Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 61
Capacity: 69
Deficiencies: 8
Jun 4, 2025
Visit Reason
The inspection was conducted as an Annual State Licensure survey combined with complaint and Facility Incident Report investigations at the assisted living facility.
Findings
The facility was found deficient in multiple areas including failure to document a person-centered service plan for a resident with fire-starting behavior, failure to obtain a bedfast waiver for a resident, incomplete incident reporting, inadequate administrator oversight for resident safety, unsafe water temperatures in resident showers, unsanitary bathroom conditions, kitchen sanitation violations, and incomplete tuberculosis testing documentation for a resident.
Complaint Details
The inspection included investigation of six complaints and one Facility Reported Incident (FRI). Four complaints and the FRI were substantiated, including issues related to resident safety, supervision, and sanitation. Two complaints were unsubstantiated and one was substantiated without deficient practice.
Severity Breakdown
Level 2: 7
Level 4: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure a person-centered service plan documented a resident's behavior issue of starting fires and possession of cigarettes and lighter by the facility. | Level 2 |
| Failure to obtain a waiver to maintain a bedfast resident in the facility. | Level 2 |
| Failure to complete an incident report for a resident who had a fire incident. | Level 2 |
| Administrator failed to provide oversight to ensure protective supervision for a resident with fire-starting behavior. | Level 4 |
| Failure to ensure hot water was available to residents in half of the facility. | Level 2 |
| Failure to ensure a resident's bathroom was properly cleaned and sanitized, with dried feces observed. | Level 2 |
| Failure to comply with food service standards including presence of dead flies, unsanitary food storage cabinets, and improper equipment. | Level 2 |
| Failure to ensure a resident received a two-step tuberculosis test upon admission. | Level 2 |
Report Facts
Licensed beds: 69
Resident census: 61
Complaints investigated: 6
Facility Reported Incidents (FRI): 1
Burns to resident: 33
Incident date: 2025
Water temperature: 94
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marcus Pegross | Executive Director | Signed report and involved in oversight failures related to resident safety and supervision |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 2
Dec 4, 2024
Visit Reason
The inspection was conducted as a complaint investigation following two complaints received by the facility, one of which was substantiated with deficiencies identified.
Findings
The investigation found deficiencies related to expired and improperly labeled food items in storage and the failure to provide readily available snacks to residents as required by facility policy and resident needs.
Complaint Details
Two complaints were investigated: Complaint #NV00072515 was substantiated with deficiencies; Complaint #NV00072629 was substantiated with no deficient practice.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure expired foods were discarded; expired or unlabeled food items were found in multiple kitchen and storage areas. | Severity: 2 |
| Facility failed to ensure snacks were offered and readily available to residents; lack of snacks such as chips, cookies, and fresh fruit was observed. | Severity: 2 |
Report Facts
Census: 65
Sample size: 5
Complaints investigated: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marcus Pegross | Executive Director | Signed the report as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Sep 24, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 09/24/24, in accordance with Nevada Administrative Code (NAC), Chapter 449, Residential Facility for Groups.
Findings
Three complaints were investigated: two were substantiated without deficient practice and one was unsubstantiated. No regulatory deficiencies were identified during the investigation, and the facility received a grade of A.
Complaint Details
Three complaints were investigated: Complaint #NV00071648 and Complaint #NV00072078 were substantiated with no deficient practice, and Complaint #NV00072000 was unsubstantiated. No regulatory deficiencies were identified.
Report Facts
Sample size: 5
Complaints investigated: 3
Inspection Report
Annual Inspection
Census: 39
Capacity: 69
Deficiencies: 5
Jun 11, 2024
Visit Reason
The inspection was an Annual State Licensure survey initiated at the facility on 06/11/2024 in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility was found to have multiple regulatory deficiencies including elevated water temperatures in resident rooms, clutter in laundry rooms, expired and improperly stored food items in the kitchen, inadequate dish machine sanitization, and blocked fire riser room access. Corrective actions were planned and implemented for each deficiency.
Severity Breakdown
2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Water temperatures in 7 of 13 resident rooms exceeded the acceptable range of 100°F to 110°F. | 2 |
| One of three laundry rooms observed was not free of clutter, posing a fire hazard. | 2 |
| Kitchen failed to comply with food safety standards: expired cottage cheese, deli products held above 41°F, and dish machine not reaching required temperature or sanitizer concentration. | 2 |
| Heavy grease and debris build-up on kitchen range and missing coving/baseboards in ice machine and chemical storage rooms. | 2 |
| Fire riser room was blocked by two out-of-use freezer units, obstructing access. | 2 |
Report Facts
Resident rooms with elevated water temperature: 7
Laundry rooms observed: 3
Expired food items: 2
Facility licensed capacity: 69
Facility census: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marcus Pegross | Executive Director | Signed the report and involved in oversight. |
| Maintenance Director | Acknowledged elevated water temperatures, clutter in laundry rooms, and blocked fire riser room; involved in corrective actions. | |
| Dietary Director | Responsible for weekly checks of sanitizer machine and food safety corrective actions. |
Inspection Report
Annual Inspection
Census: 39
Capacity: 69
Deficiencies: 5
Jun 11, 2024
Visit Reason
The inspection was an Annual State Licensure survey initiated at the facility on 06/11/2024 in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility was found to have multiple regulatory deficiencies including elevated water temperatures in resident rooms, clutter in laundry rooms, expired and improperly stored food items, inadequate dish machine sanitization, and blocked fire riser room access. Corrective actions were planned and implemented for each deficiency.
Severity Breakdown
2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Water temperatures in 7 of 13 resident rooms exceeded the acceptable range of 100 to 110 degrees Fahrenheit. | 2 |
| One of three laundry rooms observed was not free of clutter, posing a fire hazard. | 2 |
| Kitchen failed to comply with food service standards: expired cottage cheese, potentially hazardous foods held above 41 degrees F, and dish machine not reaching required temperature or sanitizer concentration. | 2 |
| Heavy grease and debris build-up on kitchen range and missing coving/baseboards in ice machine and chemical storage rooms. | 2 |
| Fire riser room was blocked by two out-of-use freezer units, obstructing access. | 2 |
Report Facts
Resident rooms with elevated water temperature: 7
Laundry rooms observed: 3
Expired food items: 2
Facility licensed bed capacity: 69
Current census: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marcus Pegross | Executive Director | Signed the report and involved in corrective action oversight |
| Maintenance Director | Measured water temperatures, acknowledged deficiencies, and responsible for corrective actions | |
| Dietary Director | Responsible for food service corrective actions and monitoring |
Inspection Report
Annual Inspection
Capacity: 69
Deficiencies: 0
May 23, 2024
Visit Reason
This inspection was conducted as a State licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups, including elderly, disabled persons, assisted living services, and persons with mental illness.
Findings
No regulatory deficiencies were identified during the inspection. The facility was licensed for 64 beds and approved for an increase to 69 beds. No further action is necessary.
Report Facts
Licensed beds: 64
Approved bed increase: 5
Total licensed beds: 69
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Apr 22, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 04/22/24, in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A with one complaint investigated which was substantiated without deficient practice. However, a regulatory deficiency was identified related to failure to obtain a medical exemption waiver for a resident with an indwelling urinary catheter who was not capable of self-care.
Complaint Details
Complaint #NV00070728 was substantiated with no deficient practice. The complaint investigation included observations, interviews with residents, caregivers, Wellness Director, and Administrator, clinical record review, and document review.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to obtain a medical exemption waiver for a resident with an indwelling urinary catheter who was not capable of caring for the catheter independently. | Severity: 2 |
Report Facts
Resident census: 62
Sample size: 5
Sample size: 5
Complaint count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marcus Pegross | Executive Director | Signed the report |
| Wellness Director | Interviewed during complaint investigation and responsible for reevaluation and monitoring of residents with catheters | |
| Administrator | Interviewed during complaint investigation and confirmed lack of medical exemption waiver submission | |
| Employee #1 | Confirmed resident was not capable of catheter care |
Inspection Report
Annual Inspection
Census: 60
Capacity: 64
Deficiencies: 3
Jun 8, 2023
Visit Reason
The inspection was conducted as a result of a State Licensure annual grading and complaint investigation survey initiated on 06/08/23 and completed on 07/03/23, including investigation of one complaint and one Facility Reported Incident (FRI).
Findings
No regulatory deficiencies were identified related to the complaint and FRI investigations. However, a regulatory deficiency was identified related to food service and kitchen standards, including critical, major, and equipment maintenance violations concerning food temperatures, storage, cleanliness, and maintenance of kitchen equipment and dumpster gates.
Complaint Details
One complaint (NV00068376) was investigated but could not be verified. One Facility Reported Incident (FRI #8252) was verified without deficiencies.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Critical violations including sliced tomato at 55°F, sliced ham at 47°F in deli refrigerator, almond milk at 61°F on ice, buffet ham stored in a cardboard box previously containing raw chicken, and improper separation of clean and dirty ware in the dishwashing area. | Severity: 2 |
| Major violations including chipped and disrepair shelving racks in the reach-in refrigerator, gaps around window air conditioning unit causing exposure, soiled cabinets under beverage counter, and soiled kitchen floor behind and underneath equipment. | Severity: 2 |
| Equipment and maintenance violation: rusted and disrepair metal gates of the dumpster enclosure. | Severity: 2 |
Report Facts
Licensed beds: 64
Resident census: 60
Severity 2 deficiencies: 3
Completion date for shelving racks: 2023
Completion date for dumpster gate repairs: 2023
Completion date for kitchen expansion plans: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Trail | Acting Administrator | Signed the report and involved in the inspection process |
| Dietary Director | Conducted in-service training on 7/13/23 related to food service deficiencies | |
| Wellness Director | Interviewed during complaint and FRI investigation | |
| Hospice Nurse | Interviewed during complaint and FRI investigation |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 64
Deficiencies: 0
Aug 30, 2022
Visit Reason
The inspection was conducted as a complaint investigation in response to Complaint #NV00066719 with three allegations regarding COVID-19 booster vaccination opportunity, assistance with a medical procedure, and quality of food.
Findings
The complaint investigation found all three allegations to be unsubstantiated. The facility provided evidence of COVID-19 booster vaccinations and planned clinics, confirmed assistance policies for medical appointments, and observed no issues with food quality or resident complaints. No regulatory deficiencies were identified.
Complaint Details
Complaint #NV00066719 with three allegations was investigated and found unsubstantiated. Allegation #1 regarding COVID-19 booster vaccination opportunity was unsubstantiated based on vaccination records and planned clinics. Allegation #2 regarding assistance with a medical procedure was unsubstantiated due to lack of evidence of procedure and confirmation of staff/family accompaniment policy. Allegation #3 regarding food quality was unsubstantiated based on observations and resident interviews.
Report Facts
Licensed capacity: 64
Census: 53
Sample size: 5
Complaint allegations: 3
Inspection Report
Annual Inspection
Census: 36
Capacity: 64
Deficiencies: 1
Jun 29, 2022
Visit Reason
The inspection was conducted as an annual grading and infection control State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility received a grade of A. One regulatory deficiency was identified related to food service compliance, including a cook not wearing a hair restraint and unsanitary kitchen conditions such as grease and debris on equipment and floors.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| A cook was not wearing a hairnet or hair restraint while preparing food; grease and debris were found on the bottom shelf of the steam table, sides of the cook's line equipment, air conditioning unit, and floors throughout the kitchen were soiled with food and debris under equipment and tables. | Severity: 2 |
Report Facts
Facility licensed capacity: 64
Census: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Tuchman | Operations Manager | Signed the plan of correction |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 2
Nov 30, 2021
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #NV00065058 with two substantiated allegations regarding notification of a resident's change in condition and medication logging.
Findings
The facility failed to notify a resident's responsible party timely after a fall and failed to maintain a complete medication receipt log for one resident. Both allegations were substantiated with severity level 2 and scope 1.
Complaint Details
Complaint #NV00065058 with two allegations was substantiated: 1) A resident's responsible party was not notified timely of a resident's change in condition; 2) A resident's medication was not logged in when delivered to the facility.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to notify a resident's responsible party within 24 hours of a fall incident. | Severity: 2 |
| Failure to maintain a complete log documenting receipt of medications delivered to the facility. | Severity: 2 |
Report Facts
Sample size: 6
Severity level: 2
Scope: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Trail | Acting Director | Signed the inspection report |
| Wellness Director | Acknowledged the deficiencies related to notification and medication logging | |
| Memory Care Director | Involved in retraining staff related to deficiencies | |
| Resident Care Coordinator | Involved in retraining staff related to deficiencies |
Inspection Report
Annual Inspection
Census: 49
Capacity: 64
Deficiencies: 8
Oct 1, 2019
Visit Reason
This inspection was conducted as an annual State Licensure survey and grading re-survey of a residential facility for groups providing assisted living services.
Findings
The facility received a grade of A. Deficiencies were identified related to food service sanitation and special diet compliance, including lack of chlorine sanitizer in the dishwasher, no drain stoppers, grime build-up, and failure to follow physician orders for special diets.
Severity Breakdown
Critical: 1
Major: 6
Severity: 2: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| No detectable level of chlorine sanitizer during the final rinse of the low temperature dishwasher. | Critical |
| No drain stoppers available for the three-compartment sink. | Major |
| Condiment cups used to plug the drains in the three-compartment sink. | Major |
| Grime build-up on the interior plastic shield of the ice machine. | Major |
| Handles of reach-in refrigerators and freezer soiled with debris build-up. | Major |
| Ventilation hood filters soiled with grease build-up. | Major |
| Floor soiled with debris across from the reach-in freezer in the activity area kitchen. | Major |
| Facility failed to ensure physician's orders for a special diet were followed for 1 of 15 residents. | Severity: 2 |
Report Facts
Residents present: 49
Licensed capacity: 64
Resident files reviewed: 15
Employee files reviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Samantha Williams | Executive Director | Named in relation to monitoring compliance with corrective actions |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Aug 20, 2019
Visit Reason
The inspection was conducted 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.
Findings
The investigation included observations, interviews with residents and staff, and review of medical records and facility policies. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
One complaint (#NV00057849) was investigated with multiple allegations including resident treatment, staff response to a sick resident, resident injuries and deaths, food preparation, meal options, dietary staffing, and facility understaffing. The complaint could not be substantiated.
Report Facts
Sample size: 5
Number of residents interviewed: 11
Number of dietary aides interviewed: 1
Number of medication technicians interviewed: 3
Number of caregivers interviewed: 2
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