administrator responsible for oversight and training |
| Wellness Director | Involved in medication administration findings and training | |
| Business Office Manager | Provided personnel training records and confirmed training deficiencies | |
| Medication Technician | Interviewed during complaint investigations and medication administration observations | |
| Maintenance Director | Confirmed oxygen tanks were not secured |
Inspection Report
Annual Inspection
Census: 54
Capacity: 60
Deficiencies: 16
Date: Feb 20, 2024
Visit Reason
This inspection was a State Licensure annual grading survey conducted by the Division of Public and Behavioral Health in accordance with NAC 449, Residential Facility for Groups.
Findings
The facility received a grade of D with multiple deficiencies identified including failure to provide adequate oversight, incomplete caregiver training, unsecured oxygen tanks, missing physical exams, medication administration issues, incomplete resident assessments, and lack of required infection control training.
Deficiencies (16)
Administrator failed to provide oversight and direction for employees to provide needed services and protective supervision.
Facility failed to ensure 2 of 15 sampled employees received required Tier 2 dementia training within 60 days of hire and annually thereafter.
Facility failed to ensure 1 of 15 sampled employees received annual elder abuse prevention training.
Facility failed to ensure first aid and CPR training was received within 30 days of employment for 5 of 15 sampled employees.
Oxygen tanks were unsecured in resident rooms.
Facility failed to ensure a general physical examination was completed on or prior to admission for 1 of 15 sampled residents.
Medication profile reviews lacked Administrator's initials for 9 of 9 residents requiring six-month reviews.
Ultimate user agreement was not completed accurately for 1 of 15 sampled residents.
Over-the-counter medication was not on-site to administer as prescribed for 1 of 15 sampled residents.
Discontinued medication was not destroyed timely for 1 of 15 sampled residents.
Facility failed to ensure tuberculosis testing requirements were met for 3 of 15 sampled residents.
Toxic substances were accessible to residents in memory care.
Facility failed to ensure 2 of 15 employees received at least 8 hours of dementia training within 3 months of hire.
Facility failed to ensure an Activities of Daily Living assessment was completed upon admission for 1 of 15 sampled residents.
Facility failed to ensure cultural competency training was completed timely for 9 of 15 sampled employees required to obtain training within 30 days of hire.
Primary infection control staff lacked the required 15 hours of infection control training.
Report Facts
Facility licensed beds: 60
Census: 54
Grade: D
Resurvey fee: 600
Number of sampled employee files reviewed: 15
Number of sampled resident files reviewed: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristy Lavey | Executive Director | Named as Executive Director responsible for oversight and corrective actions |
| Employee #1 | Administrator with missing Tier 2 dementia training and cultural competency training | |
| Employee #7 | Executive Director | Primary infection control staff lacking required infection control training |
| Employee #12 | Resident Assistant with missing CPR, dementia, cultural competency training and ADL assessment issues | |
| Employee #13 | Resident with inaccurate ultimate user agreement for medication | |
| Employee #15 | Resident Assistant with late cultural competency training | |
| Employee #17 | Resident Assistant/Medication Technician lacking required dementia training | |
| Employee #18 | Resident Assistant lacking timely cultural competency training | |
| Employee #19 | Resident Assistant lacking timely CPR and cultural competency training | |
| Employee #20 | Resident Assistant lacking timely CPR and cultural competency training | |
| Employee #21 | Resident Assistant lacking timely CPR, dementia, and cultural competency training | |
| Employee #22 | Resident Assistant/Medication Technician lacking Tier 2 dementia and cultural competency training |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Nov 13, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation and mandatory regrading State Licensure survey on 11/09/23 and 11/13/23, triggered by Complaint #NV00069718 alleging improper discharge and readmission issues.
Complaint Details
Complaint #NV00069718 alleging improper discharge and readmission was investigated and found not substantiated.
Findings
The facility was found to have several deficiencies including failure to ensure timely CPR and first aid training for one employee, inadequate staffing ratios in the Memory Care unit, failure to complete required Alzheimer's training for one employee, and issues with policy updates and endorsement applications. The complaint allegations were not substantiated.
Deficiencies (7)
Failed to ensure 1 of 7 sampled employees completed CPR and first aid training within 30 days of employment.
Failed to maintain caregiver staffing ratios of one caregiver for every six residents in the Memory Care unit during awake hours.
Failed to ensure 1 of 7 sampled employees received eight hours of Alzheimer's training within the first three months of employment.
Failed to maintain required written policies on admissions and endorsements for mental illness.
Failed to ensure toxic substances were inaccessible to residents.
Failed to display placards conspicuously within 24 hours of receipt.
Failed to post nondiscrimination statement and complaint contact information on website.
Report Facts
Licensed beds: 60
Current census: 72
Sample size: 24
Employees sampled: 7
Residents in Memory Care unit: 12
Residents in Memory Care unit: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristy Lavey | Executive Director | Interviewed during complaint investigation and named in plan of correction |
| Employee #10 | Resident Assistant | Failed to complete CPR, first aid, and Alzheimer's training within required timeframes |
| Wellness Director | Interviewed during complaint investigation and responsible for scheduling and training oversight | |
| Business Office Manager | Confirmed training dates and compliance status for Employee #10 | |
| Marketing Director | Responsible for updating website with nondiscrimination statement and complaint contact information |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Sep 22, 2023
Visit Reason
The inspection was conducted as a result of complaint investigations on 09/21/23 and 09/22/23 regarding staffing and resident care concerns at Skyline Estates, a residential facility for groups.
Complaint Details
Two complaints were investigated: Complaint #NV00069474 alleging lack of staff was substantiated; Complaint #NV00069372 alleging no staff available to allow a resident to exit the facility was not substantiated due to lack of evidence.
Findings
The facility was found to have multiple deficiencies including insufficient staffing levels, lack of proper scheduling of Medication Technicians, expired CPR certification for an employee, failure to administer hospice medications leading to a resident's death, unsafe environment hazards in Memory Care, missing incident reports, and failure to obtain required endorsements and training for chronic illness and dementia care.
Deficiencies (10)
Administrator failed to provide oversight and direction to ensure residents received needed services and protective supervision.
Insufficient number of Resident Assistants on duty to assist residents as per facility's Staffing Plan for July to September 2023.
Medication Technician not scheduled for overnight shifts on multiple dates in July, August, and September 2023.
One employee lacked current CPR and first aid certification.
Resident with physician-ordered hospice care did not have medications administered as ordered for two days preceding death.
Resident was exposed to potential fire hazard due to cable wires and cloth obstructing heat vent in Memory Care Unit.
Residents in Memory Care Unit exposed to toxic substances including lotion and hand soaps left accessible in resident rooms and bathrooms.
Facility failed to obtain Chronic Illness Endorsement prior to admitting residents requiring chronic illness care.
Employee providing care to residents with dementia did not complete required two hours of Alzheimer's training within first 40 hours of employment.
Incident reports were not completed or retained for two residents after their deaths.
Report Facts
Licensed beds: 60
Census: 74
Sample size: 6
Complaints investigated: 2
Resident Assistants scheduled: 1
Medication Technician overnight shifts missed: 10
Employees sampled: 9
Residents sampled: 5
Residents exposed to toxic substances: 10
Employees sampled for dementia training: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristy Lavey | Executive Director | Named in multiple findings including oversight failures, staffing issues, medication administration, and training deficiencies |
| Wellness Director | Named in findings related to staffing, medication administration, training, and safety hazards | |
| Employee #3 | Resident Assistant | Found to have expired CPR and first aid certification |
| Employee #5 | Resident Assistant | Did not complete required Alzheimer's training within first 40 hours of employment |
Inspection Report
Follow-Up
Capacity: 60
Deficiencies: 0
Date: Sep 21, 2023
Visit Reason
This Statement of Deficiencies was generated as a result of a follow-up survey on a complaint investigation conducted on 09/21/23 and 09/22/23 in accordance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.
Complaint Details
The visit was complaint-related and conducted as a follow-up survey. No regulatory deficiencies were found, and no further action was necessary.
Findings
No regulatory deficiencies were identified during the follow-up survey. The facility was licensed for 60 beds with a census of 72 at the time of the survey. Various administrative and operational aspects such as staffing, personnel files, resident rights, maintenance of records, Alzheimer's care standards, and care for persons with chronic illnesses and dementia were reviewed with plans for ongoing improvements.
Report Facts
Licensed capacity: 60
Census: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristy Lavey | Executive Director | Named as Executive Director responsible for oversight and various operational duties |
Inspection Report
Re-Inspection
Census: 51
Capacity: 60
Deficiencies: 8
Date: May 30, 2023
Visit Reason
This Statement of Deficiencies was generated as a result of a regrading State Licensure survey conducted at the facility on 05/30/23 in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found deficient in multiple areas including failure to ensure residents receiving skilled nursing services met eligibility requirements, medication administration documentation errors, unsecured toxic substances in the secured unit, failure to display the most recent letter grade placard, and failure to post state contact information for complaints. The facility received a grade of C.
Deficiencies (8)
Failure to ensure residents receiving skilled nursing services were not allowed to admit or remain in the facility without proper waiver.
Failure to ensure ultimate user agreements for medication administration were accurately completed and dated for sampled residents.
Failure to ensure over-the-counter medication had resident and physician name on the label.
Failure to maintain separate resident files securely and with required documentation.
Failure to ensure toxic substances were inaccessible to residents in the secured unit.
Failure to obtain endorsement for Mental Illness and admitted residents with mental illness without endorsement.
Failure to display the most recent letter grade placard conspicuously in the facility.
Failure to post prominently the State contact information to file a complaint to the State agency.
Report Facts
Licensed capacity: 60
Census: 51
Residents receiving skilled nursing services: 9
Residents with medication agreement issues: 3
Residents with mental illness diagnosis: 2
Severity 1 deficiencies: 2
Severity 2 deficiencies: 5
Severity F deficiencies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristy Lavey | Executive Director | Named in multiple findings including confirmation of deficiencies and corrective actions |
Inspection Report
Annual Inspection
Census: 42
Capacity: 60
Deficiencies: 13
Date: Jan 24, 2023
Visit Reason
This inspection was a State Licensure annual grading survey conducted by the Division of Public and Behavioral Health in accordance with NAC 449, Residential Facility for Groups.
Findings
The facility received a grade of D with multiple deficiencies identified including failure to ensure elder abuse training for employees, maintenance and sanitation issues, medication administration problems, incomplete resident assessments, and failure to post required nondiscrimination statements.
Deficiencies (13)
Failed to ensure 3 of 10 employees received initial elder abuse training prior to beginning work and annually thereafter.
Failed to ensure the interior premises were maintained, including broken blinds, clutter in laundry rooms, and dirt buildup in showers.
Failed to ensure kitchen equipment was clean and sanitary; refrigerated food was not labeled and resident utensils were improperly stored.
Failed to ensure timely first aid and CPR training for 2 of 10 sampled employees.
Failed to ensure expired medications in first aid kits were destroyed for 2 of 4 kits.
Failed to ensure residents receiving skilled nursing services were not allowed to remain in the facility without proper waivers for 9 residents.
Failed to ensure an annual history and physical was completed timely for 1 of 15 sampled residents.
Failed to ensure a resident had a valid Ultimate User Agreement authorizing medication administration.
Failed to ensure medications were on-site to administer as prescribed for 5 residents and over-the-counter medication labels lacked physician names for 1 resident.
Failed to ensure Activities of Daily Living (ADL) assessments were completed upon admission for 8 of 15 sampled residents and some lacked staff signatures.
Failed to ensure toxic substances were inaccessible to residents in memory care unit; unsecured toxic items found in 2 of 9 rooms.
Failed to post a current nondiscrimination statement prominently in the facility and on any Internet website used to market the facility.
Failed to post prominently in the facility the State contact information to file a complaint for residents who may have experienced prohibited discrimination.
Report Facts
Facility licensed beds: 60
Census: 42
Employees reviewed: 10
Residents reviewed: 15
Deficiency severity counts: 13
Resurvey fee: 600
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristy Lavey | Executive Director | Named as Executive Director signing report and involved in corrective actions |
| Business Office Manager | Involved in audit of employee files and training compliance | |
| Maintenance Director | Involved in maintenance corrective actions and education | |
| Wellness Director | Involved in training, medication, and resident care corrective actions |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Dec 30, 2022
Visit Reason
The inspection was conducted as a result of complaint investigations regarding allegations of a resident being denied restroom use while waiting for hospital transport and a resident fall with injury due to delayed response to call light.
Complaint Details
Two complaints were investigated: Complaint #NV00066563 alleging denial of restroom use, and Complaint #NV00067523 alleging a fall with injury due to delayed call light response. Both were unsubstantiated after thorough investigation including observations, interviews with residents and Executive Director, and review of records and reports.
Findings
Both complaints could not be substantiated due to lack of evidence after observations, interviews, and record reviews. No regulatory deficiencies were identified and no further action was required.
Report Facts
Licensed beds: 60
Category II residents: 46
Category II Alzheimer's Disease residents: 14
Sample size: 10
Viewing
Loading inspection reports...
