Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 0
May 20, 2025
Visit Reason
This inspection was conducted as an annual State Licensure survey 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. Eight resident files and three employee files were reviewed, and no further action is necessary.
Inspection Report
Complaint Investigation
Census: 8
Deficiencies: 2
Oct 10, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by two complaints, one of which was substantiated, to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The investigation identified regulatory deficiencies including failure to complete background checks for employees, allowing an employee with a disqualifying background check to work, and inadequate incontinence care for a resident at night. The facility received a grade of A despite these findings.
Complaint Details
Two complaints were investigated. Complaint #NV00071931 was substantiated with deficiencies found. Complaint #NV00071703 was substantiated with no deficient practice.
Severity Breakdown
Level 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure background checks were completed for 2 of 6 employees and allowing an employee with a disqualifying background check to continue working. | Level 2 |
| Failure to provide adequate incontinence care at night for a resident requiring assistance, resulting in the resident being required to wear two incontinence briefs and hold urine. | Level 2 |
Report Facts
Complaints investigated: 2
Complaints substantiated: 1
Sample size: 5
Employee files reviewed: 6
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 2
May 14, 2024
Visit Reason
The inspection was conducted as an annual State Licensure inspection of the residential facility for groups, in accordance with Nevada Administrative Code Chapter 449.
Findings
The facility received a grade of A. Deficiencies were identified related to caregiver medication management training and resident activities of daily living (ADL) assessments upon admission.
Severity Breakdown
2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 5 employees received eight hours of annual medication management training for 2023 and 2024. | 2 |
| Facility failed to ensure 2 of 9 residents had an activities of daily living (ADL) assessment upon admission (Residents #6 and #7). | 2 |
Report Facts
Number of residents present: 9
Total licensed capacity: 10
Number of employee files reviewed: 5
Number of resident files reviewed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ginalyn Baltazar | Administrator | Named as Administrator and involved in corrective actions |
| Employee #1 | Failed to have documented evidence of annual medication management training |
Inspection Report
Complaint Investigation
Census: 8
Capacity: 10
Deficiencies: 1
Mar 25, 2024
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #NV00070685, which was substantiated. The investigation included observations, interviews, clinical record reviews, employee file reviews, and document reviews related to resident care and safety.
Findings
The facility failed to provide protective supervision to two residents who eloped from the facility. Employee #3 turned off the door alarm and was asleep during the incident, leading to elopement. The employee was terminated for unsatisfactory performance and policy violations. The facility implemented corrective actions including checking and replacing alarms, installing signage, conducting staff training on elopement, and instituting routine safety checks every two hours.
Complaint Details
Complaint #NV00070685 was substantiated. The complaint involved elopement of two residents due to failure of supervision and alarm system misuse by Employee #3. The employee was terminated and corrective actions were implemented.
Severity Breakdown
Severity: 3: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide protective supervision to two residents who eloped from the facility. | Severity: 3 |
Report Facts
Licensed capacity: 10
Census: 8
Sample size: 5
Complaint count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ginalyn Baltazar | Administrator | Named as the new administrator who ensured alarms were checked and replaced, and training was conducted |
| Employee #3 | Sole caregiver during elopement incident, terminated for unsatisfactory performance and policy violations | |
| Medication Technician | Med Tech | Reported on the elopement incident and failure to notify physician or responsible parties |
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 0
Dec 6, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 2023-11-29 and completed on 2023-12-06.
Findings
No regulatory deficiencies were identified during the investigation. The complaint #NV00069879 could not be verified, and no further action was necessary.
Complaint Details
One complaint was investigated (Complaint #NV00069879) and was not substantiated.
Report Facts
Sample size: 8
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 2
Aug 15, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 2023-07-03 and completed on 2023-08-15, involving two complaints regarding the facility's compliance with Nevada Administrative Code (NAC) Chapter 449.
Findings
Two complaints were investigated; one could not be verified and the other was verified but no regulatory deficiencies were identified. However, regulatory deficiencies were found related to incomplete personnel files for one employee and failure to ensure approved bedfast waivers for two residents who were bedfast.
Complaint Details
Complaint #NV00068696 could not be verified with no regulatory deficiencies identified. Complaint #NV00068856 was verified with no regulatory deficiencies identified. The investigation included observations, interviews, record reviews, and document reviews.
Severity Breakdown
Level 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Administrator failed to ensure 1 of 4 sampled employees had a completed personnel file, lacking required background checks and training documentation. | Level 2 |
| Facility failed to ensure 2 of 3 sampled residents who were bedfast had approved bedfast waivers or submitted applications for waivers. | Level 2 |
Report Facts
Sample size: 3
Sample size: 4
Number of complaints investigated: 2
Inspection Report
Routine
Census: 9
Capacity: 10
Deficiencies: 9
Aug 3, 2023
Visit Reason
Mandatory grading resurvey conducted in accordance with Nevada Administrative Code Chapter 449 for a residential facility licensed for persons with Alzheimer Disease.
Findings
The facility received a grade of A but had several regulatory deficiencies including incomplete administrator records, staffing schedule issues, lack of CPR recertification for one employee, posting requirements not met, medication administration and storage deficiencies, maintenance of resident files, and Alzheimer’s care safety standards violations.
Severity Breakdown
F: 6
D: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Administrator failed to ensure that the records of the facility are complete and accurate. | F |
| Administrator failed to maintain a monthly written staffing schedule including number and type of staff per shift. | D |
| Personnel file for one caregiver lacked documented evidence of CPR recertification. | D |
| Failure to post license, rates for services, and contact information in a conspicuous place. | F |
| Failure to maintain proper medication administration records including type, date/time, refusals, and instructions. | D |
| Medication storage not compliant with requirements for locked, cool, dry areas and separation of external use medications. | F |
| Failure to maintain separate locked resident files with required information and confidentiality safeguards. | F |
| Failure to ensure knives, matches, firearms, tools and other dangerous items are inaccessible to residents. | F |
| Failure to ensure toxic substances are not accessible to residents. | F |
Report Facts
Licensed beds: 10
Residents present: 9
Employees reviewed: 5
Residents files reviewed: 5
Severity level 2 deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #4 | Caregiver | Failed to have documented CPR recertification |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 8
May 17, 2023
Visit Reason
This 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
The facility was found deficient in multiple areas including incomplete employee personnel files, lack of a maintained staffing schedule, missing medication administration records for some residents, improper medication and toxic substance storage, incomplete resident files, and failure to secure sharp objects and toxic substances from residents. The facility received a grade of D.
Severity Breakdown
2: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Administrator failed to ensure 4 of 5 sampled employees had completed personnel files including background checks, physical exams, tuberculosis testing, and required training. | 2 |
| Facility failed to maintain a monthly written staffing schedule listing number and types of staff assigned to each shift. | 2 |
| Facility failed to post signage indicating the designee in absence of the Administrator. | 2 |
| Medication Administration Records (MAR) were not available for 2 of 9 residents due to system transition issues. | 2 |
| Medications, including over-the-counter allergy medication, were stored unlocked and accessible to residents. | 2 |
| Resident files for 5 of 9 residents were incomplete, missing required assessments, exams, tuberculin tests, signed agreements, and resident rights documentation. | 2 |
| Sharp objects such as razors were accessible to residents and not secured in a locked area. | 2 |
| Toxic substances including Zinc Oxide, Hydrogen Peroxide, and shoe polish were accessible to residents and not properly secured. | 2 |
Report Facts
Facility licensed beds: 10
Resident census: 9
Employee files reviewed: 5
Resident files reviewed: 9
Deficiency severity level 2 count: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Theresa Brushfield | Assistant to Administrator | Signed the Statement of Deficiencies report |
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 0
May 12, 2022
Visit Reason
This inspection was conducted as an annual State Licensure and infection control survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the inspection. The facility received a grade of A and was provided guidance on nondiscrimination, privacy, cultural competency, and complaint policies.
Report Facts
Resident files reviewed: 8
Employee files reviewed: 5
Inspection Report
Re-Inspection
Census: 9
Capacity: 10
Deficiencies: 8
Nov 12, 2021
Visit Reason
This inspection was a grading resurvey conducted in the facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility received a grade of A with no regulatory deficiencies noted. The premises were found to be clean and well maintained, and the facility complied with requirements for personnel files, admissions policies, medical care, resident file maintenance, and Alzheimer's care standards.
Severity Breakdown
F: 4
D: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Administrator's Responsibilities - Oversight - NAC 449.194 Responsibilities of administrator. | F |
| Personnel File - TB Screening - NAC 449.200 Personnel files must include health certificates. | D |
| Health & Sanitation - Maintain Int/ext - NAC 449.209 Health and sanitation. | F |
| Written Policy on Admissions - NAC 449.2702 Written policy on admissions; eligibility for residency. | D |
| Medical Care of Resident After Illness - NAC 449.274 Medical care of resident after illness, injury or accident. | D |
| Maintenance and Contents of Separate File - NAC 449.2749 Maintenance and contents of separate file for each resident. | D |
| Alzheimer’s Care - NAC 449.2754 Residential facility which provides care to persons with Alzheimer’s disease: Application for endorsement; general requirements. | F |
| Alzheimer’s Care Standards for Safety - NAC 449.2756 Standards for safety; personnel required; training for employees. | F |
Report Facts
Licensed bed capacity: 10
Resident census: 9
Report
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Bella
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Home
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Sanction_Sanction
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signed.pdf
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