Inspection Reports for The Rose of Sharon
355 Evan Picone, Henderson, NV 89014, NV, 89014
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Inspection Report
Annual Inspection
Census: 5
Capacity: 8
Deficiencies: 0
Jul 29, 2025
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
No regulatory deficiencies were identified during the survey. The facility received a grade of A and no further action was necessary.
Report Facts
Resident files reviewed: 5
Employee files reviewed: 4
Inspection Report
Annual Inspection
Census: 6
Capacity: 8
Deficiencies: 4
Jul 1, 2024
Visit Reason
The 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 B with several regulatory deficiencies identified, including failure to ensure 6-month medication reviews were reviewed and initialed by the Administrator for 5 of 6 residents, failure to ensure required infection control training was completed by designated staff, and failure to ensure laundry washers were enclosed as required.
Severity Breakdown
Level 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure 6-month medication reviews were reviewed and initialed by the Administrator for 5 of 6 residents. | Level 2 |
| Failure to ensure primary and secondary infection control staff completed 15 hours of approved infection control training. | Level 2 |
| Failure to ensure 2 of 4 employees obtained required infection control training. | Level 2 |
| Failure to ensure two clothes washers located on the back patio were in an enclosure as required. | Level 2 |
Report Facts
Census: 6
Total Capacity: 8
Deficiencies cited: 4
Infection control training hours required: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Geoffery Gomez | Administrator | Named as Administrator responsible for monitoring compliance and signing the report |
| Employee #1 | Caregiver | Identified as secondary infection control staff lacking required training |
| Employee #4 | Caregiver | Identified as primary infection control staff lacking required training |
| Employee #2 | Caregiver | Lacked documented infection control training |
| Employee #3 | Administrator | Lacked documented infection control training |
Inspection Report
Complaint Investigation
Census: 5
Deficiencies: 0
Apr 11, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 04/11/24 and completed on 04/17/24 at the facility.
Findings
Two complaints were investigated and both were found to be unsubstantiated with no regulatory deficiencies identified. The investigation included observations, interviews, and record reviews.
Complaint Details
One complaint was investigated. Complaint #NV00070634 and Complaint #NV00070959 were both unsubstantiated with no regulatory deficiencies identified.
Report Facts
Sample size: 5
Complaints investigated: 2
Inspection Report
Annual Inspection
Census: 6
Capacity: 8
Deficiencies: 0
Jul 12, 2023
Visit Reason
This 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
No regulatory deficiencies were identified during the survey. The facility received a grade of A and no further action was necessary.
Inspection Report
Annual Inspection
Census: 6
Capacity: 8
Deficiencies: 0
Jul 20, 2022
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
No regulatory deficiencies were identified during the inspection. The facility received a grade of A and no further action was necessary.
Report Facts
Resident files reviewed: 6
Employee files reviewed: 4
Inspection Report
Routine
Census: 7
Capacity: 8
Deficiencies: 1
Sep 7, 2021
Visit Reason
This inspection was conducted as a 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. One deficiency was identified related to medication administration where the facility failed to ensure one of seven residents had an ultimate user agreement on file.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 7 residents had an ultimate user agreement (Resident #6). | Severity: 2 |
Report Facts
Residents present: 7
Licensed capacity: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Geoffrey Gomez | Administrator | Named as Laboratory Director's or Provider/Supplier Representative who signed the report |
Inspection Report
Abbreviated Survey
Census: 7
Capacity: 7
Deficiencies: 1
Oct 6, 2020
Visit Reason
The inspection was a COVID-19 focused infection control State Licensure survey conducted to assess compliance with infection control practices in response to the COVID-19 pandemic.
Findings
The facility had appropriate signage, screening, and sanitization practices in place, with no residents or staff positive for COVID-19. However, caregivers were observed not wearing masks, which was a failure to implement safe infection control practices.
Deficiencies (1)
| Description |
|---|
| Caregivers were observed not wearing masks. |
Report Facts
Licensed beds: 7
Census: 7
Hand sanitizer bottles: 4
Gloves: 10000
Disposable masks: 8
Reusable masks: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Quijano | Owner | Interviewed regarding infection control practices and signed the report |
Inspection Report
Re-Inspection
Census: 6
Capacity: 8
Deficiencies: 7
Nov 25, 2019
Visit Reason
This Statement of Deficiencies was generated as a result of a regrading survey conducted at the facility on 11/25/19 in accordance with Nevada Administrative Code, Chapter 449, Residential Facilities for Groups.
Findings
The facility received a grade of A with no regulatory deficiencies identified. Six resident records and four employee records were reviewed. Several deficiencies were noted related to personnel files, health and sanitation, written policies on admissions, medication administration, maintenance of resident files, and Alzheimer's care endorsement requirements.
Severity Breakdown
Level D: 5
Level F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Personnel Files - Background Checks - NAC 449.200 Personnel files must include evidence of compliance with NRS 449.122 to 449.125. | Level D |
| Health & Sanitation - Maintain Interior/Exterior - NAC 449.209 requires the premises to be clean and well maintained. | Level F |
| Written Policy on Admissions - NAC 449.2702 prohibits admission of persons who are bedfast, require restraint, confinement in locked quarters, or skilled nursing on a 24-hour basis. | Level D |
| Medication/OTCS, Supplements, Change Order - NAC 449.2742 requires administration of medications and supplements per physician orders with proper documentation. | Level F |
| Administration of Medication Restrictions - NAC 449.2746 restricts caregivers from assisting with as-needed medications unless specific conditions are met. | Level D |
| Maintenance and Contents of Separate File - NAC 449.2749 requires separate locked files for each resident with all records retained for at least 5 years. | Level D |
| Alzheimer’s Care Application for Endorsement - NAC 449.2754 requires facilities providing care to persons with Alzheimer's disease to obtain an endorsement on its license. | Level D |
Report Facts
Licensed beds: 8
Resident census: 6
Resident records reviewed: 6
Employee records reviewed: 4
Inspection Report
Annual Inspection
Census: 5
Capacity: 8
Deficiencies: 8
Sep 23, 2019
Visit Reason
The inspection was conducted as the Annual Grading Survey of the facility to assess compliance with Nevada Administrative Code, Chapter 449, Residential Facilities for Groups.
Findings
The facility received a grade of C with multiple regulatory deficiencies identified, including failure to obtain fingerprinting results for employees, maintain a clutter-free environment, provide required documentation for bedfast residents, medication administration issues, incomplete resident files, and admitting residents exceeding the level of care.
Severity Breakdown
Severity: 2: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to obtain fingerprinting results every five years for 1 of 4 employees (Employee #3). | Severity: 2 |
| Failed to ensure the back yard was free from an accumulation of cluttered items including seven wheelchairs, one desk, a washing machine, a Hoyer lift, and a shopping cart. | Severity: 2 |
| Failed to provide requested information to obtain the bedfast waiver for 1 of 5 sampled residents (Resident #4) who required extensive care exceeding the level of care available. | Severity: 2 |
| Failed to ensure medications were available and administered per physician's orders for 4 of 5 sampled residents; PRN medications were never filled. | Severity: 2 |
| Failed to ensure written instructions indicating specific symptoms for administration of as-needed medications were received for 2 of 5 sampled residents. | Severity: 2 |
| Failed to ensure tuberculin testing results were documented for 1 of 5 sampled residents (Resident #2). | Severity: 2 |
| Failed to provide an activities of daily living assessment for 2 of 5 sampled residents (Resident #2 and Resident #5). | Severity: 2 |
| Admitted and retained 2 residents with dementia who exceeded the level of care for a non-Alzheimer's residential facility for groups. | Severity: 2 |
Report Facts
Facility licensed beds: 8
Resident census: 5
Employee records reviewed: 4
Resident records reviewed: 5
Cluttered items in backyard: 10
Residents with medication issues: 4
Residents lacking ADL assessment: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Geoffrey Gomez | Administrator | Named as the Administrator responsible for monitoring compliance and signing the report |
Inspection Report
Complaint Investigation
Census: 4
Deficiencies: 0
Jul 1, 2019
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding allegations that medications were pre-poured and not secured.
Findings
The complaint was investigated through interviews and record reviews, and the allegations could not be substantiated. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
One complaint (#NV00057250) was investigated with allegations that medications were pre-poured and not secured; the complaint was not substantiated.
Report Facts
Residents interviewed: 3
Employees interviewed: 3
Residents' medication administration records reviewed: 4
Resident files reviewed: 4
Inspection Report
Complaint Investigation
Census: 8
Capacity: 8
Deficiencies: 1
Jul 6, 2016
Visit Reason
The inspection was conducted as a result of a complaint investigation and re-licensure of the facility.
Findings
The facility received a grade of A. One complaint regarding lost resident clothing was investigated and found to be unsubstantiated. A medication administration deficiency was identified related to incomplete PRN medication instructions for one resident.
Complaint Details
Complaint # NVS00046194 regarding lost resident clothing was investigated and could not be substantiated.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to ensure medication instructions for 1 of 8 residents were complete; specifically, PRN medication instructions did not include symptoms for which the medication was prescribed. | 2 |
Report Facts
Resident files reviewed: 8
Employee files reviewed: 4
Complaint count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Geoffrey Gomez | Administrator | Named as the facility administrator signing the document |
Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 1
Jul 6, 2016
Visit Reason
The inspection was conducted as a result of an annual survey combined with a complaint investigation on 7/6/2016.
Findings
The facility received a grade of A. One complaint regarding lost resident clothing was investigated and not substantiated. A medication administration deficiency was identified related to incomplete PRN medication instructions for one resident.
Complaint Details
One complaint (NVS00046194) was investigated regarding lost resident clothing and was not substantiated.
Severity Breakdown
Severity 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure medication instructions for 1 of 8 residents were complete; specifically, PRN medication instructions did not include symptoms for which the medication was prescribed. | Severity 2 |
Report Facts
Licensed beds: 8
Residents present: 8
Employee files reviewed: 4
Resident files reviewed: 8
Repeat deficiency: 1
Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 2
Jul 30, 2015
Visit Reason
The inspection was conducted as an annual State Licensure survey of a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A. Deficiencies were identified related to failure to ensure annual physical examinations for one resident and failure to ensure written instructions for PRN medications for two residents.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 out of 8 residents had an annual physical examination (Resident #5). | Severity: 2 |
| Facility failed to ensure 2 out of 8 residents had needed medications with written instructions indicating specific symptoms for medication administration (Residents #1 and #7). | Severity: 2 |
Report Facts
Residents present: 8
Licensed capacity: 8
Deficiencies cited: 2
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 4
Jul 16, 2014
Visit Reason
The inspection was conducted as an annual State Licensure survey to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of B and was found deficient in several areas including personnel background checks, health and sanitation maintenance, food storage, and housing for staff members. Multiple deficiencies were repeat findings from previous annual surveys.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 4 employees met background check requirements; no documented FBI or State background check result in employee file. | Severity: 2 |
| Facility failed to ensure the interior and exterior of the facility was well maintained; observed tears in living room and bedroom screens, and soiled stove top, back wall, and oven. | Severity: 2 |
| Facility failed to ensure food was properly stored; observed expired food items and uncovered food in refrigerator. | Severity: 2 |
| Facility failed to ensure 1 of 6 rooms met minimum requirements to be a bedroom for staff members; observed staff sleeping in living room and garage with personal items stored improperly. | Severity: 2 |
Report Facts
Census: 7
Total Capacity: 8
Repeat Deficiencies: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Named in deficiency for missing background check | |
| Employee #4 | Acknowledged deficiencies and confirmed observations during inspection |
Inspection Report
Annual Inspection
Census: 6
Capacity: 8
Deficiencies: 7
Aug 8, 2013
Visit Reason
This was a State Licensure annual grading survey conducted on 8/8/13 to assess compliance with licensing requirements for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of B with multiple deficiencies identified including caregiver medication training, elder abuse training, personnel file background checks, health and sanitation issues, housing for staff members, medication administration and storage.
Severity Breakdown
1: 1
2: 6
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 employees completed required 8 hours annual medication management refresher training. | 2 |
| Administrator failed to receive annual training in recognition, prevention and response to elder abuse. | 2 |
| Failed to ensure 1 of 4 employees met background check requirements; no State or FBI results for Employee #4. | 2 |
| Facility failed to maintain premises clean and well maintained; thick grease, lint, hole in window screen, and miscellaneous materials in backyard. | 2 |
| Facility failed to ensure 1 of 6 rooms met minimum bedroom requirements; employee living in garage which is not a living quarter. | 2 |
| Medication administration records (MAR) inaccurate; multiple residents' medications not signed as given and MAR not updated monthly. | 1 |
| Medications not kept in locked container; Resident #2 had Visine Tear Drops on stand in bedroom without locked storage. | 2 |
Report Facts
Deficiencies cited: 7
Census: 6
Total capacity: 8
Inspection Report
Annual Inspection
Census: 6
Capacity: 8
Deficiencies: 7
Aug 8, 2013
Visit Reason
This document is a State Licensure annual grading survey conducted on 8/8/2013 to assess compliance with regulatory requirements for a residential facility for group beds for elderly and disabled persons.
Findings
The facility received a grade of B with multiple deficiencies identified including failure to ensure required medication management training for one employee, failure to provide elder abuse training for the administrator, incomplete background checks for one employee, poor facility cleanliness and maintenance, inadequate staff housing, inaccurate medication administration records for multiple residents, and improper medication storage.
Severity Breakdown
Severity: 1: 1
Severity: 2: 6
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 employees completed required 8 hours of annual medication management refresher training (Employee #3). | Severity: 2 |
| Administrator failed to receive annual training in recognition, prevention, and response to elder abuse (Employee #3). | Severity: 2 |
| Failed to ensure 1 of 4 employees met background check requirements; no State or FBI results from 8/2012 fingerprints (Employee #4). | Severity: 2 |
| Facility failed to ensure premises were clean and well maintained; findings included thick grease under stove hood, lint on bathroom vent and dryer lint trap, hole in bedroom window screen, and wood/miscellaneous materials in backyard. | Severity: 2 |
| Failed to ensure 1 of 6 staff rooms met minimum requirements to be a bedroom; Employee #2 was living in the garage (repeat deficiency). | Severity: 2 |
| Medication administration records (MAR) were inaccurate for 5 of 6 residents inspected; missing signatures for administered medications and missing PRN medications on MAR. | Severity: 1 |
| Failed to ensure medications were kept in a locked container; Resident #2 had bottle of Visine Tear Drops on bedroom stand without authorization to self-administer (repeat deficiency). | Severity: 2 |
Report Facts
Licensed capacity: 8
Census: 6
Employees reviewed: 4
Resident files reviewed: 6
Deficiency severity 2 count: 6
Deficiency severity 1 count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Named in findings for expired medication management training and failure to receive elder abuse training | |
| Employee #4 | Named in finding for failure to meet background check requirements | |
| Employee #2 | Named in finding for inadequate staff housing living in garage |
Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 4
Aug 29, 2012
Visit Reason
This document is a State Licensure inspection conducted as an annual inspection of a residential facility for elderly and disabled persons and/or persons with chronic illness and/or mental illness.
Findings
The facility received a grade of B with several deficiencies identified including failure to provide proper oversight by the administrator, inadequate housing for staff members, failure to destroy expired medications, and improper medication storage.
Severity Breakdown
Severity: 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight and direction to ensure 8 of 8 residents received needed services and protective supervision. | — |
| Facility failed to ensure 1 of 6 rooms met minimum requirements to be a bedroom; staff member was living in a garage. | Severity: 2 |
| Facility did not destroy expired medications for 1 of 8 residents after expiration dates. | Severity: 2 |
| Facility failed to ensure medications were kept in a locked, cool, and dry area; medications found improperly stored. | Severity: 2 |
Report Facts
Residents present: 8
Total licensed capacity: 8
Severity 2 deficiencies: 3
Rooms inspected: 6
Scope for oversight deficiency: 3
Scope for medication storage deficiency: 3
Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 4
Aug 29, 2012
Visit Reason
Annual State Licensure inspection conducted on 8/29/2012 to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of B with several deficiencies identified including failure of the administrator to provide adequate oversight, improper housing for a staff member, failure to destroy expired medications, and improper medication storage.
Severity Breakdown
Level 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight and direction to ensure 8 of 8 residents received needed services and protective supervision, including improper storage of an oxygen concentrator outdoors causing potential hazards. | Level 2 |
| Facility failed to ensure 1 of 6 staff rooms met minimum bedroom requirements; staff member was living in a garage. | Level 2 |
| Facility did not destroy expired medications for 1 of 8 residents, including expired eye drops and ointments. | Level 2 |
| Facility failed to ensure medications were kept in a locked container; medications found unsecured in kitchen drawer and on top of refrigerator. | Level 2 |
Report Facts
Residents present: 8
Total licensed capacity: 8
Staff rooms inspected: 6
Resident files reviewed: 8
Employee files reviewed: 3
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 6
Jul 5, 2011
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 7/5/2011 at The Rose of Sharon, a residential facility for elderly and disabled persons.
Findings
The facility received a grade of B with several deficiencies identified including failure to ensure background checks for employees, failure to review the medical condition of a resident, incomplete medication management plan, improper medication container use, failure to maintain tuberculosis testing compliance, and inadequate mental illness training for employees.
Severity Breakdown
Severity: 1: 1
Severity: 2: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 3 employees met background check requirements of NRS 449.176 to 449.188 (Employee #2 and #3-5 year renewal on fingerprint due). | Severity: 2 |
| Failed to review the medical condition of 1 of 7 residents in the facility (Resident #5). | Severity: 2 |
| Administrator failed to prepare a medication plan that included all eight required components. | Severity: 1 |
| Failed to keep medications belonging to 1 of 7 residents in their original container (Resident #2-Ibuprofen pills kept in Namenda bottle). | Severity: 2 |
| Failed to ensure 1 of 7 residents complied with tuberculosis testing requirements; the facility waited a year and a half to obtain a one step test from the last one step in 2010 (Resident #3). | Severity: 2 |
| Failed to ensure 2 of 3 employees had received 8 hours of training concerning care for residents suffering from mental illnesses (Employee #2 and #3). | Severity: 2 |
Report Facts
Residents present: 7
Total licensed capacity: 8
Employees reviewed: 3
Resident files reviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Failed background check renewal, did not receive required mental illness training, commented on Resident #5's condition | |
| Employee #3 | Failed background check renewal, did not receive required mental illness training |
Inspection Report
Re-Inspection
Census: 8
Capacity: 8
Deficiencies: 2
Oct 7, 2009
Visit Reason
This inspection was a required grading re-survey conducted on October 7, 2009, to assess compliance following a previous survey.
Findings
The facility received a survey grade of A but had two repeat deficiencies: failure to ensure one caregiver met background check requirements and failure to ensure one resident received medications as prescribed.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 4 caregivers met background check requirements (Employee #4). | Severity: 2 |
| Facility failed to ensure that 1 of 8 residents received medications as prescribed (Resident #4). | Severity: 2 |
Report Facts
Number of caregivers reviewed: 4
Number of resident files reviewed: 8
Number of employee files reviewed: 4
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