Inspection Reports for Aloha Paradise Care
1809 Westwind Rd, Las Vegas, NV 89146, NV, 89146
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Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 2
Feb 20, 2024
Visit Reason
The inspection was conducted as an annual State Licensure survey and bed increase review at the facility on 02/20/24, in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found deficient for failing to develop person-centered service plans for all 8 residents and failing to document preferred pronouns, gender expression, and sexual orientation for all residents. The facility received a grade of A and was approved for a bed increase from 8 to 10 beds.
Severity Breakdown
Severity: 2: 1
Severity: 1: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to develop a person-centered service plan for 8 of 8 residents. | Severity: 2 |
| Failed to ensure resident files included documentation of preferred pronoun, gender expression, and sexual orientation for 8 of 8 residents. | Severity: 1 |
Report Facts
Bed capacity: 8
Bed capacity: 10
Resident census: 8
Resident files reviewed: 8
Employee files reviewed: 4
Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 3
Feb 20, 2024
Visit Reason
The inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but had several regulatory deficiencies including failure to ensure tuberculosis testing compliance for one resident, lack of cultural competency training for two employees, and incomplete infection control training for two designated employees.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 8 residents met tuberculosis (TB) testing requirements, lacking documented evidence of a completed second-step TB test. | Severity: 2 |
| Failure to ensure 2 of 5 employees were in compliance with initial cultural competency training requirements. | Severity: 2 |
| Failure to ensure primary and secondary infection control designees completed 15 hours of infection control training from an approved organization. | Severity: 2 |
Report Facts
Resident census: 8
Total licensed capacity: 8
Number of resident files reviewed: 8
Number of employee files reviewed: 5
Deficiency count: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rosallen Azucena | RFA | Laboratory Director's or Provider/Supplier Representative who signed the report |
Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 1
Feb 16, 2023
Visit Reason
The inspection was conducted as an annual state licensure and infection control survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. One deficiency was identified related to failure to maintain and post a written staffing schedule including staff assigned for each shift.
Severity Breakdown
Severity: 1: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain and/or post a written staffing schedule that included the staff assigned for each shift. | Severity: 1 |
Report Facts
Resident files reviewed: 8
Employee files reviewed: 3
Deficiency scope: 3
Inspection Report
Complaint Investigation
Census: 7
Capacity: 8
Deficiencies: 2
Jul 7, 2022
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by Complaint #NV00066498 with 16 allegations regarding care and conditions at the facility.
Findings
The investigation substantiated that the facility failed to provide activities that stimulated residents' interests and skill levels for all seven residents. Other allegations including removal of call bells, medication misuse, food and hygiene concerns, resident abuse, and restrictions on residents' freedoms were unsubstantiated. Additionally, the facility failed to ensure audible alarm systems were activated on two of three exit doors.
Complaint Details
Complaint #NV00066498 with 16 allegations was investigated. One allegation regarding lack of activities was substantiated. The other 15 allegations including removal of call bells, medication misuse, food and hygiene concerns, resident abuse, restrictions on residents' freedoms, and others were unsubstantiated based on observations, interviews, and record reviews.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to provide activities which stimulated residents' interests and skill levels for 7 of 7 residents. | Severity: 2 |
| Facility failed to ensure an audible alarm system was activated on 2 of 3 doors exiting the facility. | Severity: 2 |
Report Facts
Number of allegations substantiated: 1
Number of allegations unsubstantiated: 15
Number of residents present: 7
Licensed capacity: 8
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rosallen Azucena | RFA | Named as Laboratory Director's or Provider/Supplier Representative who signed the report |
Inspection Report
Complaint Investigation
Census: 8
Capacity: 8
Deficiencies: 0
Mar 22, 2022
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding in-person visitation restrictions at the facility during the COVID-19 pandemic.
Findings
The complaint alleging failure to allow in-person visitation since July 2021 was substantiated without deficiencies. The facility had restricted indoor visitation due to high COVID-19 infection rates but allowed outdoor visits with precautions and alternative virtual visitation methods. No regulatory deficiencies were identified.
Complaint Details
One complaint (#NV00065787) with one allegation was substantiated without deficiencies. The allegation concerned the facility's failure to allow in-person visitation by a family member since July 2021, which was found to be in compliance with COVID-19 safety protocols.
Report Facts
Sample size: 3
Facility grade: A
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 3
Feb 1, 2022
Visit Reason
This inspection was conducted as an annual state licensure and infection control survey in accordance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.
Findings
The facility received a grade of A but was found deficient in several safety standards related to Alzheimer's care, including non-functioning audible alarms on exit doors, unsecured sharp tools and knives, and unsecured toxic substances accessible to residents. The facility acknowledged these issues and implemented corrective actions including staff training and securing hazardous items.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure an audible alarm system was activated on 3 of 3 doors exiting the facility. | Severity: 2 |
| Failed to ensure sharp items and tools were secured from residents with Alzheimer's disease and/or dementia. | Severity: 2 |
| Failed to ensure toxic substances were inaccessible to residents with Alzheimer's disease and/or dementia. | Severity: 2 |
Report Facts
Licensed capacity: 8
Census: 7
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marjolijn M Kirby | Administrator | Named in relation to training and corrective actions for safety protocols |
Inspection Report
Annual Inspection
Census: 6
Capacity: 8
Deficiencies: 4
Jun 28, 2021
Visit Reason
This inspection was conducted as an annual state licensure and infection control survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility received a grade of A but was found deficient in several areas including failure to implement safe infection control practices related to COVID-19, inadequate maintenance of the facility exterior, missing ultimate user agreement for one resident, and medication administration errors for another resident.
Severity Breakdown
Level 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to implement safe infection control practices including lack of N95 masks, no fit testing or medical clearance for employees, and no training on donning and doffing PPE. | Level 2 |
| Failure to maintain the exterior of the facility, including brown and brittle trees and shrubs, weeds in the grass, dog feces scattered in the backyard, and presence of mattress and bed rails on the patio. | Level 2 |
| Failure to ensure one resident had an ultimate user agreement for medication administration upon admission. | Level 2 |
| Medication error where one resident's medication bottle label did not match the Medication Administration Record (MAR). | Level 2 |
Report Facts
Deficiencies cited: 4
Facility licensed capacity: 8
Resident census: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Mirando | Administrator | Named as the Administrator responsible for oversight and compliance. |
Inspection Report
Complaint Investigation
Census: 5
Capacity: 8
Deficiencies: 0
Sep 2, 2020
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding residents' ability to communicate with family and friends by telephone.
Findings
The complaint was unsubstantiated after interviews with residents and staff and testing of the facility's telephones. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #61000 with one allegation was unsubstantiated. Allegation #1 - Residents were unable to communicate with family and friends by telephone was unsubstantiated based on verification of a functioning telephone and interviews with residents and staff.
Report Facts
Complaint count: 1
Allegation count: 1
Inspection Report
Complaint Investigation
Census: 6
Deficiencies: 0
Aug 11, 2020
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 07/27/2020 and completed on 08/11/2020, concerning allegations related to resident and staff interactions at the facility.
Findings
Two allegations were substantiated without deficiencies: a resident assaulted a health care worker, and the facility retained a resident requiring a higher level of care who was subsequently discharged after violent behaviors. No regulatory deficiencies were identified.
Complaint Details
Complaint #61609 with two allegations was substantiated without deficiencies. Allegation #1 involved a resident assaulting a health care worker. Allegation #2 involved the facility retaining a resident requiring a higher level of care.
Report Facts
Complaint number: 61609
Sample size: 1
Resident files reviewed: 5
Staff files reviewed: 2
Inspection Report
Annual Inspection
Census: 5
Capacity: 8
Deficiencies: 1
Aug 10, 2020
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a focused COVID-19 Infection Control Survey to assess regulatory compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to have appropriate infection control practices such as PPE use, social distancing, and sanitation supplies; however, it lacked a comprehensive written COVID-19 Infection Control Policy and Procedure. The administrator and owner were unable to provide written policies addressing key COVID-19 topics including standard precautions, visitor screening, cohorting, and staff education.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have a comprehensive written COVID-19 Infection Control Policy and Procedure addressing standard and transmission-based precautions, visitor screening, cohorting, identification and response to COVID-19 positive residents, required notifications, staff education and monitoring, and staffing policies during emergencies. | Severity: 2 |
Report Facts
Isolation gowns: 20
Face shields: 30
Surgical Masks: 700
KN95 Masks: 130
Gloves: 1450
12 ounce hand sanitizer bottles: 14
8 ounce hand sanitizer bottles: 33
Resident files reviewed: 5
Employee files reviewed: 4
Severity: 2
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lawrence O'Shea | Administrator | Named as the administrator responsible for the facility and signatory on the report |
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