Inspection Reports for Spring Valley Alzheimer’s Care
5310 Sharon Marie Court, Las Vegas, NV 89118, NV, 89118
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 5
Capacity: 8
Deficiencies: 0
Mar 3, 2024
Visit Reason
This inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A with no regulatory deficiencies identified. Five resident files and three employee files were reviewed, and no further action was required.
Report Facts
Resident files reviewed: 5
Employee files reviewed: 3
Inspection Report
Annual Inspection
Census: 5
Capacity: 8
Deficiencies: 2
Feb 12, 2024
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with Nevada Administrative Code (NAC) Chapter 449 for a Residential Facility for Groups.
Findings
The facility received a grade of A. Deficiencies were identified related to improper storage and handling of frozen food items and failure to ensure infection control designees completed required training.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure frozen food was used or discarded prior to accumulating ice crystals, with multiple food items found overfilled with ice and dated November and December 2023, not suitable for consumption. | Severity: 2 |
| Facility failed to ensure primary and secondary infection control designees completed 15 hours of infection control training; records for 2 of 3 employees lacked documented evidence of training. | Severity: 2 |
Report Facts
Licensed beds: 8
Resident census: 5
Severity level 2 deficiencies: 2
Inspection Report
Annual Inspection
Census: 5
Capacity: 8
Deficiencies: 2
Feb 9, 2023
Visit Reason
The inspection was conducted as an annual State Licensure survey of the residential facility for groups, in accordance with Nevada Administrative Code (NAC) Chapter 449.
Findings
The facility received a grade of A. Deficiencies were identified related to caregiver qualifications for medication management training and personnel files for tuberculosis screening.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure 3 of 3 caregivers received annual medication management training; all employees' training expired on 01/04/23 with no documented evidence of 2023 training. | Severity: 2 |
| Facility failed to ensure 1 of 3 employees had an annual tuberculosis (TB) test; Employee #2 had not completed a TB test in 2022. | Severity: 2 |
Report Facts
Number of caregivers lacking annual medication training: 3
Number of employees lacking annual TB test: 1
Facility licensed capacity: 8
Census at time of survey: 5
Inspection Report
Annual Inspection
Census: 4
Capacity: 8
Deficiencies: 3
Feb 8, 2022
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 Residential Facility for Groups.
Findings
The facility received a grade of A but was cited for several deficiencies including allowing a bedfast resident without a medical exemption to remain in the facility, failure to complete an annual physical exam for one resident, and failure to complete an annual Activities of Daily Living (ADL) assessment for another resident.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident who was bedfast was not allowed to remain in the facility without an approved medical exemption. | Severity: 2 |
| Facility failed to ensure a physical exam was completed annually for one resident; last exam was over a year ago. | Severity: 2 |
| Facility failed to ensure an Activities of Daily Living (ADL) assessment was completed annually for one resident; last assessment was over a year ago. | Severity: 2 |
Report Facts
Licensed capacity: 8
Census: 4
Resident files reviewed: 4
Employee files reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul A Aquino | Administrator | Named as Administrator responsible for corrective actions and acknowledged deficiencies |
Inspection Report
Deficiencies: 3
Feb 8, 2022
Visit Reason
The inspection was conducted to assess compliance with regulations related to admissions policies, medical care of residents after illness, and maintenance of resident files at Spring Valley Alzheimers Care.
Findings
The facility was found deficient in several areas including written policies on admissions, medical care after illness, and maintenance and confidentiality of resident files. Each deficiency was assigned a severity level of D.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Written policy on admissions; eligibility for residency not fully compliant with NAC 449.2702. | D |
| Medical care of resident after illness, injury or accident; periodic physical examination and written records not fully compliant with NAC 449.274. | D |
| Maintenance and contents of separate file for each resident; confidentiality of information not fully compliant with NAC 449.2749. | D |
Inspection Report
Annual Inspection
Census: 5
Capacity: 8
Deficiencies: 2
Apr 19, 2021
Visit Reason
This inspection was conducted as an annual state licensure and infection control survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility failed to implement safe infection control practices related to COVID-19, including lack of documented fit testing and medical clearance for N95 mask use for staff, and failed to ensure annual tuberculosis testing for employees as required.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to implement safe infection control practices for COVID-19; staff lacked documented fit testing and medical clearance for N95 masks. | Severity: 2 |
| Failure to ensure 3 of 3 employees met tuberculosis testing requirements; lacked evidence of annual TB tests. | Severity: 2 |
Report Facts
Licensed beds: 8
Resident census: 5
Employees reviewed: 3
Resident files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul Aquino | Administrator | Reported none of the employees had been fit tested or medically cleared for N95 masks; responsible for compliance |
Inspection Report
Annual Inspection
Census: 5
Capacity: 8
Deficiencies: 2
Jul 28, 2020
Visit Reason
The inspection was conducted as a result of a COVID-19 focused infection control survey combined with an annual State Licensure survey to assess compliance with health and safety regulations.
Findings
The facility was found to have deficiencies related to COVID-19 infection control, including failure to screen visitors and staff for COVID-19 symptoms and temperature checks, lack of a COVID-19 infection control policy, and absence of a thermometer for visitor screening. The facility received a grade of A overall.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility staff did not check the temperature of the health facility inspector prior to entry and did not require COVID-19 screening questions for visitors. | Severity: 2 |
| The facility lacked a COVID-19 infection control policy. | Severity: 2 |
Report Facts
Resident census: 5
Total licensed capacity: 8
Surgical masks: 200
Gloves: 500
Hand sanitizer bottles: 3
Resident temperature checks: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul A Aquino | Administrator | Named in relation to infection control deficiencies and plan of correction |
Inspection Report
Re-Inspection
Census: 6
Deficiencies: 8
Jul 1, 2019
Visit Reason
This Statement of Deficiencies was generated as a result of a State licensure required re-grading survey conducted at the facility on 07/01/2019.
Findings
The facility received a grade of A with no deficiencies identified at the time of the survey. Multiple regulatory requirements related to health and sanitation, food service menus, medication administration, medication storage, resident file maintenance, and Alzheimer's care safety standards were reviewed and found to be completed.
Severity Breakdown
D: 3
C: 1
F: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Health & Sanitation - Maintain Int/ext - NAC 449.209 Health and sanitation. The administrator shall ensure premises are clean and well maintained. | D |
| Service of Food - Menus - NAC 449.2175 Menus must be in writing, planned a week in advance, dated, posted and kept on file for 90 days. | C |
| Administration of Medication Maintenance - NAC 449.2744 Maintenance and contents of logs and records. Records must include medication type, administration date/time, refusals, and instructions. | F |
| Medication: Storage - NAC 449.2748 Medication must be stored in locked areas; medications for external use must be kept separate; refrigerated medications must be locked or in locked rooms. | D |
| Maintenance and Contents of Separate File - NAC 449.2749 Separate file for each resident must be maintained and locked, containing all relevant records. | D |
| Alzheimer's Care Standards for Safety - NAC 449.2756 Operational alarms or audible devices must be installed on all exit doors. | F |
| Alzheimer's Care Standards for Safety - NAC 449.2756 Facility must have an outdoor area for residents with at least 40 square feet per resident, fenced and maintained safely. | F |
| Alzheimer's Care Standards for Safety - NAC 449.2756 All toxic substances must not be accessible to residents. | F |
Report Facts
Census: 6
Deficiency counts: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul Aquino | Administrator | Signed as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Annual Inspection
Census: 4
Deficiencies: 8
Apr 24, 2019
Visit Reason
The inspection was conducted as the Annual Grading Survey of the residential facility in accordance with Nevada Administrative Code, Chapter 449, Residential Facility for Groups.
Findings
The facility received a grade of C with multiple deficiencies identified including failure to maintain the exterior premises, inaccurate menus, medication administration documentation errors, improper medication storage, lack of required tuberculin testing, non-functional audible alarms on exit doors, unsecured sharp objects, and accessible toxic substances.
Severity Breakdown
1: 1
2: 7
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to ensure the exterior was well maintained and free of obstructions, with multiple unused furniture and items stored on the back patio. | 2 |
| Facility failed to maintain an accurate written menu; menus did not match meals served. | 1 |
| Medications administered to residents were not properly documented on the Medication Administration Record; lack of physician clarification for as-needed medications. | 2 |
| External medications were stored in the same container as oral medications, not separately as required. | 2 |
| Facility failed to ensure tuberculin testing was provided for one resident; no initial 2-step tuberculin testing completed upon admission. | 2 |
| Two doors to the back yard were not equipped with functional audible alarms. | 2 |
| Sharp garden tools were stored unsecured in an unlocked shed accessible to residents. | 2 |
| Toxic substances including paint products, dishwashing soap, and hand sanitizers were accessible to residents and not properly secured. | 2 |
Report Facts
Census: 4
Grade: Facility received a grade of C
Deficiencies cited: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul Aquino | Administrator | Named in relation to medication administration findings and facility management |
Inspection Report
Annual Inspection
Census: 4
Capacity: 8
Deficiencies: 4
Apr 18, 2018
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility to assess compliance with regulatory requirements.
Findings
The facility received a grade of A. Several deficiencies were identified including failure to ensure one employee completed elder abuse training before starting work, failure to ensure four employees completed self-disclosure of criminal history, failure to ensure one resident completed the annual physical examination, and failure to ensure two employees completed required dementia training within three months of hire.
Severity Breakdown
Level 1: 1
Level 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 5 employees completed elder abuse training before start of work (Employee #4). | Level 2 |
| Facility failed to ensure 4 of 5 employees completed self-disclosure of criminal history (Employees #2, #3, #4, and #5). | Level 1 |
| Facility failed to ensure 1 of 4 residents completed the annual physical examination (Resident #1). | Level 2 |
| Facility failed to ensure 2 of 5 employees completed ten hours of Alzheimer's training within three months from hire date (Employees #4 and #5). | Level 2 |
Report Facts
Employees reviewed: 5
Resident files reviewed: 4
Facility licensed capacity: 8
Current census: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul Aquino | Administrator | Acknowledged findings during inspection |
Inspection Report
Annual Inspection
Census: 5
Capacity: 8
Deficiencies: 5
Apr 11, 2017
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility on 4/11/2017 to assess compliance with state regulations for a residential facility for elderly and disabled persons and/or persons with Alzheimer's disease.
Findings
The facility was found deficient in several areas including caregiver medication management training, pre-employment physical examinations for employees, resident physical examinations before admission or annually, operational door alarms on exit doors, and security locks on gates. The facility received a grade of B.
Severity Breakdown
2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure 2 of 5 caregivers completed the initial 16-hour medication management training as required. | 2 |
| Facility failed to ensure 2 of 5 employees met requirements for pre-employment physical examinations. | 2 |
| Facility failed to ensure 3 of 5 residents received a physical examination before admission or annually. | 2 |
| Facility failed to ensure 1 of 2 exit doors had operational alarms that sounded when opened. | 2 |
| Facility failed to ensure that 1 of 2 gates leading from the secured fenced area was locked; padlock was hanging unlocked. | 2 |
Report Facts
Residents present: 5
Licensed capacity: 8
Employees reviewed: 5
Resident files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul Aquino | Administrator | Signed as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Annual Inspection
Census: 4
Capacity: 8
Deficiencies: 3
May 3, 2016
Visit Reason
The inspection was conducted as a State Licensure annual grading survey to evaluate compliance with regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but had several deficiencies including failure to provide a physician's order for an over-the-counter medication, lack of annual tuberculosis screening for one resident, and failure to secure a gate in the yard area. All deficiencies were corrected by mid-May 2016.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide a physician's order for an over-the-counter medication administered to a resident. | Severity: 2 |
| Failure to ensure annual screening for signs and symptoms of tuberculosis for one resident. | Severity: 2 |
| Failure to ensure one of two gates leading from the secured yard was locked and secured with a lock. | Severity: 2 |
Report Facts
Census: 4
Total Capacity: 8
Severity 2 Deficiencies: 3
Inspection Report
Annual Inspection
Census: 4
Capacity: 8
Deficiencies: 3
May 3, 2016
Visit Reason
This document is a State Licensure annual grading survey conducted to assess compliance with regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but had several deficiencies including failure to provide a physician's order for an over-the-counter medication for one resident, lack of annual tuberculosis screening for another resident, and failure to secure one of two gates in the fenced yard.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide a physician's order for an over-the-counter medication administered to one resident. | Severity: 2 |
| Failed to ensure annual screening for signs and symptoms of tuberculosis for one resident. | Severity: 2 |
| Failed to ensure that one of two gates leading from the secured fenced yard was locked. | Severity: 2 |
Report Facts
Licensed capacity: 8
Census: 4
Deficiency count: 3
Inspection Report
Annual Inspection
Census: 5
Capacity: 8
Deficiencies: 1
Sep 30, 2015
Visit Reason
This document is a State Licensure grading resurvey conducted on 09/30/15 to assess compliance with regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but had a deficiency related to dangerous items, specifically knives being accessible to residents. The deficiency was a repeat from the previous annual survey on 08/13/15.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Knives, matches, firearms, tools and other items that could constitute a danger to the residents of the facility are inaccessible to the residents. Knives were observed unlocked in the dishwasher and accessible to 5 of 5 residents. | Severity: 2 |
Report Facts
Census: 5
Total Capacity: 8
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 acknowledged the deficiency and moved the knives to a locked cabinet |
Inspection Report
Annual Inspection
Census: 5
Capacity: 8
Deficiencies: 1
Sep 30, 2015
Visit Reason
This State Licensure grading resurvey was conducted as an annual State Licensure survey to assess compliance with regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but was cited for a deficiency related to dangerous items being accessible to residents. Specifically, knives were found unlocked in the dishwasher, posing a danger to residents. This was a repeat deficiency from the prior annual survey.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure dangerous items such as knives were inaccessible to residents; knives were observed unlocked in the dishwasher. | Severity: 2 |
Report Facts
Licensed beds: 8
Residents present: 5
Repeat deficiency date: Aug 13, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 acknowledged the deficiency and moved the knives to a locked cabinet |
Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 2
Aug 5, 2014
Visit Reason
The inspection was conducted as an annual State Licensure survey to assess compliance with health and safety regulations for a Residential Facility for Group beds providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but was cited for deficiencies related to health and sanitation hazards, including blocked emergency exit doors and presence of insects and rodents. The Administrator acknowledged the issues and took corrective actions during the inspection.
Severity Breakdown
Level 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Blocked emergency exit door by furniture impeding free movement of residents within and outside the facility. | Level 2 |
| Presence of insects and rodents including a black widow spider and bugs inside kitchen floor cabinets. | Level 2 |
Report Facts
Resident census: 8
Total licensed capacity: 8
Severity level: 2
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul Aquino | Administrator | Acknowledged blocked door and insect issues during inspection |
Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 2
Aug 5, 2014
Visit Reason
This inspection was conducted as an annual State Licensure survey to assess compliance with regulatory requirements for the facility licensed to provide care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but was cited for two deficiencies: a blocked emergency exit door and presence of insects on the premises. Both deficiencies were acknowledged by facility staff and corrective actions were initiated.
Severity Breakdown
2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Door identified with emergency EXIT lighting was blocked by furniture impeding free movement. | 2 |
| Premises were not free of insects, including a black widow spider observed on the patio and bugs found inside kitchen cabinets. | 2 |
Report Facts
Resident census: 8
Total licensed capacity: 8
Employee files reviewed: 3
Resident files reviewed: 8
Deficiency severity level 2 count: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Acknowledged blocked door and insect presence, involved in corrective actions | |
| Caregiver #1 | Acknowledged blocked door and removed furniture |
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 16, 2013
Visit Reason
This document is a statement of deficiencies generated as a result of a required grading re-survey conducted at the facility on 08/16/2013 by the Division of Public and Behavioral Health under the authority of NRS 449.0307.
Findings
The facility received a re-survey grade of A and no deficiencies were identified during this inspection.
Inspection Report
Annual Inspection
Census: 4
Capacity: 8
Deficiencies: 11
May 7, 2013
Visit Reason
The inspection was an annual State Licensure survey conducted on 5/7/13 to assess compliance with state regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of D with multiple deficiencies identified, including failure to ensure caregivers received required training, incomplete background checks, poor sanitation, medication administration errors, unsecured medication storage, unlocked resident files, incomplete tuberculosis testing, inadequate Alzheimer's training, and unsafe storage of dangerous items.
Severity Breakdown
Severity: 1: 2
Severity: 2: 8
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure 3 of 3 caregivers received eight hours of annual training. | Severity: 2 |
| Failed to ensure 3 of 3 employees met background check requirements; missing criminal history statements. | Severity: 1 |
| Facility failed to ensure premises were clean and well maintained; thick layer of grease and grim on kitchen cabinets and stove. | Severity: 2 |
| Failed to ensure medication administration record (MAR) was accurate for 2 of 4 residents. | Severity: 1 |
| Failed to ensure medications were kept in a locked place; medication lock box and file cabinet found unlocked. | Severity: 2 |
| Failed to keep resident files in a locked place; file cabinet containing resident files was unlocked. | Severity: 2 |
| Failed to ensure 1 of 4 residents complied with tuberculosis testing requirements. | Severity: 2 |
| Failed to ensure swimming pools and other bodies of water were fenced or protected; hot tub door lacked lock and hot tub cover had snap instead of lock. | Severity: 2 |
| Failed to ensure 3 of 3 employees received 3 hours annual Alzheimer's training. | Severity: 2 |
| Failed to ensure dangerous items (knives, razors) were inaccessible to residents; razors found in 3 of 4 resident bedroom/bathroom drawers. | Severity: 2 |
| Failed to ensure 3 of 3 employees received annual Elder Abuse Training; missing 2012 training. | — |
Report Facts
Census: 4
Total Capacity: 8
Caregivers not meeting training requirements: 3
Employees missing criminal history statements: 3
Residents with inaccurate medication records: 2
Residents with missing TB testing: 1
Employees missing Alzheimer's training: 3
Residents with dangerous items accessible: 3
Inspection Report
Annual Inspection
Census: 4
Capacity: 8
Deficiencies: 12
May 7, 2013
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 5/7/2013 at Spring Valley Alzheimers Care, a residential facility for persons with Alzheimer's disease.
Findings
The facility received a grade of D and multiple deficiencies were identified including failure to ensure caregivers received required training, incomplete background checks, poor health and sanitation maintenance, inaccurate medication administration records, unsecured medication storage, unlocked resident files, incomplete tuberculosis testing documentation, unsecured bodies of water, inadequate Alzheimer's training, accessibility of dangerous items to residents, and missing elder abuse training for employees.
Severity Breakdown
Level 1: 2
Level 2: 9
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure that 3 of 3 caregivers received eight hours of annual training. | Level 2 |
| Failed to ensure 3 of 3 employees met background check requirements (missing criminal history statements). | Level 1 |
| Failed to ensure the premises was clean and well maintained (thick layer of grease and grime on kitchen cabinets). | Level 2 |
| Failed to ensure hot tub was protected from resident access (no lock on gazebo door and snap lock on hot tub cover). | Level 2 |
| Failed to ensure medication administration record (MAR) was accurate for 2 of 4 residents. | Level 1 |
| Failed to ensure medications were kept in a locked place (unlocked file cabinet and medication lock box in refrigerator). | Level 2 |
| Failed to keep resident files in a locked place (file cabinet unlocked). | Level 2 |
| Failed to ensure 1 of 4 residents complied with tuberculosis testing requirements. | Level 2 |
| Failed to ensure bodies of water were protected (hot tub door lacked lock and cover had snap lock). | Level 2 |
| Failed to ensure 3 of 3 employees received 3 hours annual Alzheimer training. | Level 2 |
| Failed to ensure dangerous items were inaccessible to residents (razors found in 3 of 4 resident rooms). | Level 2 |
| Failed to ensure 3 of 3 employees received annual Elder Abuse Training (missing 2012 training). | — |
Report Facts
Deficiencies cited: 11
Facility licensed capacity: 8
Census: 4
Employees reviewed: 3
Resident files reviewed: 4
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