Inspection Report
Annual Inspection
Census: 26
Capacity: 91
Deficiencies: 9
Mar 25, 2025
Visit Reason
This inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to have multiple regulatory deficiencies including failure to ensure annual caregiver training, expired CPR training for an employee, poor maintenance and sanitation issues, expired food items, malfunctioning equipment, medication administration errors, incomplete resident medical records, and lack of infection control training for unlicensed caregivers.
Severity Breakdown
Severity: 2: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure eight hours of annual caregiver training were completed for 1 of 8 employees. | Severity: 2 |
| Failed to ensure cardiopulmonary resuscitation (CPR) training was current for 1 of 8 employees. | Severity: 2 |
| Failed to maintain clean and well-maintained interior premises; laundry rooms had debris and malfunctioning washers. | Severity: 2 |
| Failed to comply with food service standards; expired food items, grime buildup, and malfunctioning kitchen equipment observed. | Severity: 2 |
| Failed to ensure a resident's bathroom call bell was functional. | Severity: 2 |
| Failed to have nitroglycerin medication on site for 1 of 10 sampled residents. | Severity: 2 |
| Medication Administration Record (MAR) lacked accurate documentation for 1 of 10 sampled residents. | Severity: 2 |
| Failed to ensure a two-step tuberculosis (TB) test was completed for 1 of 10 sampled residents. | Severity: 2 |
| Failed to ensure infection control training was completed within one year of hire for 3 of 8 unlicensed caregivers. | Severity: 2 |
Report Facts
Licensed beds: 91
Current census: 26
Employees reviewed: 8
Resident files reviewed: 10
Severity 2 deficiencies: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Frederick Brown | Executive Director | Signed the report and involved in corrective actions |
| Employee #1 | Medication Technician | Failed to complete annual caregiver training and infection control training |
| Employee #3 | Medication Technician | Failed to maintain current CPR training |
| Employee #5 | Medication Technician | Failed to complete infection control training |
| Employee #8 | Medication Technician | Failed to complete infection control training |
Inspection Report
Annual Inspection
Census: 46
Capacity: 91
Deficiencies: 6
Mar 6, 2024
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups providing assisted living services.
Findings
The facility received a grade of B with multiple regulatory deficiencies identified, including failure to ensure annual elder abuse training for one employee, incomplete tuberculosis testing for one employee and one resident, food safety violations in the kitchen, inaccurate medication administration records for one resident, and lack of cultural competency training for eight employees.
Severity Breakdown
D: 4
E: 1
F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure annual elder abuse training was completed for 1 of 10 employees (Employee #5). | D |
| Failure to ensure the second step of an initial two-step tuberculosis (TB) test was completed for 1 of 10 employees (Employee #2). | D |
| Failure to ensure kitchen and supportive dining services complied with food safety standards, including holding potentially hazardous food longer than seven days and dirty non-food contact surfaces. | E |
| Failure to ensure the Medication Administration Record (MAR) was accurate for 1 of 15 residents (Resident #2). | D |
| Failure to ensure 1 of 15 residents met tuberculosis testing requirements prior to admission (Resident #2). | D |
| Failure to ensure 8 of 10 employees were in compliance with initial cultural competency training requirements. | F |
Report Facts
Licensed beds: 91
Current census: 46
Employees reviewed: 10
Residents reviewed: 15
Severity 2 deficiencies: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Frederick Brown | Administrator | Signed the report and acknowledged deficiencies |
| Employee #5 | Caregiver | Named in elder abuse training deficiency |
| Employee #2 | Housekeeper | Named in tuberculosis testing deficiency |
| Employee #1 | Concierge | Named in cultural competency training deficiency |
| Employee #3 | Server | Named in cultural competency training deficiency |
| Employee #4 | Server | Named in cultural competency training deficiency |
| Employee #8 | Caregiver | Named in cultural competency training deficiency |
| Employee #9 | Housekeeper | Named in cultural competency training deficiency |
| Employee #10 | Medication Technician | Named in cultural competency training deficiency |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Sep 27, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 09/27/23 in accordance with Nevada Administrative Code Chapter 449.
Findings
No regulatory deficiencies were identified during the investigation. The complaint could not be verified. Observations, interviews, and record reviews were conducted with no issues found.
Complaint Details
One complaint was investigated (Complaint #NV00069112) and was unverified; no regulatory deficiencies were identified.
Report Facts
Sample size: 5
Grade: A
Inspection Report
Routine
Census: 33
Capacity: 91
Deficiencies: 10
Jun 21, 2023
Visit Reason
The inspection was a Mandatory Grading survey initiated on 06/21/23 and completed on 06/23/23 to assess compliance with Nevada Administrative Code, Chapter 449, for Residential Facilities for Groups.
Findings
The facility received a grade of A with several regulatory deficiencies identified, including issues with health and sanitation, food service permits, special diet compliance, oxygen use, medical care after illness, medication administration, medication storage, and resident file security.
Severity Breakdown
F: 3
E: 2
D: 5
Deficiencies (10)
| Description | Severity |
|---|---|
| Health and sanitation - facility premises not well maintained. | F |
| Permits - failure to comply with NAC 446 on food service permits. | E |
| Nutrition and service of food - failure to provide meals complying with special diets. | D |
| Residents requiring use of oxygen - failure to ensure oxygen administered per physician's orders and lack of backup oxygen tank. | D |
| Medical care of resident after illness - failure to obtain current physical examinations and follow physician instructions. | D |
| Medication administration - failure to ensure proper medication administration and documentation. | D |
| Medication/OTCs, supplements, change order - failure to administer medications as prescribed and maintain proper documentation. | E |
| Medication - resident refusal - failure to notify physician within 12 hours of missed or refused medication doses. | D |
| Medication storage - failure to store medications properly in locked areas and ensure proper labeling. | F |
| Maintenance and contents of separate file - failure to maintain resident files securely and protect confidentiality. | F |
Report Facts
Licensed beds: 91
Residents present: 33
Sample size: 5
Deficiency repeat: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Frederick Brown | Administrator | Signed the inspection report |
| Resident Care Director | Named in multiple findings related to oxygen orders, medication administration, and monitoring corrections | |
| Maintenance Director | Named in findings related to maintenance corrections and oxygen backup tanks | |
| Executive Director | Named in findings related to monitoring corrections and compliance | |
| Medication Technician | Named in medication administration observations and confirmations | |
| Dining Services Director | Named in findings related to dietary permits and special diet compliance | |
| Business Office Director | Named in findings related to resident file security |
Inspection Report
Annual Inspection
Census: 42
Capacity: 91
Deficiencies: 10
Feb 28, 2023
Visit Reason
This inspection was conducted as an annual State Licensure survey and a Facility Reported Incident (FRI) investigation at the assisted living facility on 02/28/2023.
Findings
The facility was found to have multiple deficiencies including health and sanitation issues, expired food in the kitchen, failure to provide special diets, unsecured oxygen tanks, missing annual physical exams, medication administration errors including missing medications and failure to notify physicians of missed doses, unsecured medications for self-medicating residents, and incomplete tuberculosis testing records.
Complaint Details
One Facility Reported Incident (FRI #8090) was investigated and substantiated related to failure to assess a resident after an elopement incident.
Severity Breakdown
Level 2: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure premises were clean and well maintained including leaking laundry solution dispenser, bulging paneling, soiled carpet, and running toilet. | Level 2 |
| Failed to comply with food service standards including expired cottage cheese, sanitizer bucket left out overnight, rusted metal flashing, and non-functioning food waste collector. | Level 2 |
| Failed to provide special diet as prescribed for Resident #10. | Level 2 |
| Failed to secure oxygen tanks properly in resident rooms. | Level 2 |
| Failed to ensure annual physical examinations and assessments after significant changes for sampled residents. | Level 2 |
| Failed to ensure signed ultimate user agreements for medication administration for 3 residents. | Level 2 |
| Failed to ensure medications were on site and physician orders were followed for 2 residents. | Level 2 |
| Failed to notify physician within 12 hours of missed medication doses for 2 residents. | Level 2 |
| Failed to secure medications for 2 residents who self-administer medications; medications found unsecured in rooms. | Level 2 |
| Failed to provide complete tuberculosis testing for 10 residents including missing initial 2-step and annual TB tests. | Level 2 |
Report Facts
Deficiencies cited: 10
Resident files reviewed: 17
Employee files reviewed: 10
Sample size: 18
Facility capacity: 91
Current census: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Named in multiple findings related to failure to ensure special diets, medication management, physical exams, oxygen tank safety, and TB testing. | |
| Administrator | Interviewed regarding findings including oxygen tank safety, medication issues, and resident assessments. | |
| Maintenance Director | Acknowledged findings related to facility maintenance and oxygen tank storage; responsible for plan of correction for maintenance issues. | |
| Dining Director | Responsible for kitchen and dietary corrective actions and monitoring. | |
| Medication Technician | Reported missing medications and unsecured medications; involved in medication administration findings. | |
| Executive Director | Conducted training and responsible for systemic corrective measures and monitoring. |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 91
Deficiencies: 8
May 13, 2022
Visit Reason
The inspection was conducted as a result of a mandatory State Licensure Re-grading survey and a Complaint Investigation survey at the facility on 05/12/22 through 05/13/22.
Findings
The facility received a grade of A. One complaint was investigated and found unsubstantiated. Several regulatory deficiencies were identified related to caregiver qualifications, elder abuse training, personnel files, kitchen cleanliness, medication administration, resident files, and training requirements.
Complaint Details
One complaint (Complaint #NV00066106) with two allegations was investigated and found unsubstantiated. Allegation #1 regarding a resident's bedsore re-opening due to lack of repositioning was unsubstantiated based on record review and interviews. Allegation #2 regarding eviction due to refusal to provide three caregivers was unsubstantiated based on interviews and documentation showing the resident did not meet eligibility criteria and was discharged safely.
Severity Breakdown
Level 2: 7
Level 3: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure two employees had certification in first aid and CPR. | Level 2 |
| Failed to maintain kitchen in a clean and functional condition; soiled and stained fiberglass wall panels in Janitor's Closet. | Level 2 |
| Failed to ensure timely 6 month medication reviews for all residents. | Level 2 |
| Failed to ensure 16 hours initial medication technician training and annual 8 hours training for administrators. | Level 2 |
| Failed to ensure medications were on-site timely per physician's order. | Level 2 |
| Failed to provide tuberculin (TB) testing for one resident. | Level 2 |
| Failed to maintain Alzheimer's Care endorsement documentation for applicable residents. | Level 2 |
| Failed to ensure caregivers received at least 4 hours of training related to care of elderly or disabled persons within 60 days of employment. | Level 3 |
Report Facts
Licensed beds: 91
Current census: 49
Employees reviewed: 8
Residents reviewed: 9
Complaint allegations: 2
Deficiency repeat date: Feb 24, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leila Hegle | Executive Director | Signed report and involved in corrective actions |
| Employee #5 | Lacked first aid and CPR certification; had incomplete training hours | |
| Employee #7 | Lacked first aid and CPR certification; completed 4.7 hours of care training | |
| Employee #2 | Signed up for CPR class; completed 13 hours of care training | |
| Employee #3 | Completed 7 hours of care training | |
| Employee #4 | Completed 2.7 hours of care training and 16-hour medication technician training |
Inspection Report
Annual Inspection
Census: 50
Capacity: 91
Deficiencies: 10
Feb 24, 2022
Visit Reason
Annual State Licensure and infection control survey conducted in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of D with multiple deficiencies identified including caregiver training, elder abuse training, CPR certification, medication administration and review, food service violations, tuberculosis testing, and Alzheimer’s care endorsement compliance.
Severity Breakdown
Level 2: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure eight hours of annual Caregiver training was completed for 2 of 8 sampled employees. | Level 2 |
| Failed to ensure 2 of 8 sampled employees completed initial and/or annual elder abuse training before providing services. | Level 2 |
| Failed to ensure 2 of 8 sampled employees had current certification in First Aid and CPR. | Level 2 |
| Failed to ensure kitchen and supportive dining services complied with NAC 446 standards including food storage, cleanliness, and staff hygiene. | Level 2 |
| Failed to ensure six-month medication review was completed for 5 of 15 residents sampled. | Level 2 |
| Failed to ensure 1 of 8 sampled employees received 16 hours of initial medication management training. | Level 2 |
| Failed to ensure medications were obtained and administered per physician's orders for 2 of 15 sampled residents. | Level 2 |
| Failed to ensure 2 of 15 sampled residents met tuberculosis testing requirements including two-step TB testing. | Level 2 |
| Failed to ensure a current Physician's Standard Placement Determination form was completed for a resident with dementia. | Level 2 |
| Failed to ensure 6 of 8 sampled employees received four hours of initial training to care for elderly and disabled residents within 60 days of hire. | Level 2 |
Report Facts
Residents sampled: 15
Employees sampled: 8
Facility licensed capacity: 91
Facility census: 50
Deficiency completion dates: Apr 15, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathrine Helton | Administrator | Signed the inspection report |
| Assistant Director of Operations | Acknowledged missing training and certification documentation for multiple employees |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 91
Deficiencies: 1
Sep 23, 2021
Visit Reason
The inspection was conducted as a result of a State Licensure Complaint Investigation initiated on 09/01/21 and completed on 09/23/21, following allegations related to medication overdose and resident absence.
Findings
The complaint allegations were not substantiated. However, other deficiencies were identified, including failure to provide a written agreement for medication administration assistance for one resident. The facility received a grade of A.
Complaint Details
Complaint #NV00064731 with two allegations was not substantiated: Allegation #1 regarding a resident overdosing on pain medications and lack of emergency contact was not substantiated due to lack of evidence. Allegation #2 regarding a resident missing medication dosages after a family member did not return the resident to the facility was not substantiated as the resident was taken to the hospital by family and the facility made multiple attempts to locate the resident and contact the family.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide a written agreement to assist in the administration of medications for one resident; the Ultimate User Agreement was unsigned, undated, and unclear regarding medication management responsibility. | Severity: 2 |
Report Facts
Licensed beds: 91
Resident census: 58
Severity level: 2
Scope: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Catherine Helton | Executive Director | Signed report as Laboratory Director's or Provider/Supplier Representative |
| Pam Ross | Nevada Health Department staff involved in visit and education |
Inspection Report
Abbreviated Survey
Census: 47
Capacity: 91
Deficiencies: 0
Mar 4, 2021
Visit Reason
The inspection was a focused COVID-19 infection control survey conducted to assess compliance with infection control practices related to COVID-19 in accordance with Nevada Administrative Code Chapter 449.
Findings
The facility demonstrated comprehensive infection control measures including staff training, PPE use, visitor restrictions, and cleaning protocols. There were no residents or employees with COVID-19 symptoms or positive tests at the time of inspection. No regulatory deficiencies were cited.
Report Facts
PPE supply count: 235
PPE supply count: 4800
PPE supply count: 4000
PPE supply count: 105
PPE supply count: 200
Hand sanitizer containers: 20
Inspection Report
Complaint Investigation
Census: 46
Capacity: 91
Deficiencies: 0
Jan 22, 2020
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated at the facility on 01/22/20, involving allegations related to resident safety, facility staffing, and resident care.
Findings
The investigation included interviews, policy reviews, observations, and file reviews. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
One complaint (#NV00059689) was investigated with allegations of resident safety, facility staffing, and resident care. The complaint was not substantiated as no deficiencies were found.
Report Facts
Licensed beds: 91
Census: 46
Sample size: 8
Number of complaints investigated: 1
Inspection Report
Annual Inspection
Census: 20
Capacity: 91
Deficiencies: 1
Apr 21, 2016
Visit Reason
The inspection was conducted as a result of an annual State Licensure survey combined with a complaint investigation regarding improper resident discharge.
Findings
The facility received a grade of A. One complaint was investigated but not substantiated. A medication storage deficiency was identified where medications were found unsecured in 4 of 20 rooms inspected, which was a repeat deficiency from the prior year's survey.
Complaint Details
Complaint #NV00045485 with one allegation that a resident was improperly discharged was investigated and not substantiated.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medication storage: facility failed to ensure medications were secure in 4 of 20 rooms inspected. | Severity: 2 |
Report Facts
Rooms inspected: 20
Rooms with unsecured medications: 4
Total licensed capacity: 91
Current census: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Interviewed during complaint investigation and acknowledged medications were found unsecured | |
| Business Office Manager | Interviewed during complaint investigation |
Inspection Report
Annual Inspection
Census: 20
Capacity: 91
Deficiencies: 1
Apr 21, 2016
Visit Reason
This inspection was conducted as a result of an annual State Licensure survey combined with a complaint investigation on 4/21/16.
Findings
The facility received a grade of A. One complaint alleging improper resident discharge was investigated and not substantiated. A medication storage deficiency was identified where medications were found unsecured in 4 of 20 rooms inspected, which was a repeat deficiency from the prior year's survey.
Complaint Details
Complaint #NV00045485 with one allegation of improper resident discharge was investigated and found not substantiated.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure medications were secure in 4 of 20 rooms inspected. | 2 |
Report Facts
Licensed capacity: 91
Census: 20
Rooms with unsecured medications: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Interviewed regarding complaint and acknowledged unsecured medications | |
| Business Office Manager | Interviewed regarding complaint investigation |
Inspection Report
Annual Inspection
Census: 52
Capacity: 91
Deficiencies: 3
May 15, 2014
Visit Reason
This report results from a State Licensure survey conducted on 05/15/14 to assess compliance with regulatory requirements for a residential facility providing assisted living services.
Findings
The facility received a survey grade of A with several deficiencies identified, including incomplete tuberculosis screenings for employees, failure to comply with kitchen food service permits and food safety standards, and medication administration errors. Corrective actions and plans of correction were documented for each deficiency.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure 6 of 15 employees completed a two-step tuberculosis screening prior to hire date. | Severity: 2 |
| Facility failed to ensure the kitchen complied with food service standards and permits; multiple food safety violations including no food safety certified person on-site, improper food storage, and equipment maintenance issues. | Severity: 2 |
| Facility failed to ensure medication was administered to a resident in accordance with the prescription. | Severity: 2 |
Report Facts
Employees reviewed: 15
Resident files reviewed: 15
Facility licensed capacity: 91
Current census: 52
Inspection Report
Annual Inspection
Census: 52
Capacity: 91
Deficiencies: 3
May 15, 2014
Visit Reason
This State Licensure survey was conducted as an annual inspection to evaluate compliance with state regulations for assisted living facilities.
Findings
The facility received a survey grade of A but had several deficiencies including failure to ensure timely tuberculosis screenings for employees, kitchen violations related to food safety and maintenance, and improper administration of medication to a resident.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 6 of 15 employees completed a two-step tuberculosis screening prior to their hire date. | Severity: 2 |
| Failed to ensure the kitchen complied with the standards of NAC 446, including no food safety certified person-in-charge, improper food storage, and equipment maintenance issues. | Severity: 2 |
| Failed to ensure medication was administered to a resident in accordance with the prescription. | Severity: 2 |
Report Facts
Number of employees with TB screening deficiency: 6
Number of resident files reviewed: 15
Number of employee files reviewed: 15
Licensed capacity: 91
Census: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #5 | Caregiver | Failed to complete TB screening prior to hire date. |
| Employee #6 | Med tech/caregiver | TB screening completed 9 days after hire date. |
| Employee #7 | Resident Care Director | TB screening completed 4 days after hire date; interviewed on 05/15/14. |
| Employee #8 | Caregiver | TB screening completed 3 days after hire date. |
| Employee #9 | Med tech/caregiver | No documented evidence of positive TB screening. |
| Employee #12 | Med tech/caregiver | TB screening completed 4 days after hire date; revealed medication administration issue for Resident #4. |
Inspection Report
Re-Inspection
Census: 59
Capacity: 91
Deficiencies: 5
Aug 28, 2013
Visit Reason
The inspection was a grading re-survey conducted by the Division of Public and Behavioral Health to assess compliance with state licensing requirements for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A but was found deficient in elder abuse training for new employees, personnel files lacking current CPR certification, and kitchen sanitation and permit compliance issues. Corrective actions and training plans were implemented to address these deficiencies.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to provide initial training in prevention, recognition and response to abuse of elder persons to 4 of 6 new employees before interaction with residents. | Severity: 2 |
| Personnel file for a caregiver lacked current certification in first aid and cardiopulmonary resuscitation. | Severity: 2 |
| Facility failed to ensure kitchen complied with standards of NAC 446 including permits and food storage. | Severity: 2 |
| Person operating dish machine did not wash hands or change gloves after handling soiled kitchenware and before handling clean kitchenware and tableware. | Severity: 2 |
| Cleaned kitchenware was stacked while still wet on the storage rack. | Severity: 2 |
Report Facts
Residents present: 59
Total licensed capacity: 91
Employees reviewed: 6
Resident files reviewed: 6
Inspection Report
Re-Inspection
Census: 59
Capacity: 91
Deficiencies: 4
Aug 28, 2013
Visit Reason
This document is a Statement of Deficiencies generated as a result of a grading re-survey conducted at The Bridge at Paradise Valley Assisted Living on 08/28/2013 by the Division of Public and Behavioral Health under the authority of NRS 449.0307.
Findings
The facility received a grade of A but was found deficient in several areas including failure to provide elder abuse prevention training to new employees, lack of first aid and CPR certification for one caregiver, and critical kitchen sanitation violations such as improper hand hygiene and wet storage of kitchenware.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide initial training in the prevention, recognition and response to abuse of elder persons to 4 of 6 new employees before they started interaction with residents. | Severity: 2 |
| Personnel file for a caregiver lacked certification for first aid and cardiopulmonary resuscitation. | Severity: 2 |
| Kitchen failed to comply with standards including a critical violation where the person operating the dishmachine did not wash hands or change gloves after handling soiled kitchenware and before handling clean kitchenware and tableware. | Severity: 2 |
| Cleaned kitchenware was stacked while still wet on the storage rack. | Severity: 2 |
Report Facts
Licensed capacity: 91
Current census: 59
Employees reviewed: 6
Resident files reviewed: 6
Deficiencies with elder abuse training: 4
Inspection Report
Annual Inspection
Census: 54
Capacity: 91
Deficiencies: 6
May 23, 2013
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure grading survey conducted on 5/23/13 to assess compliance with state regulations for a residential facility.
Findings
The facility received a grade of B with multiple deficiencies identified, including failures in tuberculosis testing, background checks, food service compliance, periodic physical examinations, medication administration, and medication storage. Several deficiencies were repeat issues from prior surveys.
Severity Breakdown
Severity: 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 10 employees complied with tuberculosis testing requirements. | Severity: 2 |
| Failed to ensure 1 of 10 employees met background check requirements. | Severity: 2 |
| Failed to ensure kitchen compliance with food service standards, including critical violations such as a turkey roast cooked at 50 degrees F and lack of sanitizer in the sink. | Severity: 2 |
| Failed to ensure 2 of 15 residents received annual physical examinations. | Severity: 2 |
| Failed to ensure 3 of 7 resident medications were maintained at proper levels. | Severity: 2 |
| Failed to ensure medications administered by residents capable of self-administration were kept secured. | Severity: 2 |
Report Facts
Licensed beds: 91
Census: 54
Deficiencies cited: 6
Inspection Report
Annual Inspection
Census: 54
Capacity: 91
Deficiencies: 6
May 23, 2013
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure grading survey conducted on 5/23/2013 at The Bridge at Paradise Valley Assisted Living.
Findings
The facility received a grade of B and was found deficient in several areas including personnel files for tuberculosis testing and background checks, kitchen food service compliance, periodic physical examinations for residents, medication administration, and medication storage.
Severity Breakdown
Severity: 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 10 employees complied with tuberculosis testing requirements (missing two step TB skin test results). | Severity: 2 |
| Failed to ensure 1 of 10 employees met background check requirements (fingerprinted approximately one month after hire date). | Severity: 2 |
| Kitchen failed to comply with food service standards including a turkey roast cooked to an internal temperature of 50 degrees F, no detectable sanitizer in the third compartment of the sink, garbage can without lid, soiled grease collection area, missing air gap on ice machine drain line, and pots stored less than six inches from the floor. | Severity: 2 |
| Failed to ensure 2 of 15 residents received annual physical examinations (missing multiple years for Resident #7 and missing 2012 exam for Resident #8). | Severity: 2 |
| Failed to ensure 3 of 7 resident medications were at a maintenance level (Residents #2, #5, and #6). | Severity: 2 |
| Failed to ensure medications administered by a resident capable of self-administration were kept secured; medications were observed in rooms without facility knowledge (Residents in Rooms #110, #113, and #120). | Severity: 2 |
Report Facts
Licensed capacity: 91
Census: 54
Resident files reviewed: 15
Employee files reviewed: 10
Grade: B
Inspection Report
Complaint Investigation
Capacity: 91
Deficiencies: 0
Mar 7, 2013
Visit Reason
The inspection was conducted as a complaint investigation initiated by the Nevada State Health Division on 2013-02-21 regarding allegations of inappropriate care for two residents with stage 4 pressure ulcers and care for a resident with a mental illness without proper endorsement.
Findings
The complaint was unsubstantiated after interviews with home health and hospice nurses and review of records showed the residents' pressure ulcers were in a healing stage and receiving daily wound care. The facility was found to be properly endorsed to care for residents with mental illnesses.
Complaint Details
Complaint #NV00034471 was unsubstantiated. Allegations regarding inappropriate care for two residents with stage 4 pressure ulcers and care for a resident with mental illness without endorsement were not substantiated through interviews and document review.
Report Facts
Licensed capacity: 91
Inspection Report
Complaint Investigation
Capacity: 91
Deficiencies: 0
Jan 30, 2013
Visit Reason
The inspection was conducted as a complaint investigation initiated by the Bureau of Health Care Quality and Compliance on 2013-01-29 regarding an allegation of resident safety involving a wandering resident.
Findings
The allegation that a resident wandered outside the facility was not substantiated based on interviews with facility staff and the resident's public guardian, as well as record reviews. The resident had wandered in the hallways but not outside the facility, and the resident's condition was declining leading to a transfer.
Complaint Details
Complaint #NV00034089 alleged resident safety concerns involving a wandering resident. The complaint was not substantiated after interviews and document review.
Report Facts
Licensed capacity: 91
Category I residents: 81
Category II residents: 10
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