Inspection Reports for Villa Court Assisted Living
4025 SOUTH PEARL STREET, LAS VEGAS, NV 89121, LAS VEGAS, NV
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 4, 2024, identified one deficiency related to the failure to ensure all portable fire extinguishers were checked annually. Earlier inspections showed ongoing issues with vandalism causing damage to the facility’s infrastructure and some safety equipment maintenance lapses, while prior resident-related inspections noted deficiencies in oxygen canister security and protective supervision. Complaint investigations mostly found unsubstantiated allegations or substantiated issues without deficiencies, except for some substantiated deficiencies involving resident care and safety in 2021 and 2022. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The inspection history shows a shift from resident care concerns in earlier years to facility maintenance and security issues more recently, reflecting changes in the facility’s operational status.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
1.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
77% better than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
0% occupied
Based on a December 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Annual Inspection
Capacity: 40
Deficiencies: 1
Date: Dec 4, 2024
Visit Reason
This inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.
Findings
The facility was locked and not in use at the time of inspection with no residents or clinical staff present. Evidence of vandalism was found including stolen electrical panels, damaged copper piping, and cut water piping to the fire suppression system causing extensive water damage. The facility has been undergoing repairs and installing security measures. Additionally, the facility failed to ensure all portable fire extinguishers were checked annually, with the last documented service in 2020.
Deficiencies (1)
Failure to ensure all portable fire extinguishers were checked annually; last service documented on 10/07/2020.
Report Facts
Total licensed beds: 40
Census at time of survey: 0
Severity level: 2
Scope: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marcus Pegross | Executive Director | Acknowledged observations during the facility tour and signed the report. |
| Maintenance Director | Acknowledged findings related to fire extinguishers and vandalism; name not provided. |
Inspection Report
Routine
Capacity: 40
Deficiencies: 1
Date: Mar 21, 2024
Visit Reason
The inspection was a well check State Licensure survey conducted on 03/21/24 in accordance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.
Findings
The facility was locked and not in use at the time of the survey with no residents or employees present. The premises showed evidence of vandalism including damage to exterior electrical panels, interior copper piping, and fire suppression water piping causing extensive water damage. Repairs were pending with bids being obtained and renovations estimated to take up to 6 months or more.
Deficiencies (1)
The premises were not maintained due to ongoing vandalism, including damage to electrical panels, copper piping, and fire suppression system causing water damage.
Report Facts
Licensed capacity: 40
Census: 0
Estimated renovation duration: 6
Estimated bid preparation duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marcus Pegross | Executive Director | Acknowledged premises had not been maintained and discussed repair plans |
Inspection Report
Annual Inspection
Capacity: 40
Deficiencies: 0
Date: Dec 4, 2023
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
No regulatory deficiencies were identified during the survey. The facility was locked and not in use at the time of the inspection, with no residents or employees present. The facility received a grade of A.
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 0
Date: Nov 2, 2022
Visit Reason
This inspection was conducted as a complaint State Licensure survey triggered by complaint #NV00066980 regarding the facility's air conditioning system.
Complaint Details
Complaint #NV00066980 with one allegation was substantiated without deficiency. The allegation concerned the air conditioner being under repair and use of portable air conditioners, which was confirmed but found not deficient.
Findings
The complaint was substantiated without deficiency; the facility's air conditioner was under repair with portable air conditioners used temporarily. Residents were relocated to maintain appropriate temperatures, and no regulatory deficiencies were identified.
Report Facts
Census: 12
Complaint Allegations: 1
Purchase Receipt Date: 62222
Temperature: 78
Inspection Report
Annual Inspection
Census: 24
Capacity: 40
Deficiencies: 1
Date: Jun 2, 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. One deficiency was identified related to unsecured oxygen canisters in Resident room #4, which was corrected by securing the oxygen tanks and retraining staff on oxygen tank storage policy.
Deficiencies (1)
Facility failed to ensure oxygen (O2) canisters were properly secured in Resident room #4; five unsecured O2 canisters were found.
Report Facts
Oxygen canisters unsecured: 5
Resident census: 24
Total licensed capacity: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Tuchman | Operations Manager | Signed as Laboratory Director's or Provider/Supplier Representative |
| Maintenance Director | Confirmed presence of unsecured oxygen canisters in Resident room #4 |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 40
Deficiencies: 2
Date: May 20, 2022
Visit Reason
The inspection was conducted as a State Licensure Complaint Investigation survey triggered by Complaint #NV00066359 with three substantiated allegations regarding air conditioning, missing window screens, and blocked doors in a COVID resident area.
Complaint Details
Complaint #NV00066359 with three allegations was substantiated: air conditioning not working properly (no deficiencies), missing window screen (deficiency TAG Y0179), and blocked doors in COVID resident area (deficiency TAG Y515).
Findings
The facility was found to have a missing window screen and blocked doors in a COVID resident area, both substantiated with regulatory deficiencies. The air conditioning issue was substantiated but did not result in deficiencies. The facility failed to provide protective supervision for two residents in a contained area, with no staff present and doors blocked, posing safety concerns.
Deficiencies (2)
Facility failed to ensure all windows and doors that provide ventilation were screened to prevent entry of insects; two windows missing screens, two windows had bent screens, and one set of doors was propped open without screens.
Facility failed to provide protective supervision for two residents in a contained area separated by double doors; no staff present, doors blocked by chairs, residents pounding on doors and yelling.
Report Facts
Licensed capacity: 40
Census: 24
Window screens missing or bent: 4
Residents in contained area: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Tuchman | Operations Manager | Signed as Laboratory Director's or Provider/Supplier Representative |
| Ken Kitto | Advised purchase and installation of auditory alarms for double doors | |
| Lisette Mendoza | Provided information about staffing and resident supervision during complaint investigation |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Date: Oct 12, 2021
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 10/12/21, in accordance with Nevada Administrative Code Chapter 449, Residential Facility for Groups.
Complaint Details
Complaint #NV00064854 with three allegations was substantiated without deficiency. Allegation #1 about overcrowding was unsubstantiated based on room measurements and interviews. Allegation #2 about residents fighting was substantiated without deficiency based on incident reports and staff interviews. Allegation #3 about unexpected weight loss was unsubstantiated based on interviews and medical record reviews.
Findings
One complaint with three allegations was investigated and substantiated without deficiency. Allegations regarding room overcrowding, resident altercations, and unexpected weight loss were all found unsubstantiated or substantiated without deficiency after review of records, interviews, and observations. No regulatory deficiencies were identified and no further action was necessary.
Report Facts
Sample size: 5
Number of allegations: 3
Inspection Report
Annual Inspection
Census: 28
Capacity: 38
Deficiencies: 0
Date: Aug 5, 2021
Visit Reason
The inspection was conducted as an annual grading and infection control survey 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. Guidance was provided on compliance with NRS 449.101, NRS 449.102, and LCB File No. R016-20 regarding discrimination, privacy, and cultural competency policies.
Inspection Report
Complaint Investigation
Census: 30
Capacity: 40
Deficiencies: 3
Date: Apr 26, 2021
Visit Reason
The inspection was conducted as a result of a complaint investigation survey triggered by Complaint #NV00063682 with five allegations at Villa Court Assisted Living and Memory Care.
Complaint Details
Complaint #NV00063682 with five allegations was investigated. Three allegations were substantiated: failure to reposition a resident timely, failure to display resident's pictures and belongings, and inability of a resident to reach the call light. Two allegations were unsubstantiated: low PPE supplies and cold room temperature.
Findings
The facility was found to have substantiated deficiencies related to failure to reposition a resident timely resulting in a pressure ulcer, failure to display a resident's pictures and belongings in their room, and failure to ensure a resident could reach the call light from their bed. Other allegations regarding PPE supplies and room temperature were unsubstantiated. The facility received a grade of A.
Deficiencies (3)
A resident was not being repositioned timely and sustained a pressure ulcer on the sacrum/left heel.
A resident's pictures and other belongings were not displayed in the room.
A resident was not able to reach the call light from their bed.
Report Facts
Licensed capacity: 40
Census: 30
Sample size: 2
Number of allegations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lee Johnson | Treasurer | Signed as Laboratory Director's or Provider/Supplier Representative |
| Memory Care Coordinator | Reported on resident care deficiencies and observations | |
| Administrator | Interviewed during investigation and involved in corrective actions | |
| Wellness Coordinator | Interviewed during investigation and involved in corrective actions | |
| Caregivers | Interviewed and reported concerns about resident repositioning | |
| Hospice Nurse | Reported concerns about resident care and repositioning |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 40
Deficiencies: 0
Date: Apr 15, 2021
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 04/15/21, in accordance with Nevada Administrative Code (NAC) Chapter 449, Residential Facility for Groups.
Complaint Details
Complaint #NV00063393 with four allegations was investigated and found unsubstantiated: (1) physical assault and notification failure, (2) visitation without signing in or checking credentials, (3) failure to notify resident's Power of Attorney when a visitor removed the resident, and (4) failure to medically assess a resident after assault.
Findings
The complaint investigation included four allegations, all of which were unsubstantiated based on observations, interviews, review of incident reports, visitation logs, resident files, and facility policies. No regulatory deficiencies were identified and no further action was necessary.
Report Facts
Sample size: 5
Number of allegations: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Technician | Interviewed during the complaint investigation | |
| Wellness Director | Interviewed and confirmed facility policies during the complaint investigation | |
| Executive Director | Interviewed and confirmed facility policies during the complaint investigation |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 40
Deficiencies: 0
Date: Apr 15, 2021
Visit Reason
This inspection was conducted as a complaint investigation triggered by Complaint #NV00063393 with four allegations at Villa Court Assisted Living and Memory Care.
Complaint Details
Complaint #NV00063393 with four allegations was investigated and found unsubstantiated. Allegations included physical assault notification failure, visitation without credential checks, failure to notify POA when a resident was removed, and lack of medical assessment after assault.
Findings
All four allegations were unsubstantiated based on observations, review of incident reports, interviews with residents and staff, and review of facility policies. No regulatory deficiencies were identified and no further action was necessary.
Report Facts
Licensed beds: 40
Census: 32
Sample size: 5
Number of allegations: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wellness Director | Interviewed during complaint investigation | |
| Executive Director | Interviewed during complaint investigation | |
| Medication Technician | Interviewed during complaint investigation |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Date: Aug 20, 2019
Visit Reason
This amended statement of deficiencies was generated as a result of a complaint investigation initiated at the facility on 08/20/19 by the Division of Public and Behavioral Health in accordance with NAC 449, Residential Facility for Groups.
Complaint Details
One complaint (#NV00057849) was investigated with multiple allegations including resident treatment, staff response to a sick resident, resident injury and death, food preparation, dietary staffing, and facility understaffing. All allegations could not be substantiated.
Findings
The investigation included a tour of the facility, lunch service, snacks, treatment of residents, interviews with residents and staff, and review of medical records and facility policies. No regulatory deficiencies were identified and no further action was necessary.
Report Facts
Sample size: 5
Number of residents interviewed: 11
Number of complaints investigated: 1
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