Inspection Report
Renewal
Census: 54
Capacity: 74
Deficiencies: 3
May 14, 2025
Visit Reason
This inspection was conducted as a regrading State Licensure survey for renewal of the facility's license, in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. Deficiencies were identified related to failure to ensure timely annual physical examinations for one resident, failure to have prescribed medications onsite for five residents, and failure to notify physicians of missed medications for four residents.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure an annual general physical examination with a review of systems was completed timely for 1 of 9 sampled residents (Resident #1). | Level 2 |
| Failure to ensure medications were onsite to administer the prescribed dosage for 5 of 9 sampled residents (Residents #4, #5, #6, #8, and #9). | Level 2 |
| Failure to notify the physician of missed medications for 4 of 9 sampled residents (Residents #4, #5, #8, and #9). | Level 2 |
Report Facts
Residents sampled: 9
Missed medication residents: 5
Residents with missed physician notification: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Molly Ratfield | Executive Director | Signed the report and mentioned as responsible for oversight in corrective actions |
Inspection Report
Annual Inspection
Census: 51
Capacity: 74
Deficiencies: 8
Jan 16, 2025
Visit Reason
The inspection was conducted as a result of a State Licensure annual grading survey combined with a complaint investigation regarding alleged theft and housekeeping services.
Findings
The facility received a grade of B with multiple deficiencies identified including failure to ensure annual physical exams, medication reviews, proper medication destruction, accurate medication administration records, secure medication storage, completion of ADL assessments, availability of current hospice plans of care, and posting of nondiscrimination complaint information. The complaint allegations of theft and insufficient housekeeping were not substantiated due to lack of evidence.
Complaint Details
The complaint alleging a resident had money stolen from their room and that housekeeping services were insufficient was investigated but could not be substantiated due to lack of evidence.
Severity Breakdown
Level 1: 2
Level 2: 6
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure an annual general physical exam was completed for 1 of 15 sampled residents (Resident #11). | Level 2 |
| Failed to ensure medication reviews were conducted at least every six months for 1 of 15 sampled residents (Resident #11). | Level 2 |
| Failed to ensure discontinued medication was destroyed for 1 of 15 sampled residents (Resident #12). | Level 2 |
| Failed to ensure the Medication Administration Record (MAR) was accurate for 1 of 15 sampled residents (Resident #12). | Level 1 |
| Failed to ensure medications were secured for 1 of 9 residents authorized for self-administration (Room #A107). | Level 2 |
| Failed to ensure an Activities of Daily Living (ADL) Assessment was completed upon admission for 1 of 15 residents (Resident #15). | Level 2 |
| Failed to ensure a current hospice Plan of Care was onsite and available for 1 of 2 sampled hospice residents (Resident #11). | Level 2 |
| Failed to post prominently the State contact information for filing complaints of discrimination. | Level 1 |
Report Facts
Licensed beds: 74
Resident census: 51
Resident files reviewed: 15
Employee files reviewed: 10
Residents authorized for self-medication: 9
Severity 2 deficiencies: 6
Severity 1 deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Molly Ratfield | Executive Director | Signed the report and was interviewed regarding medication reviews and facility operations |
| Health and Wellness Director | Interviewed multiple times regarding physical exams, medication reviews, medication destruction, MAR accuracy, hospice care, and medication storage | |
| Administrator | Interviewed regarding unsecured medication storage and complaint investigation |
Inspection Report
Annual Inspection
Census: 40
Capacity: 74
Deficiencies: 9
Oct 7, 2024
Visit Reason
This inspection was a grading resurvey State Licensure survey conducted to assess compliance with NAC 449 for Residential Facility for Groups, including assisted living services for elderly or disabled persons.
Findings
The facility received a grade of A with several deficiencies identified related to medication storage, administration, and resident assessments. Specific issues included failure to affix medication change labels, inaccurate medication administration records, and improper medication storage.
Severity Breakdown
D: 7
C: 1
E: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Medication: Storage; duties upon discharge, transfer and return of resident. Medication must be plainly labeled and kept in original container until administered. | D |
| Annual Assessment of History of Each Resident: Facility failed to conduct required annual assessments and physical examinations as mandated. | D |
| Residents Requiring Use of Oxygen: Facility failed to ensure compliance with oxygen use requirements including monitoring and equipment safety. | D |
| Medical Care of Resident After Illness: Facility failed to obtain and follow results of general physical examinations and care instructions. | D |
| Medication Administration-Report Received: Facility failed to notify physician timely of concerns noted in medication reports. | C |
| Medication/OTCS, Supplements, Change Order: Medication change label was not affixed to a resident's medication container indicating medication no longer had an end date. | D |
| Medication - Destruction: Facility failed to properly destroy discontinued or expired medications in presence of a witness and document accordingly. | D |
| Administration of Medication Maintenance: Medication Administration Record did not accurately reflect correct medication dosage and frequency for a resident. | D |
| Medication: Storage - Medications must be stored in locked areas with proper safeguards to prevent misuse. | E |
Report Facts
Facility licensed capacity: 74
Census: 40
Severity D deficiencies: 7
Severity C deficiencies: 1
Severity E deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Molly Ratfield | Administrator/ Executive Director | Signed the report and identified as facility administrator |
| Health and Wellness Director | Confirmed medication labeling and dosage discrepancies during inspection |
Inspection Report
Annual Inspection
Census: 42
Capacity: 74
Deficiencies: 11
May 30, 2023
Visit Reason
This inspection was a grading resurvey State Licensure survey conducted to assess compliance with NAC 449 for Residential Facility for Groups, including assisted living services for elderly or disabled persons.
Findings
The facility received a grade of A with several deficiencies identified related to administrator responsibilities, elder abuse training, personnel files, medication administration and destruction, mental illness endorsement, resident placement assessments, and discrimination policies. Some deficiencies were repeated from prior surveys.
Severity Breakdown
F: 4
E: 3
D: 4
C: 3
Deficiencies (11)
| Description | Severity |
|---|---|
| Administrator failed to ensure records of the facility are complete and accurate. | C |
| Failure to provide required elder abuse training to staff and administrators. | E |
| Personnel files lacked required documentation including TB screening and background checks. | D |
| Failure to ensure staff trained in first aid and CPR within required timeframe. | E |
| Facility failed to destroy expired medication for one resident as required. | F |
| Medication storage did not meet regulatory requirements. | F |
| Maintenance and contents of separate resident files were deficient. | F |
| Facility failed to obtain mental illness endorsement and admitted a resident with mental illness diagnosis without endorsement. | D |
| Facility failed to obtain physician determination for resident placement prior to admission for one resident. | D |
| Facility failed to develop and post required antidiscrimination policies and statements. | C |
| Facility failed to conduct required cultural competency training for staff. | F |
Report Facts
Resident files reviewed: 9
Employee files reviewed: 6
Medication destruction deficiency: 1
Residents sampled: 9
Inspection Report
Annual Inspection
Census: 51
Capacity: 74
Deficiencies: 17
Mar 7, 2023
Visit Reason
This annual State Licensure survey was conducted to assess compliance with NAC 449 for Residential Facility for Groups, including assisted living services for elderly or disabled persons.
Findings
The facility was found deficient in multiple areas including personnel records, elder abuse training, tuberculosis testing, medication administration and storage, resident placement, and posting requirements. Several employees lacked required training and documentation, medications were missing for some residents, and physician determinations for resident placement were incomplete or inaccurate.
Severity Breakdown
Level 1: 3
Level 2: 13
Deficiencies (17)
| Description | Severity |
|---|---|
| Administrator failed to ensure complete and accurate personnel and resident records. | Level 1 |
| Four employees failed to receive initial elder abuse training prior to employment and annually thereafter. | Level 2 |
| One employee lacked a personnel file. | Level 2 |
| Four employees lacked required tuberculosis (TB) testing documentation. | Level 2 |
| One employee failed to meet background check requirements. | Level 2 |
| Four employees failed to receive first aid and CPR training within 30 days of employment. | Level 2 |
| Facility admitted or retained nine residents receiving skilled nursing services without submitting required waivers to the State Agency. | Level 2 |
| Administrator's license, designee information, and facility rates were not posted in a conspicuous place. | Level 1 |
| Medication profile review was not performed every six months for one resident. | Level 2 |
| Medications were missing and unavailable for administration for six residents. | Level 2 |
| Medications on the medication cart were unsecured and accessible to residents. | Level 2 |
| Ten residents lacked proper tuberculosis (TB) testing documentation including missing second-step tests and missing time documentation. | Level 2 |
| One employee failed to receive four hours of initial caregiver training within 60 days of hire. | Level 2 |
| Five employees failed to complete cultural competency training timely. | Level 2 |
| Facility failed to obtain physician determinations for resident placement prior to admission for two residents. | Level 2 |
| Facility failed to post a current nondiscrimination statement prominently. | Level 1 |
| Facility failed to post State contact information for discrimination complaints prominently. | Level 1 |
Report Facts
Facility licensed capacity: 74
Resident census: 51
Deficiencies cited: 16
Resurvey application fee: 600
Employees sampled: 10
Residents sampled: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Hall | Executive Director | Named in relation to record compliance and attestation of personnel checklist accuracy |
| Employee #1 | Failed to have personnel file, elder abuse training, TB testing, background check, and CPR training; no longer with company | |
| Employee #3 | Lacked timely elder abuse training and TB testing | |
| Employee #4 | Executive Director | Cultural competency training certificate dated 10/11/22 |
| Employee #5 | Resident Care Coordinator | Lacked timely elder abuse training; cultural competency training certificate dated 11/17/22 |
| Employee #6 | Medication Technician | Lacked timely elder abuse training; cultural competency training certificate dated 02/23/23 |
| Employee #8 | Medication Technician | Received only 3 hours of initial caregiver training within 60 days of hire |
| Employee #9 | Lacked documented elder abuse training in 2022 and TB testing | |
| Employee #10 | Medication Technician | Lacked timely elder abuse training and cultural competency training; no longer with company |
| Employee #2 | Health and Wellness Director | Cultural competency training certificate dated 11/30/22 |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 74
Deficiencies: 0
Jan 30, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 01/30/23 concerning multiple allegations related to resident safety, medication administration, staffing, and facility protocols.
Findings
Four complaints with multiple allegations were investigated, including issues with safety equipment, call lights, medication administration, meal charges, weight loss, COVID protocols, incontinence care, and staffing. None of the allegations could be substantiated due to lack of evidence, and no regulatory deficiencies were identified.
Complaint Details
Four complaints were investigated: CPT #NV00067621 with three unsubstantiated allegations regarding safety equipment, call lights, and pain medication; CPT #NV00067747 with an unsubstantiated allegation of improper medication administration training; Complaint #NV00067619 with three unsubstantiated allegations about meal charges, weight loss, and COVID protocol; Complaint #NV00067661 with five unsubstantiated allegations concerning incontinence care, call light response, and staffing.
Report Facts
Licensed capacity: 74
Census: 52
Sample size: 7
Number of complaints investigated: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Interviewed during complaint investigations | |
| Executive Director | Interviewed during complaint investigations | |
| Medication Technicians | Two Medication Technicians interviewed during investigation | |
| Caregiver | Interviewed during complaint investigation |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 74
Deficiencies: 1
Sep 9, 2022
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 09/09/22 and completed on 10/17/22 regarding allegations of medication errors at the facility.
Findings
The investigation substantiated that a resident was given another resident's medications, constituting a medication error. The facility failed to administer medication per a physician's order for one sampled resident. The Executive Director confirmed the medication error and noted lack of corrective action documentation.
Complaint Details
Complaint #NV00066839 investigated two allegations: 1) A resident was given another resident's medications, which was substantiated; 2) A resident's refills were not obtained timely and the resident did not have pain medication, which was not substantiated due to lack of evidence.
Severity Breakdown
Severity: 2 Scope: 1: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to administer medication per a physician's order for 1 of 5 sampled residents, including giving a resident another resident's medication. | Severity: 2 Scope: 1 |
Report Facts
Licensed beds: 74
Resident census: 56
Sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Traci Hollingsworth | RFA | Signed the report as Laboratory Director's or Provider/Supplier Representative |
| Executive Director | Interviewed during investigation and confirmed medication error | |
| Health and Wellness Director | Interviewed during investigation |
Inspection Report
Re-Inspection
Census: 56
Capacity: 74
Deficiencies: 13
Mar 23, 2022
Visit Reason
This inspection was a grading re-survey State Licensure survey conducted to assess compliance with NAC 449 for a Residential Facility for Groups providing assisted living services.
Findings
The facility received a grade of A with multiple deficiencies identified related to caregiver qualifications, personnel files, health and sanitation, laundry services, resident rights, medical care, medication administration, medication storage, resident files, and placard display. All deficiencies were corrected or accepted on initial survey with plans of correction in place.
Severity Breakdown
Level 2: 13
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 9 sampled employees obtained annual caregiver training. | Level 2 |
| Failed to ensure 1 of 9 employees met background check requirements. | Level 2 |
| Failed to ensure caregivers were certified to perform CPR and first aid for 4 of 9 sampled caregivers. | Level 2 |
| Failed to remove used paint cans, spray enamel cans, and a cardboard box from the exterior of the facility. | Level 2 |
| Failed to ensure resident laundry room was free of lint buildup behind dryers and washing machines. | Level 2 |
| Failed to ensure visitors were screened appropriately for temperature and COVID-19 symptoms. | Level 2 |
| Failed to ensure 2 of 15 sampled residents received annual physical examinations. | Level 2 |
| Failed to ensure medication profile review was performed at least every six months for 1 of 15 residents. | Level 2 |
| Failed to ensure expired medication was destroyed for 1 of 15 residents. | Level 2 |
| Failed to ensure medication stored in resident room was locked and inaccessible to others and failed to follow Physician Standard Assessment for self-administration for 1 of 15 residents. | Level 2 |
| Failed to label an over-the-counter medication with resident's name and ordering provider's name for 1 of 15 residents. | Level 2 |
| Failed to ensure tuberculosis test read dates were documented for 1 of 15 residents. | Level 2 |
| Failed to conspicuously display the letter grade placard from the last annual State Licensure survey. | Level 2 |
Report Facts
Deficiencies cited: 13
Residents reviewed: 9
Employees reviewed: 5
Facility licensed capacity: 74
Resident census: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #4 | Med Tech | Named in deficiency for missing annual caregiver training. |
| Employee #3 | Health and Wellness Director | Named in deficiency for missing background check and CPR/First Aid certification. |
| Employee #1 | Executive Director | Named in deficiency for missing CPR/First Aid certification. |
| Employee #6 | Caregiver | Named in deficiency for missing CPR/First Aid certification. |
| Employee #8 | Caregiver | Named in deficiency for missing CPR/First Aid certification. |
| Resident Care Coordinator | Provided confirmation and interview statements related to multiple deficiencies. | |
| Licensed Practical Nurse | Confirmed medication storage and self-administration issues. | |
| Medication Technician | Confirmed expired medication and labeling issues. | |
| Maintenance Director | Provided statements related to exterior refuse and laundry lint deficiencies. | |
| Administrator | Confirmed multiple deficiencies and placard display issues. | |
| Executive Director | Executive Director | Responsible for oversight and auditing corrective actions. |
Inspection Report
Annual Inspection
Census: 62
Capacity: 74
Deficiencies: 12
Nov 22, 2021
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation regarding alleged unsanitary conditions in a resident's room.
Findings
The facility was found deficient in multiple areas including caregiver training, background checks, CPR and first aid certification, health and sanitation, laundry services, medical care documentation, medication administration and storage, resident file maintenance, and placard display. The complaint about a dirty resident room was unsubstantiated due to lack of evidence.
Complaint Details
Complaint #NV00065202 alleged a resident's room was very dirty with urine and feces on the floor. The complaint was not substantiated due to lack of evidence after observation of fifteen resident rooms, interviews with involved parties, and record and policy reviews.
Severity Breakdown
Level 2: 12
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 9 sampled employees obtained annual caregiver training for 2021. | Level 2 |
| Failure to ensure 1 of 9 employees met background check requirements including fingerprint submission and clearance letter. | Level 2 |
| Failure to ensure 4 of 9 sampled caregivers had current CPR and First Aid certification. | Level 2 |
| Failure to remove used paint cans, spray enamel cans, and a cardboard box from the exterior of the facility. | Level 2 |
| Failure to ensure resident laundry room was free of lint buildup behind dryers and washing machines. | Level 2 |
| Failure to ensure 2 of 15 sampled residents received annual physical examinations. | Level 2 |
| Failure to ensure medication profile review was performed at least every six months for 1 of 15 residents. | Level 2 |
| Failure to ensure expired medication was destroyed for 1 of 15 residents. | Level 2 |
| Failure to ensure medication stored in resident room was kept in a locked area and failure to follow Physician Standard Assessment for medication possession by resident. | Level 2 |
| Failure to label an over-the-counter medication with resident's name and ordering provider's name for 1 of 15 residents. | Level 2 |
| Failure to ensure tuberculosis test form contained read dates for two-step TB test for 1 of 15 residents. | Level 2 |
| Failure to conspicuously display the letter grade placard from the last annual State Licensure survey. | Level 2 |
Report Facts
Facility licensed capacity: 74
Census at time of survey: 62
Number of resident files reviewed: 15
Number of employee files reviewed: 9
Resurvey application fee: 600
Deficiency count: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #4 | Med Tech | Missing required eight hours of annual caregiver training for 2021 |
| Employee #3 | Health and Wellness Director | Lacked documented fingerprint submission and background check clearance letter |
| Employee #1 | Executive Director | Lacked current CPR and First Aid certification |
| Employee #6 | Caregiver | Lacked current CPR and First Aid certification |
| Employee #8 | Caregiver | Lacked current CPR and First Aid certification |
| Robert L. Matts | Executive Director | Signed report |
Inspection Report
Re-Inspection
Census: 53
Capacity: 74
Deficiencies: 8
Jan 26, 2021
Visit Reason
This inspection was a grading re-survey State Licensure survey conducted to assess compliance with NAC 449 for Residential Facility for Groups.
Findings
The facility was found to be in compliance with no regulatory deficiencies identified and received a grade of A. Several deficiencies referenced original Statement of Deficiency/Plan of Correction Event ID FIIR11.
Severity Breakdown
D: 5
E: 1
F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Personnel File - TB Screening - NAC 449.200 Personnel files must include health certificates. | D |
| Personnel Files - Background Checks - NAC 449.200 Personnel files must include evidence of compliance with background check regulations. | D |
| Service of Food-Nutritious Meals; Frequency - NAC 449.2175 requires nutritious meals served at regular intervals with snacks available. | F |
| Rights of Residents; Procedure for Filing - NAC 449.268 requires facility to be safe and comfortable and have grievance procedures. | F |
| Residents Requiring Use of Oxygen - NAC 449.2712 requires monitoring and safety measures for residents using oxygen. | D |
| Medication/OTCS, Supplements, Change Order - NAC 449.2742 requires proper administration and documentation of medications and supplements. | E |
| Medication: Storage - NAC 449.2748 requires medications to be plainly labeled and kept in original containers. | D |
| Maintenance and Contents of Separate File - NAC 449.2749 requires separate locked files for each resident with medical and other information. | D |
Report Facts
Licensed capacity: 74
Census: 53
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 0
Feb 4, 2016
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by two complaints alleging misuse of resident's personal funds and unsafe physical environment for residents.
Findings
The investigation included observations, interviews, and file reviews. Both complaints were found to be unsubstantiated, and no regulatory deficiencies were identified.
Complaint Details
Two complaints were investigated: Complaint #NV00044996 alleging misuse of resident's personal funds and Complaint #NV00045182 alleging unsafe physical environment for residents. Both allegations could not be substantiated.
Report Facts
Sample size: 5
Complaints investigated: 2
Inspection Report
Annual Inspection
Census: 53
Capacity: 74
Deficiencies: 4
Jun 2, 2015
Visit Reason
This annual State Licensure grading survey was conducted from 6/1/15 to 6/2/15 by the Division of Public and Behavioral Health to assess compliance with state regulations for the residential facility.
Findings
The facility received a grade of A but had several repeat deficiencies related to employee training and documentation, including medication management training, elder abuse recognition training, tuberculosis screening, and background checks.
Severity Breakdown
2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 10 employees completed the required sixteen hours of initial Medication Management Training. | 2 |
| Failed to ensure 1 of 10 employees met requirements for Elder Abuse Recognition and Prevention Training. | 2 |
| Failed to ensure 1 of 10 employees was in compliance with pre-employment physical examination and tuberculosis testing requirements. | 2 |
| Failed to ensure 2 of 10 employees were in compliance with background checks, lacking state and federal clearance reports and follow-up documentation. | 2 |
Report Facts
Number of employees reviewed: 10
Number of resident files reviewed: 15
Facility licensed capacity: 74
Facility census: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Resident Assistant and Medication Technician | Named in medication management training deficiency |
| Employee #6 | Resident Assistant | Named in elder abuse training and tuberculosis testing deficiencies |
| Employee #8 | Resident Assistant | Named in background check deficiency |
| Employee #9 | Resident Assistant | Named in background check deficiency |
Inspection Report
Annual Inspection
Census: 53
Capacity: 74
Deficiencies: 4
Jun 1, 2015
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure grading survey conducted from 6/1/15 to 6/2/15 at the facility.
Findings
The facility was found deficient in several areas including caregiver medication training, elder abuse training, tuberculosis testing, and background checks. The facility failed to ensure required training and documentation for multiple employees, with repeat findings from previous surveys.
Severity Breakdown
Severity: 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 10 employees completed the required sixteen hours of initial Medication Management Training. | — |
| Failure to ensure 1 of 10 employees met requirements for Elder Abuse Recognition and Prevention Training. | Severity: 2 |
| Failure to ensure 1 of 10 employees was in compliance with pre-employment physical examination and tuberculosis testing requirements. | Severity: 2 |
| Failure to ensure 2 of 10 employees were in compliance with background checks including state and federal clearance reports. | Severity: 2 |
Report Facts
Licensed beds: 74
Census: 53
Employees reviewed: 10
Resident files reviewed: 15
Inspection Report
Re-Inspection
Census: 55
Capacity: 74
Deficiencies: 0
Aug 19, 2014
Visit Reason
This visit was a required State Licensure grading re-survey conducted in the facility in accordance with NRS 449.0307, Powers of the Health Division.
Findings
No regulatory deficiencies were identified during the survey. The facility received a grade of A and no further action was necessary.
Report Facts
Resident files reviewed: 10
Employee files reviewed: 8
Inspection Report
Annual Inspection
Census: 59
Capacity: 74
Deficiencies: 12
Apr 29, 2014
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 04/29/2014 to assess compliance with regulatory requirements for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of C with multiple deficiencies identified, including caregiver training, medication management, elder abuse training, personnel file requirements, fire safety, physical examinations, medication storage, and tuberculosis testing. Several deficiencies were repeats from the previous year's survey.
Severity Breakdown
Severity: 2: 11
Severity: 1: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure that 2 of 10 caregivers received eight hours of annual training. | Severity: 2 |
| Failed to ensure that 1 of 10 caregivers completed required 8 hours of annual medication management refresher training. | Severity: 2 |
| Failed to ensure 5 of 10 employees received annual training in recognition, prevention, and response to elder abuse. | Severity: 2 |
| Failed to ensure 1 of 10 employees met tuberculosis testing requirements. | Severity: 2 |
| Failed to ensure 1 of 10 employees met background check requirements. | Severity: 2 |
| Failed to ensure monthly smoke detector tests were conducted for the past 12 months. | Severity: 2 |
| Failed to ensure 1 of 15 residents received an annual physical examination. | Severity: 2 |
| Failed to ensure medication administration records were accurate for 3 of 15 MARs inspected. | Severity: 2 |
| Failed to ensure medication containers had proper change labels for 6 of 15 residents. | Severity: 2 |
| Failed to ensure medication storage was secure and compliant with regulations. | Severity: 2 |
| Failed to ensure 2 of 15 residents met tuberculosis testing requirements. | Severity: 2 |
| Failed to ensure medication administration errors were corrected and documented. | Severity: 1 |
Report Facts
Census: 59
Total Capacity: 74
Employees reviewed: 10
Resident files reviewed: 15
Deficiencies cited: 12
Inspection Report
Annual Inspection
Census: 59
Capacity: 74
Deficiencies: 11
Apr 29, 2014
Visit Reason
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, elder abuse training, personnel file requirements, medication administration, medication storage, and tuberculosis testing. Several deficiencies were repeat findings from the previous year's survey.
Severity Breakdown
Level 1: 1
Level 2: 9
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 10 caregivers received eight hours of annual training. | Level 2 |
| Failed to ensure 1 of 10 caregivers completed required 8 hours of annual medication management refresher training. | Level 2 |
| Failed to ensure 5 of 10 employees received annual elder abuse training. | Level 2 |
| Failed to ensure 1 of 10 employees met tuberculosis testing requirements. | Level 2 |
| Failed to ensure 1 of 10 employees met background check requirements. | Level 2 |
| Failed to ensure monthly smoke detector tests were conducted for the past 12 months. | — |
| Failed to ensure 1 of 15 residents received an annual physical examination. | Level 2 |
| Failed to indicate changes in medication orders on medication containers for 6 of 15 residents and failed to ensure medication was given as prescribed for 1 of 15 residents. | Level 2 |
| Failed to maintain accurate medication administration records for 3 of 15 residents. | Level 1 |
| Failed to ensure medications administered by a resident capable of self-administration were secure. | Level 2 |
| Failed to ensure 2 of 15 residents met tuberculosis testing requirements. | Level 2 |
Report Facts
Residents files reviewed: 15
Employee files reviewed: 10
Facility licensed capacity: 74
Current census: 59
Deficiencies cited: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Failed to receive annual elder abuse training. | |
| Employee #5 | Licensed Practical Nurse | Failed to complete required medication management training. |
| Employee #6 | Failed to receive annual elder abuse training. | |
| Employee #7 | Failed to receive eight hours of annual caregiver training and annual elder abuse training. | |
| Employee #8 | Failed to receive eight hours of annual caregiver training, annual elder abuse training, and background check renewal. | |
| Employee #9 | Failed to receive annual elder abuse training. | |
| Employee #10 | Failed to meet tuberculosis testing requirements. |
Inspection Report
Annual Inspection
Census: 52
Capacity: 74
Deficiencies: 8
May 3, 2013
Visit Reason
The inspection was an annual State Licensure survey conducted from 2013-04-30 to 2013-05-03 to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of B with multiple deficiencies identified including failure to ensure caregivers received required annual training, incomplete background checks, medication administration issues, inaccurate medication records, improper medication labeling, and failure to provide elder abuse training to caregivers.
Severity Breakdown
Severity: 2: 5
Severity: 1: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure that 2 of 10 caregivers received eight hours of annual training. | Severity: 2 |
| Failed to ensure 1 of 10 employees met background check requirements (missing 5-year fingerprints and State/FBI background renewal). | Severity: 2 |
| Facility administrator failed to provide evidence of passing annual medication management examination; last test expired December 2012. | Severity: 2 |
| Facility unable to administer PRN medications as prescribed due to unavailability and failure to indicate changes on medication containers for 4 residents. | Severity: 2 |
| Facility did not destroy discontinued medications for 3 residents as required. | Severity: 2 |
| Medication administration records were inaccurate or incomplete for 4 residents. | Severity: 1 |
| Medications were not plainly labeled with resident and physician names for 2 residents. | Severity: 1 |
| Administrator failed to ensure 7 of 10 caregivers received initial training in recognition, prevention, and response to elder abuse. | — |
Report Facts
Residents' files reviewed: 15
Employee files reviewed: 10
Facility grade: B
Inspection Report
Annual Inspection
Census: 53
Capacity: 74
Deficiencies: 4
Apr 24, 2012
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at Wynwood of Sparks on 04/24/12.
Findings
The facility was found deficient in several areas including personnel files for tuberculosis testing and background checks, and health and sanitation hazards such as improper storage of sharps containers. The facility received a grade of A.
Severity Breakdown
2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 10 employees complied with tuberculosis (TB) testing requirements. | 2 |
| Failed to ensure 2 of 10 employees met background check requirements including missing FBI background check and renewal proof. | 2 |
| Facility premises were not free of hazards; a sharps container containing used needles was found on the floor and not properly stored, and the safety lid was not intact. | 2 |
| Failed to ensure 2 of 15 residents complied with tuberculosis testing requirements, including missing proof of positive TB test and missing annual signs and symptoms. | 2 |
Report Facts
Census: 53
Total Capacity: 74
Deficiencies cited: 4
Inspection Report
Annual Inspection
Census: 53
Capacity: 74
Deficiencies: 4
Apr 24, 2012
Visit Reason
This document is the result of an annual State Licensure survey conducted at the facility on 4/24/12 to assess compliance with state regulations for residential facilities for elderly and disabled persons.
Findings
The facility received a grade of A but was found deficient in several areas including personnel files missing tuberculosis testing and background check documentation, presence of hazards such as improperly stored sharps containers, and resident files missing tuberculosis testing documentation. All deficiencies were rated with severity level 2 and scope 1.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 10 employees complied with tuberculosis testing requirements (Employee #8 no proof of positive TB, Employee #10 no x-ray and no annual signs and symptoms). | Severity: 2 |
| Failed to ensure 2 of 10 employees met background check requirements (Employee #3 missing FBI background check, Employee #6 missing proof of 5 year background check renewal). | Severity: 2 |
| Facility premises were not free of hazards; a sharps container with used needles was found on the floor with a broken safety lid allowing for spillage. | Severity: 2 |
| Failed to ensure 2 of 15 residents complied with tuberculosis testing requirements (Resident #2 no proof of positive TB test, Resident #14 missing annual signs and symptoms). This was a repeat deficiency from prior survey. | Severity: 2 |
Report Facts
Residents files reviewed: 15
Employee files reviewed: 10
Facility licensed capacity: 74
Census: 53
Inspection Report
Complaint Investigation
Census: 58
Capacity: 74
Deficiencies: 1
Jul 28, 2011
Visit Reason
This inspection was conducted as a result of a complaint investigation on 7/28/11 regarding infection control practices at the facility.
Findings
The facility failed to transfer a resident with a staphylococcus infection and did not implement infection control/isolation interventions timely. The resident was not placed in contact isolation until three days after the infection was identified, and the facility lacked a policy for contact isolation and did not request a waiver to keep the resident.
Complaint Details
Complaint #NV00029016 was substantiated. The facility failed to transfer a resident with a MRSA infection and did not implement required contact isolation precautions promptly.
Severity Breakdown
Severity 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to transfer a resident with a staphylococcus infection and did not implement timely infection control/isolation interventions. | Severity 2 |
Report Facts
Total licensed capacity: 74
Census: 58
Scope: 3
Severity: 2
Inspection Report
Annual Inspection
Census: 53
Capacity: 74
Deficiencies: 4
Mar 3, 2011
Visit Reason
This document is the result of an annual State Licensure survey conducted at Wynwood of Sparks on 3/3/2011 to assess compliance with state regulations for residential facilities.
Findings
The facility received a grade of A but had several deficiencies including failure to keep resident files locked and protected, incomplete tuberculosis testing for one resident, failure to apply for a waiver to retain a bedfast hospice resident, and advertising assisted living services without proper endorsement.
Severity Breakdown
Level 1: 2
Level 2: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Resident files were kept on open shelving in an unlocked office, not protected from unauthorized use. | Level 1 |
| One resident was missing the required second step tuberculosis skin test. | Level 2 |
| Facility failed to apply for a waiver to retain one bedfast resident on hospice care. | Level 2 |
| Facility advertised providing assisted living services without an endorsement. | Level 1 |
Report Facts
Resident files reviewed: 15
Employee files reviewed: 15
Discharged resident files reviewed: 1
Residents at time of survey: 53
Licensed capacity: 74
Inspection Report
Complaint Investigation
Census: 52
Capacity: 74
Deficiencies: 2
Sep 3, 2010
Visit Reason
This document is a Statement of Deficiencies generated as a result of a complaint investigation survey started on 2010-08-19 and concluded on 2010-09-03 at Wynwood of Sparks.
Findings
The facility was found to have deficiencies related to medication storage and medication transfer protocols. Specifically, medications were not kept in their original containers for 10 of 52 residents, and the facility failed to ensure proper destruction of medications belonging to former residents within the required timeframe.
Complaint Details
Complaint # NV00026160 was substantiated.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Medication Container - Facility failed to keep medications belonging to 10 of 52 residents in their original containers until administered. | Severity: 2 |
| Medication / Resident Transfer - Facility failed to ensure medications belonging to former residents were destroyed during the 26 months prior to the survey. | Severity: 2 |
Report Facts
Licensed facility beds: 74
Census at time of survey: 52
Residents with medication container issues: 10
Months prior to survey for medication destruction: 26
Inspection Report
Complaint Investigation
Census: 52
Capacity: 74
Deficiencies: 2
Sep 3, 2010
Visit Reason
The inspection was conducted as a result of a complaint investigation survey started on 2010-08-19 and concluded on 2010-09-03, to investigate complaint #NV00026160 which was substantiated.
Findings
The facility failed to keep medications belonging to 10 of 52 residents in their original containers and failed to ensure that medications belonging to former residents were destroyed during the 26 months prior to the survey.
Complaint Details
Complaint #NV00026160 was substantiated.
Severity Breakdown
2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to keep medications belonging to 10 of 52 residents in their original containers. | 2 |
| Failed to ensure that medications belonging to former residents were destroyed during the 26 months prior to the survey. | 2 |
Report Facts
Licensed capacity: 74
Census: 52
Residents with medication container issues: 10
Months medications not destroyed: 26
Inspection Report
Annual Inspection
Census: 59
Capacity: 74
Deficiencies: 4
Mar 3, 2010
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 3/3/2010 at a residential facility for elderly and disabled persons.
Findings
The facility received a grade of B with multiple deficiencies identified including inadequate caregiver training hours, kitchen sanitation violations, improper storage of oxygen tanks, and failure to ensure proper care for residents with indwelling catheters.
Severity Breakdown
Severity 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure that 6 of 15 caregivers received eight hours of annual training. | Severity 2 |
| Kitchen equipment and size inadequate; multiple sanitation violations including improper food storage and damaged equipment. | Severity 2 |
| Facility failed to secure oxygen tanks properly; four oxygen cylinders found laying on their side. | Severity 2 |
| Facility failed to ensure caregivers received instruction on handling waste and signs of infection for resident with indwelling catheter. | Severity 2 |
Report Facts
Resident files reviewed: 15
Employee files reviewed: 15
Discharged resident files reviewed: 1
Caregivers not meeting training hours: 6
Facility licensed capacity: 74
Facility census: 59
Inspection Report
Annual Inspection
Census: 59
Capacity: 74
Deficiencies: 4
Mar 3, 2010
Visit Reason
This document is the result of an annual State Licensure survey conducted on 3/3/2010 at Wynwood of Sparks, a residential facility for elderly and disabled persons.
Findings
The facility received a grade of B with multiple deficiencies identified including failure to ensure caregivers received required annual training, critical kitchen sanitation violations, improper storage of oxygen tanks, and inadequate caregiver instruction for residents with indwelling catheters.
Severity Breakdown
2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure that 6 of 15 caregivers received eight hours of annual training. | 2 |
| Potentially hazardous foods stored improperly in kitchen refrigerators leading to cross contamination; improper cleaning and sanitation practices observed in kitchen and dining areas. | 2 |
| Oxygen tanks were not secured in a rack or to the wall; four oxygen cylinders found laying on their side on a counter in a storage closet. | 2 |
| Failed to ensure all caregivers received instruction on handling waste and signs and symptoms of infection and dehydration for resident with indwelling catheter. | 2 |
Report Facts
Number of caregivers reviewed: 15
Number of resident files reviewed: 15
Number of discharged resident files reviewed: 1
Facility licensed capacity: 74
Facility census: 59
Sanitizer solution concentration: 500
Number of oxygen cylinders improperly stored: 4
Inspection Report
Enforcement
Deficiencies: 1
Mar 27, 2009
Visit Reason
This document is a Notice of Intent to Impose Sanctions issued by the Health Division due to deficiencies found during a survey conducted on March 27, 2008, including a repeat deficiency at TAG Y250.
Findings
The Health Division is imposing monetary penalties based on the severity and scope of deficiencies found in the facility, specifically citing a repeat deficiency at TAG Y250. The Plan of Correction submitted on March 20, 2009, was reviewed and found acceptable.
Deficiencies (1)
| Description |
|---|
| Repeat deficiency at TAG Y250 |
Report Facts
Monetary Penalties: 300
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Chambers | Health Facilities Surveyor III | Signed the Notice of Intent to Impose Sanctions |
Inspection Report
Annual Inspection
Census: 64
Capacity: 74
Deficiencies: 6
Mar 10, 2009
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 3/10/2009 at Alterra Wynwood of Sparks.
Findings
The facility received a score of 24 points, graded as a 'B'. Multiple deficiencies were identified including issues with kitchen sanitation, undocumented menu substitutions, lack of dietitian consultation for one quarter, medication administration errors, inaccurate medication records, and incomplete resident tuberculosis testing files. Several deficiencies were repeat findings from the previous year's survey.
Severity Breakdown
Level 1: 2
Level 2: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Kitchen did not allow for sanitary preparation of food due to outdated and undated foods, ice build-up in freezer, soiled floor, and missing refrigerator thermometer. | Level 2 |
| Menu substitutions were not documented and kept on file for at least 90 days. | Level 1 |
| Failed to ensure dietitian consultation for planning and serving meals for 1 out of 4 calendar quarters. | Level 2 |
| Failed to ensure 4 of 9 residents received medications as prescribed. | Level 2 |
| Medication administration record did not match physician's prescription for 3 of 9 residents. | Level 1 |
| Failed to ensure resident files complied with tuberculosis testing requirements for 3 residents, affecting all residents. | Level 2 |
Report Facts
Facility score: 24
Resident files reviewed: 15
Employee files reviewed: 10
Residents with medication errors: 4
Residents with MAR discrepancies: 3
Residents with TB testing issues: 3
Inspection Report
Annual Inspection
Census: 64
Capacity: 74
Deficiencies: 6
Mar 10, 2009
Visit Reason
The inspection was conducted as an annual State Licensure survey of the residential facility for group beds for elderly and disabled persons.
Findings
The facility received a score of 24 points with a grade of 'B'. Multiple deficiencies were identified including issues with kitchen sanitation, food substitutions documentation, dietary consultant services, medication administration, medication records, and resident files related to tuberculosis testing compliance.
Severity Breakdown
1: 2
2: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Kitchens-Equipment works; Clean and Sanitary - facility did not ensure sanitary preparation of food due to outdated foods, undated foods, ice build-up, soiled floor, and no refrigerator thermometer in small dining room. | 2 |
| Service of Food - Substitutions - facility did not ensure menu substitutions were documented and kept on file for at least 90 days. | 1 |
| Dietary Consultant & Services - facility failed to ensure dietitian provided consultation for planning and serving meals for 1 out of 4 calendar quarters. | 2 |
| Medication / Change order - facility failed to ensure 4 of 9 residents received medications as prescribed. | 2 |
| Medication / MAR - facility failed to ensure the type of medication was listed on the medication administration record for 3 of 9 residents. | 1 |
| Resident file - facility failed to ensure 1 of 15 residents complied with timing of admission tuberculosis testing and 2 of 15 residents did not meet TB testing requirements. | 2 |
Report Facts
Facility score: 24
Resident files reviewed: 15
Employee files reviewed: 10
Discharged resident files reviewed: 1
Deficiency score: 24
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