Inspection Reports for Arch of Las Vegas
9483 Lightning Bay Ct., Las Vegas, NV 89123, NV, 89123
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 0
Jul 29, 2025
Visit Reason
The inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code Chapter 449.
Findings
No regulatory deficiencies were identified during the inspection. The facility received a grade of A and no further action was necessary.
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 2
Jul 29, 2024
Visit Reason
This inspection was conducted as an annual State Licensure survey of the residential facility for groups, in accordance with Nevada Administrative Code Chapter 449.
Findings
The facility was found deficient in developing person-centered service plans for all five residents and lacked an Emergency Preparedness Plan onsite. The facility received a grade of A overall.
Severity Breakdown
Level 1: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to develop a person-centered service plan for 5 of 5 residents. | Level 1 |
| Failed to ensure an Emergency Preparedness Plan was created and available onsite. | Level 1 |
Report Facts
Licensed beds: 6
Residents present: 5
Resident files reviewed: 5
Employee files reviewed: 4
Severity level 1 deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Peterson Durias | Administrator | Named as person responsible for corrective actions and signed the report |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 3
Jul 19, 2023
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 several regulatory deficiencies were identified including failure to ensure proper tuberculosis testing documentation for one resident, lack of updated policies and records reflecting resident gender identity and preferred names, and failure to ensure infection control designees completed required infection control training.
Severity Breakdown
Severity: 1: 1
Severity: 2: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 6 residents met tuberculosis (TB) testing requirements; missing read date and result for second step TB test for Resident #3. | Severity: 2 |
| Facility failed to develop policies and revise resident records to reflect preferred name, pronoun, and gender identity in compliance with regulations. | Severity: 1 |
| Facility failed to ensure primary and secondary infection control designees completed required 15 hours of infection control training. | Severity: 2 |
Report Facts
Resident files reviewed: 6
Employee files reviewed: 4
TB test injection date: Apr 16, 2023
TB test read date: Apr 23, 2023
TB test second step injection date: Apr 30, 2023
Infection control training hours required: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Peter Durias | Administrator | Named as responsible person for corrective actions and administrator signing the report |
| Faye Gagnon | Infection Preventionist | Advised and guided administrator on infection control training platform |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 0
Aug 2, 2022
Visit Reason
The inspection was conducted as an annual State Licensure and infection control survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the survey. The facility received a grade of A and no further action was necessary.
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 1
Oct 5, 2021
Visit Reason
The inspection was an annual grading and infection control State Licensure survey conducted in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facilities for Groups.
Findings
The facility received a grade of A with no regulatory deficiencies identified initially. However, a deficiency was found related to personnel files where one of four employees did not have a background check completed through the Nevada Automated Background System (NABS). The Administrator acknowledged this and corrective actions were planned.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 4 employees had met the background check requirements of Nevada Revised Statute (NRS) 449.124; background check was not completed through NABS. | Severity: 2 |
Report Facts
Resident census: 6
Total licensed capacity: 6
Employees reviewed: 4
Residents reviewed: 6
Inspection Report
Routine
Census: 3
Capacity: 6
Deficiencies: 0
Oct 28, 2020
Visit Reason
The inspection was a COVID-19 focused infection control survey conducted as a State Licensure survey to assess compliance with infection control measures during the pandemic.
Findings
The facility demonstrated adherence to COVID-19 infection control protocols including screening, PPE use, social distancing, and sanitization practices. The facility had adequate PPE supplies but lacked medically cleared and fitted staff for N95 masks. No regulatory deficiencies were identified.
Report Facts
PPE supplies: 200
PPE supplies: 41
PPE supplies: 30
PPE supplies: 8
PPE supplies: 2
PPE supplies: 6
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 3
Dec 26, 2019
Visit Reason
This inspection was conducted as a result of a State Licensure annual survey at the facility to assess compliance with Nevada Administrative Code for Residential Facility for Groups.
Findings
The facility received a grade of A but had several deficiencies including failure to secure medications in the refrigerator, an unlocked exterior gate leading to the street, and incomplete dementia care training for one employee.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure medications in the refrigerator were locked; five medications were found in a broken lock box. | Severity: 2 |
| Failed to ensure an exterior gate leading to the street was locked and properly secured. | Severity: 2 |
| Failed to ensure three hours of annual training related to Alzheimer's/dementia care was completed for 1 of 4 employees. | Severity: 2 |
Report Facts
Number of medications unsecured: 5
Number of resident files reviewed: 5
Number of employee files reviewed: 4
Facility licensed capacity: 6
Current census: 5
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 0
Jan 22, 2019
Visit Reason
This inspection was conducted as a result of an annual State Licensure at the facility on 01/22/19, in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A with no regulatory deficiencies identified. Four resident files and six employee files were reviewed during the inspection.
Report Facts
Licensed beds: 6
Resident census: 4
Employee files reviewed: 6
Resident files reviewed: 4
Inspection Report
Re-Inspection
Census: 5
Capacity: 10
Deficiencies: 0
Mar 16, 2018
Visit Reason
This Statement of Deficiencies was generated as a result of a required Grading re-survey conducted in the facility on 3/16/18.
Findings
The facility received a re-survey grade of A. No regulatory deficiencies were identified and no further action is necessary.
Report Facts
Resident files reviewed: 5
Employee files reviewed: 5
Category II residents licensed: 6
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 12
Jan 4, 2018
Visit Reason
This inspection was conducted as an annual State Licensure survey to assess compliance with regulatory requirements for a residential facility for elderly and disabled persons and/or persons with Alzheimer's disease.
Findings
The facility was found deficient in multiple areas including caregiver qualifications, personnel files, medication management, health and sanitation, resident admission policies, medication storage and destruction, resident file security, tuberculosis testing, and safety regarding toxic substances. Several deficiencies were rated with severity levels ranging from C to F, indicating varying degrees of noncompliance.
Severity Breakdown
C: 1
D: 4
E: 3
F: 4
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 5 caregivers passed an annual medication management training examination. | D |
| Failed to ensure 1 of 5 employees met tuberculosis testing and pre-employment physical examination requirements. | F |
| Failed to ensure 2 of 5 employees met background check requirements. | E |
| Failed to ensure the premises was well maintained with missing drawer handles, torn recliner, and broken dresser drawer. | F |
| Failed to obtain a bedfast waiver for 1 of 4 residents who was bedfast and lacked documented evidence of regular repositioning. | D |
| Failed to ensure medication profile review was performed at least every six months for 3 of 4 residents. | C |
| Failed to ensure over-the-counter medication was administered according to physician's instructions; medication was not refrigerated as required. | D |
| Failed to destroy expired medications for 2 of 4 residents. | E |
| Failed to keep medications belonging to 1 of 4 residents in their original container. | D |
| Failed to ensure residents' health information was secured; unsecured records found in unlocked drawer. | F |
| Failed to ensure 1 of 4 residents met tuberculosis testing requirements; no TB test after 02/13/16. | F |
| Failed to ensure toxic substances were inaccessible to residents; unsecured toxic materials found in garage. | F |
Report Facts
Licensed capacity: 6
Census: 4
Employees reviewed: 5
Residents reviewed: 4
Severity 2 deficiencies: 7
Severity 1 deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Peter Durias | Administrator | Named as person responsible for corrective actions and involved in confirming deficiencies |
| Employee #2 | Confirmed multiple deficiencies including expired training, TB testing, medication handling, and unsecured items | |
| Employee #4 | Failed annual medication management training examination | |
| Employee #5 | Lacked required TB testing, physical examination, and background check documentation |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 7
Feb 3, 2016
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 2/3/15 to assess compliance with regulations for a residential facility for elderly and disabled persons.
Findings
The facility was found deficient in multiple areas including failure to ensure tuberculosis testing for employees, inadequate health and sanitation maintenance, failure to obtain a bedfast waiver for a resident, and medication administration errors. Several residents' files lacked required documentation and medication records were incomplete or inaccurate.
Severity Breakdown
Severity: 2: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 4 employees met tuberculosis testing requirements. | Severity: 2 |
| Failed to maintain clean interior and exterior of the facility; grease and dust buildup observed. | Severity: 2 |
| Failed to obtain a bedfast waiver for 1 of 6 residents. | Severity: 2 |
| Failed to ensure 2 of 6 residents received medications as prescribed. | Severity: 2 |
| Failed to maintain complete and accurate Medication Administration Records (MAR) for residents. | Severity: 2 |
| Failed to ensure medications were administered to 1 of 6 residents requiring medical assessment. | Severity: 2 |
| Failed to ensure 1 of 6 residents met tuberculosis testing requirements. | Severity: 2 |
Report Facts
Number of employees reviewed: 4
Number of residents present: 6
Total licensed capacity: 6
Number of residents with medication deficiencies: 2
Number of residents with tuberculosis testing deficiencies: 3
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 7
Feb 3, 2016
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at the facility on 2/3/16 to assess compliance with state regulations.
Findings
The facility was found to have multiple deficiencies including failure to ensure tuberculosis testing compliance for employees and residents, failure to maintain cleanliness and sanitation, failure to obtain a bedfast waiver for a resident, and medication administration errors including incomplete medication records and failure to administer medications as prescribed.
Severity Breakdown
Severity: 2: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 4 employees met tuberculosis testing requirements. | Severity: 2 |
| Failed to ensure the interior and exterior of the facility was clean and maintained. | Severity: 2 |
| Failed to obtain a bedfast waiver for 1 of 6 residents. | Severity: 2 |
| Failed to ensure 2 of 6 residents received medications as prescribed. | Severity: 2 |
| Failed to ensure the Medication Administration Record (MAR) was complete for 1 of 6 residents receiving PRN medications. | Severity: 2 |
| Failed to ensure medications were not administered to 1 of 6 residents which required a medical assessment. | Severity: 2 |
| Failed to ensure 1 of 6 residents met tuberculosis testing requirements. | Severity: 2 |
Report Facts
Number of residents: 6
Number of employee files reviewed: 4
Number of resident files reviewed: 6
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 4
Mar 10, 2015
Visit Reason
This inspection was conducted as an annual State Licensure survey of a residential facility for elderly and disabled persons and/or persons with Alzheimer's disease.
Findings
The facility received a grade of A. Several deficiencies were identified including failure to ensure current background checks for employees, lack of documented physical examinations prior to admission for residents, incomplete medication administration records, and failure to maintain proper medication logs and records.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 6 employees had a current background check. | Severity: 2 |
| Facility failed to ensure 2 of 6 residents received a physical prior to admission. | Severity: 2 |
| Facility failed to ensure routine and as needed medications were available onsite for 1 of 6 residents. | Severity: 2 |
| Facility did not ensure medication record was complete for 1 of 6 residents receiving as needed medications. | Severity: 2 |
Report Facts
Residents present: 6
Total capacity: 6
Employees reviewed: 4
Resident files reviewed: 6
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 4
Mar 10, 2015
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility to assess compliance with regulatory requirements.
Findings
The facility received a grade of A but had several deficiencies including failure to ensure one employee had a current background check, failure to obtain physical examinations for two residents prior to admission, failure to have onsite routine and PRN medications for one resident, and incomplete medication records for one resident.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 6 employees had a current State and Federal background check. | Severity: 2 |
| Failed to ensure 2 of 6 residents received a physical examination prior to admission. | Severity: 2 |
| Failed to ensure routine and as needed (PRN) medications were available onsite for 1 of 6 residents. | Severity: 2 |
| Did not ensure the medication record was complete for 1 of 6 residents receiving as needed (PRN) medications. | Severity: 2 |
Report Facts
Residents: 6
Licensed capacity: 6
Employees reviewed: 4
Resident files reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Named in background check deficiency | |
| Employee #4 | Named in medication record deficiency |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 2
Mar 25, 2014
Visit Reason
This visit was an annual State Licensure survey conducted to assess compliance with regulations for a residential facility providing care to persons with Alzheimer's Disease.
Findings
The facility received a grade of A, but deficiencies were identified related to medication administration logs and records, including failure to maintain complete medication delivery logs and physician orders for discontinuing medications.
Severity Breakdown
Severity: 1: 1
Severity: 2: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to maintain a medication delivery log for 4 residents, lacking required details such as type, quantity, delivery date, and recipient. | Severity: 1 |
| Facility failed to maintain copies of physician's orders to discontinue medications for 2 of 4 residents. | Severity: 2 |
Report Facts
Residents present: 4
Total licensed capacity: 6
Deficiency count: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Owner/Manager | Interviewed regarding medication delivery log and physician orders |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 2
Mar 25, 2014
Visit Reason
The inspection was conducted as an annual State Licensure survey to assess compliance with regulations for a residential facility providing care to persons with Alzheimer's Disease.
Findings
The facility received a grade of A but was cited for deficiencies related to medication administration records and logs, including failure to maintain a medication delivery log for all residents and failure to maintain copies of physician's orders to discontinue medications for some residents.
Severity Breakdown
Level 1: 1
Level 2: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to maintain a medication delivery log for 4 of 4 residents, lacking complete records of medications received from the pharmacy. | Level 1 |
| Failed to maintain copies of physician's orders to discontinue medications for 2 of 4 residents. | Level 2 |
Report Facts
Residents present: 4
Total licensed capacity: 6
Deficiency severity counts: 1
Deficiency severity counts: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Owner/Manager | Employee #1 who explained medication delivery recording and acknowledged missing physician orders |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 6
Mar 7, 2013
Visit Reason
Annual State Licensure inspection conducted to assess compliance with state regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of B with several deficiencies identified including failure to inspect and recharge fire extinguishers, secure oxygen tanks properly, ensure caregiver training for Foley catheter use, medication administration issues, and medication storage problems.
Severity Breakdown
Severity: 2: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility did not ensure 1 of 2 portable fire extinguishers were inspected, recharged, and tagged annually by a certified person. | — |
| Facility did not ensure oxygen tanks were secured in a rack or to the wall in 1 of 4 resident rooms. | Severity: 2 |
| Facility failed to ensure 2 of 5 employees received Foley catheter training. | Severity: 2 |
| Facility failed to comply with medication administration requirements for 2 of 4 residents, including lack of medical assessment before administering medications. | Severity: 2 |
| Facility failed to ensure medications were stored securely; medications were found unsecured in staff office and general areas. | Severity: 2 |
| Administrator failed to ensure 1 of 5 employees received annual elder abuse training. | — |
Report Facts
Licensed beds: 6
Residents present: 4
Employees reviewed: 5
Resident files reviewed: 4
Fire extinguishers inspected: 1
Residents with medication issues: 2
Employees lacking Foley catheter training: 2
Employees lacking elder abuse training: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named as person responsible for addressing deficiencies and corrective actions |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 6
Mar 7, 2013
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure inspection conducted on 3/7/2013 at the facility licensed for 6 Residential Facility for Group beds providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of B. Several deficiencies were identified including failure to ensure fire extinguisher inspection, unsecured oxygen tanks, inadequate Foley catheter training for employees, medication administration errors, unsecured medication storage, and failure to provide annual elder abuse training to one employee.
Severity Breakdown
Severity: 2: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 2 portable fire extinguishers were inspected, recharged and tagged at least once each year by a certified person (fire extinguisher in kitchen was not charged). | — |
| Oxygen tanks were not secured in a rack or to the wall in 1 of 4 resident rooms where oxygen was used. | Severity: 2 |
| Failed to ensure 2 of 5 employees had Foley catheter training. | Severity: 2 |
| Failed to comply with medication administration requirements as 2 of 4 residents' medications were not at maintenance level and required medical assessment before administering. | Severity: 2 |
| Medications were not secured; staff office unlocked with resident and general staff medication unsecured, including expired and discontinued medications. | Severity: 2 |
| Administrator failed to ensure 1 of 5 employees received annual training in recognition, prevention, and response to elder abuse. | — |
Report Facts
Licensed beds: 6
Census: 4
Employees reviewed: 5
Resident files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Failed to receive annual elder abuse training | |
| Employee #3 | Failed to obtain Foley catheter training | |
| Employee #5 | Failed to obtain Foley catheter training |
Inspection Report
Annual Inspection
Census: 6
Capacity: 4
Deficiencies: 3
Mar 6, 2012
Visit Reason
The inspection was conducted as an annual State Licensure survey to assess compliance with regulatory requirements for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but had deficiencies related to caregiver medication management training, tuberculosis testing compliance, and ensuring toxic substances were inaccessible to residents.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure 2 of 4 caregivers were current with medication management training. | Severity: 2 |
| Facility failed to ensure 2 of 6 residents complied with tuberculosis testing requirements. | Severity: 2 |
| Facility failed to ensure toxic substances were inaccessible to 6 of 6 residents; cleaning supplies were unsecured and accessible. | Severity: 2 |
Report Facts
Resident census: 6
Total licensed capacity: 4
Caregivers reviewed: 4
Residents reviewed: 6
Inspection Report
Annual Inspection
Census: 6
Capacity: 4
Deficiencies: 3
Mar 6, 2012
Visit Reason
This document is the result of an annual State Licensure survey conducted on 3/6/2012 to assess compliance with state regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but had several deficiencies including failure to ensure caregivers were current with medication management training, failure to ensure resident tuberculosis testing compliance, and failure to secure toxic substances from residents.
Severity Breakdown
2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 4 caregivers were current with medication management training. | 2 |
| Failed to ensure 2 of 6 residents complied with tuberculosis testing requirements. | 2 |
| Failed to ensure toxic substances were inaccessible to residents; cleaning supplies were unsecured in resident bathrooms accessible to all residents. | 2 |
Report Facts
Number of caregivers not current with medication training: 2
Number of residents non-compliant with TB testing: 2
Number of residents exposed to unsecured toxic substances: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employees #1 and #3 were identified as caregivers not current with medication management training; no full names provided. |
Inspection Report
Plan of Correction
Deficiencies: 3
Sep 2, 2011
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction generated as a result of an onsite validation survey conducted on 09/02/2011 following an attestation questionnaire submitted on 04/11/2011. The survey was conducted by the authority of NRS 449.150.
Findings
The facility was cited for deficiencies including failure to ensure tuberculosis testing compliance for employees, retention of a resident with an indwelling catheter without proper exemption, and failure to provide required annual dementia-related training to employees. Severity levels were assigned to these deficiencies.
Severity Breakdown
Severity: 2: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure 2 of 3 employees complied with tuberculosis testing requirements. | — |
| Facility retained a resident with an indwelling catheter who was not mentally capable of caring for all aspects of the condition without submitting an exemption request. | Severity: 2 |
| Failure to provide annual dementia-related training for 2 of 3 employees. | Severity: 2 |
Report Facts
Severity level: 2
Scope: 3
Scope: 1
Scope: 3
Inspection Report
Deficiencies: 3
Sep 2, 2011
Visit Reason
This State Licensure survey was conducted as an onsite validation survey of the facility's attestation questionnaire submitted earlier in the year, to assess compliance with state regulations.
Findings
The facility was found deficient in several areas including failure to ensure tuberculosis testing compliance for employees, retaining a resident with an indwelling catheter who was not mentally capable of self-care without submitting an exemption request, and failure to provide required annual dementia-related training to employees.
Severity Breakdown
F: 2
D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 3 employees complied with tuberculosis testing requirements, being past due for annual 1 step TB test and due for second step. | F |
| Retained a resident with an indwelling suprapubic catheter who was not mentally capable of caring for all aspects of the condition without submitting an exemption request. | D |
| Failed to provide annual dementia-related training for 2 of 3 employees. | F |
Report Facts
Employees non-compliant with TB testing: 2
Employees lacking dementia training: 2
Severity 2 deficiencies: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Named in tuberculosis testing deficiency and as owner interviewed regarding indwelling catheter resident | |
| Employee #3 | Named in tuberculosis testing deficiency | |
| Employee #1 | Named in dementia training deficiency |
Inspection Report
Plan of Correction
Capacity: 6
Deficiencies: 0
Apr 12, 2011
Visit Reason
The facility completed a self-attestation questionnaire in lieu of a 2011 annual survey as it was in good standing with no major deficiencies found in the 2010 annual survey.
Findings
The questionnaire indicated the facility was in regulatory compliance and will receive a grade of A. No deficiencies were cited and no further action is necessary.
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 2
Mar 29, 2010
Visit Reason
This document is the result of an annual State Licensure survey conducted at the facility on 3/29/2010 to assess compliance with state regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but had deficiencies including one caregiver lacking current first aid and CPR certification and one bathroom shower missing a safety grab bar.
Severity Breakdown
2: 1
1: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| The facility failed to ensure that 1 of 4 caregivers had completed training in first aid and cardiopulmonary resuscitation (CPR). | 2 |
| The facility did not ensure that 1 of 2 bathroom showers had a grab bar; the Master bath does not have a safety grab bar. | 1 |
Report Facts
Resident census: 6
Total licensed capacity: 6
Number of caregiver files reviewed: 4
Number of resident files reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Named as caregiver who lacked current first aid and CPR certification |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 5
Mar 31, 2009
Visit Reason
The inspection was conducted as an annual State Licensure survey to assess compliance with regulations for a residential facility for persons with Alzheimer's disease.
Findings
The facility was found deficient in several areas including personnel file compliance for tuberculosis testing, failure to ensure residents received annual physical exams, medication administration errors, and incomplete resident files. Deficiencies were documented with severity levels and corrective actions were noted.
Severity Breakdown
D: 1
F: 2
E: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 5 caregivers complied with tuberculosis testing requirements. | D |
| Facility failed to ensure 4 of 6 residents received an annual physical examination. | F |
| Facility failed to ensure a medication profile review was performed at least once every six months for 4 of 4 residents residing longer than six months. | F |
| Facility failed to ensure 3 of 6 residents received medications as prescribed. | E |
| Facility failed to ensure 3 of 6 residents complied with tuberculosis testing requirements. | E |
Report Facts
Residents reviewed: 6
Employee files reviewed: 5
Deficiencies cited: 5
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 5
Mar 31, 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 3/31/2009 to assess compliance with state regulations.
Findings
The facility was found deficient in multiple areas including failure to ensure tuberculosis testing compliance for one caregiver, failure to provide annual physical examinations for four residents, failure to conduct medication profile reviews every six months for four residents, failure to administer medications as prescribed for three residents, and failure to maintain resident files properly. All deficiencies were assigned a severity level of 2.
Severity Breakdown
Severity: 2: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 5 caregivers complied with tuberculosis testing requirements for the protection of all 6 residents. | — |
| Failed to ensure 4 of 6 residents received an annual physical examination. | Severity: 2 |
| Failed to ensure medication profile review was performed at least once every six months for 4 of 4 residents residing longer than six months. | Severity: 2 |
| Failed to ensure 3 of 6 residents received medications as prescribed. | Severity: 2 |
| Failed to maintain a separate resident file containing all required records and evidence of compliance with tuberculosis regulations for 3 of 6 residents. | Severity: 2 |
Report Facts
Residents present: 6
Total licensed capacity: 6
Caregivers reviewed: 5
Resident files reviewed: 6
Residents without annual physical: 4
Residents without medication profile review: 4
Residents with medication administration issues: 3
Residents non-compliant with tuberculosis testing: 3
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