Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 74
Capacity: 85
Deficiencies: 2
Oct 3, 2024
Visit Reason
The inspection was conducted as a State Licensure annual survey of the facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but was cited for deficiencies including unsecured medications in resident rooms and lack of nondiscrimination posting and complaint contact information on the facility's internet website.
Severity Breakdown
Level 1: 1
Level 2: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Medication storage was unsecured in 2 of 27 resident rooms with residents self-administering medication, including unlocked medications and keys left in locks. | Level 1 |
| The facility's internet website lacked nondiscrimination posting and complaint contact information for the Division. | Level 2 |
Report Facts
Resident rooms with unsecured medications: 2
Resident files reviewed: 15
Employee files reviewed: 10
Category I residents: 63
Category II residents: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Stieg | Executive Director | Named in relation to medication storage deficiency and nondiscrimination posting deficiency |
Inspection Report
Renewal
Census: 66
Capacity: 85
Deficiencies: 2
Apr 2, 2024
Visit Reason
This inspection was conducted as a State Licensure regrading survey for the facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to have one deficiency related to bedroom door locks. Additionally, a deficiency was identified for failure to ensure timely completion of cultural competency training for one of five sampled employees. The facility received a grade of A.
Severity Breakdown
D: 1
2: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Bedroom doors were equipped with single motion locks that did not comply with NAC 449.220 requirements regarding deadbolt locks and key availability. | D |
| Failure to ensure cultural competency training was completed timely for 1 of 5 sampled employees required to obtain the training within the first 30 business days of employment. | 2 |
Report Facts
Category I residents: 63
Category II residents: 22
Resident files reviewed: 9
Employee files reviewed: 5
Severity 2 deficiency count: 1
Severity D deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Resident Services Assistant | Named in cultural competency training deficiency; hired 02/19/24; training completed late on 03/29/24 |
| Natasha Stieg | Executive Director | Signed report and responsible for follow-up on cultural competency training compliance |
Inspection Report
Re-Inspection
Census: 65
Capacity: 85
Deficiencies: 13
May 11, 2023
Visit Reason
This inspection was a grading re-survey State Licensure survey conducted to assess compliance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to have multiple deficiencies related to administrator responsibilities, kitchen equipment sanitation, food storage, first aid and CPR training, medication administration and storage, maintenance of resident files, and annual resident assessments. The facility received a grade of A. Specific deficiencies included failure to complete Standard Physician Assessments and Placement Determinations for two residents in the required years.
Severity Breakdown
F: 2
E: 1
D: 8
C: 1
B: 1
2: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Administrator failed to ensure records of the facility are complete and accurate. | D |
| Kitchen equipment was not adequately clean, sanitary, or in good working condition. | B |
| Insufficient storage for food and equipment; food not appropriately packaged. | F |
| Administrator or caregiver not trained in first aid and cardiopulmonary resuscitation within 30 days of employment. | F |
| Medication administration lacked accuracy and proper reporting. | D |
| Medication administration reports not received or reviewed timely. | C |
| Caregivers did not properly assist in medication administration as required by law. | D |
| Over-the-counter medications and supplements not administered per physician's written instructions. | D |
| Medication administration records incomplete or improperly maintained. | D |
| Medications not stored in locked, cool, dry areas; improper handling of medications upon discharge or transfer. | D |
| Medications not plainly labeled or kept in original containers until administration. | D |
| Separate resident files not properly maintained or secured; missing required documentation. | D |
| Failure to complete Standard Physician Assessment and Placement Determination for two residents in required years. | 2 |
Report Facts
Licensed capacity: 85
Current census: 65
Residents reviewed: 9
Employee files reviewed: 9
Residents with missing assessments: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Stieg | Executive Director | Signed report and confirmed missing Standard Physician Assessments for residents |
Inspection Report
Annual Inspection
Census: 73
Capacity: 85
Deficiencies: 16
Jan 17, 2023
Visit Reason
The inspection was conducted as a result of a State Licensure annual survey and a complaint investigation on 01/17/23, completed on 02/15/23, to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of D with multiple deficiencies identified including incomplete tuberculosis testing records, failure to ensure hair restraints in the kitchen, improper food storage, untimely CPR and first aid training for employees, missing or late physical examinations and medication reviews, medication administration errors, unsecured resident medications, and incomplete resident assessments.
Complaint Details
There was one complaint investigated (CPT #NV00067960) alleging the facility failed to perform CPR after a resident choked. The allegation could not be substantiated due to lack of evidence after interviews and record reviews.
Severity Breakdown
Level 1: 1
Level 2: 15
Deficiencies (16)
| Description | Severity |
|---|---|
| Administrator failed to ensure tuberculosis testing records were complete, including time given and time results read for 2 residents. | Level 2 |
| Facility failed to ensure hair restraints were worn by kitchen staff. | Level 2 |
| Food was stored in open, unsealed containers and food storage areas were not kept free of debris. | Level 2 |
| Employees failed to obtain timely first aid and CPR training for 6 of 10 sampled employees. | Level 2 |
| Facility failed to ensure general physical examinations were completed upon admission and annually for 4 residents. | Level 2 |
| Administrator failed to ensure six-month pharmacy review was completed timely for 1 resident. | Level 2 |
| Medication profile reviews for 7 residents lacked documented evidence of Administrator's or Designee's signature. | Level 1 |
| Ultimate User Agreement was not completed timely for 1 resident. | Level 2 |
| Medication change order sticker was missing for a resident's medication after physician order change. | Level 2 |
| Medication administration record did not accurately reflect correct dosage and number of tablets for 1 resident. | Level 2 |
| Resident medications were not kept secured in the facility for 1 resident's room. | Level 2 |
| Over-the-counter medication was not labeled with resident's name and physician's name for 1 resident. | Level 2 |
| Facility failed to ensure timely tuberculosis testing for 2 residents. | Level 2 |
| Admission Activities of Daily Living (ADL) Assessment was completed late for 1 resident. | Level 2 |
| Cultural competency training was not completed timely for 4 employees. | Level 2 |
| Facility failed to obtain a Standard Physician Assessment and Placement Determination for 1 resident. | Level 2 |
Report Facts
Deficiencies cited: 16
Facility licensed capacity: 85
Resident census: 73
Resurvey application fee: 600
Employees with late CPR training: 6
Residents sampled: 15
Employee files reviewed: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heather Regalado | Inspector | Conducted the inspection and authored the report. |
| Natasha Stieg | Executive Director | Named in relation to findings and plans of correction. |
| Resident Services Director | Interviewed and confirmed multiple deficiencies including TB testing, medication issues, and assessments. | |
| Community Business Director | Involved in auditing employee CPR training files. | |
| Director of Culinary Services | Involved in training and corrective actions related to kitchen deficiencies. | |
| Cook | Interviewed regarding food storage and kitchen practices. |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 85
Deficiencies: 0
Nov 15, 2022
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by two complaints alleging failure to provide an incident report to a resident's family and failure to perform a PCR COVID test on a symptomatic resident.
Findings
The investigation included interviews, record reviews, and policy reviews. Both complaints were found to be unsubstantiated, and no regulatory deficiencies were identified. The facility received a grade A.
Complaint Details
Complaint #NV00065561 alleging failure to provide a copy of an incident report to a resident's family was not substantiated. Complaint #NV00065648 alleging failure to perform a PCR COVID test on a symptomatic resident was not substantiated.
Report Facts
Sample size: 5
Category I residents: 63
Category II residents: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed during complaint investigations |
Inspection Report
Re-Inspection
Census: 61
Capacity: 85
Deficiencies: 9
Apr 18, 2022
Visit Reason
This Statement of Deficiencies was generated as a result of a grading re-survey State Licensure survey conducted on 04/18/22 to assess compliance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. Several deficiencies were identified including failure to ensure timely tuberculosis (TB) screenings for employees and residents, improper labeling of over-the-counter medications, and incomplete personnel files regarding certifications and training.
Severity Breakdown
F: 2
E: 2
D: 5
Deficiencies (9)
| Description | Severity |
|---|---|
| Administrator failed to provide adequate oversight and direction to ensure compliance with NAC 449.156 to 449.27706. | F |
| Caregivers did not meet qualifications including age, training, and understanding of NAC provisions. | D |
| Facility failed to ensure tuberculosis (TB) screening was completed within required timeframe for 2 of 8 sampled employees. | E |
| Personnel files lacked required first aid and CPR certification documentation. | D |
| Residents requiring use of oxygen were not properly monitored or equipment maintained as required. | D |
| Medication administration lacked required semi-annual review and reporting procedures. | E |
| Medication administration reports were not timely reviewed and concerns communicated within 72 hours. | F |
| Over-the-counter medications were not properly labeled with resident's name and prescribing provider's name for 2 of 10 sampled residents. | D |
| Resident files lacked required annual tuberculosis (TB) testing documentation for 1 of 10 sampled residents. | D |
Report Facts
Licensed beds: 85
Category I residents: 63
Category II residents: 22
Resident census: 61
Employees sampled: 8
Residents sampled: 10
Deficiencies cited: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Stieg | Executive Director | Named in relation to confirming TB screening deficiencies and scheduling community TB test clinic |
Inspection Report
Annual Inspection
Census: 68
Capacity: 85
Deficiencies: 10
Jan 4, 2022
Visit Reason
The inspection was conducted as a State Licensure annual survey of the residential facility for groups to assess compliance with Nevada Administrative Code Chapter 449.
Findings
The facility was found deficient in multiple areas including administrator oversight, caregiver qualifications and training, medication administration and documentation, oxygen tank safety, and resident tuberculosis testing. Several deficiencies were rated with severity levels ranging from D to F, indicating significant compliance issues.
Severity Breakdown
Level 2: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight and direction to staff to ensure compliance with NAC 449.156 to 449.27706 and NRS Chapter 449. | Level 2 |
| Facility failed to ensure 1 of 9 sampled employees obtained eight hours of annual caregiver training. | Level 2 |
| Facility failed to ensure 1 of 9 sampled employees received annual elder abuse prevention training prior to working with residents. | Level 2 |
| Facility failed to ensure tuberculosis screening was completed in accordance with Nevada Administrative Code for 1 of 9 sampled employees. | Level 2 |
| Facility failed to ensure 1 of 9 sampled employees were currently certified to perform CPR and first aid. | Level 2 |
| Facility failed to ensure oxygen tanks were secured in resident rooms. | Level 2 |
| Facility failed to ensure medication profile reviews were performed at least once every six months for 2 of 6 sampled residents. | Level 2 |
| Administrator failed to review and initial six month medication profile reviews within 72 hours for 5 of 6 sampled residents. | Level 2 |
| Facility failed to properly label over-the-counter medications with resident's name and prescribing provider's name for 3 of 15 sampled residents. | Level 2 |
| Facility failed to ensure 1 of 15 sampled residents met tuberculosis testing requirements, lacking evidence of a second step TB test. | Level 2 |
Report Facts
Licensed beds: 85
Current census: 68
Employee files reviewed: 9
Resident files reviewed: 15
Deficiencies cited: 10
Resurvey application fee: 600
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #9 | Administrator / Executive Director | Named in deficiencies related to caregiver training, elder abuse training, TB screening, CPR and first aid certification |
| Natasha Stieg | Executive Director | Signed the report and involved in oversight and corrective actions |
Inspection Report
Annual Inspection
Census: 76
Capacity: 85
Deficiencies: 7
Jul 9, 2021
Visit Reason
The inspection was conducted as a State Licensure annual regrading survey of the facility in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. Several deficiencies were identified related to elder abuse training, personnel file TB screening, residents requiring oxygen use, medical care after illness, medication administration and storage, and maintenance of resident files. All deficiencies were confirmed to be in compliance upon onsite revisit except for one medication labeling deficiency which was rectified on the day of inspection.
Severity Breakdown
D: 5
E: 1
I: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Elder Abuse Training - failure to ensure required training to recognize and prevent abuse of older persons. | D |
| Personnel File - TB Screening - failure to maintain required health certificates in personnel files. | D |
| Residents Requiring Use of Oxygen - failure to meet requirements for residents using oxygen including monitoring and equipment safety. | D |
| Medical Care of Resident After Illness - failure to obtain and follow physician's physical examination and care instructions. | D |
| Medication/OTCS, Supplements, Change Order - failure to ensure medication containers indicated a change in medication for 1 of 5 sampled residents (Resident #3). | D |
| Medication: Storage - failure to store medications in locked, secure areas as required. | E |
| Maintenance and Contents of Separate File - failure to maintain separate locked files for each resident with required documentation. | I |
Report Facts
Deficiencies cited: 7
Licensed capacity: 85
Census: 76
Severity 2 deficiency: 1
Severity D deficiencies: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrew Wells | Executive Director | Named as the facility representative who signed the report and confirmed medication labeling deficiency. |
Inspection Report
Annual Inspection
Census: 70
Capacity: 85
Deficiencies: 7
Mar 10, 2021
Visit Reason
The inspection was conducted as a State Licensure annual survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility was found deficient in several areas including failure to ensure annual elder abuse prevention training for one employee, incomplete tuberculosis (TB) screening for multiple employees and residents, missing annual physical exams for some residents, medication administration and storage issues, and failure to post appropriate oxygen use signage. The facility received a grade of C.
Severity Breakdown
Level 2: 6
Level 3: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 6 sampled employees completed the annual elder abuse prevention training. | Level 2 |
| Failure to ensure employees met requirements concerning tuberculosis (TB) testing for 3 of 6 sampled employees. | Level 2 |
| Failure to ensure 2 of 16 residents rooms where oxygen was in use had an oxygen in use sign posted outside of the door and an oxygen tank was stored appropriately for 1 of 16 resident rooms. | Level 2 |
| Failure to ensure a general physical examination had been completed annually for 2 of 15 sampled residents. | Level 2 |
| Failure to ensure medication containers indicated a change in medication for 2 of 15 sampled residents. | Level 2 |
| Failure to ensure medications in resident rooms were safely stored in a locked area and inaccessible to others for 6 of 26 rooms of residents who managed their own medications. | Level 2 |
| Failure to ensure required screening and testing concerning tuberculosis (TB) for 10 of 15 sampled residents and 25 unsampled residents, increasing risk of exposure to infectious agents. | Level 3 |
Report Facts
Residents sampled for physical exam deficiency: 15
Employees sampled for elder abuse training: 6
Residents rooms with oxygen use signage deficiency: 16
Residents rooms with medication storage deficiency: 26
Residents with incomplete TB screening: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #6 | Resident Medication Assistant | Failed to complete annual elder abuse prevention training and lacked TB screening documentation |
| Employee #2 | Director of Culinary Services | Lacked documented evidence of current TB screening |
| Employee #4 | Resident Services Assistant | Lacked documented TB signs and symptoms questionnaires for 2020 and 2021 |
Inspection Report
Re-Inspection
Census: 72
Capacity: 85
Deficiencies: 0
Feb 18, 2020
Visit Reason
This inspection was a State Licensure grading re-survey conducted in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A with no deficiencies cited during this survey. Five resident files and four employee files were reviewed.
Report Facts
Licensed beds: 85
Category I residents: 63
Category II residents: 22
Resident census: 72
Resident files reviewed: 5
Employee files reviewed: 4
Inspection Report
Re-Inspection
Census: 67
Capacity: 85
Deficiencies: 1
Feb 23, 2016
Visit Reason
This inspection was conducted as a required grading re-survey of the facility on 2/23/16 by the Division of Public and Behavioral Health.
Findings
The facility received a re-survey grade of A. One deficiency was identified related to tuberculosis testing compliance for an employee, with severity level 2 and scope 2.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 5 employees complied with tuberculosis (TB) testing; specifically, missing documented evidence of a valid second step TB test for Employee #5. | Severity: 2 |
Report Facts
Residents present: 67
Licensed capacity: 85
Employees files reviewed: 5
Resident files reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Services Director | Acknowledged missing TB test document | |
| Resident Services Director | Acknowledged missing TB test document |
Inspection Report
Re-Inspection
Census: 67
Capacity: 85
Deficiencies: 1
Feb 23, 2016
Visit Reason
This document is a required grading re-survey conducted on 2/23/16 as a State Licensure survey by the Division of Public and Behavioral Health.
Findings
The facility received a re-survey grade of A. One deficiency was identified related to personnel files, specifically failure to ensure 1 of 5 employees complied with tuberculosis testing requirements.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 5 employees complied with tuberculosis (TB) testing; missing documented evidence of a valid second step TB test for Employee #5. | Severity: 2 |
Report Facts
Licensed beds: 85
Census: 67
Employee files reviewed: 5
Resident files reviewed: 6
Inspection Report
Re-Inspection
Census: 73
Capacity: 85
Deficiencies: 1
Jan 21, 2015
Visit Reason
This document is a State Licensure survey re-survey conducted on 1/21/15 to assess compliance following a previous survey on 11/3/14.
Findings
The facility received a re-survey grade of A. One deficiency was identified related to personnel files and background checks, specifically a missing five-year background check for an employee. The deficiency was acknowledged by the Sales Director and is a repeat from the prior survey.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personnel file lacked documentary evidence of a five year background check for Employee #1. | Severity: 2 |
Report Facts
Licensed capacity: 85
Census: 73
Deficiency repeat: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Employee file missing five year background check | |
| Sales Director | Sales Director | Acknowledged the finding regarding background check deficiency |
| Community Business Director | Community Business Director | Will complete physical audit of employee files and track background checks |
Inspection Report
Re-Inspection
Census: 73
Capacity: 85
Deficiencies: 1
Jan 21, 2015
Visit Reason
This Statement of Deficiencies was generated as a result of a grading re-survey conducted at the facility on 1/21/15 by the Division of Public and Behavioral Health under the authority of NRS 449.0307.
Findings
The facility received a re-survey grade of A. One deficiency was identified related to personnel files: one of five employees did not have documented evidence of a five-year background check as required. This was a repeat deficiency from the prior survey on 11/3/14.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure one of five employees met background check requirements; employee file lacked documented evidence of a five-year background check. | 2 |
Report Facts
Census: 73
Total Capacity: 85
Deficiency repeat date: Nov 3, 2014
Inspection Report
Annual Inspection
Census: 74
Capacity: 85
Deficiencies: 4
Nov 3, 2014
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at the facility on 11/3/14.
Findings
The facility was found deficient in several areas including personnel background checks, fire safety inspections, oxygen tank security, and medication storage. Specific deficiencies were noted with two employees lacking required five-year background checks, failure to conduct monthly smoke detector tests, unsecured oxygen tanks in resident rooms, and unsecured medications in multiple locations.
Severity Breakdown
2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Personnel file background check requirements not met for two employees. | 2 |
| Failure to ensure monthly smoke detector tests were conducted for the past 12 months. | 2 |
| Oxygen tanks were not secured in two of six resident rooms where oxygen was used. | 2 |
| Medications were not secured in multiple rooms and medication cart was found unlocked. | 2 |
Report Facts
Resident census: 74
Total licensed capacity: 85
Employee files reviewed: 16
Resident files reviewed: 20
Inspection Report
Annual Inspection
Census: 74
Capacity: 85
Deficiencies: 4
Nov 3, 2014
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 11/3/2014 at Atria Summit Ridge, a residential facility for elderly and disabled persons.
Findings
The facility received a grade of B and was found deficient in several areas including personnel background checks, fire safety compliance, oxygen equipment safety, and medication storage security.
Severity Breakdown
2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 16 employees met background check requirements. | 2 |
| Failed to ensure monthly smoke detector tests were conducted for the past 12 months. | 2 |
| Failed to ensure oxygen tanks were secured in a rack or to the wall in 2 of 6 resident rooms where oxygen was used. | 2 |
| Failed to ensure medications were secured in multiple rooms and medication cart. | 2 |
Report Facts
Resident files reviewed: 20
Employee files reviewed: 16
Unsecured oxygen tanks: 10
Unsecured medication minders: 2
Unsecured medications: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Acknowledged the findings related to background checks | |
| Employee #2 | Background check deficiency noted | |
| Employee #15 | Background check deficiency noted |
Inspection Report
Re-Inspection
Capacity: 85
Deficiencies: 0
Apr 8, 2014
Visit Reason
This document is a required grading re-survey conducted as a re-inspection of the facility on 04/08/2014 by the Division of Public and Behavioral Health under state licensure authority.
Findings
The facility received a re-survey grade of A with no deficiencies identified after review of five resident files and two employee files.
Report Facts
Licensed capacity: 85
Category 1 residents capacity: 63
Category 2 residents capacity: 22
Resident files reviewed: 5
Employee files reviewed: 2
Inspection Report
Annual Inspection
Census: 60
Capacity: 85
Deficiencies: 11
Nov 1, 2013
Visit Reason
This document is a State Licensure annual grading survey conducted from 2013-09-18 to 2013-11-01 to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of C with multiple deficiencies identified including caregiver qualifications, medication management, tuberculosis testing compliance, kitchen sanitation, special diet provision, safety auditory system response, diabetes medication administration, periodic physical exams, and medication administration accuracy.
Severity Breakdown
Level 1: 2
Level 2: 9
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to train newly hired caregivers with appropriate knowledge, skills, and abilities to meet the needs of a legally blind resident, resulting in delayed assistance and improper meal service. | Level 2 |
| Failed to ensure 1 of 5 caregivers completed required initial medication management training. | Level 2 |
| Failed to ensure 5 of 15 employees complied with tuberculosis testing requirements. | Level 2 |
| Failed to ensure kitchen complied with sanitation standards including hair restraint, sanitizer use, and hand soap availability. | Level 1 |
| Failed to provide a diabetic diet to 1 of 15 residents ordered a special diet. | Level 2 |
| Failed to serve a meal in a manner accommodating a legally blind resident's disability, resulting in the resident burning their hand on hot soup. | Level 2 |
| Failed to ensure timely response to auditory call system; resident waited 15 to 30 minutes for assistance after a fall. | Level 2 |
| Failed to maintain accurate documentation of assistance given in administration of injectable insulin for 2 residents. | Level 2 |
| Failed to ensure accurate and current ultimate user agreement for medication administration for 2 residents. | Level 1 |
| Failed to ensure 1 resident received an annual physical examination as required. | Level 2 |
| Failed to ensure 1 resident received medications as prescribed; discrepancies in dosage and missing orders on medication administration record. | Level 2 |
Report Facts
Licensed capacity: 85
Current census: 60
Employee files reviewed: 15
Resident files reviewed: 15
Deficiencies cited: 11
Medication training hours: 16
Medication training classroom hours: 12
Medication training practical hours: 4
Annual medication training hours: 8
Fall assistance wait time: 30
Call button response time: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #15 | Medical Technician | Named in medication management training deficiency and insulin administration documentation |
| Employee #5 | Medical Technician | Interviewed regarding insulin administration assistance |
Inspection Report
Annual Inspection
Census: 60
Capacity: 85
Deficiencies: 10
Sep 18, 2013
Visit Reason
This document is a State Licensure annual grading survey conducted from 9/18/13 to 11/1/13 to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility was found deficient in multiple areas including caregiver qualifications and training, tuberculosis testing compliance, kitchen sanitation, special diet provision, safety requirements, medication administration, and physical examinations. The facility received a grade of C and was required to submit a plan of correction.
Severity Breakdown
Level 1: 3
Level 2: 7
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to train newly hired caregivers with appropriate knowledge, skills, and abilities to meet the needs of a legally blind resident requiring additional assistance. | Level 2 |
| Failed to ensure that one of five caregivers completed initial medication management training as required. | Level 2 |
| Failed to ensure five of fifteen employees complied with tuberculosis testing requirements. | Level 2 |
| Failed to ensure kitchen complied with standards including hair restraints, sanitizer use, and cleanliness. | Level 1 |
| Failed to provide a diabetic diet to one of fifteen residents ordered by a physician. | Level 1 |
| Failed to ensure timely response to call buttons in women's common area bathroom; resident waited up to 30 minutes for assistance. | Level 2 |
| Failed to maintain accurate documentation of assistance given in administration of injectable insulin for two residents. | Level 2 |
| Failed to ensure annual physical examination for one resident. | Level 2 |
| Failed to obtain current ultimate user agreements for two residents. | Level 1 |
| Failed to properly document changes in medication orders and administration of over-the-counter medications and dietary supplements. | Level 2 |
Report Facts
Licensed capacity: 85
Resident census: 60
Residents reviewed: 15
Employees reviewed: 15
Deficiency severity Level 1: 3
Deficiency severity Level 2: 7
Inspection Report
Annual Inspection
Capacity: 85
Deficiencies: 0
Dec 5, 2012
Visit Reason
The inspection was a required grading re-survey conducted as a State Licensure survey on 12/5/2012 to assess compliance with regulatory standards.
Findings
No regulatory deficiencies were identified during the survey. The facility received a re-survey grade of A and no further action was necessary.
Report Facts
Resident files reviewed: 5
Employee files reviewed: 5
Licensed capacity: 85
Category I residents: 63
Category II residents: 22
Inspection Report
Annual Inspection
Census: 58
Capacity: 85
Deficiencies: 8
Sep 13, 2012
Visit Reason
The inspection was conducted as an annual State Licensure survey of the residential facility for elderly and disabled persons.
Findings
The facility received a grade of C with multiple deficiencies identified related to caregiver qualifications, medication management training, personnel files including tuberculosis testing, first aid and CPR certifications, physical exams for residents, medication administration, and resident file maintenance.
Severity Breakdown
1: 1
2: 7
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure caregivers received at least 8 hours of annual training related to resident needs. | 2 |
| Failure to ensure 4 of 15 caregivers completed required medication management training. | 2 |
| Failure to ensure 3 of 15 employees complied with tuberculosis testing requirements. | 2 |
| Failure to ensure 5 of 15 caregivers were trained in first aid and cardiopulmonary resuscitation. | 2 |
| Failure to ensure 2 of 15 residents received a physical exam prior to admission. | 2 |
| Failure to ensure an ultimate user agreement was obtained for 1 of 15 residents. | 1 |
| Failure to ensure timely completion of tuberculosis testing for 6 of 15 residents. | 2 |
| Failure to ensure 3 of 15 caregivers received annual training in elder abuse recognition, prevention, and response. | 2 |
Report Facts
Census: 58
Total Capacity: 85
Caregivers reviewed: 15
Employee training deficiencies: 4
Employees non-compliant with TB testing: 3
Caregivers lacking CPR training: 5
Residents without physical exam: 2
Residents missing TB testing: 6
Caregivers missing elder abuse training: 3
Inspection Report
Annual Inspection
Census: 58
Capacity: 85
Deficiencies: 8
Sep 13, 2012
Visit Reason
This document is the result of an annual State Licensure survey conducted at the facility on 9/13/2012 to assess compliance with state regulations for residential facilities for elderly and disabled persons.
Findings
The facility received a grade of C and multiple deficiencies were identified related to caregiver qualifications, personnel files, resident physical examinations, medication administration, and tuberculosis testing compliance.
Severity Breakdown
1: 1
2: 7
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure that 1 of 15 caregivers received eight hours of annual training. | 2 |
| Failed to ensure that 4 of 15 caregivers completed required medication management training. | 2 |
| Failed to ensure 3 of 15 employees complied with tuberculosis testing requirements. | 2 |
| Failed to ensure 5 of 15 caregivers were trained in first aid and CPR. | 2 |
| Failed to ensure 2 of 15 residents received a physical prior to admission. | 2 |
| Failed to ensure an ultimate user agreement was obtained for 1 of 15 residents. | 1 |
| Failed to ensure 6 of 15 residents complied with tuberculosis testing requirements. | 2 |
| Failed to ensure 3 of 15 caregivers received annual training in recognition, prevention, and response to elder abuse. | 2 |
Report Facts
Caregivers reviewed: 15
Employee files reviewed: 15
Residents reviewed: 15
Facility licensed capacity: 85
Current census: 58
Inspection Report
Annual Inspection
Census: 61
Capacity: 85
Deficiencies: 1
Oct 26, 2011
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at the facility on 10/26/2011.
Findings
The facility received a grade of A. Deficiencies were identified related to food service permits and compliance with NAC 446 standards, including critical violations such as improper use of a handwashing sink and sanitation issues with food storage and equipment cleanliness.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Permits - Comply with NAC 446 on Food Service. The facility failed to ensure the kitchen complied with standards, including use of a handwashing sink as a water glass filler, blocked handwashing sink, and sanitation issues with food storage and equipment. | Severity: 2 |
Report Facts
Resident files reviewed: 15
Employee files reviewed: 15
Discharged resident files reviewed: 1
Deficiency scope: 3
Inspection Report
Annual Inspection
Census: 61
Capacity: 85
Deficiencies: 4
Oct 26, 2011
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at the facility on 10/26/2011.
Findings
The facility received a grade of A but was found deficient in food service permits and compliance with NAC 446 standards. Critical violations included improper use and blockage of handwashing sinks, and cleaning and sanitation issues such as unprotected food storage and soiled equipment and surfaces.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure the kitchen complied with the standards of NAC 446, including use of handwashing sink as water glass filler and blockage of handwashing sink. | Severity: 2 |
| Talapia fillets and mint ice cream were stored unprotected during refrigerator and freezer storage. | Severity: 2 |
| The deli slicer blade sharpener was soiled with food debris. | Severity: 2 |
| Non-food contact surfaces soiled: shelf under walk-in refrigerator condenser, microwave unit on wait staff station, and soda spill under bottom shelf of walk-in refrigerator. | Severity: 2 |
Report Facts
Licensed capacity: 85
Census: 61
Resident files reviewed: 15
Employee files reviewed: 15
Discharged resident files reviewed: 1
Scope: 3
Inspection Report
Annual Inspection
Census: 62
Capacity: 85
Deficiencies: 4
Sep 9, 2010
Visit Reason
This document is the result of an annual grading survey conducted at the facility on 9/9/2010 to assess compliance with state licensure requirements.
Findings
The facility received a grade of A but had several deficiencies including failure to ensure tuberculosis testing, background checks, and first aid/CPR certification for some employees, as well as multiple kitchen sanitation and permit compliance issues.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 15 employees complied with tuberculosis testing requirements. | Severity: 2 |
| Failed to ensure 2 of 15 caregivers met background check requirements. | Severity: 2 |
| Failed to ensure 2 of 15 employees had completed first aid and CPR training, and 1 of 15 had not completed first aid training. | Severity: 2 |
| Failed to ensure the kitchen complied with food service standards, including multiple cleaning and sanitation issues such as raw pork thawing improperly, dirty ice scoop container, soiled dishwasher and kitchen equipment, stained cutting boards, and improper storage of mop. | Severity: 2 |
Report Facts
Employees non-compliant with tuberculosis testing: 2
Employees non-compliant with background checks: 2
Employees non-compliant with first aid/CPR training: 3
Licensed capacity: 85
Census: 62
Inspection Report
Complaint Investigation
Census: 59
Capacity: 85
Deficiencies: 0
Aug 12, 2010
Visit Reason
The inspection was conducted as a result of a complaint investigation between 8/5/10 and 8/12/10 at the facility.
Findings
Complaint #NV00026105 was substantiated, but no deficiencies were cited due to actions taken by the facility.
Complaint Details
Complaint #NV00026105 was substantiated, but no deficiencies were cited due to actions taken by the facility.
Report Facts
Licensed beds: 85
Census: 59
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 23, 2010
Visit Reason
The inspection was conducted as a complaint investigation survey from 7/21 through 7/23/2010, triggered by complaint #NV00025915.
Findings
No regulatory deficiencies were identified during the complaint investigation survey, and the complaint was found to be unsubstantiated. No further action was necessary.
Complaint Details
Complaint #NV00025915 was unsubstantiated.
Inspection Report
Annual Inspection
Census: 66
Capacity: 85
Deficiencies: 3
Sep 3, 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 09/03/2009.
Findings
The facility received a grade of A but had several deficiencies related to tuberculosis testing and medication administration. Deficiencies included failure to ensure employee compliance with TB testing requirements, failure to obtain ultimate user agreements for some residents, and failure to maintain proper resident files regarding TB testing.
Severity Breakdown
Level 2: 2
Level 1: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 3 of 12 employees complied with tuberculosis testing requirements including missing annual Signs and Symptoms TB Check and proof of positive TB skin test. | Level 2 |
| Failed to ensure that an ultimate user agreement was obtained for 3 of 15 residents. | Level 1 |
| Failed to ensure 1 of 15 residents complied with tuberculosis testing requirements, missing proof of positive skin test. | Level 2 |
Report Facts
Residents reviewed: 15
Employee files reviewed: 12
Residents with missing ultimate user agreement: 3
Employees non-compliant with TB testing: 3
Residents non-compliant with TB testing: 1
Inspection Report
Annual Inspection
Census: 74
Capacity: 85
Deficiencies: 7
Sep 4, 2008
Visit Reason
This inspection was conducted as an annual State Licensure survey from 9/2/08 to 9/4/08 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 ensure annual tuberculosis testing for employees, unsanitary kitchen conditions, improper food storage, lack of timely fire drills, inadequate smoke detector testing, missing signed medication assistance agreements for residents, and incomplete discharge documentation for a resident.
Severity Breakdown
Level 1: 5
Level 2: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure 3 of 6 employees met annual tuberculosis testing requirements, with tests initiated six months late. | Level 2 |
| Kitchen floors and walk-in refrigerator/freezer were dirty and needed cleaning; sanitizing solution concentration was too high. | Level 1 |
| Spoiled perishable foods (moldy lemons, soft cucumbers, bruised melon) were not discarded in a timely manner. | Level 2 |
| Monthly evacuation fire drills were not conducted on an irregular schedule for 6 of the past 12 months; missing documentation for multiple months. | Level 1 |
| Smoke detectors, including battery-operated ones in resident rooms, were not tested or maintained properly for 6 of the past 12 months. | Level 1 |
| Facility did not obtain signed written agreements to assist 2 of 14 residents with medication administration; repeat deficiency. | Level 1 |
| Discharge documentation was missing for 1 resident who left the facility, lacking time and date of discharge and notification details. | Level 1 |
Report Facts
Licensed capacity: 85
Current census: 74
Employees reviewed: 11
Resident files reviewed: 15
Discharged resident files reviewed: 1
Deficiencies cited: 7
Sanitizing solution concentration: 400
Months missing fire drill documentation: 6
Months missing smoke detector testing: 6
Residents without signed medication agreements: 2
Inspection Report
Annual Inspection
Census: 74
Capacity: 85
Deficiencies: 7
Sep 2, 2008
Visit Reason
This inspection was conducted as an annual State Licensure survey from 9/2/08 to 9/4/08 to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The survey identified multiple deficiencies including incomplete tuberculosis testing for employees, unclean kitchen conditions, improper food storage, lack of documentation for emergency drills, inadequate smoke detector testing, missing signed ultimate user agreements for medications, and incomplete discharge documentation for residents. Corrective actions and monitoring plans were implemented for each deficiency.
Severity Breakdown
Severity: 1: 4
Severity: 2: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure 3 of 6 employees met annual tuberculosis testing requirements. | — |
| Kitchen equipment and area were not clean; high concentration of Quaternary sanitizing solution. | Severity: 2 |
| Spoiled food was not discarded in a timely manner. | Severity: 2 |
| Lack of documentation for monthly fire drills conducted irregularly over past 6 of 12 months. | Severity: 1 |
| Smoke detectors were not tested during several months in the past year and lacked proper documentation. | Severity: 1 |
| Missing signed ultimate user agreements for medication assistance for 2 residents. | Severity: 1 |
| Discharge documentation was incomplete for 1 resident who left the facility. | Severity: 1 |
Report Facts
Licensed capacity: 85
Census: 74
Employees reviewed: 11
Resident files reviewed: 15
Deficiency severity 1 count: 4
Deficiency severity 2 count: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #7 | Named in tuberculosis testing deficiency | |
| Employee #8 | Named in tuberculosis testing deficiency | |
| Employee #10 | Named in tuberculosis testing deficiency | |
| Facility Food Service Director | Responsible for kitchen cleaning and sanitizing corrective actions | |
| Facility Executive Director | Responsible for monitoring TB testing and fire drill compliance | |
| Facility Maintenance Director | Responsible for monitoring smoke detector testing and fire drill documentation | |
| Facility Community Business Director | Responsible for monitoring resident files and discharge documentation |
Document
Deficiencies: 0
XHUY11 poc
Visit Reason
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Findings
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