Inspection Reports for Casa Norte Group Home
4935 N Miller Ln, Las Vegas, NV 89149, NV, 89149
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 9
Capacity: 9
Deficiencies: 1
Sep 18, 2024
Visit Reason
The inspection was conducted as an annual State Licensure survey of the residential facility for groups, in accordance with Nevada Administrative Code Chapter 449.
Findings
The facility received a grade of A. A deficiency was identified related to the use of full bed rails as restraints for 2 of 9 residents, which staff were unaware constituted a restraint.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure full bed rails were not used as a restraint for 2 of 9 residents (Resident #1 and #7). | Severity: 2 |
Report Facts
Residents present: 9
Licensed capacity: 9
Employee files reviewed: 13
Resident files reviewed: 9
Inspection Report
Annual Inspection
Census: 9
Capacity: 9
Deficiencies: 0
Sep 7, 2023
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
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: 9
Employee files reviewed: 6
Inspection Report
Annual Inspection
Census: 5
Capacity: 9
Deficiencies: 3
Sep 12, 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 received a grade of A but had regulatory deficiencies including failure to ensure annual medication management training for 4 of 5 employees, a bathroom toilet not securely fastened to the floor, and failure to ensure annual Tuberculosis testing for 3 of 5 residents.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure 8 hours of annual Medication Management training was completed for 4 of 5 employees. | Severity: 2 |
| Bathroom toilet was not well maintained and not safely secured to the floor. | Severity: 2 |
| Failure to ensure annual Tuberculosis (TB) testing was completed for 3 of 5 residents. | Severity: 2 |
Report Facts
Licensed beds: 9
Residents present: 5
Employees lacking training: 4
Residents lacking TB testing: 3
Inspection Report
Complaint Investigation
Census: 9
Capacity: 9
Deficiencies: 0
Feb 3, 2022
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding allegations of reckless driving by a staff member and residents screaming for help in the backyard.
Findings
The complaint investigation found both allegations to be unsubstantiated based on interviews with staff and residents and review of documentation. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00065321 with two allegations was unsubstantiated. Allegation #1 regarding reckless driving was unsubstantiated based on interviews and documentation. Allegation #2 regarding residents screaming for help was unsubstantiated based on interviews and lack of evidence.
Report Facts
Sample size: 4
Category I residents: 4
Category II residents: 5
Inspection Report
Annual Inspection
Census: 9
Capacity: 9
Deficiencies: 0
Oct 20, 2021
Visit Reason
The inspection was conducted as an annual grading and infection control survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility received a grade of A with no regulatory deficiencies noted. Guidance was provided on nondiscrimination, privacy protection, cultural competency training, complaint policy, and gender identity/expression policy requirements.
Report Facts
Resident files reviewed: 9
Employee files reviewed: 6
Inspection Report
Abbreviated Survey
Census: 8
Capacity: 9
Deficiencies: 0
Oct 27, 2020
Visit Reason
This focused Infection Control survey was conducted to assess compliance with infection control protocols at the facility on 10/27/2020.
Findings
The survey found that the facility had appropriate infection control measures in place, including PPE supplies, staff training, resident monitoring, and visitor restrictions. No regulatory deficiencies were identified.
Report Facts
PPE supplies: 210
PPE supplies: 800
PPE supplies: 115
Residents present: 8
Licensed capacity: 9
N95 masks on order: 20
Inspection Report
Complaint Investigation
Census: 8
Deficiencies: 0
Aug 19, 2020
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by Complaint #NV00061771.
Findings
The complaint alleging the facility failed to follow their visiting policy was investigated and found to be unsubstantiated based on interviews with caregiving staff and the Administrator, and review of facility policies and visiting logs.
Complaint Details
One complaint was investigated and found to be unsubstantiated. Allegation #1 regarding failure to follow the visiting policy was unsubstantiated.
Report Facts
Complaint number: 61771
Sample size: 8
Inspection Report
Annual Inspection
Census: 10
Capacity: 9
Deficiencies: 1
Oct 21, 2019
Visit Reason
The inspection was conducted as a State Licensure annual survey to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to have no deficiencies initially and received a grade of A; however, a deficiency was cited for exceeding the licensed capacity by having 10 residents while licensed for 9.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure the number of residents did not exceed the licensed capacity; census was 10 while licensed for 9. | Severity: 2 |
Report Facts
Resident files reviewed: 10
Employee files reviewed: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shelle Sponseller | Administrator | Named in relation to census and corrective action |
Inspection Report
Complaint Investigation
Census: 10
Capacity: 10
Deficiencies: 2
Jul 31, 2019
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #NV00058049 regarding allegations of resident mistreatment and other concerns at the facility.
Findings
The investigation substantiated that a resident was instructed by staff to wash walls and hit himself as a form of punishment. Other allegations regarding fluid restrictions, lack of outings, and insufficient food were not substantiated. Additionally, the facility failed to document menu substitutions and did not post them as required.
Complaint Details
Complaint #NV00058049 was substantiated regarding staff instructing a resident to wash walls and hit himself. Other allegations about fluid restrictions, outings, and food quantity were not substantiated.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure substitutions were posted on the current menu; lunch served did not match the posted menu and no substitutions were documented. | Severity: 2 |
| Failed to treat a resident with respect and dignity; staff encouraged a resident to hit himself and clean walls as punishment. | Severity: 2 |
Report Facts
Licensed beds: 10
Residents present: 10
Sample size: 5
Employee files reviewed: 3
Severity 2 deficiencies: 2
Inspection Report
Annual Inspection
Census: 9
Capacity: 9
Deficiencies: 1
Dec 8, 2015
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.
Findings
The facility received a grade of A. One deficiency was identified related to personnel files and tuberculosis (TB) testing compliance, specifically that one of ten employees did not have documented evidence of an annual TB test.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 10 employees met TB testing requirements; Employee #2 lacked documented evidence of annual 2015 TB test. | Severity: 2 |
Report Facts
Number of residents present: 9
Total licensed capacity: 9
Number of employees reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Employee who lacked documented annual TB test | |
| Program Administrator | Program Administrator | Named in TB testing compliance finding |
Inspection Report
Annual Inspection
Census: 9
Capacity: 9
Deficiencies: 1
Dec 8, 2015
Visit Reason
The inspection was conducted as an annual State Licensure survey of the CASA NORTE GROUP HOME facility on 12/8/15 by the Division of Public and Behavioral Health.
Findings
The facility received a grade of A. One deficiency was identified related to personnel files, specifically the failure to ensure that 1 of 10 employees had documented evidence of an annual tuberculosis (TB) test for 2015.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 10 employees met the requirements concerning tuberculosis (TB) testing; Employee #2 lacked documented evidence of an annual 2015 TB test. | 2 |
Report Facts
Number of employees reviewed: 10
Number of resident files reviewed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Named in deficiency related to lack of annual TB test documentation |
Inspection Report
Annual Inspection
Census: 9
Capacity: 9
Deficiencies: 2
Jan 20, 2015
Visit Reason
This 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 grade of A. Two deficiencies were identified: failure to maintain the interior premises in a clean and well-maintained condition, and failure to ensure expired medications were properly destroyed.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure the interior premises was well maintained, including dust and debris on kitchen vents and food pantry floor, and exposed wires in the kitchen dining area. | Severity: 2 |
| Facility failed to ensure expired medications were destroyed for 1 out of 9 residents; expired Aspirin 81 mg was found and not removed timely. | Severity: 2 |
Report Facts
Residents present: 9
Licensed capacity: 9
Residents with expired medication: 1
Deficiency repeat: 1
Inspection Report
Annual Inspection
Census: 9
Capacity: 9
Deficiencies: 2
Jan 20, 2015
Visit Reason
This Statement of Deficiencies was generated as a result of an annual State Licensure survey conducted in the facility on 1/20/15 through 1/21/15 by the Division of Public and Behavioral Health.
Findings
The facility received a grade of A. Deficiencies were identified related to maintenance of the interior premises including dust and exposed wires, and failure to destroy expired medications for one resident.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure the interior premises was well maintained, including dust on kitchen vents, dust and debris in the food pantry closet, and exposed wires protruding from the wall. | Severity: 2 |
| Facility failed to ensure expired medications were destroyed for 1 out of 9 residents (Resident #2), specifically expired Aspirin 81 mg. | Severity: 2 |
Report Facts
Resident census: 9
Total licensed capacity: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver #1 | Indicated thermostat was removed and replaced in the living room | |
| Caregiver #7 | Indicated monthly medication reviews were done by a Registered Nurse |
Inspection Report
Complaint Investigation
Census: 9
Capacity: 9
Deficiencies: 0
Mar 21, 2014
Visit Reason
The inspection was conducted as a result of a state complaint investigation regarding an allegation of resident abuse at the facility.
Findings
The allegation of resident abuse was unsubstantiated based on document review, record review, and interviews with staff and residents. The facility followed its policies and procedures for investigation and reporting.
Complaint Details
Complaint #NV00038724 was investigated and found unsubstantiated through document review, record review, and interviews with staff and residents. The complaint investigation was initiated by the Division of Public and Behavioral Health on 3/21/14.
Report Facts
Licensed beds: 9
Census: 9
Inspection Report
Annual Inspection
Census: 9
Capacity: 9
Deficiencies: 6
Feb 11, 2014
Visit Reason
This document is a State Licensure annual grading survey conducted to assess compliance with regulatory requirements 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 required initial physical examinations for employees, inadequate maintenance and cleanliness of the facility, missing annual physical examinations for residents, medication administration record errors, and unsecured resident files.
Severity Breakdown
1: 2
2: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to ensure 7 of 17 employees had required initial physical examination prior to hire. | 2 |
| Facility failed to maintain a clean exterior and interior, including dirt accumulation and replacement needs. | 2 |
| Facility failed to ensure 5 of 9 residents received an annual physical examination. | 2 |
| Medication administration record errors found; MAR was not signed for medications administered for 2 of 9 MARs inspected. | 1 |
| Facility failed to ensure medication administration records were accurate for residents. | 1 |
| Facility failed to ensure resident files were secured; personal health information was found unsecured on a shelf. | 2 |
Report Facts
Employees without required initial physical exam: 7
Residents without annual physical exam: 5
MARs accurate: 2
Resident files unsecured: 8
Total employees reviewed: 17
Total resident files reviewed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #4 | Failed to have required initial physical examination prior to hire | |
| Employee #6 | Failed to have required initial physical examination prior to hire; acknowledged missing initials on MAR | |
| Employee #7 | Failed to have required initial physical examination prior to hire | |
| Employee #8 | Failed to have required initial physical examination prior to hire | |
| Employee #12 | Failed to have required initial physical examination prior to hire | |
| Employee #15 | Failed to have required initial physical examination prior to hire | |
| Employee #17 | Failed to have required initial physical examination prior to hire | |
| Employee #13 | Behavior Technician | Indicated unawareness that resident files had to be secured |
Inspection Report
Annual Inspection
Census: 9
Capacity: 9
Deficiencies: 5
Feb 11, 2014
Visit Reason
This document is a State Licensure annual grading survey conducted on 2/11/14 to assess compliance with regulatory requirements for the Casa Norte Group Home.
Findings
The facility received a grade of B and was found deficient in multiple areas including personnel files lacking timely physical examinations, failure to maintain clean interior and exterior premises, missing annual physical exams for residents, inaccurate medication administration records, and unsecured resident files containing personal health information.
Severity Breakdown
Level 2: 4
Level 1: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 7 of 17 employees had the required initial physical examination prior to hire. | Level 2 |
| Failed to maintain a clean exterior and interior facility, including dirt accumulation and maintenance issues. | Level 2 |
| Failed to ensure 5 of 9 residents received an annual physical examination. | Level 2 |
| Failed to ensure the medication administration record (MAR) was accurate for 2 of 9 MARs inspected. | Level 1 |
| Failed to ensure resident files were secured, with files containing personal health information left unsecured on a shelf. | Level 2 |
Report Facts
Residents present: 9
Total licensed beds: 9
Employee files reviewed: 17
Resident files reviewed: 9
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #4 | Named in deficiency for missing initial physical examination | |
| Employee #6 | Behavior Technician | Named in deficiency for missing initial physical examination and acknowledged missing medication administration initials |
| Employee #7 | Named in deficiency for missing initial physical examination | |
| Employee #8 | Named in deficiency for missing initial physical examination | |
| Employee #12 | Named in deficiency for missing initial physical examination | |
| Employee #15 | Named in deficiency for missing initial physical examination | |
| Employee #17 | Named in deficiency for missing initial physical examination | |
| Employee #13 | Behavior Technician | Indicated unawareness that resident files had to be secured |
Inspection Report
Plan of Correction
Capacity: 9
Deficiencies: 0
May 16, 2013
Visit Reason
This Statement of Deficiencies was generated as a result of a request for a Change of Administrator for the facility's license.
Findings
A desk review was completed and approval was given on 5/16/13. The facility must ensure the new administrator attends initial medication training and Elder Abuse training, with evidence of these trainings maintained in the administrator's facility file. Additional required trainings for administrators providing direct care will be verified during the next on-site survey.
Report Facts
Licensed capacity: 9
Inspection Report
Original Licensing
Capacity: 9
Deficiencies: 4
Feb 5, 2013
Visit Reason
The inspection was conducted as an initial State licensure survey for a facility requesting licensure for nine Residential Facility for Groups beds for elderly and disabled persons, persons with chronic illness, persons with mental retardation, and persons with mental illness.
Findings
The survey identified deficiencies related to personnel files and tuberculosis testing, bedroom window size, closet space, and mental illness training for employees. Specific failures included noncompliance with tuberculosis testing requirements for some employees, inadequate window size in certain bedrooms, insufficient closet space in one bedroom, and lack of required mental illness training for some staff.
Deficiencies (4)
| Description |
|---|
| Personnel file did not comply with tuberculosis testing requirements; 2 of 6 sampled employees failed to comply with NAC 441A.375 regarding TB testing. |
| Bedroom windows did not meet the requirement of at least 10 percent of the floor space; 3 of 9 bedroom window panes and doors failed to meet this requirement (Bedrooms #6, #7, and #9). |
| Closet space in bedrooms did not meet requirement of at least 24 inches of space for hanging garments; failed in 1 of 9 bedrooms (Bedroom #9). |
| Mental illness training requirement not met; 2 of 6 sampled employees had not received 8 hours of training concerning care for residents with mental illnesses. |
Report Facts
Licensed beds: 9
Employees sampled: 6
Resident files reviewed: 9
Bedrooms with window deficiency: 3
Employees noncompliant with TB testing: 2
Employees noncompliant with mental illness training: 2
Bedrooms with closet space deficiency: 1
Inspection Report
Original Licensing
Capacity: 9
Deficiencies: 4
Feb 5, 2013
Visit Reason
This document is an initial State licensure survey conducted from 2/4/13 to 2/5/13 for Casa Norte Group Home, requesting licensure for nine Residential Facility for Groups beds for elderly and disabled persons, persons with chronic illness, persons with mental retardation, and persons with mental illness.
Findings
The survey identified deficiencies including failure to ensure tuberculosis testing compliance for 2 of 6 sampled employees, inadequate bedroom window size in 3 of 9 bedrooms, insufficient closet space in 1 of 9 bedrooms, and failure to provide required mental illness training to 2 of 6 sampled employees.
Deficiencies (4)
| Description |
|---|
| Failed to ensure 2 of 6 sampled employees complied with tuberculosis testing requirements. |
| 3 of 9 bedroom window panes and doors with windows failed to meet the requirement of at least 10 percent of the floor space (Bedrooms #6, #7, and #9). |
| Failed to ensure at least 24 inches of closet space was made available for hanging garments in 1 of 9 bedrooms (Bedroom #9). |
| Failed to ensure 2 of 6 sampled employees received 8 hours of mental illness training within 60 days of employment. |
Report Facts
Licensed beds: 9
Employees sampled: 6
Resident files reviewed: 9
Bedrooms with window deficiency: 3
Bedrooms with closet space deficiency: 1
Employees non-compliant with TB testing: 2
Employees non-compliant with mental illness training: 2
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