Inspection Reports for Volante Senior Living of Reno
222 E Patriot Blvd, Reno, NV 89511, United States, NV, 89511
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
23 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
224% worse than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
81% occupied
Based on a May 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 108
Capacity: 134
Deficiencies: 6
May 28, 2025
Visit Reason
This inspection was conducted as a result of a State Licensure re-survey and complaint investigations regarding allegations of staffing and medication administration issues.
Findings
The facility was found to have multiple deficiencies including unsafe premises with trip hazards due to torn carpets, improper dryer venting causing lint accumulation, medication administration errors including missing medications and unclear physician orders, unsecured medications in resident rooms, and incomplete or inaccurate medication administration records. Some complaints were substantiated while others were not.
Complaint Details
Three complaints were investigated: 1) Allegation that a qualified med-tech was not present during night shifts was not substantiated. 2) Allegations regarding medication technician availability, failure to notify family of missed medications, and wrong medication dosage were not substantiated. 3) Allegation that resident dryer vents were not venting outside was substantiated.
Severity Breakdown
Level 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Carpet in multiple areas was torn and patched creating trip hazards. | Level 2 |
| One dryer vent hose was partially disconnected causing lint buildup and improper ventilation. | Level 2 |
| Facility failed to ensure medications were on-site and administered as prescribed for several residents. | Level 2 |
| Medication administration records were inaccurate and lacked required details for one resident. | Level 2 |
| Medication orders lacked clarification for assessment requirements for holding medication based on heart rate. | Level 2 |
| Medications were not securely stored in a locked area in one resident room. | Level 2 |
Report Facts
Licensed beds: 134
Resident census: 108
Complaints investigated: 3
Medication deficiencies: 3
Severity 2 deficiencies: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Timothy M Grafton | Executive Director | Named as facility representative and involved in interviews regarding findings |
| Maintenance Director | Provided information and confirmation regarding carpet condition and dryer vent issues | |
| Medication Technician | Confirmed medication availability and administration record issues | |
| Wellness Director | Interviewed regarding medication administration and complaint investigations |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 134
Deficiencies: 15
Oct 10, 2024
Visit Reason
This inspection was conducted as a result of a State Licensure grading resurvey and a complaint investigation triggered by five complaints alleging various deficiencies including insufficient staffing, medication administration issues, neglect, and abuse.
Findings
The facility received a grade of D with multiple substantiated complaints including insufficient staffing in the memory care unit and failure to administer medications as ordered. Deficiencies were noted in elder abuse training, staffing schedules, medication administration, resident safety, and documentation. Several repeat deficiencies from prior surveys were identified.
Complaint Details
Five complaints were investigated. Two complaints were substantiated: insufficient staffing in the memory care unit and failure to administer medications as ordered. Other allegations including neglect, failure to notify family, improper medication administration, and abuse were not substantiated due to lack of evidence.
Severity Breakdown
Level 1: 1
Level 2: 13
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to ensure 8 of 10 sampled employees received initial elder abuse training prior to beginning work and annual training with competency determined by graded post test. | Level 2 |
| Failure to maintain an accurate staffing schedule including all amended changes for the Memory Care Unit. | Level 1 |
| Failure to ensure employees had CPR and first aid training including skills testing for 6 of 10 employees. | Level 2 |
| Failure to update person-centered service plan to address hospice care for a resident admitted to hospice services. | Level 2 |
| Failure to report abuse of a resident to the Aging and Disability Services Division or law enforcement within 24 hours of the incident. | Level 2 |
| Failure to keep a resident safe from verbal and physical abuse by a visitor in the dining room. | Level 2 |
| Failure to ensure physical examinations including review of systems were completed prior to admission or annually for 4 of 23 residents. | Level 2 |
| Failure to ensure medication profile review was reviewed and initialed by the Administrator within 72 hours for 1 of 23 residents. | Level 2 |
| Failure to administer medications as ordered by the physician for 2 of 23 residents and failure to have medications available for 1 of 23 residents. | Level 2 |
| Failure to maintain medication records accurately including documentation of medication administration and changes for 2 of 23 residents. | Level 2 |
| Failure to ensure resident medications were kept secured in the facility for 1 of 10 resident rooms with residents self-administering medication. | Level 2 |
| Failure to ensure staffing of one caregiver for every assigned interaction group of not more than six residents in the memory care unit during residents' waking hours in an Alzheimer's endorsed facility. | Level 2 |
| Failure to ensure prescriber's name and resident's name were documented on the label of over-the-counter medications for 2 of 23 residents. | Level 2 |
| Failure to ensure 2 of 10 employees completed cultural competency training within 30 days of hire. | Level 2 |
| Failure to obtain an annual Standard Physician Assessment and Placement Determination for a resident with Alzheimer's disease. | Level 2 |
Report Facts
Complaints investigated: 5
Residents present: 101
Licensed capacity: 134
Employees reviewed: 9
Resident files reviewed: 23
Elder abuse training deficiencies: 8
CPR/First aid training deficiencies: 6
Staffing schedule months reviewed: 5
Medication administration errors: 2
Residents with missing annual physicals: 4
Residents with missing cultural competency training: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #7 | Resident Care Partner | Named in elder abuse training deficiency |
| Employee #8 | Resident Care Partner | Named in elder abuse and CPR training deficiencies |
| Employee #9 | Resident Care Partner | Named in elder abuse and CPR training deficiencies |
| Employee #10 | Medication Technician | Named in elder abuse and CPR training deficiencies |
| Employee #11 | Medication Technician | Named in elder abuse, CPR, and cultural competency training deficiencies |
| Employee #12 | Medication Technician | Named in elder abuse training deficiency |
| Employee #13 | Medication Technician | Named in elder abuse training deficiency |
| Employee #14 | Resident Care Partner | Named in elder abuse and cultural competency training deficiencies |
| Timothy M Grafton | Executive Director | Named in multiple findings including elder abuse training, staffing, medication administration, and complaint investigations |
Inspection Report
Annual Inspection
Census: 102
Capacity: 134
Deficiencies: 16
Feb 28, 2024
Visit Reason
The inspection was conducted as a result of a State Licensure annual grading survey and complaint investigations in accordance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.
Findings
The facility received a grade of D with multiple deficiencies including failure to maintain complete and accurate records, inadequate elder abuse training, inaccurate advertising, delayed first aid and CPR training, improper use of bed rails, incomplete annual physical exams, medication administration errors, incomplete medication profile reviews, unsecured resident medications, unsafe items accessible in memory care, failure to notify residents of discharge rights, delayed cultural competency training, and incomplete infection control training and designation.
Complaint Details
Two complaints were investigated. Complaint #NV00070248 was substantiated without deficient practice regarding communication barriers, resident privacy, medication security, staff behavior, and staffing levels. Complaint #NV00070252 was not substantiated due to lack of evidence regarding service plans, medication accuracy, and staff training.
Severity Breakdown
Level 1: 4
Level 2: 10
Level 3: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Facility lacked policies addressing dangerous and toxic items in the memory care unit and pharmacy medication reviews. | Level 1 |
| One employee failed to receive initial elder abuse training prior to employment and annually thereafter. | Level 2 |
| Promotional materials misrepresented services by stating 24/7 trained medical professionals on-site. | Level 1 |
| First aid and CPR training was not completed within 30 days of employment for one employee. | Level 2 |
| Bed rails were used as restraints for one resident in violation of policy. | Level 2 |
| Annual physical examination was not completed for one resident. | Level 2 |
| Medication profile reviews for 21 residents lacked administrator's initials and dates within required timeframe. | Level 2 |
| Medication was administered once daily instead of twice daily as ordered for one resident. | Level 2 |
| Medication Administration Records (MAR) were incomplete and inaccurate for 9 residents due to system issues. | Level 3 |
| Resident medications were not secured in one resident's room where self-administered medications were stored unlocked. | Level 2 |
| Dangerous items such as batteries, blow dryer, and dice were accessible to residents in the memory care unit. | Level 2 |
| Toxic substances such as hairspray and toothpaste were accessible to residents in the memory care unit. | Level 2 |
| Facility failed to notify residents upon admission of discharge notification rights to the State Ombudsman. | Level 1 |
| Two employees did not complete cultural competency training within the required 30 business days of hire. | Level 2 |
| Facility failed to identify a secondary person responsible for infection control. | Level 2 |
| Primary infection control person lacked required 15 hours of infection control training. | Level 2 |
Report Facts
Facility licensed beds: 134
Resident census: 102
Employee records reviewed: 15
Resident records reviewed: 25
Inspection grade: D
Resurvey fee: 600
Deficiency count: 21
Training hours required: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Timothy M Grafton | Executive Director | Named in relation to multiple findings and plans of correction |
| Business Office Manager | Provided personnel checklist and attestation of compliance for training and records | |
| Director of Wellness | Named as primary infection control person and involved in training and policy reviews | |
| Medication Technician | Named in medication administration findings | |
| Maintenance Director | Confirmed unsafe items in memory care unit |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 134
Deficiencies: 15
Apr 13, 2023
Visit Reason
The inspection was conducted as a result of a State Licensure grading re-survey, a change of ownership, and a complaint investigation at the facility on 04/13/23.
Findings
The facility received a grade of A. Two complaints were investigated but could not be substantiated due to lack of evidence. Several regulatory deficiencies were identified related to health and sanitation, storage of food, first aid and CPR training, medication administration, maintenance of resident files, Alzheimer's care safety standards, and cultural competency training.
Complaint Details
Two complaints (#68122 and #NV00068232) were investigated but could not be substantiated due to lack of evidence. Allegations included failure to communicate resident condition changes, unclean resident rooms, residents left soiled, frequent falls, refusal of staff assistance, full bedside urinal not emptied, resident's room cold due to heat off, and failure to deliver food to resident's room.
Severity Breakdown
D: 7
F: 3
E: 2
C: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Health & Sanitation - Screens: All windows and doors left open for ventilation must be screened to prevent insect entry. | D |
| Storage of Food - Adequate Storage; Packaging: Sufficient storage must be available for all food and equipment; food must be appropriately packaged. | F |
| First Aid & CPR: Administrator or caregiver must be trained in first aid and cardiopulmonary resuscitation within 30 days of employment. | D |
| Written Policy on Admissions: Facility shall not admit or allow to remain persons who are bedfast, require restraint, confinement in locked quarters, or skilled nursing on 24-hour basis. | F |
| Medical Care of Resident After Illness: Facility must obtain general physical examination results before admission and annually or more frequently if condition changes. | D |
| Medication Administration-Accuracy & Report: Administrator must ensure medication regimen is reviewed every 6 months and reports maintained. | D |
| Medication/OTCs, Supplements, Change Order: Over-the-counter medications and supplements must be administered per physician's written instructions and documented. | D |
| Medication - Destruction: Discontinued or expired medications must be destroyed in presence of witness and documented. | D |
| Maintenance and Contents of Separate File: Separate resident files must be maintained, locked, confidential, and retained for at least 5 years. | E |
| Alzheimer’s Care - Interaction Groups: Facility must establish interaction groups with no more than six residents per caregiver during awake hours. | F |
| Alzheimer's Care Standards for Safety: Dangerous items (e.g., pushpins) were accessible in memory care unit rooms; facility lacked policy on dangerous items. | D |
| Alzheimer's Care Standards for Safety: Toxic substances were unsecured in memory care unit rooms; facility lacked policy on toxic items. | D |
| Discrimination prohibited: Facility must post nondiscrimination notices and contact information prominently. | C |
| Cultural Competency Training: Facility must conduct cultural competency training for employees providing care within 30 business days of hire and annually thereafter. | E |
| Annual Assessment of History of Each Resident: Facility must annually assess each resident's history and physical condition and conduct examinations as required. | D |
Report Facts
Total licensed capacity: 134
Census: 104
Residents in categories: 57
Residents in categories: 45
Residents in categories: 32
Complaints investigated: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Douglas Hopkins | Administrator | Signed report and verbally confirmed facility policies |
| Memory Care Manager | Interviewed regarding complaints and deficiencies related to memory care unit | |
| Caregiver | Interviewed during complaint investigation | |
| Director of Dining Services | Interviewed during complaint investigation | |
| Wellness Director | Interviewed during complaint investigation and responsible for education and audits |
Inspection Report
Annual Inspection
Census: 102
Capacity: 134
Deficiencies: 17
Feb 7, 2023
Visit Reason
The inspection was conducted as a result of a State Licensure annual survey and complaint investigations on 02/07/2023, in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found deficient in multiple areas including staffing ratios in the Alzheimer's unit, medication administration and destruction, timely completion of physical exams and assessments, infection control, safety hazards in the memory care unit, and failure to post required discrimination complaint information. Several complaints related to understaffing were substantiated.
Complaint Details
Two complaints (#67601 and #67556) alleging understaffing were substantiated. Other allegations related to resident care and dignity were not substantiated due to lack of evidence.
Severity Breakdown
Level 1: 1
Level 2: 16
Deficiencies (17)
| Description | Severity |
|---|---|
| Failed to ensure all windows capable of being opened were screened to prevent insect entry. | Level 2 |
| Failed to ensure food was labeled, expired food discarded, staff wore hairnets, and proper sanitizing agents were available in the kitchen. | Level 2 |
| Failed to ensure timely first aid and CPR training for employees. | Level 2 |
| Failed to ensure residents receiving skilled nursing services were admitted or retained with required waivers. | Level 2 |
| Failed to ensure physical examinations were completed upon admission for some residents. | Level 2 |
| Failed to ensure medication profile reviews were performed every six months for some residents. | Level 2 |
| Failed to ensure medications were on-site to administer as prescribed for a resident. | Level 2 |
| Failed to ensure discontinued medications were destroyed timely and not stored with active medications. | Level 2 |
| Failed to ensure tuberculosis testing was completed timely and documented properly for several residents. | Level 2 |
| Failed to ensure activities of daily living assessments were completed timely upon admission for some residents. | Level 2 |
| Failed to keep resident medical information confidential; computer screen with resident info was left unlocked. | Level 2 |
| Failed to maintain adequate staffing ratios of one caregiver per six residents in the Alzheimer's unit during waking hours. | Level 2 |
| Failed to ensure dangerous items such as razors, push pins, space heaters, and other items were inaccessible to residents in the memory care unit. | Level 2 |
| Failed to ensure toxic substances were secured and inaccessible to residents in the memory care unit. | Level 2 |
| Failed to post prominently the State contact information for filing complaints of discrimination. | Level 1 |
| Failed to ensure cultural competency training was completed by all employees providing care. | Level 2 |
| Failed to obtain complete and accurate Standard Physician Assessment and Placement Determination for some residents. | Level 2 |
Report Facts
Licensed beds: 134
Current census: 102
Complaints investigated: 2
Staffing ratio: 1
Severity Level 1 deficiencies: 1
Severity Level 2 deficiencies: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Douglas S Hopkins | Administrator | Named in relation to findings and attestation of compliance |
| Alicia Mazy | Regulation I49N | Named in relation to food storage deficiencies |
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