Inspection Reports for Caring Hearts Care Home
64 N Pearl St, Las Vegas, NV 89110, NV, 89110
Back to Facility ProfileDeficiencies per Year
28
21
14
7
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 10
Capacity: 7
Deficiencies: 5
Oct 10, 2024
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found deficient in several areas including failure to ensure initial two-step tuberculosis testing and background checks for one employee, lack of policy and documentation for residents' preferred name, pronoun, and gender identity, and failure to ensure required infection control training for designated employees and unlicensed caregivers.
Severity Breakdown
Severity: 1: 1
Severity: 2: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure an initial two-step tuberculosis (TB) test was completed upon hire for 1 of 4 employees (Employee #3). | Severity: 2 |
| Failure to ensure a background check through the Nevada Automated Background Check System was completed for 1 of 4 employees (Employee #3). | Severity: 2 |
| Failure to develop a policy and revise resident records to include residents' preferred name, pronoun, and gender identity or expression; documentation lacking for all 10 residents. | Severity: 1 |
| Failure to ensure the primary and secondary infection control designees completed 15 hours of infection control training (Employees #1 and #4). | Severity: 2 |
| Failure to ensure 2 of 2 unlicensed caregivers (Employees #2 and #3) acquired required infection control training from an approved nationally recognized infection control organization. | Severity: 2 |
Report Facts
Resident files reviewed: 10
Employee files reviewed: 4
Facility grade: B
Infection control training hours: 19.75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lucky Archie Guy | Owner | Confirmed deficiencies and signed the report |
| Employee #3 | Caregiver | Named in deficiencies for missing TB test and background check |
| Employee #1 | Owner | Primary infection control designee lacking required training |
| Employee #4 | Administrator | Secondary infection control designee lacking required training |
| Employee #2 | Caregiver | Lacked required infection control training |
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 5
Sep 7, 2023
Visit Reason
This inspection was conducted as an annual State Licensure survey of the residential facility for groups, to assess compliance with Nevada Administrative Code (NAC) Chapter 449.
Findings
The facility was found to have multiple regulatory deficiencies including failure to maintain clean and well-maintained premises, failure to obtain required medical exemptions for bedfast residents, incomplete medication regimen reviews, failure to destroy expired medications, and incomplete tuberculin testing for residents.
Severity Breakdown
2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure the premises were clean and well maintained, with excessive weeds approximately ten inches throughout the front and back yard. | 2 |
| Facility failed to obtain medical exemptions to maintain two bedfast residents without approved exemptions on file. | 2 |
| Facility failed to ensure medication regimen reviews were completed for one resident, with last review dated over 8 months prior. | 2 |
| Facility failed to ensure medications were destroyed for one resident, with expired medication not destroyed timely. | 2 |
| Facility failed to ensure tuberculin testing was completed per requirements for two residents. | 2 |
Report Facts
Residents present: 10
Licensed capacity: 10
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lucky Archie Guy | Owner | Signed as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 1
Sep 8, 2022
Visit Reason
The inspection was conducted as an annual State Licensure and infection control survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to have expired CPR/First Aid certifications for 3 of 4 employees reviewed. The facility received a grade of A overall. A deficiency was cited for failure to maintain current CPR certification for employees.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure 3 of 4 employees had current cardiopulmonary resuscitation/first aid (CPR) certification; expired on 07/23/22. | 2 |
Report Facts
Number of employees with expired CPR certification: 3
Number of resident files reviewed: 10
Number of employee files reviewed: 4
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 4
Oct 27, 2021
Visit Reason
The inspection was conducted as an annual grading and infection control State licensure survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facilities for Groups.
Findings
The facility received a grade of A. Deficiencies were identified related to personnel background checks, fire extinguisher maintenance, medication review accuracy, and medication administration record completeness.
Severity Breakdown
2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure background checks and fingerprints were completed every five years for 3 of 4 employees and failed to ensure a background check with fingerprints was completed for a new employee. | 2 |
| Failed to ensure fire extinguishers were checked annually for 3 of 3 fire extinguishers; last checked on 08/06/18. | — |
| Failed to ensure a medication review by a pharmacist was completed every six months for 2 of 8 residents (Resident #3 and Resident #7). | 2 |
| Failed to ensure a medication was transcribed on the Medication Administration Record for 1 of 8 residents (Resident #5). | 2 |
Report Facts
Number of employees with incomplete background checks: 4
Number of fire extinguishers not checked annually: 3
Number of residents without medication review every six months: 2
Number of residents with medication administration record errors: 1
Inspection Report
Routine
Census: 10
Capacity: 10
Deficiencies: 2
Nov 4, 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 COVID-19 pandemic.
Findings
The facility had no residents or staff positive for COVID-19 and implemented various infection control measures such as signage, screening, temperature checks, and social distancing. However, deficiencies were found related to lack of staff medical clearance and fit testing for N95 masks, and incomplete infection control policies regarding respirator programs and staff fit testing.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure at least one employee was medically cleared and fit tested for an N95 mask. | Severity: 2 |
| Infection Control Program policies and procedures did not address staff fit testing and medical clearance for N95 masks and respirator program. | Severity: 2 |
Report Facts
Number of beds: 10
Census: 10
Inventory counts: 7
Inventory counts: 300
Inventory counts: 10
Inventory counts: 3
Inventory counts: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lucky Archie Guy | Owner | Reported no employees were medically cleared and fit tested for N95 masks; involved in infection control oversight |
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 0
Nov 19, 2019
Visit Reason
This inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A with no regulatory deficiencies identified during the survey. Ten resident files and five employee files were reviewed.
Report Facts
Resident files reviewed: 10
Employee files reviewed: 5
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 10
Sep 5, 2019
Visit Reason
Annual State Licensure survey conducted in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility was found deficient in multiple areas including failure to ensure appropriate placement of residents with dementia, lack of annual physical examinations for some residents, medication review not performed bi-annually, incomplete medication administration records, improper medication storage, failure to label over-the-counter medications properly, lack of annual tuberculin tests for several residents, and failure to obtain Alzheimer's care endorsement for dementia residents.
Severity Breakdown
E: 3
D: 6
F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure residents with dementia were placed appropriately to meet their needs. | E |
| Failed to ensure annual physical examinations were obtained for some residents. | D |
| Failed to ensure medication reviews were performed every six months for residents. | F |
| Failed to ensure 16 hours of Initial Medication Administration training was completed for an employee. | D |
| Failed to ensure discontinued medication was destroyed properly. | D |
| Failed to ensure Medication Administration Record (MAR) was accurate for a resident. | D |
| Failed to ensure medications were refrigerated per label instructions. | D |
| Failed to properly label over-the-counter medications with resident's and physician's name. | D |
| Failed to ensure annual tuberculin test was completed for several residents. | E |
| Failed to obtain endorsement for Alzheimer's care for residents with dementia. | E |
Report Facts
Residents with dementia diagnosis: 5
Residents lacking annual physical exam: 2
Residents lacking bi-annual medication review: 9
Employees lacking initial medication training: 1
Residents with inaccurate MAR: 1
Residents with improper medication storage: 1
Residents with unlabeled OTC medications: 1
Residents lacking annual TB test: 5
Residents without Alzheimer's care endorsement: 5
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 4
Sep 12, 2018
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility to assess compliance with Nevada Administrative Code for Residential Facility for Groups.
Findings
The facility was found to have multiple regulatory deficiencies including failure to obtain required physical examinations prior to admission, incomplete medication reviews, missing annual tuberculosis tests, and lack of Alzheimer's disease endorsement for certain residents. The facility received a grade of A overall.
Severity Breakdown
Level 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure a resident had history and physical examination completed by a physician prior to admission for 1 of 10 residents (Resident #8). | Level 2 |
| Failure to ensure a medication review was completed every six months for accuracy and appropriateness for 1 of 10 residents (Resident #10). | Level 2 |
| Failure to ensure required purified protein derivative (PPD)/tuberculosis test was administered to 2 of 10 residents (Resident #2 and #3). | Level 2 |
| Failure to ensure an Alzheimer's disease endorsement was in place to meet care needs for 3 of 10 residents (Resident #5, #7, and #8). | Level 2 |
Report Facts
Residents files reviewed: 10
Employee files reviewed: 5
Facility licensed capacity: 10
Census: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lucky Archie Guy | Owner | Facility owner who signed the statement of deficiencies |
| Employee #2 acknowledged multiple deficiencies but no full name provided |
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 1
Sep 19, 2017
Visit Reason
This inspection was conducted as a result of an annual State Licensure survey combined with a complaint investigation on 9/19/2017.
Findings
The facility received a survey grade of A. One complaint was substantiated regarding medication not being given per physician's orders for one resident. The facility failed to ensure medications were available on site and administered as prescribed for 1 of 10 residents.
Complaint Details
Complaint # NV00050380 was substantiated. Allegation #1 - medication not given per physician's orders.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure medications were available on site and administered as prescribed for Resident #1; medication Lantus was not on site on 9/19/17 as ordered by the physician. | Severity: 2 |
Report Facts
Resident census: 10
Total licensed capacity: 10
Deficiency severity: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Guy | Administrator/owner | Signed the report and involved in corrective action plan |
| Employee #1 | Acknowledged medication was not available on 9/19/17 |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 4, 2016
Visit Reason
This document is a statement of deficiencies generated as a result of a required grading re-survey conducted on 1/4/16 at Caring Hearts Care Home.
Findings
The facility received a re-survey grade of A and no deficiencies were identified during this inspection.
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 8
Nov 4, 2015
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with regulations for a residential facility for elderly and disabled persons.
Findings
The facility was found deficient in several areas including elder abuse training, tuberculosis screening, background checks, first aid and CPR certification, fire safety, periodic physical examinations, tuberculosis testing for residents, and resident file maintenance. Multiple deficiencies were repeat findings from the previous year's survey.
Severity Breakdown
Severity: 2: 7
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 4 employees received training to recognize and prevent abuse of older persons (Employee #4). | Severity: 2 |
| Failure to ensure 3 of 4 employees met tuberculosis screening requirements (Employees #1, #3, and #4). | Severity: 2 |
| Failure to participate in mandatory Nevada Automated Background Check Screening System (NABS). | Severity: 2 |
| Failure to ensure 2 of 4 employees were trained with current first aid and CPR certification (Employees #2 and #4). | Severity: 2 |
| Failure to ensure monthly fire drills and smoke detector checks were conducted and portable fire extinguishers inspected and tagged yearly. | — |
| Failure to ensure 1 of 10 residents received an annual physical examination. | Severity: 2 |
| Failure to ensure 5 of 10 residents met tuberculosis testing requirements. | Severity: 2 |
| Failure to provide evidence of evaluation of resident's ability to perform activities of daily living for 1 of 10 residents (Resident #10). | Severity: 2 |
Report Facts
Census: 10
Total Capacity: 10
Employees reviewed: 4
Residents reviewed: 10
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 8
Nov 4, 2015
Visit Reason
This annual State Licensure survey was conducted on 11/4/2015 by the Division of Public and Behavioral Health to assess compliance with state regulations for the facility.
Findings
The facility received a grade of C and multiple deficiencies were identified including failure to ensure elder abuse training, tuberculosis screening, background checks, current first aid and CPR certification, fire safety compliance, annual physical examinations for residents, and evaluations of residents' ability to perform activities of daily living.
Severity Breakdown
D: 3
E: 2
F: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 employees received elder abuse training for 2015. | E |
| Failed to ensure 3 of 4 employees met tuberculosis screening requirements. | F |
| Failed to participate in the Nevada Automated Background Check Screening System (NABS). | F |
| Failed to ensure 2 of 4 employees had current first aid and CPR certification. | E |
| Failed to ensure fire drills and smoke detector checks were conducted monthly and failed to ensure 2 of 2 portable fire extinguishers were inspected and tagged yearly. | D |
| Failed to ensure 1 of 10 residents received an annual physical examination for 2015. | D |
| Failed to ensure 5 of 10 residents met tuberculosis testing requirements. | F |
| Failed to provide evidence of an evaluation of a resident's ability to perform activities of daily living for 1 of 10 residents. | D |
Report Facts
Employees reviewed: 4
Residents reviewed: 10
Deficiencies cited: 8
Facility licensed capacity: 10
Current census: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #4 | Failed to complete elder abuse training for 2015 and lacked current first aid and CPR certification | |
| Employee #1 | Failed to have documented annual TB screening for 2015 | |
| Employee #3 | Failed to have documented annual TB screening for 2015 | |
| Employee #2 | Lacked current first aid and CPR certification |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 5
Nov 25, 2014
Visit Reason
This inspection was an annual State Licensure survey conducted on 11/25/14 to assess compliance with regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of B and was found deficient in several areas including caregiver medication management training, elder abuse training, personnel background checks, and resident physical examinations. Multiple employees and residents were noted to have expired or missing documentation.
Severity Breakdown
Level 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 3 of 4 caregivers received annual medication management training. | Level 2 |
| Failed to ensure 3 of 4 employees received annual elder abuse training. | Level 2 |
| Failed to ensure 3 of 4 employees had current background checks. | Level 2 |
| Failed to ensure 3 of 9 residents had an initial physical examination on file. | Level 2 |
| Failed to maintain a resident file on site for one resident. | Level 2 |
Report Facts
Census: 9
Total Capacity: 10
Employees reviewed: 4
Residents reviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ana Guy | Administrator | Signed the report and acknowledged missing documentation |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 5
Nov 25, 2014
Visit Reason
This annual State Licensure survey was conducted to assess compliance with state regulations for the residential facility for group beds for elderly and disabled persons.
Findings
The facility received a grade of B with multiple deficiencies identified including failure to ensure annual medication management training, elder abuse training, and current background checks for 3 of 4 employees, failure to ensure initial physical exams for 3 of 9 residents, and failure to maintain a resident file on site for 1 of 9 residents.
Severity Breakdown
Level 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 3 of 4 caregivers received annual medication management training. | Level 2 |
| Failed to ensure 3 of 4 employees received annual elder abuse training. | Level 2 |
| Failed to ensure 3 of 4 employees had current background checks. | Level 2 |
| Failed to ensure 3 of 9 residents had an initial physical examination. | Level 2 |
| Failed to ensure 1 of 9 residents had a file on site. | Level 2 |
Report Facts
Residents present: 9
Total licensed capacity: 10
Employees reviewed: 4
Residents reviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Owner/Caregiver | Named in findings for medication training, elder abuse training, and background check deficiencies |
| Employee #2 | Caregiver | Named in findings for medication training, elder abuse training, and background check deficiencies |
| Employee #3 | Administrator | Named in findings for medication training, elder abuse training, and background check deficiencies |
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 0
Dec 31, 2013
Visit Reason
This visit was a State Licensure annual grading survey conducted by the authority of NRS 449.0307, Powers of the Health Division.
Findings
No 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: 3
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 3
Dec 20, 2012
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with health and sanitation regulations and medication administration requirements.
Findings
The facility received a grade of A but had deficiencies related to cleanliness and maintenance of premises, medication administration training for the administrator, and failure to provide initial training to new caregivers on abuse prevention and response.
Severity Breakdown
Severity: 2: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Outside washroom and clothes dryers were not clean; mold on wall and grease above stove; lint accumulation behind dryers. | Severity: 2 |
| Administrator failed to complete required medication management training within the first year of employment. | Severity: 2 |
| Facility failed to provide initial training in prevention, recognition, and response to abuse of elder persons to 1 of 4 new caregivers before interaction with residents. | — |
Report Facts
Resident census: 10
Total capacity: 10
Deficiency scope: 3
Deficiency severity: 2
Deficiency scope: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Agmaluenda | Administrator | Named in relation to inspection and plan of correction |
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 3
Dec 20, 2012
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at the facility on 12/20/2012.
Findings
The facility received a grade of A but was found deficient in maintaining clean and well-maintained premises, failure to ensure the administrator received required annual medication training, and failure to provide initial training on abuse prevention to one new caregiver before resident interaction.
Severity Breakdown
Level 2: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure the premises was clean and well maintained, including mold on washroom wall, greasy stove hood, and lint accumulation behind dryers. | Level 2 |
| Facility failed to ensure the administrator received the annual medication training requirement. | Level 2 |
| Facility failed to provide initial training in prevention, recognition, and response to abuse of elder persons to 1 of 4 new caregivers before resident interaction. | — |
Report Facts
Resident census: 10
Total licensed capacity: 10
Employee files reviewed: 4
Resident files reviewed: 10
Severity 2 deficiencies: 2
Inspection Report
Re-Inspection
Census: 9
Capacity: 10
Deficiencies: 2
Jan 12, 2012
Visit Reason
This was a required grading re-survey conducted as a re-survey after a prior inspection to verify correction of deficiencies.
Findings
The facility was found to have deficiencies related to bedroom door locks and medication administration records. The locks on resident bedroom and bathroom doors did not meet regulatory requirements, and medication administration records were inaccurate for some residents. Both deficiencies were repeat findings from a prior survey.
Severity Breakdown
Severity 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Bedroom doors and bathroom doors did not have locks that open with a single motion without a key or special knowledge. | — |
| Medication administration records (MAR) were inaccurate for 5 of 9 residents, with missing documentation for medications given in prior months. | Severity 2 |
Report Facts
Census: 9
Total licensed capacity: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Guy | Administrator | Named in relation to monitoring compliance for deficiencies |
Inspection Report
Re-Inspection
Census: 9
Capacity: 10
Deficiencies: 2
Jan 12, 2012
Visit Reason
This was a required grading re-survey conducted as a result of a previous survey to verify compliance and grading status of the facility.
Findings
The facility received a re-survey grade of A. Deficiencies were identified related to bedroom door locks not opening with a single motion and inaccuracies in the medication administration record (MAR) for 5 of 9 residents.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Bedroom doors were equipped with locks that did not open with a single motion from the inside as required. | Severity: 2 |
| Medication administration records (MAR) were inaccurate for 5 of 9 residents, including failure to record administration or refusal of medications as prescribed. | Severity: 2 |
Report Facts
Resident census: 9
Total licensed capacity: 10
Residents with inaccurate MAR: 5
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 6
Nov 3, 2011
Visit Reason
This document is an annual State Licensure survey conducted at Caring Hearts Care Home on 11/3/2011 to assess compliance with regulatory requirements for residential facilities.
Findings
The facility received a grade of C with multiple deficiencies identified including personnel file issues related to tuberculosis testing, health and sanitation problems such as unclean premises and dust buildup, bedroom door lock deficiencies, medication administration errors, and failure to ensure required mental retardation training for caregivers.
Severity Breakdown
Severity: 1: 0
Severity: 2: 5
Severity: 3: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Personnel file did not comply with tuberculosis testing requirements for employees. | Severity: 2 |
| Facility failed to maintain clean and well-maintained premises including backyard patio area and resident bathrooms. | Severity: 3 |
| Bedroom doors lacked proper single motion locks for security. | Severity: 2 |
| Facility failed to ensure residents received medications as prescribed. | Severity: 2 |
| Resident files did not comply with tuberculosis testing and record retention requirements. | Severity: 2 |
| Facility failed to ensure caregivers received required 4 hours of mental retardation training. | Severity: 2 |
Report Facts
Licensed capacity: 10
Current census: 9
Number of employees reviewed: 4
Number of residents reviewed: 9
Number of deficiencies cited: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Guy | RN Administrator | Named in plan of correction signature and monitoring compliance |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 8
Nov 3, 2011
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 received a grade of C with multiple deficiencies identified including failure to comply with tuberculosis testing requirements for employees and residents, inadequate facility cleanliness and maintenance, improper locks on resident bedroom doors, medication administration errors, inaccurate medication administration records, and lack of required mental retardation training for caregivers.
Severity Breakdown
Level 2: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 4 employees complied with tuberculosis testing requirements. | Level 2 |
| Facility premises not clean and well maintained; debris in backyard patio, dusty vents, urine smell in bathrooms, and dust buildup behind dryer. | Level 2 |
| Locks on resident bedroom doors did not open with a single motion. | Level 2 |
| Failed to ensure 1 of 8 residents received medications as prescribed; medication ran out with no refill onsite. | Level 2 |
| Medication administration record (MAR) inaccurate for 3 of 8 residents with discrepancies between prescribed and recorded medication administration. | Level 2 |
| Failed to maintain resident files with evidence of tuberculosis compliance. | Level 2 |
| Failed to ensure 1 of 8 residents complied with tuberculosis testing requirements (no 2 step TB test completed). | Level 2 |
| Failed to ensure 4 of 4 caregivers received required 4 hours of mental retardation training. | Level 2 |
Report Facts
Census: 9
Total Capacity: 10
Residents reviewed: 9
Employee files reviewed: 4
Residents with medication errors: 4
Caregivers lacking training: 4
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 2
Dec 16, 2009
Visit Reason
This 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 received a grade of A but had deficiencies including failure to secure oxygen tanks properly in one resident room and failure to ensure that three residents received medications as prescribed.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure oxygen tanks were secured in a rack or to the wall in 1 of 5 resident rooms that utilized oxygen (bedroom #1). | Severity: 2 |
| Failed to ensure that 3 of 9 residents received medications as prescribed (Resident #1, #3, and #9). | Severity: 2 |
Report Facts
Residents present: 9
Licensed capacity: 10
Residents with medication deficiencies: 3
Resident rooms using oxygen: 5
Resident rooms with oxygen tank deficiency: 1
Notice
Deficiencies: 0
May 26, 2009
Visit Reason
The Health Division intends to impose sanctions on the facility based on deficiencies cited in a prior survey conducted on July 30, 2007, including repeat deficiencies.
Findings
The notice details the imposition of monetary penalties totaling $900 for repeat deficiencies at specific tags, outlines the statutory authority, and explains the appeal process and payment requirements.
Report Facts
Monetary penalties: 900
Penalty amount per deficiency: 300
Appeal deadline: 10
Sanction effective date: 11
Payment due days: 15
Penalty reduction: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Chambers | Health Facilities Surveyor III | Signed the notice imposing sanctions. |
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 27
Nov 12, 2008
Visit Reason
Annual state licensure survey conducted at the facility to assess compliance with Nevada Administrative Code (NAC) 449, Residential Facility Groups Regulations.
Findings
The facility was found deficient in multiple areas including incomplete and inaccurate records, medication training deficiencies, staffing schedule issues, personnel file deficiencies, health and sanitation violations, menu and dietary issues, inadequate resident activities, missing rate agreements, incomplete physical examinations, medication administration errors, tuberculosis screening non-compliance, missing resident assessments, and lack of required training for mental retardation and mental illness care.
Severity Breakdown
Severity: 1: 12
Severity: 2: 15
Deficiencies (27)
| Description | Severity |
|---|---|
| Administrator failed to keep the records of the facility complete and accurate. | Severity: 2 |
| Failed to ensure 3 of 5 employees had required medication training. | Severity: 2 |
| Failed to provide a monthly staffing schedule. | Severity: 1 |
| Failed to ensure 3 of 5 employees received not less than 8 hours of annual training related to resident needs. | Severity: 2 |
| Failed to maintain required health certificates for employees. | Severity: 2 |
| Failed to ensure criminal history investigations and fingerprinting compliance for employees. | Severity: 2 |
| Failed to ensure all employees had current first aid and CPR certification. | Severity: 2 |
| Failed to ensure outside garbage cans were covered and clean. | Severity: 2 |
| Failed to provide weekly menus that are dated and posted. | Severity: 1 |
| Failed to provide special diets as ordered by physicians for 4 residents. | Severity: 2 |
| Failed to provide sufficient showers for the number of residents. | Severity: 1 |
| First aid kit lacked a CPR shield or mask. | Severity: 1 |
| Failed to provide at least 10 hours of activities for residents and failed to post activity calendar. | Severity: 2 |
| Failed to provide rate agreements for 3 residents. | Severity: 1 |
| Failed to obtain initial and/or annual physical examinations for 5 residents. | Severity: 2 |
| Failed to have medication reviewed by a physician, pharmacist or nurse at least every 6 months for 8 residents. | Severity: 1 |
| Failed to have ultimate user medication agreements signed for 3 residents. | Severity: 1 |
| Medication administration records were inaccurate for 3 residents. | Severity: 2 |
| Over-the-counter medications were not kept in original containers for 6 residents. | Severity: 2 |
| Failed to maintain physician assessments for 3 residents. | Severity: 1 |
| Failed to comply with tuberculosis screening requirements for 6 residents. | Severity: 2 |
| Failed to perform initial activities of daily living (ADL) evaluation for 2 residents. | Severity: 1 |
| Failed to perform annual ADL evaluation for 2 residents. | Severity: 1 |
| Failed to have facility rules signed by administrator and/or resident for 7 residents. | Severity: 1 |
| Failed to ensure 4 of 5 employees received required training related to care of mentally retarded adults. | Severity: 2 |
| Failed to ensure 4 of 5 caregivers received 8 hours of training concerning care of residents with mental illnesses. | Severity: 2 |
| Failed to maintain medication receipt logs for all residents. | Severity: 1 |
Report Facts
Number of residents: 10
Total licensed beds: 10
Employees reviewed: 5
Resident files reviewed: 10
Deficiency severity 2: 15
Deficiency severity 1: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Named in multiple training and certification deficiencies | |
| Employee #2 | Named in medication administration, training, and compliance deficiencies | |
| Employee #3 | Named in medication training and personnel file deficiencies | |
| Employee #4 | Named in medication training, dietary, and personnel file deficiencies | |
| Employee #5 | Named in medication training and personnel file deficiencies |
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