Deficiencies per Year
8
6
4
2
0
Severe
High
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 89
Capacity: 105
Deficiencies: 2
Feb 25, 2025
Visit Reason
The inspection was conducted as an annual State Licensure survey of the facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but was cited for deficiencies related to infection control training. The primary infection control designee and several unlicensed caregivers lacked documented evidence of required infection control training from nationally recognized organizations.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure the primary infection control designee completed the initial 15 hour infection control training from a nationally recognized organization. | Severity: 2 |
| Failed to ensure 7 of 10 unlicensed caregivers received infection control training through a nationally recognized course. | Severity: 2 |
Report Facts
Licensed beds: 105
Current census: 89
Residents reviewed: 20
Employee files reviewed: 8
Employees lacking training: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashlee Jensen | Executive Director | Named as the primary person responsible for infection control and signer of the report |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Nov 12, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 11/12/24.
Findings
The investigation found no regulatory deficiencies and the complaint was unsubstantiated. Observations, interviews, and record reviews were conducted with no issues identified.
Complaint Details
One complaint (#NV00072454) was investigated and found to be unsubstantiated with no regulatory deficiencies identified.
Report Facts
Sample size: 5
Grade: A
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 0
Sep 25, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 09/25/24.
Findings
The complaint was substantiated without any deficient practice. Observations included memory care unit conditions, isolation precautions, PPE usage, and signage. Interviews and record reviews found no regulatory deficiencies.
Complaint Details
Complaint #NV00072306 was substantiated with no deficient practice.
Report Facts
Sample size: 5
Inspection Report
Annual Inspection
Census: 86
Capacity: 105
Deficiencies: 3
Feb 22, 2024
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility received a grade of A but had several regulatory deficiencies including failure to comply with food service hygiene standards, unsecured toxic substances accessible to residents, and lack of documented cultural competency training for employees.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Not all dietary staff were wearing hairnets or had their hair restrained while working in the kitchen or serving exposed food and beverages. | Severity: 2 |
| The facility failed to ensure toxic substances were secured; an unsecured bottle of multi-purpose cleaner was found in a resident's cabinet without a lock. | Severity: 2 |
| The facility failed to ensure 10 sampled employees received cultural competency training through a Bureau approved course. | Severity: 2 |
Report Facts
Licensed capacity: 105
Current census: 86
Number of resident files reviewed: 20
Number of employee files reviewed: 10
Number of employees lacking cultural competency training: 10
Inspection Report
Annual Inspection
Census: 78
Capacity: 105
Deficiencies: 5
Jan 31, 2023
Visit Reason
The 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 received a grade of A but was found deficient in food service compliance with NAC 446 standards. Major violations included unsealed and unlabeled frozen cookie dough, a soiled deli slicer, dust and debris on kitchen equipment, and heavy dust build-up on freezer condenser and ventilation hood components.
Severity Breakdown
2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| A bag of frozen cookie dough was not sealed and was not labeled or dated in the freezer located in the Bistro. | 2 |
| The deli slicer was soiled with food debris around the back of the blade. | 2 |
| There was dust and debris on the internal components of the range on the cook's line. | 2 |
| There was heavy dust build-up on the condenser of the freezer in the Bistro. | 2 |
| There was heavy dust build-up in the duct of the ventilation hood above the dish machine. | 2 |
Report Facts
Licensed beds: 105
Resident census: 78
Files reviewed: 20
Files reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashlee Jensen | Executive Director | Signed as Laboratory Director's or Provider/Supplier Representative's signature on the report |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 105
Deficiencies: 0
May 24, 2022
Visit Reason
This inspection was conducted as a complaint investigation triggered by Complaint #NV00066174 with four allegations concerning resident visitation, oxygen administration, walker accessibility, and resident grooming.
Findings
The complaint investigation substantiated one allegation without deficiencies regarding a family member's visitation restriction due to disturbances. The other three allegations were not substantiated. No regulatory deficiencies were identified and the facility received a grade of A.
Complaint Details
Complaint #NV00066174 with four allegations was investigated. Allegation #1 regarding visitation restriction was substantiated without deficiencies. Allegations #2 (oxygen not received as prescribed), #3 (staff hiding resident's walker), and #4 (resident left in bed and not groomed) were not substantiated based on documentation review, observations, and interviews.
Report Facts
Licensed beds: 105
Census: 79
Number of allegations: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Reminiscence Coordinator | Interviewed regarding visitation disturbances and resident care | |
| Executive Director | Interviewed regarding visitation disturbances and resident care |
Inspection Report
Annual Inspection
Census: 63
Capacity: 105
Deficiencies: 2
Jan 19, 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 found deficient in food service temperature control and medication administration documentation. Specifically, a refrigerator was found at 45.6°F, and a discontinued medication order was missing for one resident.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The reach-in refrigerator containing milk and juice was at 45.6 degrees Fahrenheit, exceeding safe temperature limits. | Severity: 2 |
| Failure to obtain discontinue orders for medications for 1 of 15 residents (Resident #14). | Severity: 2 |
Report Facts
Resident files reviewed: 15
Employee files reviewed: 6
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Traci Hollingsworth | Executive Director | Signed the report and responsible for ongoing compliance to corrective plans |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 105
Deficiencies: 0
Apr 22, 2021
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #NV00063570 alleging inadequate infection control protocols contributing to resident deaths.
Findings
The complaint was unsubstantiated based on observations of infection control practices, interviews with residents and staff, and review of infection control policies and training. No regulatory deficiencies were identified and the facility received a grade of A.
Complaint Details
One complaint was investigated with one allegation that the facility failed to implement adequate infection control protocols which directly contributed to the deaths of residents. The allegation was unsubstantiated.
Report Facts
Sample size: 8
Licensed capacity: 105
Census: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Coordinator | Interviewed during infection control investigation | |
| Resident Care Director | Interviewed during infection control investigation | |
| Executive Director | Interviewed during infection control investigation |
Inspection Report
Abbreviated Survey
Census: 62
Capacity: 105
Deficiencies: 0
Dec 10, 2020
Visit Reason
The inspection was a focused COVID-19 infection control survey conducted to assess compliance with infection prevention and control measures related to COVID-19 in the facility.
Findings
The facility implemented screening and temperature checks for staff, visitors, and residents, used PPE appropriately, isolated a COVID-19 positive resident with designated staff, and maintained cleaning and sanitization protocols. The Administrator was arranging medical clearance and fit testing for N95 masks. Policies and procedures for infection control and emergency staffing were reviewed and found documented.
Report Facts
Sanitizer storage: 7
Electronic temporal thermometers: 10
Gloves: 20000
Surgical masks: 6000
N-95 masks: 200
KN-95 masks: 900
Face shields: 150
Gowns: 3000
Inspection Report
Complaint Investigation
Census: 75
Capacity: 105
Deficiencies: 0
Mar 3, 2020
Visit Reason
The inspection was conducted as a result of a complaint and a State Licensure survey initiated at the facility on 03/03/20 in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The complaint regarding medications not given was investigated and found to be unsubstantiated. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00060204 alleging medications not given was investigated and found unsubstantiated.
Report Facts
Sample size: 15
Inspection Report
Annual Inspection
Census: 89
Capacity: 105
Deficiencies: 5
Feb 23, 2016
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 2/23/16 to assess compliance with regulatory requirements for a residential care facility.
Findings
The facility was found deficient in several areas including personnel files for tuberculosis testing and background checks, medication destruction and storage, and Alzheimer's training for employees. The facility received a grade of A despite these deficiencies.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 15 employees met tuberculosis (TB) testing requirements; lack of documented evidence of annual TB test being read. | Severity: 2 |
| Failure to ensure 1 of 15 employees met background check requirements; lack of documented evidence of background check after five years of employment. | Severity: 2 |
| Failure to destroy medications after discontinuation as required; observed medication not documented on Medication Administration Record. | Severity: 2 |
| Failure to ensure medications were securely stored in 6 of 35 rooms observed; medications found in resident rooms not authorized for self-medication. | Severity: 2 |
| Failure to ensure 2 of 15 employees completed required initial Alzheimer's training. | Severity: 2 |
Report Facts
Resident census: 89
Total licensed capacity: 105
Employees reviewed: 15
Rooms observed for medication storage: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #14 | Failed to meet TB testing requirements | |
| Employee #15 | Failed to meet background check requirements | |
| Employee #1 | Medication Care Manager | Failed to complete required initial Alzheimer's training |
| Employee #6 | Medication Care Manager | Failed to complete required initial Alzheimer's training |
Inspection Report
Annual Inspection
Census: 89
Capacity: 105
Deficiencies: 5
Feb 23, 2016
Visit Reason
This inspection was conducted as an annual State Licensure survey to assess compliance with regulatory requirements for the residential facility.
Findings
The facility was found to have multiple deficiencies including incomplete tuberculosis testing for one employee, missing background check for another employee, failure to destroy discontinued medications, unsecured medications in resident rooms, and incomplete Alzheimer's training for two employees. The facility received a grade of A.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 15 employees met tuberculosis testing requirements; lack of documented evidence the test had been read for Employee #14. | Severity: 2 |
| Failed to ensure 1 of 15 employees met background check requirements; lack of documented evidence of a background check after five years of employment for Employee #15. | Severity: 2 |
| Failed to destroy discontinued medication (Chlorpheniramine Malfate 4 mg) for Resident #1. | Severity: 2 |
| Failed to ensure medications were secure in 6 of 35 resident rooms observed (Rooms #121, #129, #134, #229, #238, and #240). | Severity: 2 |
| Failed to ensure 2 of 15 employees completed required initial Alzheimer's training (Employees #1 and #6). | Severity: 2 |
Report Facts
Resident census: 89
Total licensed capacity: 105
Employee files reviewed: 15
Resident files reviewed: 21
Rooms with unsecured medications: 6
Rooms observed: 35
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Mar 25, 2015
Visit Reason
This inspection was conducted as a result of a State Licensure complaint investigation initiated by the Division of Public and Behavioral Health on 3/25/15, following complaint #NV00042309 which contained three allegations.
Findings
The complaint allegations were investigated and none were substantiated. The investigation included interviews with staff and residents, observations, and record reviews. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00042309 contained three allegations: 1) A resident received an inappropriate level of care; 2) A resident removes their oxygen cannula and oxygen levels are not maintained properly; 3) Caregivers dropped a resident causing a skin tear. None of these allegations were substantiated after investigation.
Report Facts
Sample size: 5
Inspection Report
Annual Inspection
Census: 91
Capacity: 105
Deficiencies: 0
Mar 11, 2015
Visit Reason
This inspection was conducted as an annual State Licensure survey combined with a complaint investigation between 3/4/15 and 3/11/15.
Findings
The facility was found to be in substantial compliance with regulations, receiving a grade of A. The complaint investigation with four allegations was unsubstantiated, and no deficiencies were identified.
Complaint Details
Complaint #NV00041797 contained four allegations: resident over sedation, failure to ensure resident safety, failure to notify responsible party of an event, and falsification of records. All allegations were investigated and found to be unsubstantiated.
Report Facts
Licensed capacity: 105
Census: 91
Resident files reviewed: 20
Discharged resident files reviewed: 1
Employee files reviewed: 10
Inspection Report
Plan of Correction
Census: 92
Capacity: 105
Deficiencies: 7
Apr 16, 2014
Visit Reason
The document is a plan of correction submitted in response to deficiencies identified during a facility survey conducted on 4/16/2014. The facility is licensed for 105 residential beds for elderly and disabled persons, including those with Alzheimer's disease.
Findings
The facility received a grade of A but had several deficiencies including failure to provide 8 hours of annual caregiver training for one employee, critical and major food service violations, non-operational Alzheimer's facility door alarms, dangerous items accessible to residents, and inadequate dementia training for staff. The plan of correction outlines specific actions and dates to address these issues.
Severity Breakdown
Severity: 2: 6
Critical Violation: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure 1 out of 15 sampled employees received 8 hours of caregiver training annually. | Severity: 2 |
| Failure to comply with food service permits and kitchen safety standards, including lack of food-safety certification and uncovered food items. | Critical Violation |
| Major violations in food service including uncovered juice and lack of utensils for cookie removal. | Severity: 2 |
| Equipment and maintenance violations including improper refrigerator use and improper dishwasher drain line installation. | Severity: 2 |
| Failure to ensure operational alarms on exit doors leading to patios were functioning. | Severity: 2 |
| Failure to ensure dangerous items (knives, matches, tools) were inaccessible to residents with Alzheimer's disease. | Severity: 2 |
| Failure to ensure 1 out of 15 sampled employees received at least 8 hours of dementia training within 3 months of hire. | Severity: 2 |
Report Facts
Licensed capacity: 105
Census: 92
Employees sampled: 15
Residents files reviewed: 12
Training hours: 8
Training hours: 8.5
Training hours: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #6 | Named in deficiency for lack of required caregiver and dementia training | |
| Caregiver #16 | Lead Caregiver | Responsible for monitoring patio use |
| Caregiver #17 | Responsible for monitoring patio use and census |
Inspection Report
Annual Inspection
Census: 92
Capacity: 105
Deficiencies: 5
Apr 16, 2014
Visit Reason
The inspection was conducted as an annual survey of the Sunrise of Henderson residential facility to assess compliance with regulatory standards for elderly and disabled persons, including those with Alzheimer's disease.
Findings
The facility received a grade of A but had several deficiencies including failure to ensure one employee received required caregiver and dementia training, kitchen food safety violations, non-operational Alzheimer's facility door alarms, and unsafe access to dangerous items on an outdoor patio.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure 1 out of 15 sampled employees received 8 hours of caregiver training annually. | Severity: 2 |
| Failure to comply with food service standards including lack of food-safety certification for kitchen person-in-charge, uncovered juice, no utensils for cookies, improper refrigerator use, and improper dishmachine drain line. | Severity: 2 |
| Failure to ensure operational alarms on exit doors leading to patios were in operation. | Severity: 2 |
| Failure to ensure dangerous items such as tomato cages, sharp shovels, fertilizer, and a hammer were inaccessible to residents with Alzheimer's disease on an outdoor patio. | Severity: 2 |
| Failure to ensure 1 out of 15 sampled employees received at least 8 hours of dementia training within 3 months of hire. | Severity: 2 |
Report Facts
Number of residents present: 92
Total licensed capacity: 105
Number of employee files reviewed: 15
Number of resident files reviewed: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #6 was identified as lacking required caregiver and dementia training but no full name or title was provided. | ||
| Caregiver #17 | Provided information about patio door being unlocked and monitoring procedures. | |
| Caregiver #16, Lead Caregiver | Indicated patio monitoring frequency and door alarm status. | |
| Maintenance Coordinator | Indicated memory care residents use patio only while supervised or passing through. |
Notice
Deficiencies: 0
Jun 3, 2013
Visit Reason
The Health Division is notifying the facility of its intent to impose sanctions and monetary penalties due to repeat deficiencies found in a prior survey dated 04/17/12.
Findings
The notice details the imposition of a $300 monetary penalty for a repeat deficiency, references the severity and scope of deficiencies, and outlines the facility's rights to appeal and reduce penalties.
Report Facts
Monetary penalty amount: 300
Working days until sanctions effective: 11
Days to appeal: 10
Days to pay penalty: 15
Penalty reduction percentage: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dorothy Sims | Health Facilities Inspector III | Signed the notice and is the inspector involved |
| Kyle Devine | Bureau Chief | Referenced as the Bureau Chief in the notice |
Inspection Report
Annual Inspection
Census: 82
Capacity: 105
Deficiencies: 8
Apr 16, 2013
Visit Reason
This State Licensure survey was conducted as an annual State Licensure survey to assess compliance with regulatory standards.
Findings
The facility received a grade of A. Several deficiencies were identified including failure to comply with food service permits, improper hand washing by food service personnel, equipment and maintenance issues, lack of monthly smoke detector inspections, medication storage violations, and failure to secure dangerous items in the Alzheimer's unit.
Severity Breakdown
Critical Violation: 1
Severity 2: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to obtain necessary permits from the Bureau of Health Protection Services for food service. | — |
| Person washing dishes did not wash hands after handling soiled kitchenware and before handling clean kitchenware. | Critical Violation |
| Hot water was turned off on a handwashing sink in a food preparation area. | Severity 2 |
| Debris was found in the dumpster enclosure. | Severity 2 |
| Portable fire extinguishers were not inspected, recharged, and tagged at least once each year by a certified person. | — |
| Facility did not ensure monthly smoke detector tests were conducted for the past 12 months. | — |
| Facility failed to ensure medications self-administered by residents were kept in locked containers in 7 of 12 sampled bedrooms. | Severity 2 |
| Facility failed to ensure dangerous items (razors and fingernail clippers) were inaccessible to residents in the Alzheimer's unit. | Severity 2 |
Report Facts
Resident files reviewed: 20
Employee files reviewed: 15
Deficiencies cited: 7
Total licensed capacity: 105
Census: 82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julia Hines | Executive Director | Signed the report as Executive Director |
Inspection Report
Annual Inspection
Census: 82
Capacity: 105
Deficiencies: 4
Apr 16, 2013
Visit Reason
This document is the result of an annual State Licensure survey conducted on 4/16/2013 to assess compliance with state regulations for the Sunrise of Henderson residential facility.
Findings
The facility received a grade of A but was found deficient in several areas including food service permit compliance, kitchen hygiene and maintenance, monthly smoke detector testing, medication storage, and accessibility of dangerous items in the Alzheimer's unit.
Severity Breakdown
Severity 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| The kitchen failed to comply with NAC 446 standards, including a critical violation where the person washing dishes did not wash hands after handling soiled kitchenware and before handling clean kitchenware; hot water was turned off on a handwashing sink; debris was found in the dumpster enclosure. | Severity 2 |
| The facility did not ensure monthly smoke detector tests were conducted for the past 12 months as required. | — |
| Medications self-administered by residents were not kept in locked containers in 7 of 12 sampled bedrooms. | Severity 2 |
| Dangerous items such as razors and fingernail clippers were accessible to residents in the Alzheimer's unit; this was a repeat deficiency from the prior annual survey. | Severity 2 |
Report Facts
Resident files reviewed: 20
Employee files reviewed: 15
Licensed capacity: 105
Current census: 82
Sampled bedrooms with medication storage issues: 7
Months without smoke detector testing: 12
Inspection Report
Re-Inspection
Census: 78
Capacity: 105
Deficiencies: 3
Jun 21, 2012
Visit Reason
This document is a required grading re-survey conducted by the Health Division on 6/21/12 to assess compliance with state licensure regulations for a residential facility.
Findings
The facility was found to have deficiencies related to cleaning and sanitation issues, equipment and maintenance problems, and failure to ensure adequate dementia training for employees. Corrective actions were implemented and accepted.
Severity Breakdown
Severity 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| The facility failed to ensure the kitchen complied with standards of NAC 446, including cleaning and sanitation issues such as inadequate sanitizer concentration in wiping cloths, heavily soiled ovens, and uncovered staff beverage on a shelf. | Severity 2 |
| Equipment and maintenance issues including worn and stained caulking around the dishmachine and presence of a household-grade blender in the kitchen. | Severity 2 |
| Failure to ensure 2 of 6 caregivers completed 3 hours of continuing education training related to caring for residents with Alzheimer's disease. | Severity 2 |
Report Facts
Licensed capacity: 105
Census: 78
Deficiency count: 3
Scope: 3
Scope: 2
Loading inspection reports...
