Inspection Reports for Better Days Group Home
261 E Eldorado Lane, Las Vegas, NV 89123, NV, 89123
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 3
Dec 24, 2024
Visit Reason
The inspection was conducted as a State Licensure annual survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for a Residential Facility for Groups.
Findings
The facility received a grade of A but had regulatory deficiencies including expired food served to residents, failure to ensure six-month medication reviews were reviewed and initialed by the Administrator within 72 hours for 5 of 9 residents, and failure to ensure primary and secondary infection control staff completed 15 hours of annual infection control training from an approved organization.
Severity Breakdown
Level 2: 2
Level 1: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure food was not expired and suitable for residents; expired potato salad and applesauce were found. | Level 2 |
| Facility failed to ensure six-month Medication Reviews were reviewed and initialed by the Administrator within 72 hours for 5 of 9 residents. | Level 2 |
| Facility failed to ensure primary and secondary infection control staff completed 15 hours of annual infection control training from an approved organization. | Level 1 |
Report Facts
Residents reviewed: 9
Employee files reviewed: 4
Beds licensed: 10
Residents with missing medication review initials: 5
Hours of infection control training required: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Howard Hughes | Administrator | Acknowledged expired food and medication review deficiencies |
| Employee #1 | Owner/Administrator | Designated primary infection control person; lacked documented infection control training |
| Employee #3 | Owner/Manager | Designated secondary infection control person; lacked documented infection control training |
Inspection Report
Re-Inspection
Census: 7
Capacity: 10
Deficiencies: 11
Feb 13, 2024
Visit Reason
This inspection was a State Licensure mandatory grading resurvey conducted in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A with several regulatory deficiencies identified, including issues with health and sanitation, medication administration accuracy, medication destruction, medication storage, resident supervision and treatment, oxygen use, maintenance of resident files, and caregiver training.
Severity Breakdown
F: 4
E: 1
D: 6
Deficiencies (11)
| Description | Severity |
|---|---|
| Health & Sanitation - Maintain interior/exterior premises clean and well maintained. | F |
| Health & Sanitation - All windows and doors used for ventilation must be screened to prevent insect entry. | D |
| Supervision and Treatment of Residents - Facility must collaborate with residents, families, and healthcare providers to develop and review person-centered service plans annually. | F |
| Provision of Dental, Optical and Hearing Care - Staff shall not use restraints or lock residents in rooms. | D |
| Residents Requiring Use of Oxygen - Facility must ensure proper monitoring and safety measures for residents using oxygen. | D |
| Medication Administration - Accuracy & Report - Facility failed to ensure medication destruction for 1 of 7 residents and inaccurate medication administration records. | E |
| Medication - Destruction - Facility failed to destroy discontinued medications properly. | D |
| Administration of Medication Maintenance - Facility failed to maintain accurate Medication Administration Records (MAR) for 1 of 7 residents. | D |
| Medication: Storage - Facility failed to store medications in a locked area or container for 1 of 7 residents. | D |
| Maintenance and Contents of Separate File - Facility must maintain locked, confidential resident files for at least 5 years. | F |
| Unlicensed Caregiver Training - Facility must ensure unlicensed caregivers complete annual infection control training. | F |
Report Facts
Licensed beds: 10
Residents present: 7
Residents reviewed: 7
Employee files reviewed: 3
Severity 2 deficiencies: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Howard Hughes | Administrator | Named as Administrator responsible for facility and corrective actions |
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 10
Dec 18, 2023
Visit Reason
This inspection was conducted as a result of a State Licensure annual survey completed at the facility on 12/18/23, in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found deficient in multiple areas including cleanliness and maintenance of the premises, missing window screens, lack of person-centered service plans for all residents, improper use of full bed rails as restraints, unsecured oxygen tanks, missing medication regimen reviews for several residents, failure to destroy discontinued medications, unsecured medications in the refrigerator, missing Physician Placement Determination forms for multiple residents, and incomplete infection control training for several employees.
Severity Breakdown
Level 2: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Facility failed to ensure premises were clean and well maintained, with excessive weeds and discarded items in the backyard. | Level 2 |
| Resident's bedroom window and bathroom window lacked proper screens. | Level 2 |
| Failed to develop person-centered service plans for 8 of 8 residents. | Level 2 |
| Full bed rails were used as restraints for 1 resident. | Level 2 |
| Oxygen tanks were unsecured in a resident's bedroom closet. | Level 2 |
| Medication regimen review was not completed for 4 of 8 residents. | Level 2 |
| Failed to destroy discontinued medications for 2 residents. | Level 2 |
| Medications were found unsecured in a refrigerator. | Level 2 |
| Failed to obtain Physician Placement Determination forms for 6 of 8 residents. | Level 2 |
| Employees #2, #3, and #4 lacked documented infection control training. | Level 2 |
Report Facts
Licensed capacity: 10
Census: 8
Residents lacking person-centered service plans: 8
Residents lacking medication regimen review: 4
Residents lacking Physician Placement Determination form: 6
Employees lacking infection control training: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Howard Hughes | Administrator | Acknowledged multiple deficiencies including premises maintenance, missing window screens, lack of person-centered service plans, improper use of bed rails, unsecured oxygen tanks, missing medication reviews, failure to destroy discontinued medications, unsecured medications, missing Physician Placement Determination forms, and incomplete infection control training. |
| Employee #2 | Caregiver | Lacked documented infection control training. |
| Employee #3 | Caregiver | Lacked documented infection control training. |
| Employee #4 | Caregiver | Lacked documented infection control training. |
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 4
Dec 29, 2022
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 received a grade of A but had several regulatory deficiencies including unclear medication administration orders, missing tuberculosis testing documentation for residents, incomplete employee background checks, and missing physician orders for medications.
Severity Breakdown
Level 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to clarify the exact amount of medication to be administered for 1 of 9 residents (Resident #2). | Level 2 |
| Failed to ensure 4 of 9 residents had required tuberculosis (TB) testing documentation. | Level 2 |
| Failed to ensure 1 of 6 employees met background check requirements; employee #5 lacked five year renewal fingerprints. | Level 2 |
| Failed to have physician's order on-site and failed to administer medication as prescribed for residents #1 and #3. | Level 2 |
Report Facts
Residents reviewed: 8
Employee files reviewed: 6
Facility licensed capacity: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Howard Hughes | Administrator | Named as Administrator responsible for plan of correction and acknowledged deficiencies |
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 4
Dec 21, 2021
Visit Reason
This inspection was a State licensure annual survey initiated at the facility on 12/21/21 in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to have multiple deficiencies including failure to implement and maintain infection control practices related to COVID-19, incomplete background checks for employees, poor maintenance of the facility interior and exterior, and failure to ensure medication reviews were completed every six months for most residents.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure infection control practices were implemented and maintained in response to the COVID-19 pandemic, including staff not wearing masks and lack of N95 mask stock. | Severity: 2 |
| Failure to ensure one of four employees met background check requirements. | Severity: 2 |
| Failure to maintain the interior and exterior of the facility, including debris in the yard, cracked and peeling flooring, missing transition pieces, holes in walls and foundation, and unsafe cinder block wall. | Severity: 2 |
| Failure to ensure medication reviews were completed every six months for 9 of 10 residents. | Severity: 2 |
Report Facts
Resident files reviewed: 10
Employee files reviewed: 4
Residents lacking medication review: 9
Facility licensed beds: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Howard Hughes | Administrator | Named as responsible for ensuring implementation of plans of correction |
| Employee #1 | Observed not wearing mask properly during infection control survey | |
| Employee #2 | Caregiver | Failed to complete required background check |
Inspection Report
Routine
Census: 8
Capacity: 10
Deficiencies: 1
Dec 9, 2020
Visit Reason
This inspection was a COVID-19 focused infection control State Licensure survey conducted to assess compliance with infection control measures during the pandemic.
Findings
The facility had implemented multiple infection control measures including visitor screening, staff PPE use, and resident social distancing; however, the facility lacked N95 respirators and staff had not been medically cleared or fit tested for N95 masks, constituting a regulatory deficiency.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Administrator failed to ensure safe infection control practices related to COVID-19; facility lacked N95 respirators and staff were not medically cleared or fit tested for N95 masks. | Severity: 2 |
Report Facts
Licensed beds: 10
Census: 8
Inventory counts: 1
Inventory counts: 100
Inventory counts: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Howard Hughes | Administrator | Named as responsible for ensuring plan of correction and oversight of infection control |
Inspection Report
Re-Inspection
Census: 8
Capacity: 10
Deficiencies: 12
Aug 25, 2020
Visit Reason
This inspection was a State Licensure re-survey initiated at the facility on 08/25/2020 in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to have multiple deficiencies related to health and sanitation, laundry and linen services, kitchen equipment, medication administration, medication storage, and maintenance of resident files. The facility received a grade of A despite these deficiencies.
Severity Breakdown
F: 7
D: 3
C: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Health & Sanitation - odors, hazards, insects, dirt - premises must be kept free from offensive odors, hazards, insects, rodents, and accumulations of dirt and refuse. | F |
| Health & Sanitation - Maintain interior and exterior premises clean and well maintained. | F |
| Laundry & Linen Services - Facility must provide laundry services with adequate and sanitary accommodations; laundry room must be separate from food areas and equipment maintained in good repair. | F |
| Kitchens - Equipment must work, be clean and sanitary, and adequate for number of residents. | F |
| Service of Food - Menus must be in writing, planned a week in advance, dated, posted, and kept on file for 90 days. | C |
| Residents Requiring Use of Oxygen - Facility must ensure residents are capable of operating oxygen equipment and safety measures are followed. | F |
| Medication Administration - Failed to ensure medications were given as prescribed to residents #3 and #4. | F |
| Medication/OTCs, Supplements, Change Order - Over-the-counter medications and supplements must be administered per physician's written instructions; medication changes must be documented. | D |
| Administration of Medication Maintenance - Facility must maintain accurate medication administration records including type, date, time, refusals, and instructions. | D |
| Medication Storage - Medication cabinet was unlocked and keys left in the lock, violating storage requirements. | F |
| Medication Storage - Medications must be plainly labeled and kept in original containers until administered. | D |
| Maintenance and Contents of Separate File - Facility must maintain a locked, fire-resistant file for each resident containing all records and evaluations. | F |
Report Facts
Licensed beds: 10
Residents present: 8
Severity level: 2
Scope: 3
Severity level: 2
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Howard J Hughes | Administrator | Signed the report and responsible for plan of correction |
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 12
Feb 26, 2020
Visit Reason
This inspection was a State licensure annual survey initiated at the facility on 02/26/2020 in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to have multiple deficiencies including damaged floors creating trip hazards, poor sanitation and maintenance issues, medication administration errors, unsecured medications, incomplete resident assessments, and failure to maintain accurate medication records. The facility received a grade of D.
Severity Breakdown
Level 1: 1
Level 2: 11
Deficiencies (12)
| Description | Severity |
|---|---|
| Floors throughout the home were damaged, cracked, and could not be properly cleaned and sanitized, creating movement and trip hazards. | Level 2 |
| Facility failed to ensure the interior and exterior were clean and properly maintained, including heavy dirt and dust buildup, soiled furniture, mold-like substances, and clutter. | Level 2 |
| Washer was leaking, soiled, and had heavy lint buildup; laundry room was not maintained in a sanitary manner. | Level 2 |
| Kitchen was not clean or properly maintained with oily countertops, dirty floors, dried food residue on appliances, and dust on refrigerators. | Level 2 |
| Facility failed to post a current menu; posted menu was outdated. | Level 1 |
| Three oxygen tanks were unsecured in a resident's room. | Level 2 |
| Five of eight residents lacked ultimate user agreements for medication administration. | Level 2 |
| Two residents did not receive medications as prescribed; medication administration errors documented. | Level 2 |
| Medication Administration Records (MARs) were incomplete and not initialed for all medications given for two residents. | Level 2 |
| Refrigerated medications were not stored in a locked container; unsecured medications found in residents' rooms and caregiver's room. | Level 2 |
| Over-the-counter medications were not labeled with resident and physician names for one resident. | Level 2 |
| Initial Activities of Daily Living (ADL) assessments were not completed for eight of nine residents; annual assessment completed for only one resident. | Level 2 |
Report Facts
Licensed capacity: 10
Census: 8
Residents reviewed: 8
Employee files reviewed: 5
Deficiencies with severity Level 2: 11
Deficiencies with severity Level 1: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Howard Hughes | Administrator | Named in relation to findings and responsible for plan of correction |
Inspection Report
Re-Inspection
Census: 8
Capacity: 10
Deficiencies: 5
Sep 10, 2019
Visit Reason
The inspection was conducted as a Re-grading State Licensure survey for a Residential Facility for Groups in accordance with Nevada Administrative Code Chapter 449.
Findings
The facility received a grade of A but was cited for multiple deficiencies related to admitting a resident with an open wound without a written exemption, failure to provide a written ultimate user agreement for medication, failure to administer medications per physician's orders, failure to document reasons and results for PRN medications, and failure to secure medications in a locked area.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to request a written exemption to admit and retain a resident with an open wound. | Severity: 2 |
| Facility failed to provide a written ultimate user agreement for medication for a resident. | Severity: 2 |
| Facility failed to ensure medications were administered per physician's orders for two residents. | Severity: 2 |
| Facility failed to ensure a caregiver documented reasons and results for PRN medications for three residents. | Severity: 2 |
| Facility failed to ensure medications were secured in a locked area, including over-the-counter supplements. | Severity: 2 |
Report Facts
Residents present: 8
Licensed capacity: 10
Medications in resident's bucket: 11
Deficiencies cited: 5
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 9
Mar 8, 2019
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to have multiple regulatory deficiencies including failure to maintain updated background checks for employees, poor health and sanitation conditions, lack of posted menus and activity calendars, incomplete physical examinations for residents, medication administration and storage issues, and failure to obtain required Alzheimer's care endorsement for certain residents.
Severity Breakdown
Level 1: 2
Level 2: 6
Level 3: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 3 employees met background check requirements; background check was outdated and not renewed every 5 years. | Level 2 |
| Failed to ensure the interior and exterior premises were clean and well-maintained; kitchen cabinet door missing, grease build-up on oven, dirty microwave, stained shower, and unused furniture outside. | Level 2 |
| Failed to ensure a menu was posted for March 2019. | Level 1 |
| Failed to offer and encourage activities for all 10 residents; no posted activity calendar for March 2019. | Level 3 |
| Failed to post activities calendar for March 2019 in a common area. | Level 1 |
| Failed to ensure 4 of 10 residents received initial and annual physical examinations as required. | Level 2 |
| Failed to ensure medications were written on the Medication Administration Record (MAR) for 2 of 10 residents. | Level 2 |
| Failed to ensure medications were secured; medications found unsecured on resident's bedside table. | Level 2 |
| Failed to obtain required Alzheimer's endorsement for provision of care for 2 of 10 residents with Alzheimer's disease or related dementia. | Level 2 |
Report Facts
Residents present: 10
Total licensed beds: 10
Employees reviewed: 3
Resident files reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Howard Hughes | Administrator | Named as Administrator responsible for compliance and plan of correction |
Inspection Report
Complaint Investigation
Census: 9
Capacity: 10
Deficiencies: 0
Jul 10, 2016
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding an allegation that a staff member treated a resident roughly.
Findings
The investigation included observations, interviews, and chart review, and found no evidence that staff treated residents roughly. No regulatory deficiencies were identified and no action was necessary.
Complaint Details
Complaint #NV00046408 alleged rough treatment of a resident by staff, which could not be substantiated after investigation.
Report Facts
Licensed beds: 10
Residents present: 9
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 3
Jun 1, 2016
Visit Reason
The inspection was conducted as a State Licensure Annual Grading Survey to assess compliance with regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A but had deficiencies including failure to complete background checks for employees and failure to ensure oxygen and medication administration complied with physician orders for several residents.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure background checks were completed for 2 of 4 employees. | Level 2 |
| Failure to ensure oxygen was administered according to physician's orders for 1 of 9 residents. | Level 2 |
| Failure to obtain specific physician instructions for PRN medication administration for 5 of 9 residents. | Level 2 |
Report Facts
Census: 9
Total Capacity: 10
Employees reviewed: 4
Residents reviewed: 9
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 3
Jun 1, 2016
Visit Reason
The inspection was conducted as a State Licensure Annual Grading Survey to assess compliance with regulatory requirements for the facility.
Findings
The facility received a grade of A but had several deficiencies including failure to complete background checks every five years for two employees, failure to ensure oxygen was administered according to physician's orders for one resident, and failure to obtain specific written instructions for as-needed medications for five residents.
Severity Breakdown
2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure a background check was completed every five years for 2 of 4 employees (Employee #1 and #2). | 2 |
| Failure to ensure oxygen was administered in accordance with physician's orders for 1 of 9 residents (Resident #3). | 2 |
| Failure to ensure specific instructions were obtained for medication ordered on an as-needed basis for 5 of 9 residents (Resident #3, #4, #5, #8, and #9). | 2 |
Report Facts
Residents present: 9
Total licensed capacity: 10
Employees reviewed: 4
Resident files reviewed: 9
Residents with PRN medication deficiencies: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Administrator | Named in background check deficiency |
| Employee #2 | Assistant Administrator / relief caregiver | Named in background check deficiency and oxygen administration deficiency |
| Employee #3 | Caregiver | Named in oxygen administration deficiency and PRN medication deficiency |
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 2
May 20, 2015
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 5/20/15 at the facility.
Findings
The facility received a grade of A. Deficiencies were identified related to incomplete and inaccurate resident records and failure to ensure proper tuberculosis testing documentation for 5 of 10 residents.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Administrator failed to keep 1 of 10 resident records complete and accurate. | Severity: 2 |
| Facility failed to ensure 5 of 10 residents met the requirements for Tuberculosis (TB) testing, lacking documented evidence of two-step TB tests and annual TB tests. | Severity: 2 |
Report Facts
Resident records reviewed: 10
Employee files reviewed: 5
Residents with TB testing deficiencies: 5
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 2
May 20, 2015
Visit Reason
This inspection was conducted as an annual State Licensure survey to assess compliance with regulatory requirements for a residential facility for group beds for elderly and disabled persons and/or persons with mental illness.
Findings
The facility received a grade of A but was found deficient in maintaining complete and accurate resident records for one resident and in ensuring tuberculosis testing compliance for five residents. The administrator failed to keep one resident's records complete and accurate, and five residents lacked required tuberculosis testing documentation.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Administrator failed to keep 1 of 10 resident records complete and accurate (Resident #1). | Severity: 2 |
| Facility failed to ensure 5 of 10 residents met tuberculosis testing requirements, including lack of two-step TB tests and signs and symptoms screening. | Severity: 2 |
Report Facts
Resident files reviewed: 10
Employee files reviewed: 5
Residents with TB testing deficiencies: 5
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 3
Jun 9, 2014
Visit Reason
This Statement of Deficiencies was generated as a result of an annual grading State Licensure survey conducted in the facility on 6/9/14 and finalized on 6/11/14.
Findings
The facility received a grade of A. Deficiencies were identified related to health and sanitation (window screens), restriction on use of restraints, and medication administration including documentation and proper orders.
Severity Breakdown
Severity: 2: 4
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure windows of 2 of 8 residents were screened to prevent entry of insects. | Severity: 2 |
| Facility failed to ensure 1 of 8 residents had bed rails with a form of restraint. | Severity: 2 |
| Facility failed to ensure medication administration and documentation were accurate and complete for multiple residents, including failure to write medication orders and proper MAR documentation. | Severity: 2 |
Report Facts
Residents reviewed: 8
Employee files reviewed: 5
Licensed capacity: 10
Current census: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Acknowledged windows needed screens and stated verification with physician for medication | |
| Employee #5 | Stated windows never had screens and acknowledged missing 'as needed' medication documentation |
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 7
Jun 12, 2013
Visit Reason
The inspection was an annual grading State Licensure survey conducted to assess compliance with state regulations for a residential facility for elderly or disabled persons.
Findings
The facility received a grade of B with multiple deficiencies identified including personnel file issues related to tuberculosis testing, health and sanitation problems such as unclean premises and malfunctioning equipment, temperature regulation issues, fire safety concerns, medication destruction failures, and resident file maintenance deficiencies.
Severity Breakdown
Severity: 2: 5
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 5 employees complied with tuberculosis testing requirements. | Severity: 2 |
| Premises were not clean and well maintained; issues included dirty oven, inoperable dishwasher, unclean toilets, ants, missing door handle, mold, lint buildup, falling screen door, inoperable washer and dryer, tripping hazards, and urine odor. | Severity: 2 |
| Facility interior temperature was not maintained within required range (68-82 degrees Fahrenheit). | Severity: 2 |
| Failed to ensure 2 of 3 emergency lights illuminated when tested. | — |
| Facility did not destroy discontinued, expired, or transferred resident medications; eight medications found in medicine cupboard. | Severity: 2 |
| Failed to ensure 1 of 10 residents complied with tuberculosis testing requirements. | Severity: 2 |
| Administrator failed to ensure 1 of 5 employees received annual training on elder abuse recognition, prevention, and response. | — |
Report Facts
Census: 10
Total Capacity: 10
Employees reviewed: 5
Resident files reviewed: 10
Medications found: 8
Emergency lights failed: 2
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 3
Jun 19, 2012
Visit Reason
The 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 mental illness.
Findings
The facility received a grade of A but was found deficient in several areas including failure to ensure one resident received an annual physical examination, failure to maintain resident files in a secure location, and failure to ensure tuberculosis testing compliance for two residents. Some deficiencies were repeat findings from prior surveys.
Severity Breakdown
Severity: 1: 1
Severity: 2: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure one of ten residents received an annual physical examination. | Severity: 2 |
| Failure to ensure resident files were stored in a secure location. | Severity: 1 |
| Failure to ensure two residents complied with tuberculosis testing requirements. | Severity: 2 |
Report Facts
Residents present: 10
Licensed capacity: 10
Resident files reviewed: 10
Employee files reviewed: 5
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 3
Jun 19, 2012
Visit Reason
This document is a State Licensure survey conducted as a grading re-survey and annual inspection of the Better Days Group Home facility on 6/19/2012.
Findings
The facility received a grade of A but had several deficiencies including failure to ensure one resident received an annual physical examination, failure to store resident files securely, and failure to ensure tuberculosis testing compliance for two residents. Some deficiencies were repeat findings from prior surveys.
Severity Breakdown
Severity: 1: 1
Severity: 2: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 10 residents received an annual physical examination (Resident #8 - Unable to provide evidence of an initial physical examination). | Severity: 2 |
| Failed to ensure resident files were stored in a secure location (Files of former residents were stored in an unlocked cabinet in the laundry room). | Severity: 1 |
| Failed to ensure 2 of 10 residents complied with tuberculosis testing requirements (Resident #4 and Resident #8 unable to provide evidence of required two-step TB tests). | Severity: 2 |
Report Facts
Residents reviewed: 10
Employee files reviewed: 5
Facility licensed capacity: 10
Current census: 10
Inspection Report
Complaint Investigation
Capacity: 10
Deficiencies: 3
Jan 12, 2012
Visit Reason
This visit was conducted as a complaint investigation following Complaint #NV00030246, which was substantiated.
Findings
The facility failed to notify a family member following an injury to a resident, failed to request emergency medical services when necessary, and failed to ensure an incident report was generated for a resident following an injury.
Complaint Details
Complaint #NV00030246 was substantiated based on interviews and evidence that the facility did not notify a family member, did not request emergency services, and did not generate an incident report for Resident #1 following an injury.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure a family member of the resident was notified following an injury. | Severity: 2 |
| Failed to request emergency medical services when necessary following an injury. | Severity: 2 |
| Failed to ensure an incident report was generated for a resident following an injury. | Severity: 2 |
Report Facts
Licensed capacity: 10
Severity level 2 deficiencies: 3
Inspection Report
Complaint Investigation
Capacity: 10
Deficiencies: 3
Jan 12, 2012
Visit Reason
This inspection was conducted as a complaint investigation following Complaint #NV00030246 at Better Days Group Home.
Findings
The facility was found deficient in ensuring family members were notified following a resident injury, obtaining emergency medical services when necessary, and generating incident reports for injuries. These deficiencies were substantiated during the investigation.
Complaint Details
Complaint #NV00030246 was substantiated based on failures related to notification of family, emergency services, and incident reporting for Resident #1.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure a family member of the resident was notified following an injury (Resident #1). | Severity: 2 |
| Failed to ensure emergency medical services were obtained for a resident following an injury (Resident #1). | Severity: 2 |
| Failed to ensure an incident report was generated for a resident following an injury (Resident #1). | Severity: 2 |
Report Facts
Licensed capacity: 10
Inspection Report
Enforcement
Deficiencies: 0
Nov 8, 2011
Visit Reason
The Bureau conducted a grading resurvey at Better Days Group Home on 11/8/11 to assess deficiencies and impose sanctions based on prior survey findings.
Findings
The facility received a grade of C for their survey, and sanctions including monetary penalties were imposed due to repeat deficiencies. The Plan of Correction submitted was deemed acceptable.
Report Facts
Monetary Penalties: 300
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna C. McCafferty | Health Facilities Surveyor III | Signed the enforcement notice imposing sanctions. |
Inspection Report
Re-Inspection
Census: 8
Capacity: 10
Deficiencies: 7
Nov 8, 2011
Visit Reason
This document is a Statement of Deficiencies generated as a result of a required grading re-survey conducted on 11/8/11 at Better Days Group Home, a residential facility for elderly and disabled persons. The visit was to assess compliance with state licensure regulations and to assign a re-survey grade.
Findings
The facility received a re-survey grade of C with multiple deficiencies identified, including failure to display the grading placard conspicuously, inadequate maintenance of premises, failure to provide scheduled activities, improper admission policy enforcement, failure to ensure physical examinations, medication administration errors, and improper resident file storage. Several deficiencies were repeat findings from prior surveys.
Severity Breakdown
1: 3
2: 4
Deficiencies (7)
| Description | Severity |
|---|---|
| Administrator failed to display the grading placard conspicuously in a public area as required. | 2 |
| Facility premises were not clean and well maintained, including hall vents, patio ceiling plaster, closet doors creating hazards. | 2 |
| Failed to provide at least 10 hours of scheduled activities for 8 of 8 residents; activities calendar was posted but no activities observed. | 1 |
| Failed to ensure 3 of 10 residents were not restrained with full side bed rails as required by admission policy. | 2 |
| Failed to ensure 1 of 8 residents received a physical examination as required. | 2 |
| Failed to ensure 1 of 7 residents received medications as prescribed; medication administration record showed empty bottle and missing doses. | 2 |
| Failed to maintain resident files in a locked place protected from unauthorized use; files were kept on a desk in hallway. | 1 |
Report Facts
Census: 8
Total Capacity: 10
Severity 1 Deficiencies: 3
Severity 2 Deficiencies: 4
Inspection Report
Re-Inspection
Census: 8
Capacity: 10
Deficiencies: 7
Nov 8, 2011
Visit Reason
This document is a State Licensure re-survey conducted on 11/8/2011 to assess compliance with regulatory requirements following a prior survey.
Findings
The facility received a re-survey grade of C with multiple deficiencies identified including failure to display the grading placard properly, inadequate maintenance and cleanliness of premises, insufficient scheduled activities for residents, improper use of restraints, failure to ensure annual physical examinations, medication administration errors, and unsecured resident files.
Severity Breakdown
Severity: 1: 2
Severity: 2: 4
Deficiencies (7)
| Description | Severity |
|---|---|
| Administrator failed to ensure the grading placard was displayed conspicuously in a public area. | Severity: 2 |
| Facility failed to ensure the premises were clean and well maintained, including dirty hallway vents, damaged patio ceiling plaster, and closet doors off railing creating hazards. | Severity: 2 |
| Facility failed to provide at least 10 hours of scheduled activities for residents. | Severity: 1 |
| Facility failed to ensure 3 of 10 residents were not restrained with full side bed rails as required. | Severity: 2 |
| Facility failed to ensure 1 of 8 residents received a required physical examination. | Severity: 2 |
| Facility failed to ensure 1 of 7 residents received medications as prescribed; medication bottle was empty and not refilled. | Severity: 2 |
| Facility failed to ensure 8 of 8 resident files were kept in a locked place protected from unauthorized use. | Severity: 1 |
Report Facts
Licensed capacity: 10
Census: 8
Residents reviewed: 8
Employee files reviewed: 3
Residents not restrained properly: 3
Residents without physical exam: 1
Residents with medication error: 1
Resident files unsecured: 8
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 15
May 12, 2011
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 05/12/2011 at Better Days Group Home.
Findings
The facility was found deficient in multiple areas including personnel files, tuberculosis testing, background checks, health and sanitation, first aid and CPR training, activities for residents, medication plans, and resident file storage. The facility received a grade of D.
Severity Breakdown
1: 4
2: 11
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 5 employees complied with tuberculosis testing requirements. | 2 |
| Failed to ensure 3 of 5 employees had evidence of fingerprints in background check files; repeat deficiency. | 2 |
| Failed to maintain a safe and sufficient water and sewer system; water was turned off due to non-payment. | 2 |
| Failed to keep premises clean and well maintained; water leak in kitchen and kitchen flooring needed replacement. | 2 |
| Failed to provide at least 24 inches of closet space for 2 of 8 residents. | 2 |
| Failed to ensure 1 of 5 caregivers received first aid and CPR training within 30 days of employment. | 2 |
| Failed to provide at least 10 hours of scheduled activities for 8 of 8 residents; repeat deficiency. | 1 |
| Failed to ensure 4 of 8 residents received a physical examination before admission or annually. | 2 |
| Failed to prepare a medication plan including all required components. | 1 |
| Failed to obtain physician orders to administer OTC medications to 1 of 8 residents. | 2 |
| Failed to ensure 2 of 8 residents received medications as prescribed. | 2 |
| Failed to ensure 8 of 8 resident files were kept in a locked place protected from unauthorized use. | 1 |
| Failed to ensure 3 of 8 residents had required tuberculosis testing documentation. | 2 |
| Failed to ensure 2 of 5 employees received 8 hours of mental illness training within 60 days of employment. | 2 |
| Failed to ensure 2 of 5 employees received 4 hours of chronic illness training within 60 days of employment. | 2 |
Report Facts
Census: 8
Total Capacity: 10
Deficiencies cited: 15
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 16
May 12, 2011
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at Better Days Group Home on 5/12/2011 to assess compliance with state regulations for residential facilities.
Findings
The facility received a grade of D and was found deficient in multiple areas including personnel files, tuberculosis testing, background checks, health and sanitation, medication administration, resident file security, and staff training. Several deficiencies were repeat findings from prior surveys.
Severity Breakdown
Level 1: 3
Level 2: 12
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 5 employees complied with tuberculosis testing requirements prior to employment. | Level 2 |
| Failed to ensure 3 of 5 employees met background check requirements; repeat deficiency. | Level 2 |
| Failed to maintain a safe and sufficient water and sewer system; water was turned off due to non-payment. | Level 2 |
| Failed to keep premises free of insects and rodents; ants observed in kitchen. | Level 2 |
| Failed to ensure premises were clean and well maintained; water leak in kitchen and flooring needed replacement. | Level 2 |
| Failed to provide at least 24 inches of closet space for hanging garments for 2 of 8 residents. | — |
| Failed to ensure 1 of 5 caregivers received first aid and CPR training within 30 days of employment. | Level 2 |
| Failed to provide at least 10 hours of scheduled activities for all 8 residents; repeat deficiency. | Level 1 |
| Failed to ensure 4 of 8 residents received physical examinations before admission or annually. | Level 2 |
| Failed to prepare a medication plan including all required components. | Level 1 |
| Failed to obtain physician orders for over-the-counter medication for 1 of 8 residents. | Level 2 |
| Failed to ensure 2 of 8 residents received medications as prescribed. | Level 2 |
| Failed to keep 8 of 8 resident files locked and protected from unauthorized use. | Level 1 |
| Failed to ensure 3 of 8 residents complied with tuberculosis testing requirements. | Level 2 |
| Failed to ensure 2 of 5 employees received 8 hours of mental illness training within 60 days of employment. | Level 2 |
| Failed to ensure 2 of 5 employees received 4 hours of chronic illness training within 60 days of employment. | Level 2 |
Report Facts
Residents present: 8
Total licensed capacity: 10
Employees reviewed: 5
Resident files reviewed: 8
Deficiency repeat count: 2
Inspection Report
Complaint Investigation
Census: 10
Capacity: 10
Deficiencies: 5
Jul 26, 2010
Visit Reason
The inspection was conducted as a result of a complaint investigation and a State Licensure survey on 07/26/2010 at Better Days Group Home, a residential facility for elderly and disabled persons.
Findings
Multiple deficiencies were identified including hazards impeding free movement, failure to document menu substitutions, inadequate nutritional portions, lack of scheduled activities, and improper medication administration procedures.
Complaint Details
Complaint #25603 was substantiated.
Severity Breakdown
1: 1
2: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| The premises were not free of hazards including obstacles and pests outside the facility. | 2 |
| Failure to document and retain menu substitutions for at least 90 days; posted menus not followed. | 1 |
| Facility failed to provide a reasonable portion of daily dietary allowances for residents. | 2 |
| Facility failed to provide at least 10 hours of scheduled activities per week for residents. | 2 |
| Facility failed to comply with medication administration requirements for one resident, lacking a medical assessment from a licensed physician. | 2 |
Report Facts
Census: 10
Total Capacity: 10
Severity 1 Deficiencies: 1
Severity 2 Deficiencies: 4
Scope: 3
Scope: 1
Inspection Report
Complaint Investigation
Census: 10
Capacity: 10
Deficiencies: 5
Jul 26, 2010
Visit Reason
This inspection was conducted as a result of a complaint investigation at Better Days Group Home on 7/26/2010.
Findings
The facility was found to have multiple deficiencies including hazards on the premises, undocumented menu substitutions, inadequate nutritional portions for residents, lack of scheduled activities, and failure to comply with medication administration requirements.
Complaint Details
Complaint #25603 was substantiated.
Severity Breakdown
Severity: 1: 1
Severity: 2: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure the premises was clear of hazards, including obstacles that could breed mice, rats, bugs and other pests outside the facility. Excessive broken furniture, wheel chairs, old beds piled on the outside patio. | Severity: 2 |
| Facility failed to ensure menu substitutions were documented and retained for at least 90 days. Menus posted were not followed and food prepared did not match the menu. | Severity: 1 |
| Facility failed to provide a reasonable portion of the daily dietary allowances recommended for 10 of 10 residents. The caregiver stated residents do not eat much and doctors advised limited intake. | Severity: 2 |
| Facility failed to provide at least 10 hours of scheduled activities suited to residents' interests and capacities. Caregiver admitted no activities except watching TV. | Severity: 2 |
| Facility failed to comply with medication administration requirements as 1 of 10 residents' medications required a medical assessment from a licensed physician before administering. | Severity: 2 |
Report Facts
Licensed beds: 10
Residents present: 10
Residents affected: 10
Residents affected: 10
Residents affected: 1
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 8
Mar 29, 2010
Visit Reason
This document is the result of an annual State Licensure survey conducted on 3/29/2010 to assess compliance with state regulations for the Better Days Group Home, a residential facility for elderly and disabled persons.
Findings
The facility received a grade of D with multiple deficiencies including failure to properly endorse care for residents with mental and chronic illness, incomplete tuberculosis testing for employees, inadequate background checks, lack of current first aid and CPR certifications, improper bedroom door locks, missed emergency evacuation drills, untested smoke detectors, and unsecured oxygen tanks.
Severity Breakdown
2: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility was caring for 1 of 10 persons with mental illness and chronic illness without an endorsement and failed to obtain necessary training. | 2 |
| Failed to ensure 5 of 5 employees complied with tuberculosis testing requirements. | 2 |
| Failed to ensure 4 of 5 employees met background check requirements; repeat deficiency from prior year. | 2 |
| Failed to ensure 3 of 5 employees renewed training in first aid and CPR. | 2 |
| One of four resident bedrooms had a double motion and sliding latch lock not compliant with regulations; repeat deficiency. | 2 |
| Facility did not ensure monthly evacuation drills were conducted on an irregular schedule for 1 of 12 months (February 2010). | 2 |
| Facility did not ensure smoke detectors were tested 2 out of the past 12 months (January and February 2010). | 2 |
| Facility failed to secure an oxygen tank in a rack or to the wall. | 2 |
Report Facts
Licensed beds: 10
Current census: 9
Employee files reviewed: 5
Resident files reviewed: 9
Discharged resident files reviewed: 1
Repeat deficiencies: 2
Inspection Report
Re-Inspection
Capacity: 8
Deficiencies: 0
Jun 2, 2009
Visit Reason
This Statement of Deficiencies was generated as a result of a required grading re-survey conducted in the facility on 6/2/09 under the authority of NRS 449.150.
Findings
The facility received a grade of A. It is licensed for eight Residential Facility for Group beds for elderly and disabled persons, with three beds Category I and five beds Category II residents. No deficiencies requiring further action were cited.
Report Facts
Licensed beds: 8
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 7
Mar 25, 2009
Visit Reason
The inspection was an annual State Licensure survey conducted 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 training, personnel background checks, bedroom door locks, medication administration, medication container storage, and resident file maintenance. Several caregivers did not meet training requirements, and some residents did not receive medications as prescribed.
Complaint Details
Complaint #21421 was unsubstantiated.
Severity Breakdown
Level 1: 1
Level 2: 6
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to ensure 5 of 5 caregivers received eight hours of annual training. | Level 2 |
| Facility failed to ensure 1 of 5 caregivers completed required initial three-hour medication management training. | Level 2 |
| Facility failed to ensure 4 of 5 caregivers had proof of negative criminal history background checks. | Level 2 |
| Facility failed to ensure all bedroom doors maintained single motion locks. | Level 1 |
| Facility failed to ensure 3 of 7 residents received medications as prescribed. | Level 2 |
| Facility failed to keep medications for 7 of 7 residents in original containers until administered. | Level 2 |
| Facility failed to ensure 1 of 7 residents complied with tuberculosis screening requirements. | Level 2 |
Report Facts
Residents present: 7
Licensed capacity: 8
Caregivers reviewed: 5
Employee files reviewed: 5
Residents reviewed for medication compliance: 7
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 7
Mar 25, 2009
Visit Reason
This annual State Licensure survey was conducted on March 25, 2009, to assess compliance with state regulations for the Better Days Group Home.
Findings
The facility was found deficient in multiple areas including caregiver training, medication management, personnel background checks, bedroom door locks, medication container storage, and resident file maintenance. Several deficiencies were repeated from a prior survey.
Complaint Details
Complaint #21421 was unsubstantiated.
Severity Breakdown
Level 1: 1
Level 2: 6
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure 5 of 5 caregivers received eight hours of annual training. | Level 2 |
| Failed to ensure 1 of 5 caregivers completed required initial three hour medication management training. | Level 2 |
| Failed to ensure 4 of 5 caregivers had proof of negative criminal history background checks on file. | Level 2 |
| Failed to ensure all bedroom doors maintained single motion locks. | Level 1 |
| Failed to ensure 3 of 7 residents received medications as prescribed. | Level 2 |
| Failed to keep medications belonging to 7 of 7 residents in their original container. | Level 2 |
| Failed to ensure 1 of 7 residents complied with tuberculosis regulations affecting all residents. | Level 2 |
Report Facts
Residents present: 7
Total licensed capacity: 8
Caregivers reviewed: 5
Residents reviewed: 7
Loading inspection reports...
