Inspection Reports for A Summerdale Homes @ Ribeiro
1868 Ribeiro Circle, Reno, NV 89521, NV, 89521
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Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 15
Jul 3, 2024
Visit Reason
This inspection was conducted as a result of a State Licensure annual grading survey and a complaint survey at the facility on 07/03/2024.
Findings
The facility received a grade of D with multiple deficiencies including failure to ensure timely elder abuse training for employees, incomplete personnel files, inadequate background checks, health and sanitation issues such as presence of ants and unsecured grab bars, improper disposal of sharps, lack of required physical and medication profile reviews for residents, failure to inform residents of their rights upon admission, and incomplete infection control training for designated staff.
Complaint Details
Three complaints were investigated. Two complaints (#NV00070354 and #NV00070355) were not substantiated due to lack of evidence. Complaint #NV00070656 was substantiated with deficiencies related to unsecured grab bars, incomplete background checks, and other facility issues.
Severity Breakdown
Level 1: 2
Level 2: 11
Level 3: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 3 employees had initial elder abuse prevention training prior to working with residents and 1 of 3 completed timely annual elder abuse prevention training. | Level 2 |
| Failed to ensure 1 of 3 employees had a completed personnel file including application, reference checks, background check, and pre-employment physical. | Level 2 |
| Failed to ensure a pre-employment physical examination was completed for 1 of 3 employees. | Level 2 |
| Failed to ensure 1 of 3 employees met background check requirements. | Level 2 |
| Failed to maintain kitchen free from ants and failed to provide documented evidence of pest control treatment. | Level 2 |
| Failed to maintain a safe environment including unsecured grab bars in resident bathroom, exposed live electrical wires, and improper storage of food with chemicals. | Level 2 |
| Failed to protect residents from financial exploitation when Administrator requested a resident pay $350.75 for transportation to medical appointments, payable directly to Administrator, contrary to admission agreement. | Level 3 |
| Failed to properly dispose of glucose lancets in a sharps container for a resident who self-monitored glucose levels. | Level 2 |
| Failed to ensure initial and annual physical examinations were completed for sampled residents. | Level 2 |
| Failed to ensure medication profile reviews were performed at least every six months for 2 of 6 sampled residents. | Level 2 |
| Failed to ensure 1 of 3 employees completed required initial and annual medication management training. | Level 2 |
| Failed to ensure 4 of 6 sampled residents had required annual tuberculosis testing documentation. | Level 2 |
| Failed to ensure residents and/or representatives were informed of resident rights upon admission for 6 of 6 sampled residents. | Level 1 |
| Failed to ensure physician placement determination was completed upon admission and annually for residents with dementia. | Level 2 |
| Failed to ensure primary and secondary infection control staff completed required 15 hours of infection control training. | Level 1 |
Report Facts
Complaints investigated: 3
Facility grade: D
Resident count: 6
Licensed capacity: 6
Transportation fee charged: 350.75
Administrator hourly rate: 75
Medication management training hours: 16
Infection control training hours: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Administrator | Named in findings related to elder abuse training lapse, incomplete personnel file, infection control training not completed, and financial exploitation complaint. |
| Employee #2 | Caregiver | Named in findings related to lack of elder abuse training, incomplete personnel file, medication management training not completed, infection control training not completed. |
| Employee #3 | Caregiver | Named in findings related to incomplete personnel file, lack of pre-employment physical, incomplete background check. |
Inspection Report
Complaint Investigation
Census: 4
Capacity: 6
Deficiencies: 2
Dec 19, 2023
Visit Reason
The inspection was conducted as a State Licensure complaint survey triggered by two complaints alleging medication administration issues, specialized diet provision, and neglect resulting in injury after an unwitnessed fall.
Findings
The investigation found that the complaints could not be substantiated due to lack of evidence. However, deficiencies unrelated to the allegations were identified, including failure to retain a resident requiring Alzheimer's care endorsement and failure to obtain Physician Placement Determination Statements for three residents.
Complaint Details
Two complaints were investigated: Complaint #NV00069938 alleging medications were not administered and specialized diet not provided; Complaint #NV00069949 alleging neglect resulting in injury after an unwitnessed fall. Both complaints were not substantiated due to lack of evidence.
Severity Breakdown
Level 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident with dementia requiring a facility endorsed for Alzheimer's care was retained for admission. | Level 2 |
| Facility failed to obtain Physician Placement Determination Statements for three residents to determine appropriate facility type and care. | Level 2 |
Report Facts
Licensed beds: 6
Residents present: 4
Complaints investigated: 2
Residents sampled: 5
Employee records reviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eugene Gasataya | Administrator | Named in relation to findings and interview regarding deficiencies and complaint investigation |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 3
Jul 5, 2023
Visit Reason
This inspection was a State Licensure annual grading survey conducted by the Division of Public and Behavioral Health in accordance with NAC 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but had several deficiencies including unsecured oxygen tanks, lack of timely tuberculosis (TB) screening for a resident, and failure to complete annual Activities of Daily Living (ADL) assessments for two residents. Some areas were found to be in compliance such as maintenance of resident files and annual needs assessments.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Oxygen tanks were not stored securely; six tall oxygen tanks were standing in the garage without being secured in a rack or to a wall. | Severity: 2 |
| Resident #1 lacked documented evidence of tuberculosis (TB) screening since 03/05/22. | Severity: 2 |
| Residents #1 and #2 did not have annual Activities of Daily Living (ADL) assessments completed for 2023. | Severity: 2 |
Report Facts
Number of resident records reviewed: 5
Number of employee records reviewed: 3
Number of extra oxygen tanks picked up: 8
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 4
Aug 1, 2022
Visit Reason
The inspection was conducted as a State Licensure annual grading and complaint survey at the facility on 08/01/22, including investigation of one complaint.
Findings
The facility received a grade of A. One complaint was investigated but not substantiated due to lack of evidence. Several regulatory deficiencies were identified including failure to ensure timely tuberculosis (TB) testing for employees and residents, failure to ensure medication profile reviews every six months for some residents, and failure to develop policies addressing cultural competency. The facility has since taken corrective actions and is now in compliance.
Complaint Details
One complaint (NV00066739) was investigated with allegations including failure to provide medications, denial of blood sugar checks, removal of continuous blood glucose monitor, failure to provide insulin, improper diet, denial of transportation to appointments, and lack of staff assistance. The complaint was not substantiated due to lack of evidence.
Severity Breakdown
Level 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure employees met TB testing requirements for 1 of 3 employees. | Level 2 |
| Failed to ensure medication profile reviews were performed at least every six months for 3 of 6 sampled residents. | Level 2 |
| Failed to ensure 3 of 6 sampled residents met TB testing requirements in accordance with NAC 441A. | Level 2 |
| Failed to develop policies addressing the facility's program for cultural competency. | Level 2 |
Report Facts
Number of beds: 6
Resident census: 6
Number of employees reviewed: 3
Number of resident files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eugene Gasataya | Administrator | Named in relation to TB testing deficiencies and corrective actions |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 3
Sep 14, 2021
Visit Reason
The inspection was conducted as a result of a State Licensure complaint survey triggered by complaint #NV00064732 alleging issues with emergency contact numbers and caregiver availability during an emergency.
Findings
The facility was found deficient in staffing and emergency preparedness, specifically that a caregiver on duty was hard of hearing and unable to respond to a resident's fall and cries for help, and that an emergency phone list was not posted or available. The caregiver's failure to hear the resident resulted in the resident being transferred to the hospital without caregiver knowledge.
Complaint Details
Complaint #NV00064732 was substantiated in part: Allegation #1 regarding emergency contact numbers was not substantiated due to lack of evidence; Allegation #2 regarding caregiver unavailability was substantiated.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Administrator failed to ensure a caregiver on duty was able to provide care and supervision; caregiver was hard of hearing and did not respond to resident's fall and cries for help. | Level 2 |
| Facility failed to create and post a list of telephone numbers to be called in case of an emergency, resulting in emergency personnel being unable to contact anyone associated with the facility. | Level 2 |
| Caregiver on night shift was unable to hear resident yelling for help after a fall, resulting in resident being transferred to hospital without caregiver knowledge. | Level 2 |
Report Facts
Residents present: 6
Total licensed beds: 6
Severity 2 deficiencies: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eugene Gasataya | Administrator | Named in relation to findings and corrective actions regarding caregiver supervision and emergency preparedness |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 3
Jul 16, 2021
Visit Reason
This inspection was a State Licensure annual grading survey conducted by the Division of Public and Behavioral Health in accordance with NAC 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. Deficiencies identified included failure to maintain the premises (common hallway, kitchen, and outside yard), failure to ensure a physical examination was completed prior to admission for one resident, and failure to ensure a medication profile review was performed every six months for one resident.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure the common hallway area and kitchen were maintained and the outside premise was free of debris, including stored washing machine equipment, damaged drywall, black marks on walls, and missing/ripped floor tiles. | Level 2 |
| Facility failed to ensure a physical examination was completed prior to admission for 1 of 5 residents (Resident #5). | Level 2 |
| Administrator failed to ensure a medication profile review was performed by a physician, pharmacist, or registered nurse at least once every six months for 1 of 5 sampled residents (Resident #3). | Level 2 |
Report Facts
Licensed beds: 6
Residents present: 5
Resident files reviewed: 5
Employee files reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eugene Gasataya | Administrator | Named as the facility administrator in relation to findings and report |
Inspection Report
Routine
Census: 6
Capacity: 6
Deficiencies: 0
Oct 19, 2020
Visit Reason
The inspection was conducted as a State Licensure COVID-19 Infection Control and Prevention Plan Survey to assess compliance with infection control requirements for a Residential Facility for Groups.
Findings
The facility was found to have adequate infection control measures in place, including PPE supplies, staff training, screening procedures, and a quarantine plan. No regulatory deficiencies were identified during the survey.
Report Facts
Licensed beds: 6
Census: 6
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 4
Jul 7, 2020
Visit Reason
This inspection was conducted as a State Licensure annual grading survey to assess compliance with regulations for a Residential Facility for Groups.
Findings
The facility received a grade of A but had several deficiencies including failure to ensure timely annual medication management training for one employee, lack of medication profile reviews every six months for three residents, medication not on-site as prescribed for one resident, and delayed tuberculosis testing for four residents.
Severity Breakdown
Level 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 3 employees completed the required 8 hours of annual medication management training on a timely basis. | Level 2 |
| Failure to ensure medication profile review was performed at least once every six months for 3 of 6 sampled residents. | Level 2 |
| Failure to ensure medications were on-site to administer as prescribed for 1 of 6 sampled residents. | Level 2 |
| Failure to ensure 4 of 6 sampled residents met tuberculosis testing requirements; tests were not placed and read within 12 months of previous negative result. | Level 2 |
Report Facts
Residents present: 6
Total licensed capacity: 6
Employees reviewed: 3
Resident files reviewed: 6
Medication management training hours required: 8
Medication management training hours initial: 16
Medication management training hours classroom: 12
Medication management training hours practical: 4
Medication profile reviews missed: 3
Residents with delayed TB testing: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eugene Gasataya | Administrator | Named as facility administrator responsible for corrective actions |
| Employee #3 | Caregiver who failed to complete required annual medication management training on time and was dispensing medications with expired certification |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 6
Jul 10, 2019
Visit Reason
This inspection was a State Licensure annual grading survey conducted by the Division of Public and Behavioral Health in accordance with NAC 449, Residential Facility for Groups.
Findings
The facility received a grade of B with several regulatory deficiencies identified, including failure to ensure employees completed required elder abuse training, incomplete personnel files lacking hire dates and pre-employment physical exams, failure to obtain physical exams prior to resident admission, late or missing annual ADL assessments, and lack of physician placement determination for residents with dementia.
Severity Breakdown
Level 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 4 employees completed initial elder abuse prevention training prior to providing resident care. | Level 2 |
| Failure to document exact hire dates for 2 of 4 employees in personnel files. | Level 2 |
| Failure to ensure pre-employment physical exams included physician statement of freedom from communicable disease for 2 of 4 employees. | Level 2 |
| Failure to obtain physical examination including review of systems prior to admission for 2 of 6 residents. | Level 2 |
| Failure to evaluate resident's ability to perform activities of daily living upon admission for 1 of 6 residents and failure to perform annual ADL assessments for 2 of 6 residents. | Level 2 |
| Failure to obtain physician placement determination for dementia diagnosis for 1 of 6 residents. | Level 2 |
Report Facts
Number of residents present: 6
Total licensed capacity: 6
Number of employee files reviewed: 4
Number of resident files reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eugene Gasataya | Administrator | Named as Administrator responsible for corrective actions and signature on report |
| Employee #4 | Caregiver | Failed to complete initial elder abuse prevention training and lacked documented hire date |
| Employee #2 | Caregiver | Lacked documented hire date and incomplete pre-employment physical exam |
| Employee #3 | Caregiver | Incomplete pre-employment physical exam lacking physician statement |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 1
Jan 30, 2019
Visit Reason
This inspection was conducted as a result of a State Licensure complaint survey triggered by complaint #NV00055564 alleging staffing issues at the facility.
Findings
The investigation substantiated the complaint that the facility failed to ensure sufficient qualified caregivers were on duty to provide proper care for one of six residents, resulting in a resident falling twice and requiring assistance from the Fire Department. The caregiver neglected duties including failure to notify hospice and to write incident reports.
Complaint Details
Complaint #NV00055564 alleging staffing issues was substantiated. The caregiver failed to provide adequate supervision and assistance, resulting in resident falls and failure to notify hospice or write incident reports.
Severity Breakdown
Severity: 2 Scope: 1: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a sufficient number of qualified caregivers were on duty to provide proper care for one of six residents, leading to resident falls and inadequate response. | Severity: 2 Scope: 1 |
Report Facts
Number of residents present: 6
Total licensed capacity: 6
Complaint number: Complaint #NV00055564
Inspection Report
Complaint Investigation
Census: 6
Deficiencies: 0
Jun 22, 2017
Visit Reason
The inspection was conducted as a complaint investigation based on complaint #NV00049602 with two allegations regarding the facility environment and air conditioning.
Findings
Both allegations—unsafe environment and lack of air conditioning—could not be substantiated after observation and interviews with the caregiver and all six residents.
Complaint Details
Complaint #NV00049602 with two allegations was investigated; both allegations were not substantiated.
Report Facts
Census at time of survey: 6
Sample size: 6
Number of complaints investigated: 1
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 8
Jul 11, 2016
Visit Reason
The inspection was conducted as an annual State Licensure survey for re-licensure of the residential facility.
Findings
The facility received a grade of C with multiple deficiencies identified including expired medication management training, missing elder abuse training, incomplete criminal background checks, lack of scheduled activities, inadequate lighting in resident bedrooms, missing annual physical exams, and incomplete tuberculosis testing for residents.
Severity Breakdown
2: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Medication management training for 1 of 4 employees was not current; Employee #4's certification expired on 12/17/15. | 2 |
| 2 of 4 employees failed to comply with elder abuse training requirements; missing initial and annual training. | 2 |
| 2 of 4 employees failed to comply with criminal background check requirements; missing documentation. | 2 |
| Scheduled activities were not provided for residents; activity calendar was missing and residents reported no scheduled activities. | 2 |
| CPR training for 1 of 4 employees was not current; Employee #4's CPR certification expired on 3/11/16. | 2 |
| Bedroom lighting for 2 of 6 residents was dim and not comfortable; residents had requested additional lighting. | 2 |
| 1 of 6 residents did not receive an annual physical examination in 2016. | 2 |
| 3 of 6 residents lacked required tuberculosis testing or had late testing. | 2 |
Report Facts
Deficiencies cited: 8
Census: 6
Total Capacity: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Acknowledged expired medication training, missing elder abuse training, missing background checks, and expired CPR certification. | |
| Employee #4 | Had expired medication training and CPR certification, missing elder abuse training and background checks; no longer employed as of June 15, 2015. |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 8
Jul 11, 2016
Visit Reason
This annual State Licensure survey was conducted to assess compliance with regulatory requirements for a Residential Facility for Group beds for elderly and disabled persons.
Findings
The facility received a grade of C with multiple deficiencies identified including expired medication management training, missing elder abuse training, incomplete criminal background checks, expired CPR certification, inadequate bedroom lighting, lack of scheduled activities, missing annual physical for a resident, and incomplete tuberculosis testing for residents.
Severity Breakdown
2: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure medication management training for 1 of 4 employees was current (Employee #4). | 2 |
| Failed to ensure 2 of 4 employees complied with elder abuse training requirements (Employees #2 and #4). | 2 |
| Failed to ensure 2 of 4 employees complied with criminal background check requirements (Employees #2 and #4). | 2 |
| Failed to ensure CPR training for 1 of 4 employees was current (Employee #4). | 2 |
| Failed to ensure bedroom lighting for 2 of 6 residents was comfortable (Residents #4 and #6). | 2 |
| Failed to ensure scheduled activities were provided for residents; activity calendar could not be located and residents reported no scheduled activities. | 2 |
| Failed to ensure 1 of 6 residents received an annual physical (Resident #5). | 2 |
| Failed to ensure 3 of 6 residents complied with tuberculosis testing requirements (Residents #1, #4, and #6). | 2 |
Report Facts
Number of residents: 6
Total licensed capacity: 6
Number of employee files reviewed: 4
Number of resident files reviewed: 6
Severity level 2 deficiencies: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Acknowledged expired medication training, missing elder abuse training, missing background checks, expired CPR card, and missing annual physical for Resident #5 | |
| Employee #4 | Had expired medication management training and CPR certification, lacked elder abuse training and background check documentation |
Inspection Report
Re-Inspection
Deficiencies: 1
Jun 15, 2015
Visit Reason
This document is a Statement of Deficiencies generated as a result of a required grading re-survey conducted on 6/15/15 to assess compliance with state licensure requirements.
Findings
The facility received a re-survey grade of A. The administrator failed to ensure the current grading placard was displayed conspicuously in a public area, as the posted placard had expired on 12/31/13.
Severity Breakdown
1: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to display the current grading placard conspicuously in a public area; the posted placard expired 12/31/13. | 1 |
Report Facts
Severity: 1
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in relation to failure to ensure placard display |
Inspection Report
Re-Inspection
Deficiencies: 1
Jun 15, 2015
Visit Reason
This document is a Statement of Deficiencies generated as a result of a required grading re-survey conducted at the facility on 6/15/15 by the Division of Public and Behavioral Health.
Findings
The administrator failed to ensure the current grading placard was displayed conspicuously in a public area of the residential facility, as the grade placard posted on the wall had expired on 12/31/13.
Severity Breakdown
Severity: 1: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to display current grading placard conspicuously in a public area; the posted placard was expired. | Severity: 1 |
Report Facts
Severity: 1
Scope: 3
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 9
May 8, 2015
Visit Reason
This document is an annual State Licensure survey conducted on 5/8/2015 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 including failure to ensure pre-employment physical exams for staff, unsafe facility conditions, inadequate scheduled activities, unsecured oxygen tanks, missing annual physical exams for residents, missing medications on site, inaccurate medication administration records, unsecured medication storage, and incomplete tuberculosis testing documentation for residents.
Severity Breakdown
Level 1: 1
Level 2: 8
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 4 employees had pre-employment physical examinations within 6 months prior to hire. | Level 2 |
| Facility interior and exterior were not clean and maintained; backyard had holes creating tripping hazards. | Level 2 |
| Failed to document at least 10 hours of scheduled activities for 5 of 5 residents. | Level 1 |
| Oxygen tanks were not secured in a rack or to the wall in the storage room. | Level 2 |
| Failed to ensure 1 of 5 residents received an annual physical examination. | Level 2 |
| Failed to ensure 3 of 5 residents had medications on site to administer as prescribed. | Level 2 |
| Medication administration record (MAR) was inaccurate for 1 of 5 residents; medication present without documented prescription. | Level 2 |
| Medications were not stored in a locked container; medication cabinet unlocked and medications unsecured on kitchen counter. | Level 2 |
| Failed to maintain separate resident files with required tuberculosis testing documentation for 2 of 6 residents. | Level 2 |
Report Facts
Deficiencies cited: 9
Facility licensed capacity: 6
Resident census: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Named in deficiency for missing pre-employment physical examination. | |
| Employee #3 | Named in multiple deficiencies including missing pre-employment physical, acknowledging findings, and medication issues. |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 3
Oct 1, 2013
Visit Reason
This document is a State Licensure annual grading survey conducted from 9/23/13 to 10/1/13 to assess compliance with regulatory requirements for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A but had deficiencies related to tuberculosis testing compliance for employees and residents, medication storage issues, and maintenance of resident files. Specific failures included incomplete TB testing for employees and residents, unsecured over-the-counter medications in resident rooms, and incomplete resident files regarding TB testing evidence.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 4 employees complied with tuberculosis testing requirements (missing steps of two-step TB test). | Severity: 2 |
| Failed to ensure over-the-counter medications were kept in locked containers in residents' rooms for all 6 residents. | Severity: 2 |
| Failed to ensure 4 of 6 residents complied with tuberculosis testing requirements (missing steps of two-step TB test). | Severity: 2 |
Report Facts
Residents present: 6
Total licensed capacity: 6
Employees reviewed: 4
Resident files reviewed: 6
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 3
Sep 23, 2013
Visit Reason
This document is a State Licensure annual grading survey conducted from 09/23/2013 to 10/01/2013 at Summerdale Home Care, a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A. Several deficiencies were identified related to tuberculosis testing compliance for employees and residents, medication storage, and maintenance of resident files. Deficiencies included missing steps in two-step TB testing for employees and residents, failure to store over-the-counter medications in locked containers in resident rooms, and incomplete resident files.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Personnel file did not meet NAC 441A requirements for tuberculosis testing; missing second step of two-step TB test for Employee #2 and Employee #4. | Level 2 |
| Medication storage did not comply with NAC 449.2748; over-the-counter medications were not kept in locked containers in residents' rooms for 6 of 6 residents observed. | Level 2 |
| Resident files did not meet NAC 449.2749 requirements; missing second step of two-step TB test for Residents #1, #2, #4, and #6. | Level 2 |
Report Facts
Number of residents present: 6
Total licensed capacity: 6
Number of employee files reviewed: 4
Number of resident files reviewed: 6
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 1
Sep 10, 2012
Visit Reason
The inspection was conducted as an annual State Licensure survey of the facility on 09/10/2012.
Findings
The facility received a grade of A. One deficiency was identified related to personnel files and background checks, specifically a missing state background check for one of three employees reviewed.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 3 employees met background check requirements; Employee #1 missing State background check. | Severity: 2 |
Report Facts
Number of employees reviewed: 3
Number of resident files reviewed: 6
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 1
Sep 10, 2012
Visit Reason
This document is the result of an annual State Licensure survey conducted at the facility on 09/10/2012 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 A. One deficiency was identified related to personnel files: the facility failed to ensure that 1 of 3 employees met background check requirements, specifically missing a State background check.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 3 employees met background check requirements of NRS 449.176 to 449.188 (Employee #1 - missing State background check). | Severity: 2 |
Report Facts
Number of resident files reviewed: 6
Number of employee files reviewed: 3
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 0
Nov 2, 2011
Visit Reason
The inspection was conducted as a complaint investigation regarding an allegation of abuse at the facility.
Findings
The allegation of abuse was not substantiated based on document review, interviews with residents and caregivers, and observations of the home and interactions between caregivers and residents.
Complaint Details
Complaint #NV00029739: The allegation regarding abuse was not substantiated.
Report Facts
Licensed beds: 6
Census: 5
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 4
Sep 20, 2010
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual licensure survey conducted at Summerdale Home Care on 09/20/2010 to assess compliance with state regulations for residential care facilities.
Findings
The facility received a grade of A but was found deficient in several areas including medication administration errors, incomplete medication records, failure to indicate medication changes on containers, and non-compliance with tuberculosis testing requirements for residents.
Severity Breakdown
Severity: 1: 1
Severity: 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure that 1 of 4 residents received medication as prescribed (Resident #4 - Depakene, 250/5 ml). | Severity: 2 |
| Failed to indicate on the medication container that a physician's order had been changed for 1 of 4 residents (Resident #2 - Lorazepam, 0.5 mg). | Severity: 2 |
| Medication record was incomplete for 1 of 4 residents receiving PRN medications (Resident #1 - Transderm-Scop, 1.5 mg). | Severity: 1 |
| Failed to ensure 1 of 4 residents complied with tuberculosis testing requirements (Resident #2). | Severity: 2 |
Report Facts
Licensed capacity: 6
Census: 4
Deficiencies cited: 4
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 5
Sep 23, 2009
Visit Reason
This document is an annual State Licensure survey conducted 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 and was found deficient in several areas including personnel background checks, window screens, fire extinguisher inspections, medication administration, and medication labeling.
Severity Breakdown
1: 1
2: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 4 caregivers met background check requirements (Employee #2 and #3). | 2 |
| Failed to provide screens that fit tightly against windows in bedrooms #1 and #3 to prevent the entry of insects. | 2 |
| Failed to ensure that 2 of 2 facility fire extinguishers were inspected annually. | 1 |
| Failed to ensure that 2 of 5 residents received medications as prescribed (Resident #2 and #5). | 2 |
| Failed to ensure medications were plainly labeled for 2 of 5 residents (Resident #1 and #5). | 2 |
Report Facts
Residents present: 5
Licensed capacity: 6
Caregivers reviewed: 4
Resident files reviewed: 5
Fire extinguishers: 2
Residents with medication issues: 2
Residents with medication labeling issues: 2
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 10
Sep 17, 2008
Visit Reason
The inspection was conducted as an annual State Licensure survey to assess compliance with regulations for a residential facility for elderly and disabled persons.
Findings
The survey identified multiple deficiencies including caregiver training, insurance endorsement, menu posting, physical examinations, medication administration, medication administration records, resident file maintenance, discharge documentation, and posting of rates for services.
Severity Breakdown
Level 1: 8
Level 2: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| One of four caregivers did not complete the required eight hours of annual training. | Level 2 |
| The facility failed to provide a certificate of insurance with the required endorsement to the Bureau of Licensure and Certification 30 days prior to cancellation or non-renewal. | Level 1 |
| Menus were not posted in a conspicuous location, substitutions were not documented, and copies of menus were not kept for 90 days. | Level 1 |
| The facility did not obtain results of a physical examination for one of five residents prior to admission. | Level 2 |
| Medication profile reviews were not performed at least every six months for two of five residents. | Level 1 |
| Medication administration records (MAR) were inaccurate for one of five residents; evening doses were not documented. | Level 1 |
| The facility did not perform an evaluation of activities of daily living (ADL) upon admission for one of five residents. | Level 1 |
| The facility did not perform an annual ADL evaluation for one of five residents residing longer than a year. | Level 1 |
| The facility did not provide proper documentation regarding the discharge of a resident, including date, time, destination, or who picked up the resident and belongings. | Level 1 |
| The facility did not ensure that rates for room and services were posted in a conspicuous place. | Level 1 |
Report Facts
Residents present: 5
Total licensed capacity: 6
Caregiver training hours required: 8
Deficiency severity counts: 10
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 9
Sep 17, 2008
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 9/17/2008 at Summerdale Home Care, a residential facility for elderly and disabled persons.
Findings
The inspection identified multiple deficiencies including failure to ensure caregivers received required annual training, lack of proper insurance endorsement, inadequate documentation of food substitutions, missing physical examinations prior to admission, incomplete medication profile reviews, inaccurate medication administration records, missing resident evaluations upon admission and annually, and improper discharge documentation.
Severity Breakdown
Level 1: 7
Level 2: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| One of four caregivers did not have the required eight hours of annual training. | Level 2 |
| Facility's Certificate of Liability Insurance did not contain an endorsement to provide 30 days notice to the Bureau before cancellation or non-renewal. | Level 1 |
| Facility failed to post menus in a conspicuous location, document substitutions, and keep copies of menus for 90 days. | Level 1 |
| Facility did not obtain results of a physical examination for one resident prior to admission. | Level 2 |
| Medication profile reviews were not performed at least once every six months for two residents. | Level 1 |
| Medication administration record was inaccurate for one resident; evening doses were not documented. | Level 1 |
| Facility did not perform an evaluation of one resident's ability to perform activities of daily living upon admission. | Level 1 |
| Facility did not perform an annual evaluation of one resident's ability to perform activities of daily living. | Level 1 |
| Facility did not provide proper discharge documentation for a resident, including date, time, destination, and who picked up the resident. | Level 1 |
Report Facts
Number of caregivers reviewed: 4
Number of resident files reviewed: 5
Number of employee files reviewed: 4
Number of discharged resident files reviewed: 1
Facility licensed capacity: 6
Facility census at time of survey: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Named in medication administration record deficiency for not charting evening doses | |
| Employee #2 | Named in caregiver training deficiency for missing annual training documentation |
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