Inspection Reports for A Summerdale Homes @ Riata
14315 Riata Circle, Reno, NV 89521, NV, 89521
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Inspection Report
Complaint Investigation
Census: 8
Capacity: 8
Deficiencies: 12
Nov 6, 2024
Visit Reason
The inspection was conducted as a result of a State Licensure mandatory regrading survey and complaint investigation initiated at the facility on 11/06/2024, including investigation of three complaints.
Findings
The facility was found deficient in multiple areas including failure to complete required physician placement determinations, infection control training, medication administration and management, cultural competency training, and person-centered service plans. One complaint regarding a resident not receiving medication was substantiated. The facility received a grade of D.
Complaint Details
Complaint #NV00072719 alleging a resident was not given medication for several days was substantiated. Complaints #NV00072113 and #NV00071813 alleging neglect and other issues were not substantiated due to lack of evidence.
Severity Breakdown
Level 2: 12
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to ensure physician placement determination was completed upon admission and annually for residents with dementia. | Level 2 |
| Failure to ensure secondary infection control staff completed required 15 hours of infection control training. | Level 2 |
| Failure to ensure one employee completed required annual medication management training on time. | Level 2 |
| Failure to ensure one employee received CPR and first aid training equivalent to American Red Cross within 30 days of hire. | Level 2 |
| Failure to develop person-centered service plans for all residents. | Level 2 |
| Failure to ensure medication profile review was performed at least every six months for residents on medications. | Level 2 |
| Failure to implement and maintain a medication management plan and ensure caregivers were trained on it. | Level 2 |
| Failure to administer medication as ordered and failure to notify physician of missed doses for one resident. | Level 2 |
| Failure to notify physician within 12 hours of missed medication administration for one resident. | Level 2 |
| Failure to maintain initial assessment of activities of daily living upon admission for some residents. | Level 2 |
| Failure to obtain Alzheimer's care endorsement for residents with dementia as required. | Level 2 |
| Failure to ensure cultural competency training approved by the Division was completed for some employees. | Level 2 |
Report Facts
Complaints investigated: 3
Residents files reviewed: 6
Employee files reviewed: 3
Medication doses missed: 2
Medication administration training hours: 16
Infection control training hours: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Caregiver and secondary infection control staff | Failed to complete required infection control training and annual medication management training. |
| Employee #3 | Caregiver | Failed to complete CPR/first aid training equivalent to American Red Cross and cultural competency training. |
| Eugene Gasataya | Administrator | Named in multiple findings including failure to ensure physician placement determinations, medication management, and training compliance. |
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 18
May 13, 2024
Visit Reason
The inspection was conducted as a result of a State Licensure annual survey and complaint investigation initiated on 2024-04-16 and concluded on 2024-05-13, in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of D with multiple deficiencies including failure to provide adequate oversight by the administrator, incomplete personnel and resident records, lapses in caregiver training including medication management and elder abuse prevention, safety hazards on the premises, failure to maintain bathroom ventilation, incomplete person-centered service plans for all residents, missing six-month medication reviews, incomplete tuberculosis testing documentation, lack of Alzheimer's care endorsement despite residents with dementia, failure to post the required letter grade, and deficiencies in infection control program designation and training.
Complaint Details
Two complaints were investigated. Complaint #NV00069691 alleging misuse of resident funds, limiting family contact, and verbal abuse by the administrator was not substantiated due to lack of evidence. Complaint #NV00070765 alleging an obstacle impeding residents' free movement and failure to maintain a bathroom fan was substantiated.
Severity Breakdown
Level 1: 1
Level 2: 16
Deficiencies (18)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight and direction to staff to ensure compliance with NAC 449.156 to 449.27706 and NRS Chapter 449. | Level 2 |
| Administrator failed to ensure personnel and resident medical records were complete and accurate. | Level 2 |
| One caregiver failed to complete required annual medication management training on time. | Level 2 |
| One caregiver failed to complete required elder abuse prevention training timely. | Level 2 |
| Two employees failed to meet tuberculosis testing and pre-employment physical examination requirements. | Level 2 |
| Facility had obstacles impeding residents' free movement including unsafe backyard ramp conditions. | Level 2 |
| Bathroom ceiling fan was non-operational, failing to provide proper ventilation. | Level 2 |
| One caregiver lacked current CPR and first aid certification. | Level 2 |
| Person-centered service plans were not developed for 7 of 7 residents reviewed. | Level 2 |
| Medication profile reviews were not performed at least every six months for 2 of 7 residents. | Level 2 |
| Two residents lacked required tuberculosis testing documentation for 2024. | Level 2 |
| Annual Activities of Daily Living (ADL) assessments were not completed for 3 of 7 residents for 2023. | Level 2 |
| Facility failed to obtain Alzheimer's care endorsement while admitting and retaining 3 residents with dementia. | Level 2 |
| Facility failed to display the current D letter grade placard conspicuously in a public area. | Level 1 |
| Two employees lacked required cultural competency training approved by the Division of Public and Behavioral Health. | Level 2 |
| Three residents with dementia lacked a standard placement determination completed by a provider prior to admission. | Level 2 |
| Facility failed to designate a primary and secondary person responsible for infection control program. | Level 2 |
| Primary infection control staff lacked required infection control training. | Level 2 |
Report Facts
Deficiencies cited: 17
Facility licensed beds: 8
Residents present: 7
Resurvey fee: 600
Administrator incapacitation weeks: 8
Caregiver medication training hours: 8
Caregiver medication training expiration date: 2024
Caregiver elder abuse training missing years: 2
Housekeeper employment months: 2
Backyard ramp drop height inches: 1.5
Diamond plate ramp width inches: 30
CPR certification expiration year: 2023
Infection control training hours: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Caregiver | Failed to complete required annual medication management training, elder abuse training, CPR certification, and cultural competency training on time; lacked tuberculosis testing documentation. |
| Employee #2 | Administrator | Failed to complete required cultural competency training. |
| Employee #3 | Housekeeper | Worked at the facility for two months without an employee file including tuberculosis testing and pre-employment physical. |
| Eugene Gasataya | Administrator | Named in relation to oversight failures and corrective action plans. |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 8
Deficiencies: 3
Oct 18, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #NV00062361 with multiple allegations regarding resident care and staff behavior.
Findings
The investigation found that none of the complaint allegations were substantiated. However, unrelated deficiencies were identified including failure to ensure background check renewals for an employee, retention of a bedfast resident without proper waiver, and failure to obtain a mental illness endorsement for the facility.
Complaint Details
Complaint #NV00062361 included five allegations: employee yelling at a resident, missed administration of eye drops, resident left wet in brief, resident not allowed to use walker, and resident not receiving therapeutic meals. None of these allegations were substantiated based on observations, interviews, and record reviews.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 2 employees met background check renewal requirements; Employee #2 lacked fingerprint renewal since 2020. | Severity: 2 |
| Facility failed to ensure a bedfast resident was not retained or admitted without a bedfast waiver or exemption request (Resident #3). | Severity: 2 |
| Facility failed to obtain a mental illness endorsement and admitted and retained a resident with a mental illness diagnosis (Resident #2). | Severity: 2 |
Report Facts
Sample size: 7
Complaints investigated: 1
Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 10
Jul 13, 2022
Visit Reason
The inspection was conducted as a result of a State Licensure annual survey and a complaint investigation regarding a resident being at an inappropriate level of care for the facility.
Findings
The facility received a grade of D with multiple deficiencies including incomplete clinical records for residents, failure to ensure tuberculosis testing for a volunteer housekeeper, inadequate maintenance of the facility exterior, incomplete physical examinations prior to admission for residents, lack of physician notification of pharmacist recommendations, missing ultimate user agreements for medication administration, untimely ADL assessments, failure to obtain Alzheimer's care endorsement despite admitting residents with dementia, and failure to complete standard placement assessments for residents with dementia.
Complaint Details
Complaint #NV00065751 alleging a resident was at an inappropriate level of care for the facility was substantiated.
Severity Breakdown
Level 2: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Administrator failed to ensure clinical records were complete for 3 of 8 residents, missing admission packets, ultimate user agreements, history and physicals, and TB tests. | Level 2 |
| Facility failed to ensure a volunteer housekeeper met TB testing and pre-employment physical requirements. | Level 2 |
| Facility failed to maintain cleanliness and proper storage of items on the exterior of the building. | Level 2 |
| Facility failed to ensure physical examinations including review of systems were completed prior to admission and annually for 3 of 8 residents. | Level 2 |
| Administrator failed to ensure physician notification of pharmacist recommendations was documented for 2 of 8 residents. | Level 2 |
| Facility failed to ensure ultimate user agreements were completed for 2 of 8 residents. | Level 2 |
| Facility failed to ensure tuberculosis testing compliance for 1 of 8 residents. | Level 2 |
| Facility failed to ensure initial and annual ADL assessments were completed timely for 3 of 8 residents. | Level 2 |
| Facility failed to obtain Alzheimer's care endorsement while admitting and retaining 7 of 8 residents with Alzheimer's or dementia diagnoses. | Level 2 |
| Facility failed to ensure standard placement assessments were completed by a provider prior to admission for 7 of 8 residents with dementia. | Level 2 |
Report Facts
Deficiencies cited: 10
Census: 8
Total Capacity: 8
Resurvey fee: 600
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eugene Gasataya | Administrator | Named in multiple findings related to administrative responsibilities and corrective actions. |
Inspection Report
Complaint Investigation
Census: 4
Capacity: 8
Deficiencies: 2
Oct 19, 2021
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 10/19/21 and completed on 10/28/21 regarding allegations of medication hiding by a resident and failure to provide a 30-day eviction notice.
Findings
The facility was found to have failed in providing protective supervision for one resident who intentionally ingested accumulated medications in a suicide attempt. Additionally, the facility failed to ensure resident medical records were available on site during the investigation. The allegation regarding eviction notice was not substantiated.
Complaint Details
Complaint #NV00064989 was substantiated for the allegation that a resident was hiding medication without caregiver knowledge. The allegation that the facility refused to provide a 30-day eviction notice was not substantiated due to lack of evidence.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide protective supervision for 1 of 4 residents resulting in an intentional medication overdose. | Severity: 2 |
| Failed to ensure resident medical records were available at the facility upon request during a complaint investigation. | Severity: 2 |
Report Facts
Licensed beds: 8
Residents present: 4
Medication pills accumulated: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eugene Gasataya | Administrator | Administrator involved in investigation and corrective actions |
Inspection Report
Complaint Investigation
Census: 8
Capacity: 8
Deficiencies: 2
Sep 30, 2021
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 2021-09-07 and completed on 2021-09-30 regarding neglect of a resident by a caregiver.
Findings
The investigation substantiated that a caregiver left a resident on the floor for an extended period while waiting for the Administrator to assist after a fall. The Administrator failed to provide adequate oversight and ensure sufficient caregiver staffing to provide timely assistance and protective supervision.
Complaint Details
Complaint #NV00064751 was substantiated. The allegation was that a resident was neglected by the caregiver who left the resident on the floor for 20 to 30 minutes while calling the Administrator for assistance after a fall.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight and direction to staff to ensure compliance with Nevada Administrative Code and Revised Statutes. | Severity: 2 |
| Administrator failed to ensure sufficient number of caregivers were on duty to assist a resident in a timely manner after a fall. | Severity: 2 |
Report Facts
Complaint investigated: 1
Sample size: 5
Resident census: 8
Total licensed capacity: 8
Time resident left on floor: 20
Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 3
Jul 9, 2021
Visit Reason
This inspection was conducted as a State Licensure annual survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but had several deficiencies including inaccurate medication administration records for one resident, failure to ensure timely tuberculosis testing for two residents, and failure to obtain an Alzheimer's care endorsement for one resident with dementia.
Severity Breakdown
Level 1: 1
Level 2: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Medication Administration Record (MAR) was inaccurate for 1 of 8 residents; missing documentation of fluoxetine and sertraline medications compared to physician orders. | Level 1 |
| Failed to ensure 2 of 8 residents had timely tuberculosis (TB) testing upon admission as required by Nevada Administrative Code. | Level 2 |
| Facility failed to obtain an Alzheimer's endorsement to provide care for 1 of 8 residents with Alzheimer's disease or related dementia. | Level 2 |
Report Facts
Residents reviewed: 8
Employee files reviewed: 3
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eugene Gasataya | Administrator | Named as Laboratory Director's or Provider/Supplier Representative who signed the report |
Inspection Report
Routine
Census: 7
Capacity: 8
Deficiencies: 3
Dec 22, 2020
Visit Reason
This inspection was conducted as a State Licensure COVID-19 Focused Infection Control Survey to assess compliance with infection control and prevention practices in the facility.
Findings
The facility failed to provide a safe environment by not screening all residents for COVID-19 symptoms at regular intervals, not fit testing one employee for the N95 mask they were using, and lacking documented staff education on proper donning and doffing of PPE. The facility had no COVID-19 positive residents or staff at the time of the survey and had implemented additional measures for early detection of COVID-19 symptoms.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to screen 7 of 7 residents for signs and symptoms of COVID-19 at regular intervals. | Severity: 2 |
| One of three employees was not fit tested for the use of the 3M 8160S N95 mask they were wearing. | Severity: 2 |
| Lack of documented evidence that 3 of 3 employees had education on appropriate donning and doffing of PPE. | Severity: 2 |
Report Facts
Residents present: 7
Total licensed beds: 8
Employees fit tested: 2
COVID-19 symptom screenings missed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eugene Gasataya | Administrator | Administrator confirmed facility noncompliance with screening and fit testing policies |
| Employee #2 | Verbalized failure to screen residents regularly, was not fit tested for the N95 mask worn, and lacked PPE donning/doffing training |
Inspection Report
Follow-Up
Census: 8
Capacity: 8
Deficiencies: 0
Oct 1, 2020
Visit Reason
This follow-up State Licensure COVID-19 Infection Control and Prevention Plan Survey was conducted to assess the facility's compliance with infection control practices and prevention plans related to COVID-19.
Findings
The facility was found to have implemented comprehensive COVID-19 infection control measures including visitor screening, use of PPE, social distancing, cleaning protocols, and staff training. No regulatory deficiencies were identified during this survey.
Report Facts
Licensed beds: 8
Census: 8
Inspection Report
Routine
Census: 8
Capacity: 8
Deficiencies: 0
Sep 16, 2020
Visit Reason
This inspection was conducted as a State Licensure COVID-19 Infection Control and Prevention Plan Survey to assess the facility's compliance with infection control requirements.
Findings
No regulatory deficiencies were identified; however, the facility did not have a documented Infection Control and Prevention Plan. Resources were provided and the Administrator committed to having a documented plan ready for follow-up by 09/30/20.
Inspection Report
Re-Inspection
Census: 8
Capacity: 8
Deficiencies: 2
Jul 13, 2016
Visit Reason
The inspection visit was a required grading re-survey conducted at the facility on 7/13/16 to assess compliance with staffing and personnel file requirements.
Findings
The facility failed to ensure that 2 of 4 employees met physical examination and background check requirements, with missing documentation for physical exams and fingerprint submissions. The facility received a re-survey grade of A.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to have documented evidence of completed physical examination for Employee #2. | Severity: 2 |
| Failure to have documented evidence of recent fingerprint submission and background check clearance for Employees #2 and #4. | Severity: 2 |
Report Facts
Census: 8
Total Capacity: 8
Employees reviewed: 4
Residents files reviewed: 5
Inspection Report
Re-Inspection
Census: 8
Capacity: 8
Deficiencies: 2
Jul 13, 2016
Visit Reason
This inspection was a required grading re-survey conducted on 7/13/16 to evaluate compliance with state licensure requirements for a Residential Facility for Groups.
Findings
The facility received a re-survey grade of A. Deficiencies were identified related to personnel files, including missing physical examination documentation for one employee and missing background check documentation for two employees.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 4 employees had documented evidence of a completed physical examination. | Severity: 2 |
| Failure to ensure 2 of 4 employees met background check requirements, lacking fingerprint submission forms and clearance reports. | Severity: 2 |
Report Facts
Census: 8
Total Capacity: 8
Employees reviewed: 4
Resident files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Caregiver | Named in findings for missing physical examination and background check documentation |
| Employee #4 | Caregiver | Named in findings for missing background check documentation |
Inspection Report
Complaint Investigation
Census: 8
Deficiencies: 3
Jun 2, 2016
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by two complaints alleging resident neglect and unsafe environment/premises cleanliness.
Findings
Two complaints were investigated and found not substantiated. However, deficiencies unrelated to the complaints were identified, including medication storage issues and failure to display a current grading placard.
Complaint Details
Two complaints were investigated: Complaint #NV00045828 alleging resident neglect was not substantiated; Complaint #NV00046029 alleging unsafe environment and unclean premises was not substantiated.
Severity Breakdown
Level 2: 2
Level 1: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Medication storage was not secure; two baskets of residents' medications were observed on the kitchen countertop. | Level 2 |
| Failure to ensure medications stored in a refrigerator were kept in a locked box unless the refrigerator was locked or in a locked room. | Level 2 |
| Failure to display the current grading placard conspicuously in a public area; the placard posted was dated 4/27/15. | Level 1 |
Report Facts
Census: 8
Sample size: 5
Sample size: 4
Severity: 2
Scope: 3
Severity: 1
Scope: 3
Inspection Report
Complaint Investigation
Census: 8
Deficiencies: 2
Jun 2, 2016
Visit Reason
The inspection was conducted as a complaint investigation triggered by two complaints alleging resident neglect and unsafe, unclean environment conditions.
Findings
The investigation found that the allegations of resident neglect and unsafe, unclean environment were not substantiated. However, unrelated deficiencies were identified regarding medication storage security and failure to display the current grading placard.
Complaint Details
Two complaints were investigated: Complaint #NV00045828 alleging resident neglect, and Complaint #NV00046029 alleging unsafe environment and unclean premises. Both complaints were not substantiated.
Severity Breakdown
Severity: 2: 1
Severity: 1: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Medications were not stored securely; two baskets of residents' medications were observed on the kitchen counter top. | Severity: 2 |
| The current grading placard was not displayed conspicuously; the posted placard was dated over a year old. | Severity: 1 |
Report Facts
Census: 8
Sample size: 5
Sample size: 4
Severity 2 deficiencies: 1
Severity 1 deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 confirmed medication storage observation but no full name provided |
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 9
Apr 19, 2016
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 4/19/16 to assess compliance with regulations for a residential facility for elderly and disabled persons.
Findings
The facility was found deficient in multiple areas including caregiver medication training, elder abuse training, personnel file requirements such as tuberculosis testing, background checks, CPR certification, health and sanitation, periodic physical examinations of residents, and medication administration records. The facility received a grade of D.
Severity Breakdown
1: 1
2: 8
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure 3 of 5 employees completed required 16 hours initial and/or 8 hours annual medication management training and post-training exam. | 2 |
| Failed to provide initial and annual elder abuse training for 4 of 5 employees. | 2 |
| Failed to ensure 3 of 5 employees met tuberculosis testing and pre-employment physical exam requirements. | 2 |
| Failed to ensure 3 of 5 employees met background check requirements. | 2 |
| Failed to ensure 1 of 5 employees was currently certified in CPR and first aid. | 2 |
| Failed to maintain clean and well-maintained interior; ceiling over resident bed was damaged and covered with plastic sheeting. | 2 |
| Failed to ensure 2 of 7 residents had initial and/or annual physical examinations. | 2 |
| Medication Administration Record (MAR) was inaccurate for 2 of 7 residents. | 1 |
| Failed to ensure 1 of 7 residents met tuberculosis testing requirements. | 2 |
Report Facts
Residents present: 7
Total licensed capacity: 8
Employees reviewed: 5
Resident files reviewed: 7
Deficiency severity 2 count: 8
Deficiency severity 1 count: 1
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 9
Apr 19, 2016
Visit Reason
This annual State Licensure survey was conducted on 4/19/2016 by the Division of Public and Behavioral Health to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of D with multiple deficiencies identified including failure to ensure required medication management training for employees, incomplete elder abuse training, inadequate tuberculosis and background check documentation, expired CPR certification, poor facility maintenance, missing resident physical exams, inaccurate medication administration records, and incomplete resident tuberculosis compliance.
Severity Breakdown
Level 2: 8
Level 1: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure 3 of 5 employees completed required initial and annual medication management training and post-training examination. | Level 2 |
| Failed to provide initial and annual training in prevention, recognition, and response to elder abuse for 4 of 5 employees. | Level 2 |
| Failed to ensure 3 of 5 employees met tuberculosis and pre-employment physical examination requirements. | Level 2 |
| Failed to ensure 3 of 5 employees met background check requirements. | Level 2 |
| Failed to ensure 1 of 5 employees was currently certified to perform CPR and first aid. | Level 2 |
| Failed to ensure the interior of the facility was clean and maintained; ceiling over resident beds damaged and covered with plastic sheeting. | Level 2 |
| Failed to ensure 2 of 7 residents had initial and/or annual physical examinations. | Level 2 |
| Medication Administration Record (MAR) was inaccurate for 2 of 7 residents receiving medications. | Level 1 |
| Failed to ensure 1 of 7 residents met tuberculosis requirements; two-step TB test initiated 10 days after admission. | Level 2 |
Report Facts
Residents present: 7
Total licensed capacity: 8
Employees reviewed: 5
Residents reviewed: 7
Deficiency severity counts: 8
Deficiency severity counts: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Caregiver | Named in medication training, tuberculosis, and elder abuse training deficiencies |
| Employee #3 | Caregiver | Named in medication training, tuberculosis, elder abuse training, background check, CPR certification, and MAR inaccuracies |
| Employee #4 | Caregiver | Named in medication training, tuberculosis, elder abuse training, and background check deficiencies |
| Employee #5 | Caregiver | Named in medication training, tuberculosis, and background check deficiencies |
| Employee #1 | Administrator | Named in elder abuse training deficiency |
Inspection Report
Annual Inspection
Census: 6
Capacity: 8
Deficiencies: 3
Apr 27, 2015
Visit Reason
This 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 but had deficiencies including failure to ensure pre-employment physical examinations for some employees, lack of scheduled activities for residents, and inaccurate medication administration records for several residents.
Severity Breakdown
Level 2: 1
Level 1: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure 2 of 3 employees had required pre-employment physical examinations within 6 months prior to hire date. | Level 2 |
| Facility failed to document at least 10 hours of scheduled activities for residents and lacked a posted schedule of activities. | Level 1 |
| Medication administration records were inaccurate or incomplete for 3 of 6 residents, including missing medications on site and incorrect documentation. | Level 1 |
Report Facts
Licensed beds: 8
Residents present: 6
Employees reviewed: 3
Resident MARs reviewed: 6
Inspection Report
Annual Inspection
Census: 6
Capacity: 8
Deficiencies: 3
Apr 27, 2015
Visit Reason
This 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 A but had several deficiencies including missing pre-employment physical examinations for 2 of 3 employees, failure to provide at least 10 hours of scheduled activities for residents, and inaccuracies in medication administration records for 3 of 6 residents.
Severity Breakdown
Level 2: 1
Level 1: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 3 employees had pre-employment physical examinations within 6 months prior to hire date. | Level 2 |
| Failed to provide at least 10 hours of scheduled activities suited to residents' interests and capacities for 6 of 6 residents. | Level 1 |
| Medication administration records were inaccurate for 3 of 6 residents, including missing medications on site and lack of doctor's orders. | Level 1 |
Report Facts
Residents present: 6
Licensed capacity: 8
Employee files reviewed: 3
Resident files reviewed: 6
Severity 2 deficiencies: 1
Severity 1 deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Named in deficiency for missing pre-employment physical examination | |
| Employee #3 | Named in deficiencies for missing pre-employment physical examination and acknowledged medication administration record deficiencies |
Inspection Report
Complaint Investigation
Capacity: 8
Deficiencies: 0
Sep 18, 2014
Visit Reason
The inspection was conducted as a complaint investigation regarding an allegation of inappropriate level of care for a resident.
Findings
The allegation of inappropriate level of care was not substantiated based on interviews, observation, and record review. No deficiencies were identified and no further action was required.
Complaint Details
Complaint #NV00040475 contained one allegation regarding inappropriate level of care for a resident. The complaint was not substantiated after investigation including interviews with the resident and caregiver, observation, and record review.
Report Facts
Total licensed capacity: 8
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 3
May 8, 2014
Visit Reason
The inspection was conducted as an annual State Licensure survey from 2014-04-10 to 2014-05-08 to assess compliance with licensing requirements for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A but was found deficient in licensing requirements related to mental illness and chronic illness training for employees. Specifically, the facility failed to provide appropriate endorsements and training for care of a resident with schizophrenia and hepatitis C, and lacked documented training for three employees regarding mental illness and chronic illness care.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility provided care for Resident #4 without appropriate endorsements for mental illness and chronic illness training. | Severity: 2 |
| Facility failed to ensure three employees received at least 8 hours of mental illness training within 60 days of employment. | Severity: 2 |
| Facility failed to ensure three employees received at least 4 hours of chronic illness and infection control training within 60 days of employment. | Severity: 2 |
Report Facts
Residents present: 7
Total licensed capacity: 8
Training hours required: 8
Training hours required: 4
Employees lacking training: 3
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 3
May 8, 2014
Visit Reason
This document is a result of an annual State Licensure survey conducted at the facility from 2014-04-10 to 2014-05-08 to assess compliance with state regulations for residential facilities.
Findings
The facility was found to have deficiencies related to providing care for a resident without appropriate endorsements and failing to ensure employees received required training on mental illness and chronic illness care. The facility received a grade of A despite these deficiencies.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility provided care for 1 of 7 residents without appropriate endorsements and failed to obtain necessary training to care for such person. | Severity: 2 |
| Facility failed to ensure 3 of 3 employees received 8 hours of training concerning care for residents with mental illness. | Severity: 2 |
| Facility failed to ensure 3 of 3 employees had received at least 4 hours of training concerning care for residents with chronic illnesses and infection control methods. | Severity: 2 |
Report Facts
Residents present: 7
Licensed capacity: 8
Employees reviewed: 3
Residents reviewed: 7
Training hours required for mental illness care: 8
Training hours required for chronic illness care: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Administrator | Failed to receive required mental illness and chronic illness training |
| Employee #2 | Caregiver | Failed to receive required mental illness and chronic illness training |
| Employee #3 | Caregiver | Failed to receive required mental illness and chronic illness training |
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 6
Apr 15, 2013
Visit Reason
This document is the result of an annual State Licensure survey conducted on 4/15/2013 to assess compliance with state regulations 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 maintain current tuberculosis testing for an employee, poor facility maintenance and sanitation, inadequate first aid and CPR training for caregivers, inaccurate medication administration records, violation of low income bed occupancy requirements, and failure to provide elder abuse prevention training to employees.
Severity Breakdown
Severity: 2: 3
Severity: 1: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 3 employees had current annual tuberculosis skin test. | Severity: 2 |
| Facility premises not clean and well maintained, including accumulated dryer lint, gasoline fumes/fire risk, missing dog door flap, unstable gate and fence, mold and missing caulking in bathrooms, missing showerhead, and broken closet door. | Severity: 2 |
| 2 of 3 caregivers completed online first aid and CPR training without hands-on proficiency testing, not meeting Bureau standards. | Severity: 2 |
| Medication administration record inaccurate for 1 of 7 MARs inspected (Resident 2 - Lorazepam 0.5 mg documentation). | Severity: 1 |
| Facility violated low income bed occupancy by having 3 of 6 low income beds occupied by residents who did not qualify as low income. | Severity: 1 |
| Failed to provide initial training in prevention, recognition, and response to elder abuse to 3 of 3 employees before resident interaction. | — |
Report Facts
Licensed beds: 8
Current census: 7
Low income beds: 6
Low income beds occupied by non-qualifying residents: 3
MARs inspected: 7
Caregivers reviewed: 3
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 1
Apr 30, 2012
Visit Reason
The inspection was conducted as an annual State Licensure survey from 04/27/12 through 04/30/12 to assess compliance with state regulations for the facility.
Findings
The facility received a grade of A. One deficiency was identified related to the failure to ensure that 2 of 7 residents received an annual physical examination as required by regulation.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure 2 of 7 residents received an annual physical examination as required by NAC 449.274. | Severity: 2 |
Report Facts
Residents reviewed: 7
Employee files reviewed: 3
Licensed capacity: 8
Residents not receiving annual physical: 2
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 1
Apr 30, 2012
Visit Reason
This document is the result of an annual State Licensure survey conducted at the facility from 4/27/2012 through 4/30/2012 to assess compliance with state regulations.
Findings
The facility received a grade of A. However, deficiencies were identified related to failure to ensure 2 of 7 residents received an annual physical examination as required by regulation.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure 2 of 7 residents received an annual physical examination. | Severity: 2 |
Report Facts
Residents reviewed: 7
Employee files reviewed: 3
Inspection Report
Annual Inspection
Census: 5
Capacity: 8
Deficiencies: 4
Mar 30, 2011
Visit Reason
This document reports on an annual State Licensure survey and a complaint investigation conducted from 2011-01-31 to 2011-03-30 at Summerdale at Riata, a residential facility for elderly and disabled persons.
Findings
The facility received a grade of B. The complaint investigation found allegations regarding lack of protective supervision, inappropriate level of care, expired TB test, and insulin assistance to be unsubstantiated. However, deficiencies were cited related to employee tuberculosis testing, medication administration, and medication destruction.
Complaint Details
Complaint #NV00027395 was initiated on 2011-01-31. Allegations regarding lack of protective supervision for Resident #3, inappropriate level of care for Resident #4, expired TB test for Resident #2, and assistance with insulin for a diabetic resident were unsubstantiated after review and observation. The allegation regarding medications not given per physician's instructions was substantiated.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 2 employees complied with tuberculosis testing requirements (repeat deficiency). | Severity: 2 |
| Did not obtain physician orders to administer over-the-counter medications to 1 of 5 residents (Resident #1 - Imodium, 2 mg). | Severity: 2 |
| Failed to ensure that 2 of 5 residents received medications as prescribed (Resident #1 - Carbidopa/Levodopa, Promethazine; Resident #2 - Lantus insulin; Resident #4 - Bengay Ointment). | Severity: 2 |
| Did not destroy medications after discontinuation for 2 of 5 residents (Resident #3 - Hydrocodone, Amlodipine, Caltrate; Resident #5 - Amiodarone). | Severity: 2 |
Report Facts
Licensed capacity: 8
Census: 5
Employees reviewed: 2
Resident files reviewed: 5
Discharged resident files reviewed: 1
Deficiencies cited: 4
Inspection Report
Annual Inspection
Census: 5
Capacity: 8
Deficiencies: 4
Mar 30, 2011
Visit Reason
The inspection was conducted as a result of an annual State Licensure survey and a complaint investigation conducted from 2011-01-31 to 2011-03-30. The complaint investigation was initiated by the Bureau of Health Care Quality and Compliance on 2011-01-31.
Findings
The facility received a grade of B. Several allegations were investigated including lack of protective supervision, inappropriate level of care, expired TB test, and assistance with insulin, most of which were unsubstantiated. One allegation regarding medications not being given per physician's instructions was substantiated. Multiple deficiencies related to personnel files, medication administration, and medication destruction were identified.
Complaint Details
Complaint #NV00027395 was investigated. Allegations regarding lack of protective supervision, inappropriate level of care, expired TB test, and assistance with insulin were unsubstantiated. The allegation regarding medications not being given per physician's instructions was substantiated.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 2 employees complied with tuberculosis testing requirements. | Severity: 2 |
| Facility did not obtain physician orders to administer over-the-counter medications to 1 of 5 residents. | Severity: 2 |
| Facility failed to ensure that 2 of 5 residents received medications as prescribed. | Severity: 2 |
| Facility did not destroy medications after they were discontinued for 2 of 5 residents. | Severity: 2 |
Report Facts
Residents present: 5
Total licensed capacity: 8
Deficiencies cited: 4
Severity level 2 deficiencies: 4
Inspection Report
Capacity: 8
Deficiencies: 0
Mar 7, 2011
Visit Reason
This Statement of Deficiencies was generated as a result of a Change Category survey conducted in the facility from 2/22/11 to 3/7/11. The facility is requesting a change from Category I to Category II.
Findings
No regulatory deficiencies were identified during this State Licensure survey. No further action is necessary.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 6, 2010
Visit Reason
The inspection was conducted as a complaint investigation initiated by the Bureau of Health Care Quality and Compliance on 10/6/10 regarding allegations of misappropriation of property, resident abuse, neglect, restraint and seclusion, quality of care, and physical environment at the facility.
Findings
The complaint allegations were not substantiated due to lack of evidence after interviews with residents, family members, facility staff, and physician's office, as well as review of resident files, medication logs, and medical records. No deficiencies were cited and no further action was necessary.
Complaint Details
Complaint #NV00026569 included allegations of misappropriation of property, resident abuse, neglect, restraint and seclusion, quality of care, and physical environment. All allegations were found not substantiated through interviews and record reviews. The complaint was filed over a year after the resident had left the facility.
Inspection Report
Complaint Investigation
Census: 6
Capacity: 8
Deficiencies: 4
Apr 22, 2010
Visit Reason
This document is a complaint investigation conducted at Summerdale at Riata between 4/19/10 and 4/22/10, triggered by Complaint #NV00025068 which was substantiated.
Findings
The facility was found to have multiple deficiencies including allowing Category II residents to reside in a Category I group home, failure to provide protective supervision for one resident, failure to ensure a physical examination prior to admission for one resident, and failure to re-evaluate a resident's ability to perform activities of daily living after a decline in mental condition.
Complaint Details
Complaint #NV00025068 was substantiated.
Severity Breakdown
Severity 3: 1
Severity 2: 2
Severity 1: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility allowed Category II residents to reside in a Category I group home. | Severity: 2 Scope: 3 |
| Facility failed to provide protective supervision for 1 of 6 residents (Resident #1) who exhibited disruptive behaviors and cognitive decline. | Severity: 3 Scope: 1 |
| Facility failed to ensure that 1 of 6 residents received a physical examination prior to admission (Resident #1). | Severity: 2 Scope: 1 |
| Facility failed to re-evaluate 1 of 6 resident's ability to perform activities of daily living after a decline in mental condition (Resident #1). | Severity: 1 Scope: 1 |
Report Facts
Licensed capacity: 8
Census: 6
Residents reviewed: 3
Employee files reviewed: 0
Inspection Report
Complaint Investigation
Census: 6
Capacity: 8
Deficiencies: 4
Apr 22, 2010
Visit Reason
This Statement of Deficiencies was generated as a result of a complaint investigation conducted in the facility between 2010-04-19 and 2010-04-22.
Findings
The facility was found to have allowed Category II residents to reside in a Category I group home, failed to provide protective supervision for one resident with dementia exhibiting disruptive behaviors, did not ensure a physical examination prior to admission for one resident, and failed to re-evaluate a resident's ability to perform activities of daily living after a decline in mental condition.
Complaint Details
Complaint #NV00025068 was substantiated.
Severity Breakdown
Severity: 1: 1
Severity: 2: 2
Severity: 3: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility allowed Category II residents to reside in a Category I group home. | Severity: 2 |
| Failed to provide protective supervision for 1 of 6 residents (Resident #1) with dementia and disruptive behaviors. | Severity: 3 |
| Failed to ensure that 1 of 6 residents received a physical examination prior to admission. | Severity: 2 |
| Failed to re-evaluate 1 of 6 resident's ability to perform activities of daily living after a decline in mental condition. | Severity: 1 |
Report Facts
Licensed beds: 8
Resident census: 6
Residents reviewed: 3
Residents with deficiencies: 1
Inspection Report
Enforcement
Deficiencies: 1
Apr 19, 2010
Visit Reason
The Bureau conducted a complaint survey at Summerdale At Riata from April 19, 2010 through April 22, 2010, which led to the imposition of sanctions.
Findings
The Health Division is imposing sanctions based on deficiencies found during the complaint survey, with monetary penalties assessed. The Plan of Correction submitted by the facility was reviewed and found acceptable.
Complaint Details
The visit was complaint-related, with a complaint survey conducted from April 19 to April 22, 2010. The Plan of Correction submitted in response to the survey was acceptable.
Severity Breakdown
Level 3: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiency at TAG Y810 with a severity level of three and a scope level of two or less | Level 3 |
Report Facts
Monetary Penalties: 400
Working days until sanctions effective: 11
Days to pay penalty for reduction: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna C. McCafferty | Health Facilities Surveyor III | Signed the notice imposing sanctions |
Inspection Report
Original Licensing
Census: 7
Capacity: 8
Deficiencies: 3
Feb 18, 2010
Visit Reason
This document is a State Licensure survey conducted on 2/18/2010 to assess compliance with licensing requirements for the facility Summerdale at Riata.
Findings
The facility received a grade of A but had deficiencies including failure to ensure tuberculosis testing compliance for employees, failure to inspect fire extinguishers annually, and failure to provide required caregiver training within 60 days of hire.
Severity Breakdown
Level 2: 1
Level 1: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 3 employees complied with tuberculosis testing requirements. | Level 2 |
| Failed to ensure that 2 of 2 facility fire extinguishers were inspected annually. | Level 1 |
| Failed to ensure that a minimum of 4 hours of training related to care of elderly and disabled residents was received within 60 days of hire by 2 of 3 employees. | Level 1 |
Report Facts
Number of residents present: 7
Total licensed capacity: 8
Number of employees reviewed: 3
Number of resident files reviewed: 7
Number of discharged resident files reviewed: 1
Inspection Report
Complaint Investigation
Deficiencies: 3
Mar 11, 2009
Visit Reason
This inspection was conducted as a result of a complaint investigation (Complaint #NV00021192) at the facility on 3/11/09 to 3/12/09.
Findings
The investigation substantiated deficiencies including failure of the administrator to ensure adequate denture cleaning for one resident, failure to notify a resident's physician when the resident became ill, and failure to administer prescribed medication (oxygen) as ordered.
Complaint Details
Complaint #NV00021192 was substantiated with deficiencies related to resident care and medication administration.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Administrator did not ensure 1 of 2 residents received needed services to adequately clean her dentures (Resident #1). | Severity: 2 |
| Facility failed to notify a resident's physician when the resident became ill (Resident #1). | Severity: 2 |
| Facility failed to ensure that 1 of 6 residents received medication (oxygen) as prescribed (Resident #1). | Severity: 2 |
Report Facts
Residents involved in denture cleaning deficiency: 2
Residents involved in medication administration deficiency: 6
Inspection Report
Annual Inspection
Census: 6
Capacity: 7
Deficiencies: 5
Feb 9, 2009
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The survey identified multiple deficiencies including failure to maintain proper personnel files, improper storage of food, inadequate smoke detector maintenance, lack of caregiver re-certification in first aid and CPR, and inaccurate medication administration records.
Severity Breakdown
1: 1
2: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Personnel file did not ensure tuberculosis testing compliance for 1 of 3 caregivers for protection of 6 residents. | 2 |
| Food (rice) was not stored separately from soap/detergents under the kitchen sink, risking contamination for 6 residents. | 2 |
| Smoke detectors were not properly maintained or tested monthly; 2 battery-operated detectors were not working. | 2 |
| One of three caregivers was not re-certified in first aid and CPR as required within 30 days of employment. | 2 |
| Medication administration records were not accurate, failing to reflect current prescriptions for 3 of 6 residents. | 1 |
Report Facts
Residents present: 6
Licensed capacity: 7
Caregivers reviewed: 3
Resident files reviewed: 6
Inspection Report
Annual Inspection
Census: 6
Capacity: 7
Deficiencies: 7
Feb 9, 2009
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 2/9/2009 at Summerdale at Riata, a residential facility for elderly and disabled persons.
Findings
The survey identified multiple deficiencies including failure to ensure tuberculosis testing compliance for one caregiver, improper storage of food and chemicals, inadequate smoke detector testing and maintenance, lack of current first aid and CPR certification for a caregiver, missing ultimate user agreement for a resident, inaccurate medication administration records for several residents, and failure to maintain complete records for a discharged resident.
Severity Breakdown
Level 1: 4
Level 2: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure that 1 of 3 caregivers complied with tuberculosis testing requirements for the protection of 6 residents. | Level 2 |
| Food (rice) was stored together with soap/detergents under the kitchen sink, possibly contaminating food consumed by 6 residents. | Level 1 |
| Smoke detectors were not tested 5 out of the past 12 months and 2 battery-operated smoke detectors were not maintained in working order. | Level 2 |
| One of three caregivers was not re-certified in first aid and CPR as required. | Level 2 |
| Failed to obtain an ultimate user agreement for 1 of 6 residents. | Level 1 |
| Medication administration records were inaccurate, not reflecting current prescriptions for 3 of 6 residents. | Level 1 |
| Failed to maintain a record of all care and pertinent information for 1 discharged resident for 5 years. | Level 1 |
Report Facts
Residents present: 6
Total licensed capacity: 7
Caregivers reviewed: 3
Resident files reviewed: 6
Discharged resident files reviewed: 1
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