Inspection Reports for Angels House Adult Care
5496 Tamarus St, Las Vegas, NV 89119, NV, 89119
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 7
Capacity: 9
Deficiencies: 1
Mar 19, 2025
Visit Reason
The inspection was conducted as an annual State licensure and complaint investigation survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility received a grade of A. One complaint was substantiated regarding failure to retain resident records for at least five years after discharge. The facility failed to maintain the file for one of eight sampled residents who was discharged in December 2023.
Complaint Details
One complaint (#NV00073237) was investigated and substantiated related to resident record retention.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure resident records were retained for at least 5 years after discharge for 1 of 8 sampled residents. | Severity: 2 |
Report Facts
Licensed beds: 9
Current census: 7
Sampled residents: 8
Sampled employee files: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heather Marie Jacalne | Administrator | Acknowledged missing resident file and responsible for oversight |
Inspection Report
Annual Inspection
Census: 7
Capacity: 9
Deficiencies: 0
Mar 28, 2024
Visit Reason
The inspection was conducted as an annual State licensure and complaint investigation survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
No regulatory deficiencies were identified during the inspection. One complaint was investigated and found to be unsubstantiated. The facility received a grade of A.
Complaint Details
One complaint (#NV00070514) was investigated and found to be unsubstantiated with no regulatory deficiencies identified.
Report Facts
Resident files reviewed: 8
Employee files reviewed: 4
Facility grade: A
Inspection Report
Annual Inspection
Census: 6
Capacity: 9
Deficiencies: 2
Mar 29, 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
Two regulatory deficiencies were identified: a smoke detector in Room 5 was detached from its ceiling bracket exposing wiring, and the bathroom light bulbs in Room 5 were not working, resulting in inadequate lighting. Both issues were acknowledged by staff and subsequently corrected by an electrician.
Severity Breakdown
2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Smoke detector in Room 5 was detached from the ceiling bracket leaving wiring exposed. | 2 |
| Bathroom lighting in Room 5 was inadequate due to non-working light bulbs. | 2 |
Report Facts
Licensed beds: 9
Resident census: 6
Inspection Report
Annual Inspection
Census: 8
Capacity: 9
Deficiencies: 2
Mar 15, 2022
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 but was found deficient in medication administration practices, including failure to complete a required six-month medication review for one resident and inaccuracies in medication administration records for two residents.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure one of eight sampled residents had a six-month medication review as required. | Severity: 2 |
| Failure to ensure the Medication Administration Record (MAR) was accurate for two of eight sampled residents, with documented medication administration not matching physician orders. | Severity: 2 |
Report Facts
Resident files reviewed: 8
Employee files reviewed: 4
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Acknowledged failure to complete six-month medication review and responsible for holding education sessions to ensure accurate medication administration records | |
| Brad Boman | Administrator | Signed the inspection report |
Inspection Report
Annual Inspection
Census: 9
Capacity: 9
Deficiencies: 4
Jul 20, 2021
Visit Reason
This inspection was an annual survey conducted at the facility on 07/20/21 in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received an annual survey grade of A. Deficiencies were identified related to failure to designate an employee in charge during the Administrator's absence, incomplete medication management training documentation for one employee, missing six-month medication reviews for three residents, and missing initial or annual activities of daily living assessments for two residents.
Severity Breakdown
Level 1: 1
Level 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to designate in writing one or more employees to be in charge during the Administrator's absence; no written posted designation was available. | Level 1 |
| Facility failed to ensure one of four employees had a current certificate for 8 hours of annual medication management training; documentation was expired. | Level 2 |
| Facility failed to ensure six-month medication reviews were completed for 3 of 9 residents. | Level 2 |
| Facility failed to ensure 2 of 9 residents had initial and/or annual activities of daily living assessments documented. | Level 2 |
Report Facts
Residents files reviewed: 9
Employee files reviewed: 4
Facility licensed capacity: 9
Facility census: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brad Boman | Administrator | Named as Administrator responsible for facility and acknowledged deficiencies |
| Employee #4 | Named in medication training deficiency and responsible for monitoring training and assessments |
Inspection Report
Routine
Census: 9
Capacity: 9
Deficiencies: 3
Sep 17, 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 requirements during the COVID-19 pandemic.
Findings
The facility lacked a comprehensive written infection control and prevention plan related to COVID-19, including policies for screening, notification, visitation, social distancing, cohorting, PPE use, and staff training. The facility did not have a thermometer for screening, did not screen staff daily, and caregivers were unaware of procedures if a resident or staff tested positive. Some infection control practices were observed, such as mask wearing and hand hygiene.
Severity Breakdown
Severity: 2 Scope: 3: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to develop and implement a safe, comprehensive Infection Control & Prevention Plan in response to COVID-19, lacking policies on screening, notification, visitation, social distancing, cohorting, PPE use, cleaning, and staff training. | Severity: 2 Scope: 3 |
| Facility did not have a thermometer to screen essential visitors, residents, or staff and did not screen staff daily for COVID-19 symptoms. | — |
| Caregivers did not know what to do if a resident or staff member tests positive or shows signs and symptoms of COVID-19. | — |
Report Facts
Facility licensed beds: 9
Census: 9
Surgical masks: 5
Gloves: 1000
Hand sanitizer: 1
Staff on duty: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brad Boman | Administrator | Signed report and referenced in plan of correction |
Inspection Report
Annual Inspection
Census: 8
Capacity: 9
Deficiencies: 3
May 30, 2019
Visit Reason
The inspection was an annual survey conducted to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received an overall grade of A but had deficiencies including failure to encourage resident participation in activities for 2 residents, failure to provide prescribed diabetic and low fat diets for 2 residents, and issues related to care for a resident with dementia.
Severity Breakdown
Severity: 2: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to encourage residents to participate in activities for 2 of 8 residents. | Severity: 2 |
| Failed to provide diabetic and low fat diets as prescribed by the physician for 2 of 8 residents. | Severity: 2 |
| Admitted and retained a resident with dementia without Alzheimer's endorsement; monitoring ongoing. | — |
Report Facts
Residents reviewed: 8
Employee files reviewed: 5
Licensed capacity: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brad Boman | Administrator | Signed the inspection report and involved in corrective actions |
| Employee #3 | Involved in activity scheduling and menu review for diabetic and low fat diets |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 9
Deficiencies: 2
Jul 31, 2018
Visit Reason
The inspection was conducted as a complaint investigation initiated on 07/30/18 and completed on 07/31/18, in response to allegations regarding facility accessibility, bathroom conditions, food quality, lighting, and lack of resident activities.
Findings
The investigation found the facility failed to post the current month's activity calendar and admitted a resident with exit-seeking behavior contrary to admission policy. One complaint was investigated but not substantiated. Deficiencies unrelated to the complaint were also identified.
Complaint Details
One complaint (#NV00053384) was investigated but could not be substantiated. Allegations included lack of wheelchair accessibility, ant-ridden bathrooms, unusable or cracked toilet seats, leaky sink faucet creating slip hazard, poor food quality, insufficient lighting, and lack of resident activities.
Severity Breakdown
Level 1: 1
Level 2: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to post the current month's calendar of activities. | Level 1 |
| Facility admitted and retained a resident exhibiting exit-seeking behavior contrary to admission policy. | Level 2 |
Report Facts
Complaint count: 1
Resident count: 5
Beds licensed: 9
Residents present: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brad Boman | Administrator | Signed the report |
| House Manager #1 | Interviewed and involved in resident monitoring and investigation | |
| House Manager #2 | Interviewed and involved in resident monitoring and investigation | |
| Caregiver | Interviewed and involved in resident monitoring and investigation | |
| Nurse Practitioner | Interviewed from resident's primary physician clinic | |
| Case Manager | Interviewed from resident's primary physician clinic |
Inspection Report
Annual Inspection
Capacity: 9
Deficiencies: 4
May 9, 2018
Visit Reason
The inspection was an annual survey initiated on May 9, 2018, conducted as a State Licensure Complaint Survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of B with deficiencies including a caregiver unable to effectively read, speak, or understand English, missing initial two-step tuberculosis screenings and pre-employment physicals for some employees, incomplete background checks for two employees, and a bathroom faucet that was not in good working order.
Severity Breakdown
Level 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Caregiver #3 failed to demonstrate the ability to read, speak, and understand English, causing communication difficulties with residents and inspectors. | Level 2 |
| Two of five employees lacked initial two-step tuberculosis screening prior to employment, and one employee lacked a pre-employment physical. | Level 2 |
| Two of five employees did not have completed background checks as required. | Level 2 |
| One bathroom faucet was loose and not in good working order. | Level 2 |
Report Facts
Licensed capacity: 9
Resident files reviewed: 9
Employee files reviewed: 5
Annual survey grade: B
Severity and scope: 2
Severity and scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Caregiver / Kitchen Staff | Named in deficiency for inability to read, speak, and understand English; missing initial TB screening; incomplete background check |
| Employee #4 | Caregiver | Named in deficiency for missing initial two-step TB screening and missing pre-employment physical |
| Employee #5 | Caregiver | Named in deficiency for missing pre-employment physical and incomplete background check |
| Employee #1 | Performed in-house repair of bathroom faucet |
Inspection Report
Re-Inspection
Census: 5
Capacity: 9
Deficiencies: 2
Mar 27, 2018
Visit Reason
This inspection was a required State Licensure grading re-survey conducted to assess compliance with state regulations for a residential facility for group beds for elderly and disabled persons and/or persons with mental illness.
Findings
The facility received a grade of A but had two repeat deficiencies: failure to ensure one employee had documented negative two-step tuberculosis screening and failure to secure medications properly, with over-the-counter medications found unsecured in a resident's room.
Severity Breakdown
2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 4 employees had documented evidence of a negative two-step tuberculosis test. | 2 |
| Failure to ensure medications were secured; Bengay and vapo rub found unsecured in resident's room. | 2 |
Report Facts
Licensed beds: 9
Census: 5
Repeat deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Named in tuberculosis screening and medication security deficiencies | |
| Employee #2 | Involved in counseling and ensuring medication security | |
| Brad Boman | Administrator | Signed the report and responsible for oversight |
Notice
Deficiencies: 1
Oct 31, 2016
Visit Reason
The notice informs the facility of sanctions and monetary penalties imposed due to deficiencies identified by the Division of Public and Behavioral Health.
Findings
The facility was assessed an initial monetary penalty of $400.00 for a deficiency at TAG Y515 with a severity level of three and a scope level of two or less.
Severity Breakdown
Level 3: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiency at TAG Y515 with a severity level of three and scope level of two or less | Level 3 |
Report Facts
Monetary Penalties: 400
Penalty Payment Deadline: 15
Penalty Reduction: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pat Elkins | Health Facilities Inspector III | Signed the sanction notice |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 9
Deficiencies: 9
Jul 20, 2016
Visit Reason
The inspection was conducted as a result of a required State Licensure grading re-survey and complaint investigation conducted on 7/20/16 and completed on 7/28/16, with a second complaint investigation on 8/2/16.
Findings
The facility was found deficient in multiple areas including lack of protective supervision, inadequate staffing, incomplete personnel files, failure to provide necessary care and supervision to residents, and failure to follow physician's orders for medication administration. Two complaints were investigated, one substantiated and one unsubstantiated.
Complaint Details
Two complaints were investigated: Complaint #NV00046470 was substantiated, involving lack of protective supervision. Complaint #NV00046641 was unsubstantiated, involving allegations of physical abuse and injuries of unknown origin.
Severity Breakdown
Level 2: 8
Level 3: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| The facility lacked protective supervision as evidenced by failure to replace an administrator resulting in lack of oversight to ensure residents received necessary care and protective supervision. | Level 2 |
| The facility failed to ensure adequate number of caregivers were present to provide necessary care and supervision to 3 of 7 residents. | Level 2 |
| The facility failed to ensure 1 of 4 employees completed required physical examination and Tuberculosis screening within required timeframe. | Level 2 |
| The facility failed to ensure 1 of 4 employees completed criminal background check within required timeframe. | Level 2 |
| The facility failed to provide protective supervision to 1 of 7 residents (Resident #7). | Level 3 |
| The facility failed to ensure medications were administered to 1 of 7 residents following physician's orders. | Level 2 |
| The facility failed to ensure 1 of 7 residents was provided necessary personal care. | Level 2 |
| The facility failed to ensure 1 of 7 residents was not allowed to remain in the facility because the resident was not eligible for residency. | Level 2 |
| The facility failed to ensure 1 of 7 residents completed required physical examination and Tuberculosis skin test. | Level 2 |
Report Facts
Deficiencies cited: 9
Census: 6
Total capacity: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy J. Ramirez | Administrator | Named as the new Administrator responsible for oversight and compliance. |
Inspection Report
Annual Inspection
Census: 4
Capacity: 9
Deficiencies: 11
Apr 14, 2016
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with regulatory requirements for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of D with multiple deficiencies identified related to administrator oversight, caregiver qualifications and training, personnel files, resident physical exams, medication administration, and resident files. Several employees lacked required training and documentation, and residents' medication and physical exam records were incomplete or missing.
Severity Breakdown
Level 2: 9
Level 1: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight to ensure compliance with NRS Chapter 449. | Level 2 |
| Caregiver failed to receive required annual medication management training. | Level 2 |
| Facility failed to ensure 3 of 4 employees completed annual Elder Abuse training. | Level 2 |
| Facility failed to ensure 2 of 4 employees completed required two-step tuberculosis screening. | Level 2 |
| Facility failed to ensure 2 of 4 residents received initial physical examinations upon admission. | Level 2 |
| Facility failed to ensure 4 of 4 residents had ultimate user agreements in their files. | Level 2 |
| Facility failed to ensure 4 of 4 residents received medications as prescribed. | Level 2 |
| Facility failed to maintain accurate and complete Medication Administration Records (MAR) for 2 of 4 residents. | Level 2 |
| Facility failed to maintain complete documentation for PRN medication administration for 2 residents. | Level 1 |
| Facility failed to maintain separate resident files with required confidentiality and documentation for 2 residents' tuberculosis screening. | Level 1 |
| Facility failed to ensure 1 of 4 employees received annual caregiving training. | Level 2 |
Report Facts
Deficiencies cited: 11
Census: 4
Total capacity: 9
Training hours: 8
Training hours: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Owner/Caregiver | Failed to complete annual medication management, elder abuse, and caregiving training; lacked documentation for training and tuberculosis screening. |
| Employee #1 | Administrator | Failed to provide oversight; lacked documentation of two-step TB screening. |
| Caregiver #4 | Unaware of missing training and documentation; could not explain medication administration discrepancies. | |
| Employee #3 | Caregiver | No longer with the facility; responsible for medication administration and PRN meds administration. |
Inspection Report
Annual Inspection
Census: 4
Capacity: 9
Deficiencies: 10
Apr 14, 2016
Visit Reason
This annual State Licensure survey was conducted to assess compliance with regulatory requirements for Angels House Adult Care, a residential facility for group beds for elderly and disabled persons.
Findings
The facility received a grade of D with multiple deficiencies identified including failures in administrator oversight, caregiver training, personnel health screenings, resident physical exams, medication administration, and record keeping.
Severity Breakdown
Level 1: 1
Level 2: 9
Deficiencies (10)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight to ensure compliance with NRS Chapter 449. | Level 2 |
| Facility failed to ensure 1 of 4 employees received annual medication management training. | Level 2 |
| Facility failed to ensure 3 of 4 employees completed annual Elder Abuse training for 2016. | Level 2 |
| Facility failed to ensure 2 of 4 employees had completed required tuberculosis screenings. | Level 2 |
| Facility failed to ensure 2 of 4 residents received initial physical examinations upon admission. | Level 2 |
| Facility failed to ensure 4 of 4 residents had an ultimate user agreement in their files. | Level 2 |
| Facility failed to ensure 4 of 4 residents received medications as prescribed, with multiple medication errors and missing documentation. | Level 2 |
| Facility failed to maintain accurate medication administration records for 2 of 4 residents. | Level 1 |
| Facility failed to ensure 2 of 4 residents received two-step tuberculosis screening. | Level 2 |
| Facility failed to ensure 1 of 4 employees received annual caregiving training. | Level 2 |
Report Facts
Deficiencies cited: 10
Facility licensed capacity: 9
Resident census: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Owner/Caregiver | Named in findings related to lack of annual medication management training, elder abuse training, tuberculosis screening, and caregiving training. |
| Employee #1 | Administrator | Named in findings related to lack of two-step tuberculosis screening. |
| Caregiver #4 | Mentioned as unaware of multiple deficiencies including training and documentation issues. |
Inspection Report
Complaint Investigation
Census: 4
Capacity: 9
Deficiencies: 4
Mar 10, 2016
Visit Reason
The inspection was conducted as a complaint investigation initiated on 2016-03-07 and finalized on 2016-03-10, triggered by a complaint containing two allegations regarding resident treatment and misuse of resident funds.
Findings
The investigation substantiated that the facility failed to treat a resident with dignity and respect and did not allow the resident to make their own decisions. One allegation of misappropriation of property was not substantiated. The facility administrator failed to provide proper oversight to ensure residents' rights were respected.
Complaint Details
Complaint #NV00045350 contained two allegations: 1) failure to treat a resident with dignity and respect, which was substantiated; 2) misappropriation of property/misuse of resident's funds, which was not substantiated. The investigation included observations, interviews with staff and residents, and record reviews. Elder Protective Services and Aging and Disability Services Division reports supported findings of exploitation and isolation.
Severity Breakdown
3: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight and guidance to ensure residents were treated with dignity and respect, allowed to make their own decisions, and not prohibited from speaking to advocates. | 3 |
| Facility failed to ensure a resident was not prohibited from speaking to persons who advocate for residents' rights. | 3 |
| Facility failed to ensure residents were treated with respect and dignity. | 3 |
| Facility failed to ensure residents were allowed to make their own decisions whenever possible. | 3 |
Report Facts
Licensed capacity: 9
Census: 4
Sample size: 5
Severity level: 3
Scope: 1
Inspection Report
Enforcement
Deficiencies: 3
Mar 7, 2016
Visit Reason
The Division of Public and Behavioral Health conducted a complaint investigation at Angels House Adult Care from 3/7/16 through 3/10/16, which led to the imposition of sanctions.
Findings
The report notifies the facility of sanctions imposed due to deficiencies found during the complaint investigation. Monetary penalties of $400 each were assessed for three specific deficiencies, each with a severity level of three and a scope level of two or less.
Complaint Details
The sanctions are based on a complaint investigation conducted from 3/7/16 to 3/10/16. The Plan of Correction submitted on 5/9/16 was reviewed and found acceptable. The document notes that a separate invoice may be issued if the sanctions were imposed due to a substantiated complaint investigation.
Severity Breakdown
Severity level 3: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Deficiency at TAG Y050 | Severity level 3 |
| Deficiency at TAG Y591 | Severity level 3 |
| Deficiency at TAG Y592 | Severity level 3 |
Report Facts
Monetary penalty amount: 400
Number of deficiencies penalized: 3
Working days until sanctions effective: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pat Elkins | Health Facilities Inspector III | Signed the sanction notice |
| Kyle Devine | Bureau Chief | Referenced as Bureau Chief in sanction notice |
Inspection Report
Complaint Investigation
Census: 4
Capacity: 9
Deficiencies: 4
Mar 7, 2016
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 2016-03-07 and finalized on 2016-03-10, regarding allegations of failure to treat a resident with dignity and respect and misappropriation of resident's funds.
Findings
The complaint investigation substantiated the allegation that the facility failed to treat a resident with dignity and respect but did not substantiate the allegation of misappropriation of resident's funds. The facility failed to provide oversight and guidance to ensure residents were treated with dignity and respect, and one resident was found to be prohibited from speaking to advocates for their rights.
Complaint Details
One complaint (#NV00045350) containing two allegations was investigated. The allegation that the facility failed to treat a resident with dignity and respect was substantiated. The allegation of misappropriation of property - misuse of resident's funds was not substantiated.
Severity Breakdown
Severity: 3: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight and guidance to ensure residents were treated with dignity and respect. | Severity: 3 |
| Facility failed to ensure a resident was not prohibited from speaking to any person who advocates for the rights of the residents. | Severity: 3 |
| Facility failed to ensure a resident was treated with dignity and respect. | Severity: 3 |
| Facility failed to ensure a resident was allowed to make their own decisions whenever possible. | Severity: 3 |
Report Facts
Census: 4
Total Capacity: 9
Sample Size: 5
Complaint Allegations: 2
Severity Level 3 Deficiencies: 4
Inspection Report
Complaint Investigation
Census: 9
Deficiencies: 0
Oct 27, 2015
Visit Reason
This inspection was conducted as a result of a complaint investigation at Angels House Adult Care on 10/27/2015.
Findings
The investigation included observations, interviews, and file reviews. No regulatory deficiencies were identified and the complaint allegations could not be substantiated.
Complaint Details
Complaint #NV00044262 included allegations that call bells were not answered timely, a resident was left wet for an extended period, and residents were left alone. None of these allegations were substantiated.
Report Facts
Sample size: 5
Inspection Report
Annual Inspection
Census: 6
Capacity: 9
Deficiencies: 7
May 5, 2014
Visit Reason
The inspection was an annual State Licensure survey conducted on 05/05/14 to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of B with several deficiencies identified including failure to provide annual elder abuse training, presence of insects, maintenance issues, fire alarm panel trouble lights, unsecured oxygen tanks, and medication administration record inaccuracies.
Severity Breakdown
1: 1
2: 5
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure of the administrator to receive annual elder abuse training for 2012 and 2013. | 2 |
| Facility failed to ensure premises were free of insects; ant trail observed in west hallway. | 2 |
| Facility failed to ensure premises were clean and well maintained; missing electrical outlet cover and wall/baseboard damage in Bathroom #3. | 2 |
| Fire alarm panel was operating with trouble lights blinking, indicating malfunction. | — |
| Facility failed to secure oxygen tanks in Bedroom #1; four unsecured tanks observed. | 2 |
| Medication administration record (MAR) was inaccurate for 2 of 6 MARs inspected, including documentation errors and missing dosage frequency. | 2 |
| Resident #1 was non-verbal and unable to communicate need for PRN medication; facility failed to ensure communication of medication needs. | 1 |
Report Facts
Licensed capacity: 9
Census: 6
Deficiencies cited: 7
Severity 1 deficiencies: 1
Severity 2 deficiencies: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Acknowledged medication documentation errors and PRN medication issues | |
| Employee #2 | Acknowledged lack of annual elder abuse training and fire alarm trouble lights | |
| Employee #3 | Acknowledged presence of ant trail and unsecured oxygen tanks |
Inspection Report
Annual Inspection
Census: 6
Capacity: 9
Deficiencies: 7
May 5, 2014
Visit Reason
This document is an annual State Licensure survey conducted on 05/05/2014 to assess compliance with state regulations for Angels House Adult Care, a residential facility for elderly and disabled persons.
Findings
The facility received a grade of B with multiple deficiencies identified including failure to provide annual elder abuse training to the administrator, presence of insects, maintenance issues such as missing electrical outlet covers and damaged walls, fire alarm panel trouble lights, unsecured oxygen tanks, and medication administration record inaccuracies.
Severity Breakdown
Severity: 2: 5
Severity: 1: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Administrator failed to receive annual elder abuse training for 2012 and 2013. | Severity: 2 |
| Facility failed to ensure premises was free of insects; ants observed in West hallway. | Severity: 2 |
| Facility failed to ensure premises was clean and well maintained; missing electrical outlet cover, hole with exposed nail, and broken baseboard observed. | Severity: 2 |
| Fire alarm panel had illuminated trouble lights indicating malfunction. | — |
| Oxygen tanks were unsecured in Bedroom #1. | Severity: 2 |
| Medication administration records (MAR) inaccurate for two residents; missing documentation of doses and transcription errors. | Severity: 1 |
| Facility failed to ensure resident was able to communicate need for as needed medication; Resident #1 non-verbal. | Severity: 2 |
Report Facts
Licensed beds: 9
Census: 6
Employee files reviewed: 3
Resident files reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Acknowledged medication administration record errors and explained Resident #1 was non-verbal | |
| Employee #2 | Administrator | Failed to receive annual elder abuse training; acknowledged fire alarm trouble lights |
| Employee #3 | Acknowledged presence of ant trail, unsecured oxygen tanks, and maintenance issues |
Inspection Report
Annual Inspection
Census: 7
Capacity: 9
Deficiencies: 4
May 23, 2013
Visit Reason
The inspection was an annual State Licensure grading survey conducted to assess compliance with health, sanitation, medication administration, resident physical examinations, and tuberculosis testing regulations.
Findings
The facility received a grade of B but failed to ensure the premises were clean and well maintained, failed to ensure annual physical examinations for some residents, and had multiple medication administration record inaccuracies. Additionally, the facility did not ensure compliance with tuberculosis testing requirements for some residents.
Severity Breakdown
Severity: 1: 1
Severity: 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to maintain clean premises; lint accumulation and leaks found, trash cans without lids, and miscellaneous trash and appliances in the backyard. | Severity: 2 |
| Facility failed to ensure annual physical examinations for 2 of 7 residents. | Severity: 2 |
| Medication administration records were inaccurate for 5 of 7 residents, including missing documentation and incorrect medication details. | Severity: 1 |
| Facility failed to ensure tuberculosis testing compliance for 3 of 7 residents. | Severity: 2 |
Report Facts
Residents present: 7
Total licensed capacity: 9
Deficiencies cited: 4
Severity 1 deficiencies: 1
Severity 2 deficiencies: 3
Inspection Report
Annual Inspection
Census: 7
Capacity: 9
Deficiencies: 4
May 23, 2013
Visit Reason
This document is an annual State Licensure grading survey conducted on 5/23/2013 to assess compliance with state regulations for a residential facility for group beds for elderly and disabled persons and/or persons with mental illness.
Findings
The facility received a grade of B with multiple deficiencies identified including failure to maintain clean and well-maintained premises, failure to ensure residents received annual physical examinations, inaccuracies in medication administration records, and failure to comply with tuberculosis testing requirements.
Severity Breakdown
Level 1: 1
Level 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure the premises was clean and well maintained, including issues such as lint accumulation, leaking tub nozzle, torn screen door, uncovered trash cans, paint cans and garbage bags stored improperly, standing water in mop bucket, miscellaneous trash and appliances in backyard, and piles of clothes/linens on laundry room floor. | Level 2 |
| Facility failed to ensure 2 of 7 residents received an annual physical examination. | Level 2 |
| Facility failed to ensure medications were plainly labeled for 1 of 7 residents and medication administration records were inaccurate for 5 of 7 residents inspected, including discrepancies in medication orders and documentation. | Level 1 |
| Facility failed to ensure 3 of 7 residents complied with tuberculosis testing regulations, including delayed or invalid tests and lack of evidence of required testing. | Level 2 |
Report Facts
Deficiencies cited: 4
Resident files reviewed: 7
Employee files reviewed: 3
Facility licensed capacity: 9
Census at time of survey: 7
Inspection Report
Annual Inspection
Census: 6
Capacity: 9
Deficiencies: 3
Jun 5, 2012
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 6/5/12 to assess compliance with licensing requirements for a residential facility for elderly and disabled persons.
Findings
The facility was found deficient for failing to obtain a mental illness endorsement prior to admitting a resident with a mental illness diagnosis and for failing to employ a licensed administrator. Additionally, the facility was allowing an unauthorized boarder to reside on premises. The facility received a grade of A.
Severity Breakdown
Severity: 2: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to obtain a mental illness endorsement prior to admitting a resident with a diagnosis of mental illness. | Severity: 2 |
| Failure to employ a licensed administrator as required for residential facilities for groups. | Severity: 2 |
| Allowing an unauthorized boarder to reside at the facility. | — |
Report Facts
Licensed capacity: 9
Census: 6
Severity level: 2
Scope: 3
Inspection Report
Annual Inspection
Census: 6
Capacity: 9
Deficiencies: 2
Jun 5, 2012
Visit Reason
The inspection was conducted as an annual State Licensure survey to assess compliance with regulations for the residential facility.
Findings
The facility failed to obtain a mental illness endorsement prior to admitting a resident with a diagnosis of mental illness and failed to employ a licensed administrator. Additionally, the facility allowed a non-resident boarder to live on premises in an RV and interact with residents.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to obtain a mental illness endorsement prior to admitting a resident with a diagnosis of mental illness (Resident #5). | Severity: 2 |
| Failed to employ a licensed administrator as required for supervision of the residential facility. | Severity: 2 |
Report Facts
Licensed capacity: 9
Current census: 6
Inspection Report
Annual Inspection
Census: 8
Capacity: 9
Deficiencies: 3
May 26, 2011
Visit Reason
This document is the result of an annual State Licensure survey conducted at Angels House Adult Care on 5/26/2011 to assess compliance with state regulations.
Findings
The facility was found to have deficiencies related to admission policies for bedfast residents and the care of residents with indwelling catheters. The facility admitted two bedfast residents without proper waivers and failed to obtain waivers for hospice care residents. The facility received a grade of A.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Admission Policy: The facility admitted two residents who were bedfast, which is not permitted without proper waivers. | Severity: 2 |
| Indwelling Catheter: The facility admitted and retained a resident not mentally capable of caring for an indwelling catheter without proper oversight. | Severity: 2 |
| Waivers: The facility failed to obtain waivers for 2 of 3 bedfast residents receiving hospice care. | Severity: 2 |
Report Facts
Licensed capacity: 9
Census: 8
Deficiency count: 3
Inspection Report
Annual Inspection
Census: 8
Capacity: 9
Deficiencies: 3
May 26, 2011
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at Angels House Adult Care on 5/26/2011.
Findings
The facility was found to have admitted two bedfast residents, which is against admission policy, and retained one resident not capable of caring for an indwelling catheter. Additionally, the facility failed to obtain required waivers for two bedfast residents receiving hospice care. The facility received a grade of A.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility admitted two residents who were bedfast, violating admission policy. | Severity: 2 |
| Facility admitted and retained one resident not mentally capable of caring for an indwelling catheter. | Severity: 2 |
| Facility failed to obtain waivers for two of three bedfast residents receiving hospice care. | Severity: 2 |
Report Facts
Licensed capacity: 9
Census: 8
Employee files reviewed: 4
Resident files reviewed: 8
Inspection Report
Re-Inspection
Deficiencies: 4
Sep 2, 2010
Visit Reason
This document is a statement of deficiencies generated as a result of a requested grading re-survey conducted on 09/02/2010 at Angels House Adult Care.
Findings
The facility failed to ensure proper food temperatures were maintained, ramps were not located outside at least two primary exits, and staff did not receive adequate training on handling indwelling catheter waste and recognizing signs of urinary tract infections and dehydration. Additionally, the administrator failed to obtain a waiver to retain a resident who became bedfast.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Storage of food-perishable foods refrigerated; two dozen eggs were kept at room temperature for approximately eight hours. | Severity: 2 |
| Accommodations for residents; ramps were not located outside at least two of the primary exits (front exit). | Severity: 2 |
| Indwelling catheter; three out of three caregivers failed to receive instruction on handling catheter waste and recognizing signs of urinary tract infections and dehydration. | Severity: 2 |
| Waivers; administrator failed to obtain a waiver to retain a resident who became bedfast. | Severity: 2 |
Report Facts
Deficiency severity: 2
Scope: 3
Scope: 1
Scope: 2
Number of eggs: 24
Temperature: 40
Date survey completed: Sep 2, 2010
Inspection Report
Re-Inspection
Deficiencies: 4
Sep 2, 2010
Visit Reason
This document is a Statement of Deficiencies generated as a result of a requested grading re-survey conducted at Angels House Adult Care on 9/2/2010 by the Division of Public and Behavioral Health under the authority of NRS 449.150.
Findings
The facility received a re-survey grade of B and was found deficient in several areas including improper storage of perishable foods at room temperature, lack of ramps at primary exits for residents with restricted mobility, failure to ensure caregivers were trained in handling indwelling catheter care, and failure to obtain a waiver to retain residents who became bedfast.
Severity Breakdown
2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure proper food temperatures were maintained; two dozen eggs were left at room temperature for approximately eight hours. | 2 |
| Facility failed to ensure ramps were located outside at least two of the primary exits (front exit) for residents with restricted mobility. | 2 |
| Administrator failed to ensure 3 out of 3 caregivers received instructions in handling indwelling catheter waste and recognizing signs and symptoms of urinary tract infections and dehydration. | 2 |
| Administrator failed to obtain a waiver to retain residents who became bedfast (Resident #1 and #2). | 2 |
Report Facts
Number of eggs left at room temperature: 24
Number of caregivers not trained: 3
Number of residents without waiver: 2
Inspection Report
Annual Inspection
Census: 8
Capacity: 9
Deficiencies: 6
Jun 17, 2010
Visit Reason
This document is a State Licensure annual survey conducted on 06/17/2010 to assess compliance with state regulations for Angels House Adult Care, a residential facility for elderly and disabled persons.
Findings
The facility was found to have multiple deficiencies including failure to maintain clean premises, inadequate bathroom door locks, insufficient scheduled activities, incomplete annual physical exams for residents, medication administration record errors, and incomplete tuberculosis testing for residents.
Severity Breakdown
Severity: 2: 5
Severity: 1: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to ensure premises are clean and well maintained, including excessive lint behind dryer, weeds, dead roaches on floor, and uncovered outside garbage can. | Severity: 2 |
| Bathroom doors did not have single motion locks as required for resident safety. | Severity: 2 |
| Facility failed to provide at least 10 hours of scheduled activities for residents. | Severity: 2 |
| Facility failed to ensure 1 of 8 residents received an annual physical examination. | Severity: 2 |
| Medication administration record was not accurately signed off for 1 of 8 residents; missing caregiver initials on MAR for Cardivil medication. | Severity: 1 |
| Facility failed to ensure 2 of 8 residents complied with tuberculosis testing requirements. | Severity: 2 |
Report Facts
Residents present: 8
Total licensed capacity: 9
Residents reviewed: 8
Employee files reviewed: 4
Residents with scheduled activities: 8
Residents with annual physical exam missing: 1
Residents with MAR signature missing: 1
Residents with incomplete tuberculosis testing: 2
Inspection Report
Annual Inspection
Census: 8
Capacity: 9
Deficiencies: 9
Jun 17, 2010
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at Angels House Adult Care on 6/17/2010 to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of B and was found deficient in multiple areas including personnel tuberculosis testing, facility cleanliness and maintenance, food storage and diet compliance, bathroom door locks, resident activities, medication administration records, and resident tuberculosis testing compliance.
Severity Breakdown
Level 1: 1
Level 2: 8
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 8 employees complied with tuberculosis testing requirements. | Level 2 |
| Facility premises were not clean and well maintained, including excessive lint behind dryer, unmaintained landscaping, dead roaches on floor, and uncovered outside garbage can. | Level 2 |
| Failed to ensure proper refrigeration of perishable foods at 40 degrees Fahrenheit or less. | Level 2 |
| Failed to provide diabetic or low sodium diet menus to 4 of 8 residents as prescribed. | Level 2 |
| Bathroom door lock on 1 of 3 bathrooms did not open with a single motion from inside without a key. | Level 2 |
| Failed to provide at least 10 hours of scheduled activities for all 8 residents. | Level 2 |
| Medication administration record (MAR) was not initialed indicating medication was given for 1 of 8 residents (Resident #6). | Level 2 |
| Medication administration record (MAR) was not accurately signed off for 1 of 8 residents; caregiver initials missing for Cardivil medication. | Level 1 |
| Failed to ensure 2 of 8 residents complied with tuberculosis testing requirements. | Level 2 |
Report Facts
Residents present: 8
Total licensed capacity: 9
Residents reviewed: 8
Employee files reviewed: 4
Discharged resident files reviewed: 1
Residents without diabetic or low sodium diet: 4
Residents without scheduled activities: 8
Residents with medication administration record issues: 1
Employees without tuberculosis testing: 2
Residents without tuberculosis testing: 2
Inspection Report
Re-Inspection
Census: 9
Capacity: 9
Deficiencies: 2
Mar 30, 2010
Visit Reason
This was a required grading re-survey conducted as a State Licensure survey by the authority of NRS 449.150.
Findings
The facility failed to ensure compliance with tuberculosis testing for 3 of 5 employees and failed to ensure 4 of 5 caregivers met background check requirements. Both deficiencies were repeat findings from prior surveys.
Severity Breakdown
2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure 3 of 5 employees complied with tuberculosis testing requirements (NAC 441A.375). | 2 |
| Failed to ensure 4 of 5 caregivers met background check requirements (NRS 449.176 to 449.185). | 2 |
Report Facts
Employees reviewed: 5
Repeat deficiency date: Nov 4, 2009
Repeat deficiency date: Nov 4, 2010
Inspection Report
Complaint Investigation
Census: 8
Capacity: 8
Deficiencies: 13
Nov 4, 2009
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by complaint #NV00023478, which was substantiated.
Findings
The facility was found deficient in multiple areas including incomplete and inaccurate records, insufficient caregiver training, failure to ensure qualified caregivers on duty at all times, missing and improperly administered medications, failure to notify physicians of missed medications, and improper medication destruction procedures.
Complaint Details
Complaint #NV00023478 was substantiated.
Severity Breakdown
Level 1: 1
Level 2: 10
Level 3: 2
Deficiencies (13)
| Description | Severity |
|---|---|
| Administrator failed to keep the records of the facility complete and accurate. | Level 2 |
| Facility failed to ensure that 3 of 4 caregivers received eight hours of annual training. | Level 2 |
| Facility failed to ensure that 1 of 4 caregivers completed required three hour medication management refresher training every three years. | Level 2 |
| Administrator failed to ensure that a qualified caregiver was on duty at all times, leaving an unqualified caregiver alone with residents. | Level 3 |
| Personnel files missing hire dates for 2 of 4 employees. | Level 1 |
| Facility failed to ensure 2 of 4 employees complied with tuberculosis testing requirements. | Level 2 |
| Facility failed to ensure 3 of 4 caregivers met background check requirements. | Level 2 |
| Facility failed to ensure the only caregiver on duty had completed training in first aid and CPR. | Level 2 |
| Facility did not obtain physician orders to administer over-the-counter medications to 1 of 8 residents. | Level 2 |
| Facility failed to ensure that 3 of 8 residents received medications as prescribed. | Level 3 |
| Facility failed to notify physicians within 12 hours after medication was missed or refused for 3 of 8 residents. | Level 2 |
| Facility failed to destroy medications after they were discontinued, expired, or after resident transfer; discontinued medications were stored unsecured. | Level 2 |
| Facility failed to maintain accurate medication administration records for 8 of 8 residents. | Level 2 |
Report Facts
Number of residents: 8
Number of caregivers reviewed: 4
Number of employees reviewed: 5
Severity 1 deficiencies: 1
Severity 2 deficiencies: 10
Severity 3 deficiencies: 2
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 6, 2009
Visit Reason
This document is a required grading re-survey conducted at the facility on 10/6/09 as part of a State Licensure survey by the Health Division.
Findings
No regulatory deficiencies were identified during this re-survey. The facility received a grade of A.
Inspection Report
Annual Inspection
Census: 6
Capacity: 9
Deficiencies: 8
Jun 22, 2009
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at the facility on June 22, 2009, to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility was found to have multiple deficiencies including failure to meet background check requirements for staff, hazards on the premises, non-functioning smoke detectors, lack of proper oxygen use signage, failure to ensure annual physical exams for residents, incomplete medication profile reviews, missing ultimate user agreements for medications, and incomplete medication administration records.
Severity Breakdown
Level 1: 3
Level 2: 5
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 caregivers met background check requirements (Employee #3). | Level 2 |
| Facility premises not kept free from hazards including broken window with sharp edges, holes in patio roof, and tree branches impeding walkway. | Level 2 |
| Smoke detector in bedroom #3 did not emit an audible sound during testing; last tested on 5/20/09. | Level 2 |
| Failed to post signs prohibiting smoking and notifying persons that oxygen was in use in 1 of 9 bedrooms where oxygen was used or stored (#3). | Level 1 |
| Failed to ensure 2 of 6 residents received an annual physical examination (Residents #2 and #4). | Level 2 |
| Failed to ensure medication profile review was performed at least once every six months for 4 of 6 residents (Residents #1, #2, #4, and #6). | Level 2 |
| Failed to obtain ultimate user agreement for 3 of 6 residents (#1, #3, #5). | Level 1 |
| Failed to maintain accurate medication administration records for 4 of 6 residents (#1, #2, #3, and #5); medications administered but not documented. | Level 1 |
Report Facts
Residents present: 6
Total licensed capacity: 9
Deficiencies cited: 8
Employee files reviewed: 4
Resident files reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Named in findings related to background check failure and medication administration documentation |
Inspection Report
Annual Inspection
Census: 8
Capacity: 9
Deficiencies: 15
Sep 17, 2008
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation at the facility.
Findings
The facility was found to have multiple deficiencies including failure to provide required annual training for caregivers, incomplete personnel files, failure to maintain health and sanitation standards, missing physician orders for medications, incomplete resident physical examinations, failure to maintain activity records, and non-compliance with diabetes care regulations.
Complaint Details
Complaint #NV00018802 was substantiated with deficiencies. Complaint #NV00018862 was substantiated but no regulatory deficiencies were cited due to actions taken by the facility.
Severity Breakdown
Level 1: 4
Level 2: 9
Level 3: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 employees received the required eight hours of annual training related to the needs of residents. | Level 2 |
| Failed to comply with mandatory tuberculosis testing requirements for 3 of 4 employees. | Level 2 |
| Failed to maintain complete personnel files with mandatory background check requirements for 3 of 4 employees. | Level 2 |
| Failed to ensure caregivers were current with first aid and CPR certifications for 1 of 4 employees. | Level 2 |
| Failed to ensure the premises was clean; cigarette butts and debris observed in yard areas. | Level 1 |
| Failed to provide window screen for 1 of 7 resident bedrooms. | Level 1 |
| Failed to ensure special diets were provided as prescribed by a physician for 2 of 8 residents. | Level 2 |
| Failed to perform required monthly evacuation drills for 1 of the past 12 months. | Level 2 |
| Failed to perform monthly smoke detector checks. | Level 2 |
| Failed to ensure physical examinations were completed for 2 of 8 residents. | Level 2 |
| Failed to ensure signed agreements for medication administration were obtained for 3 of 8 residents. | Level 1 |
| Failed to obtain physician orders for medications administered to 3 of 8 residents. | Level 2 |
| Failed to ensure 5 of 8 residents received required tuberculosis screening tests. | Level 2 |
| Failed to maintain written records of weekly activity programs for residents. | Level 1 |
| Failed to comply with diabetes care regulations for 1 of 8 residents; resident received insulin and blood sugar testing assistance without proper oversight. | Level 3 |
Report Facts
Residents present: 8
Total licensed beds: 9
Employees reviewed: 4
Residents reviewed: 8
Deficiencies severity counts: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Named in findings related to lack of annual training, expired CPR and first aid certification, missing tuberculosis testing, missing background check documentation, failure to perform fire and smoke detector drills, lack of awareness of special diet orders, and diabetes care assistance. | |
| Employee #1 | Named in findings related to missing tuberculosis testing, missing background check documentation, and missing physical examination paperwork. | |
| Employee #3 | Named in findings related to missing tuberculosis testing and missing background check documentation. | |
| Employee #4 | Named in findings related to missing background check documentation, lack of awareness of medication administration, and cleaning staff interview. |
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