Inspection Report
Annual Inspection
Census: 96
Capacity: 150
Deficiencies: 2
Oct 17, 2024
Visit Reason
The inspection was an annual State Re-licensure survey conducted in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. Deficiencies were identified including failure to obtain a Mental Illness endorsement while admitting a resident with a mental illness diagnosis, and failure to secure medications properly in one resident room. Several previous deficiencies were cleared during this survey.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to obtain an endorsement for Mental Illness and admitted and retained a resident with a mental illness diagnosis (Resident #9). | Severity: 2 |
| Facility failed to ensure resident medications were kept secured for 1 of 12 resident rooms with a resident self-administering medications (Room #248) where medications were unsecured in the resident's fridge. | Severity: 2 |
Report Facts
Licensed beds: 150
Resident census: 96
Resident records reviewed: 12
Employee records reviewed: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Gardner | Executive Director | Confirmed facility was not endorsed for Mental Illness and involved in corrective action plans. |
Inspection Report
Annual Inspection
Census: 91
Capacity: 150
Deficiencies: 6
Jul 30, 2024
Visit Reason
The inspection was conducted as an annual State Licensure survey on 05/16/2024 and a complaint investigation on 07/30/2024, in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of D with multiple deficiencies including substantiated complaints of resident to resident sexual abuse and neglect, failure to complete timely annual physical exams, unsecured medication storage, incomplete tuberculosis testing, lack of non-discrimination policy and posting, and absence of a privacy policy. Several residents were involved in incidents of neglect and sexual abuse, and the facility failed to ensure proper supervision and safety measures.
Complaint Details
Three complaints were investigated. Complaint #NV00071675 was substantiated for resident to resident sexual abuse involving Resident #22 and Resident #15. Complaint #NV00071653 was substantiated for a resident escaping memory care and being found outside all night resulting in hospitalization for dehydration (Resident #21). Other allegations in complaints #NV00071679 and #NV00071653 were not substantiated due to lack of evidence.
Severity Breakdown
G: 1
D: 3
C: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure a resident's care was not neglected and a resident was kept safe from sexual abuse by another resident in the memory care unit. | G |
| Failed to complete an annual general physical examination timely for 1 of 20 sampled residents. | D |
| Failed to ensure resident medications were kept secured in the facility for 2 of 25 resident rooms with a resident self-administering medications. | D |
| Failed to ensure tuberculosis testing met requirements; missing second step TB test for 1 of 20 sampled residents. | D |
| Failed to have a policy to document, investigate, and resolve a report of discrimination, and failed to post a non-discrimination statement. | C |
| Failed to maintain confidentiality of personally identifiable information concerning sexual orientation, gender identity, and HIV status; failed to prohibit unauthorized presence during physical exams; failed to use visual barriers and allow refusal of examination for educational purposes. | C |
Report Facts
Licensed capacity: 150
Census: 91
Complaints investigated: 3
Resident records reviewed: 22
Employee records reviewed: 25
Late physical exam days: 49
Medications unsecured rooms: 2
Severity 3 deficiency: 1
Severity 2 deficiencies: 3
Severity 1 deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris K Gardner | Executive Director | Named as Executive Director responsible for facility oversight and plan of correction |
| Wellness Director | Interviewed regarding neglect and abuse investigations, physical exams, medication storage, and TB testing | |
| Assistant Executive Director | Interviewed regarding abuse investigations and staff training | |
| Medication Technician | Involved in locating resident outside and reporting incidents | |
| Care Associate | Interviewed regarding resident supervision and incidents | |
| Memory Care Coordinator | Provided information on resident mental capacity and concerns | |
| Maintenance Director | Interviewed regarding medication storage security |
Inspection Report
Annual Inspection
Census: 57
Capacity: 150
Deficiencies: 16
Sep 15, 2023
Visit Reason
Annual State Re-licensure survey conducted in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of C with multiple deficiencies identified including failure to ensure proper caregiver training, medication administration issues, inadequate dementia care training, unsafe storage of toxic substances, and incomplete resident assessments. Two complaints were investigated but not substantiated except for hiring unqualified staff.
Complaint Details
Two complaints investigated: Complaint NV00069014 allegations of no director/manager in memory care, Executive Director credentials, and facility oversight were not substantiated. Complaint NV00069198 allegations of COVID outbreak equipment, resident care, staffing, cleanliness, and unqualified staff; all except hiring unqualified staff were not substantiated. Hiring unqualified staff was substantiated.
Severity Breakdown
Level 2: 12
Level 3: 3
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 1 sampled employees completed at least eight hours of annual caregiver training. | Level 2 |
| Failed to ensure 1 of 9 employees received annual elder abuse training. | Level 2 |
| Failed to have medication latanoprost solution 0.005% onsite and administered per physician's orders for 1 of 9 sampled residents. | Level 2 |
| Failed to ensure discontinued medication was destroyed for 1 of 9 sampled residents. | Level 2 |
| Failed to maintain complete medication administration records as required. | Level 2 |
| Failed to ensure as needed medication had specific symptom for use for 1 of 9 sampled residents. | Level 2 |
| Failed to ensure medication storage complied with regulations requiring locked and secure storage. | Level 2 |
| Failed to maintain separate locked resident files with required documentation. | Level 2 |
| Failed to ensure knives, matches, firearms, tools and other dangerous items were inaccessible to residents. | Level 3 |
| Failed to ensure toxic substances were inaccessible to residents in memory care unit. | Level 2 |
| Failed to ensure 2 of 9 sampled employees received four hours of initial caregiver training within 60 days of hire. | Level 2 |
| Failed to ensure 5 of 9 sampled employees received two hours of dementia training within 40 hours of employment. | Level 3 |
| Failed to ensure 2 of 3 sampled employees received eight hours of dementia training within 90 days of employment. | Level 2 |
| Failed to ensure 1 of 1 sampled employees completed three hours of annual dementia training by hire anniversary date. | Level 2 |
| Failed to conduct cultural competency training as required. | Level 3 |
| Failed to conduct annual assessment of history and condition of each resident as required. | Level 2 |
Report Facts
Facility licensed beds: 150
Current census: 57
Complaints investigated: 2
Grade received: C
Resurvey application fee: 600
Deficiency severity counts: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #7 | Care Associate | Failed to complete annual caregiver training, elder abuse training, and dementia training. |
| Employee #2 | Care Associate | Failed to complete initial caregiver training within 60 days and dementia training within 90 days. |
| Employee #3 | Medication Technician | Failed to complete initial caregiver training within 60 days and dementia training within 90 days. |
| Employee #4 | Care Associate | Failed to complete dementia training within 40 hours. |
| Employee #5 | Care Associate | Failed to complete dementia training within 40 hours. |
| Employee #6 | Care Associate | Failed to complete dementia training within 40 hours. |
| Employee #8 | Medication Technician | Failed to complete dementia training within 40 hours. |
| Employee #9 | Care Associate | Failed to complete dementia training within 40 hours. |
| Administrator | Administrator/Executive Director | Confirmed deficiencies and lack of documented training for employees. |
| Director of Plant Operations | Director of Plant Operations | Confirmed presence of unsecured toxic substances in memory care unit. |
Inspection Report
Annual Inspection
Census: 54
Capacity: 150
Deficiencies: 13
May 1, 2023
Visit Reason
Annual State Re-licensure survey conducted in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of D with multiple deficiencies identified including medication administration issues, unsecured medications and toxic substances, incomplete assessments, and safety concerns in the memory care unit. Several deficiencies were repeat findings from prior surveys.
Severity Breakdown
Level 2: 6
Level F: 3
Level C: 1
Level D: 2
Level E: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| High temperature dishwashing machine was not sanitizing properly; cook's line equipment heavily soiled and in disrepair. | Level 2 |
| Personnel files lacked current CPR/First Aid certification. | Level F |
| Advertising and promotional materials must be accurate and not misrepresent services. | Level C |
| Failed to ensure on-site medications contained current physician's orders for 1 of 9 sampled residents. | Level 2 |
| Discontinued medication was not destroyed for 1 of 9 sampled residents. | Level 2 |
| Failed to ensure PRN medications had symptoms being treated documented on MAR for 4 of 9 sampled residents and a medication was not transcribed on MAR for 1 of 9 residents. | Level 2 |
| Resident medications were not secured in 4 of 13 assisted living resident rooms and thickening powder was unsecured in memory care unit. | Level 2 |
| Failed to complete annual Activities of Daily Living (ADL) assessment for 1 of 9 sampled residents. | Level 2 |
| Failed to ensure hospice care residents had required plan of care documentation onsite. | Level D |
| Failed to remove dangerous items from resident rooms in memory care unit. | Level F |
| Failed to ensure toxic substances were inaccessible to residents in memory care unit. | Level F |
| Failed to complete cultural competency training timely for 3 of 9 sampled employees. | Level E |
| Failed to obtain initial Physician Determination form to confirm proper placement for 1 of 9 sampled residents. | Level D |
Report Facts
Licensed beds: 150
Census: 54
Deficiencies cited: 13
Resurvey fee: 600
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Molly Ratfield | Administrator | Named as Administrator signing the report and referenced in oversight roles |
| Business Office Manager | Responsible for cultural competency training oversight and employee record audits | |
| Wellness Director | Responsible for medication audits, resident assessments, hospice care oversight, and safety rounds | |
| Kitchen Manager | Responsible for kitchen equipment maintenance and compliance | |
| Sales Director | Responsible for advertising compliance |
Inspection Report
Annual Inspection
Census: 72
Capacity: 150
Deficiencies: 16
Jan 5, 2023
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 expired CPR certifications for employees, inaccurate advertising of nursing services, food service violations, admission policy noncompliance for hospice residents, unsecured oxygen tanks, medication administration issues, missing annual assessments, unsecured medications in resident rooms, unsafe items accessible in memory care unit, and late cultural competency training for employees.
Severity Breakdown
F: 6
D: 6
C: 2
E: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Personnel files lacked current first aid and CPR certification for 10 of 20 sampled employees. | F |
| Advertising and promotional materials misrepresented nursing services offered by the facility. | C |
| Food service violations including expired foods, improper hot holding temperatures, lack of handwashing, and unsanitary kitchen conditions. | F |
| Facility failed to ensure residents on hospice care were admitted or retained without required waivers. | F |
| Service rates were not posted in a conspicuous place as required. | C |
| Oxygen tanks were unsecured in resident rooms. | D |
| Medications for two residents were not on-site as prescribed. | D |
| Discontinued medication was not destroyed timely for one resident. | D |
| PRN medication lacked documentation of symptoms being treated on the Medication Administration Record. | D |
| Resident medications were unsecured in 4 resident rooms where residents self-medicate. | E |
| Annual Activities of Daily Living (ADL) assessments were missing for 7 of 15 sampled residents. | D |
| Facility failed to obtain and retain hospice Plan of Care for one resident receiving hospice care. | D |
| Unsafe electric fireplace accessible to residents in memory care unit. | F |
| Toxic substances were accessible to residents in the memory care unit. | F |
| Cultural competency training was not completed timely for 12 of 12 sampled employees. | F |
| Annual Physician Determination forms were not obtained for 3 of 15 sampled residents to confirm proper placement. | D |
Report Facts
Beds licensed: 150
Current census: 72
Employees reviewed: 20
Residents reviewed: 15
Expired CPR certifications: 10
Severity 2 deficiencies: 7
Severity 1 deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Molly Ratfield | Administrator | Signed the report and involved in oversight. |
| Corporate Executive Director | Provided attestation of compliance and confirmed late cultural competency training. | |
| Interim Executive Director | Interviewed regarding advertising and posting deficiencies. | |
| Wellness Director | Involved in confirming hospice care, waiver needs, ADL assessments, medication issues, and oxygen tank storage. |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Oct 19, 2022
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint# NV00066936 regarding an allegation of a resident's missing wedding ring.
Findings
The allegation of the missing wedding ring being stolen could not be substantiated due to lack of evidence. Observations, interviews, and record reviews were conducted, and no regulatory deficiencies were identified.
Complaint Details
Complaint# NV00066936 was investigated and found unsubstantiated regarding the missing wedding ring allegation.
Report Facts
Sample size: 5
Resident records reviewed: 7
Inspection Report
Annual Inspection
Census: 60
Capacity: 150
Deficiencies: 5
Oct 21, 2021
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation at the facility.
Findings
The facility was found to have multiple deficiencies including cleanliness issues in laundry rooms and resident rooms, kitchen sanitation violations, improper posting of licenses and rates, incomplete tuberculosis testing for a resident, and unsafe storage of toxic substances in the memory care unit. The complaint allegations were investigated and found to be unsubstantiated.
Complaint Details
One complaint (#NV00062852) was investigated with four allegations regarding cleanliness, grooming, laundry, and medication administration. All allegations were found to be unsubstantiated based on interviews, incident reports, and policy reviews.
Severity Breakdown
Level 1: 1
Level 2: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Resident laundry rooms had accumulation of dust and lint; a large stain was observed on a carpet in a resident's memory care room. | Level 2 |
| Kitchen and dining services failed to comply with sanitation standards including biofilm and mold in ice machine, food debris under dishmachine, dirty refrigerator shelves, and damaged flooring. | Level 2 |
| Administrator's license, facility license, grade placard, and service rates were posted in a location not visible to residents or the public. | Level 1 |
| One resident's tuberculosis testing was incomplete; second step TB test was missing. | Level 2 |
| Toxic substances such as moisturizing lotion were accessible to residents in the memory care unit due to unlocked cabinets. | Level 2 |
Report Facts
Licensed beds: 150
Current census: 60
Resident records reviewed: 15
Employee records reviewed: 10
Complaint sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Molly Ratfield | Associate Executive Director/Administrator | Interviewed during complaint investigation and named in report signature |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Apr 21, 2021
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint# NV00063297 with multiple allegations regarding resident care and COVID-19 precautions.
Findings
The investigation found that none of the allegations were substantiated. The facility was monitoring residents for COVID-19 symptoms, staff were trained in infection prevention, and resident care including pain management and oxygen monitoring was appropriately documented. No regulatory deficiencies were identified.
Complaint Details
Complaint# NV00063297 included four allegations: failure to protect a resident from COVID-19, neglect in treating a resident's pain, neglect in treating low oxygen levels leading to hospital transfer, and denial of window visits to a resident's family. All allegations were not substantiated based on documented evidence and interviews.
Report Facts
Sample size: 5
Complaint count: 1
Inspection Report
Complaint Investigation
Census: 72
Capacity: 150
Deficiencies: 1
Dec 3, 2020
Visit Reason
The inspection was conducted as a complaint investigation following an allegation that a resident had a bruise and skin tear on the forehead of unknown origin.
Findings
The facility failed to ensure a resident's safety during transfer, resulting in injury to one resident. The Care Associate did not use the required gait belt during transfer, causing the resident to fall and sustain a skin tear above the right eye. Additional training was provided to staff following the incident.
Complaint Details
Complaint #NV00062655 was substantiated regarding a resident having a bruise and skin tear on the forehead of unknown origin. Another allegation of a bruise on the chin was not substantiated.
Severity Breakdown
Severity: 3: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure resident safety during transfer causing injury to one resident due to not using a gait belt as required. | Severity: 3 |
Report Facts
Licensed beds: 150
Resident census: 72
Resident records reviewed: 10
Staff records reviewed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Molly Ratfield | Associate Executive Director | Named as the facility representative and involved in oversight of training |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 150
Deficiencies: 1
Nov 5, 2020
Visit Reason
This inspection was conducted as a result of a complaint investigation initiated on 2020-10-05 and completed on 2020-11-05 regarding allegations of neglect and failure to respond timely to resident auditory call bells.
Findings
The investigation substantiated that the facility failed to respond timely to the auditory call bell for 1 of 73 residents. Other allegations including neglect, failure to prevent accidents, leaving residents soiled, inadequate staffing, and cleanliness issues were not substantiated. The resident auditory system response time was found to be as long as 48 minutes on one occasion.
Complaint Details
Complaint #NV00062090 was substantiated for failure to respond timely to the auditory call bell. Other allegations were not substantiated based on observations, record reviews, and interviews.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure the resident auditory system was responded to timely for 1 of 73 residents (Resident #1). | Severity: 2 |
Report Facts
Licensed beds: 150
Resident census: 73
Response time: 48
Resident records reviewed: 9
Employee files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Molly Ratfield | Associate Executive Director | Signed the report as the provider representative. |
| Wellness Director | Provided information on auditory system response times and participated in interviews. |
Inspection Report
Annual Inspection
Census: 120
Capacity: 150
Deficiencies: 9
Dec 12, 2017
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation initiated on 2017-12-07 and completed on 2017-12-12.
Findings
The facility was found deficient in multiple areas including personnel training, safety hazards, food service compliance, oxygen equipment monitoring, medication administration, and toxic substance accessibility in the Alzheimer's unit. Two complaints were investigated but not substantiated.
Complaint Details
Two complaints were investigated: Complaint #NV00051334 alleging lack of protective supervision and Complaint #NV00051324 alleging inappropriate transfer; both were not substantiated.
Severity Breakdown
Level 2: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 25 employees were trained in first aid (Employee #5). | Level 2 |
| Parking lot safety hazard due to damaged handicapped parking block with protruding rebar. | Level 2 |
| Kitchen and dining services failed to comply with NAC 446 standards including dishmachine sanitization failure, dirty dish room counter, mold in ice machine, and improper storage of cleaning chemicals. | Level 2 |
| Failed to secure oxygen tanks in a rack or to the wall; two portable oxygen tanks observed unsecured in resident's room. | Level 2 |
| Failed to ensure medication profile review was performed at least once every six months and initialed by Administrator for 4 residents. | Level 2 |
| Failed to ensure 1 resident signed an ultimate user agreement authorizing medication administration by the facility. | Level 2 |
| Failed to ensure medications were available for 2 residents as prescribed (missing medications in medication cart). | Level 2 |
| Failed to ensure medication package documented dosage change for 2 residents; discrepancies in medication strength and missing change order stickers. | Level 2 |
| Failed to ensure toxic substances were inaccessible to residents; observed soap, shampoo, lotion, and perfume in unlocked cupboards in memory care unit rooms. | Level 2 |
Report Facts
Licensed beds: 150
Current census: 120
Resident files reviewed: 25
Employee files reviewed: 25
Complaints investigated: 2
Severity 2 deficiencies: 9
Severity 2 scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #5 | Medication Technician | Named in deficiency for lack of first aid training |
| Employee #25 | Medication Technician | Confirmed ultimate user agreement deficiency for Resident #20 |
| Wellness Director | Interviewed and acknowledged multiple deficiencies including medication issues and toxic substances accessibility | |
| Administrator | Interviewed and acknowledged multiple deficiencies including medication reviews and training | |
| Director of Plant Operations | Interviewed regarding parking lot safety hazard |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 9, 2017
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding allegations that the facility was not clean and had unqualified staff.
Findings
The complaint investigation found that the allegations could not be substantiated and no regulatory deficiencies were identified. No further action was necessary.
Complaint Details
Complaint #NV00049637 included allegations that the facility was not clean and had unqualified staff; both allegations were not substantiated after investigation.
Report Facts
Sample size: 5
Number of complaints investigated: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed during the complaint investigation | |
| Administrator | Interviewed during the complaint investigation | |
| Wellness Director | Interviewed during the complaint investigation | |
| Housekeeping Supervisor | Interviewed during the complaint investigation |
Inspection Report
Re-Inspection
Census: 95
Capacity: 150
Deficiencies: 2
Jan 25, 2017
Visit Reason
This was a grading re-survey conducted as a re-inspection following previous deficiencies identified in prior surveys.
Findings
The facility received a re-survey grade of A. Deficiencies were found related to medication administration, including failure to document medication changes and ensure medications were available on site as prescribed, and failure to keep medications stored in a locked area.
Severity Breakdown
2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure packages of medication documented a change had occurred for 2 of 5 residents and failed to ensure available medications were on site to administer as prescribed for 3 of 5 residents. | 2 |
| Failed to ensure medications were kept in a locked area; medication room and medication cart were left unlocked and unsecure. | 2 |
Report Facts
Total licensed beds: 150
Current census: 95
Residents files reviewed: 5
Employee files reviewed: 5
Severity 2 deficiencies: 2
Inspection Report
Annual Inspection
Census: 96
Capacity: 150
Deficiencies: 9
Dec 7, 2016
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation regarding facility cleanliness, odors, and safety concerns.
Findings
The facility was found deficient in multiple areas including elder abuse training, tuberculosis testing, kitchen sanitation and food safety, medication administration, Alzheimer's facility safety, and dementia training. Several deficiencies were cited with varying severity levels, and some were repeat deficiencies.
Complaint Details
Complaint #NV00047313 alleging facility not clean, offensive odors, and unsafe environment was investigated and the allegations were not substantiated.
Severity Breakdown
Level 1: 1
Level 2: 8
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure 14 of 20 employees completed Elder Abuse Prevention training before providing care. | Level 2 |
| Failed to ensure 1 of 20 employees complied with tuberculosis (TB) testing requirements. | Level 2 |
| Failed to ensure kitchen vents, utensil racks, and smoke alarms were free from dirt and grime. | Level 1 |
| Failed to comply with food service standards including improper food temperatures, cross-contamination, expired food, broken sanitizer equipment, and unsanitary food contact surfaces. | Level 2 |
| Failed to ensure medication containers documented changes, medications were available as prescribed, and medications were administered according to physician orders for several residents. | Level 2 |
| Failed to ensure all knives and sharp objects were secure and locked in the Alzheimer's care unit kitchen. | Level 2 |
| Failed to secure toxic substances in locked areas in the Alzheimer's care unit, exposing residents to hazardous chemicals. | Level 2 |
| Failed to ensure 7 of 17 caregivers completed at least two hours of Alzheimer's training within the first 40 hours of employment. | Level 2 |
| Failed to ensure 1 of 17 caregivers acquired an additional eight hours of Alzheimer's disease training within 90 days of hire. | Level 2 |
Report Facts
Beds licensed: 150
Residents present: 96
Employees reviewed: 20
Residents files reviewed: 20
Deficiencies cited: 9
Severity 2 deficiencies: 8
Severity 1 deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Care Associate | Named in elder abuse training and tuberculosis testing deficiencies. |
| Employee #2 | Care Associate | Named in elder abuse training and dementia training deficiencies. |
| Employee #3 | Care Associate | Named in elder abuse training deficiency. |
| Employee #4 | Care Associate | Named in elder abuse training and dementia training deficiencies. |
| Employee #6 | Care Associate | Named in elder abuse training deficiency. |
| Employee #9 | Care Associate | Named in elder abuse training and dementia training deficiencies. |
| Employee #10 | Care Associate | Named in elder abuse training and dementia training deficiencies. |
| Employee #12 | Care Associate | Named in elder abuse training deficiency. |
| Employee #13 | Care Associate | Named in elder abuse training and dementia training deficiencies. |
| Employee #14 | Dining Server | Named in elder abuse training deficiency. |
| Employee #15 | Care Associate | Named in elder abuse training and dementia training deficiencies. |
| Employee #16 | Care Associate | Named in elder abuse training deficiency. |
| Employee #18 | Care Associate | Named in elder abuse training and dementia training deficiencies. |
| Employee #20 | Care Associate | Named in elder abuse training deficiency. |
Inspection Report
Annual Inspection
Census: 105
Capacity: 150
Deficiencies: 4
Dec 16, 2015
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility to assess compliance with regulatory requirements.
Findings
The facility received a grade of A, but several deficiencies were identified including issues with personnel files for first aid and CPR certification, food service permits and storage, medication administration, and documentation of ultimate user agreements for residents.
Severity Breakdown
Level 1: 1
Level 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Personnel file for a caregiver lacked proper first aid and CPR certification documentation. | Level 2 |
| Facility failed to ensure kitchen compliance with food service standards; ice-cream containers uncovered, soiled dishwashing area, and improper storage of cleaning supplies. | Level 1 |
| Facility failed to ensure valid ultimate user agreements were on file for 3 of 25 residents. | Level 2 |
| Medication administration deficiencies including lack of documented change orders and medications not administered as prescribed for some residents. | Level 2 |
Report Facts
Deficiencies cited: 4
Employees reviewed: 15
Resident files reviewed: 20
Residents total: 25
Inspection Report
Annual Inspection
Census: 105
Capacity: 150
Deficiencies: 4
Dec 16, 2015
Visit Reason
This inspection was conducted as an annual State Licensure survey by the Division of Public and Behavioral Health to assess compliance with state regulations.
Findings
The facility received a grade of A but had several deficiencies including failure to ensure one employee had valid in-person first aid/CPR certification, kitchen sanitation violations, incomplete ultimate user medication agreements for three residents, and medication administration and availability issues for two residents.
Severity Breakdown
Level 1: 1
Level 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Personnel file for a caregiver lacked valid in-person first aid and CPR certification; training was delivered entirely online. | Level 2 |
| Kitchen failed to comply with food service standards: uncovered ice-cream containers in freezers, soiled and damaged dishwashing area, peeling wall covering, and improper storage of cleaning supplies. | Level 1 |
| Failed to ensure valid ultimate user medication agreements were on file for 3 residents; agreements were incomplete or unsigned. | Level 2 |
| Medications were not administered as prescribed for one resident and medication was not on-site for another resident. | Level 2 |
Report Facts
Resident files reviewed: 25
Employee files reviewed: 15
Residents with incomplete ultimate user agreements: 3
Residents with medication administration issues: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #4 | Named in deficiency for lacking valid in-person first aid/CPR certification | |
| Employee #6 | Explained medication order change and lack of documented physician change order | |
| Employee #16 | Explained medication inventory and communication with physician regarding medication discontinuation |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 30
Deficiencies: 0
Jun 15, 2015
Visit Reason
The inspection was conducted as a complaint investigation based on allegation #NV00042784 regarding insufficient staffing in the memory care unit.
Findings
The complaint was investigated through review of schedules, interviews with residents, caregivers, and managers, and observation of the facility. The allegation of insufficient staffing was not substantiated and no regulatory deficiencies were identified.
Complaint Details
Complaint #NV00042784 alleging insufficient staffing in the memory care unit was investigated and found to be unsubstantiated.
Report Facts
Sample size: 3
Inspection Report
Annual Inspection
Census: 118
Capacity: 150
Deficiencies: 3
Oct 14, 2014
Visit Reason
The inspection was conducted as an annual State Licensure survey of a residential facility for group beds providing care to persons with Alzheimer's disease and Category II residents.
Findings
The facility received a grade of A but had several deficiencies including unsanitary laundry facilities, inaccurate medication administration records for multiple residents, and dangerous items accessible to residents in the memory care unit.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Laundry room facilities were not maintained in a sanitary manner; front load washers appeared dirty with a musty odor. | Severity: 2 |
| Medication administration records (MAR) were inaccurate for 11 of 30 reviewed MARs, with multiple residents' medications not documented as given. | Severity: 2 |
| Dangerous items such as a razor were accessible to residents in the memory care unit; 23 of 23 residents had dangerous items accessible. | Severity: 2 |
Report Facts
Resident files reviewed: 24
Employee files reviewed: 15
Medication administration records reviewed: 30
MARs inaccurate: 11
Residents with dangerous items accessible: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Molly Ratfield | Administrator | Signed the statement of deficiencies |
| Director of Maintenance | Acknowledged laundry room and dangerous items findings | |
| Director of Wellness | Counted used bubble pacts in medication audit and oversaw corrective actions |
Inspection Report
Annual Inspection
Census: 118
Capacity: 150
Deficiencies: 3
Oct 14, 2014
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at the facility on 10/14/2014.
Findings
The facility received a grade of A but had several deficiencies including unsanitary laundry facilities, inaccurate medication administration records for multiple residents, and failure to secure dangerous items from residents in the Alzheimer's care unit.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Laundry room was not maintained in a sanitary manner; front load washers appeared dirty with a musty odor. | Severity: 2 |
| Medication administration records (MAR) were inaccurate for 11 of 30 reviewed MARs, with multiple instances of undocumented medication administration. | Severity: 2 |
| Dangerous items such as a razor were accessible to residents in the Memory Care unit. | Severity: 2 |
Report Facts
Resident files reviewed: 24
Employee files reviewed: 15
MARs reviewed: 30
Residents in Memory Care unit: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Wellness | Mentioned in relation to identifying medication documentation errors | |
| Director of Maintenance | Acknowledged the finding of a razor accessible to residents | |
| Maintenance Director | Acknowledged the laundry facility problem |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 150
Deficiencies: 0
Aug 18, 2014
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #NV00040140, which contained two allegations regarding staff glove use and medication administration without a doctor's order.
Findings
The complaint investigation found that the allegations could not be substantiated. Staff were trained and observed to use gloves appropriately, and medication administration records showed no medication was given without a doctor's order. No regulatory deficiencies were identified.
Complaint Details
Complaint #NV00040140 contained two allegations: 1) staff did not use gloves during personal contact with residents, and 2) a resident was given medication without a doctor's order. Both allegations were investigated and found unsubstantiated.
Report Facts
Licensed capacity: 150
Census: 100
Inspection Report
Complaint Investigation
Capacity: 150
Deficiencies: 0
Jul 24, 2014
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations of quality of care and treatment related to call lights not being answered in a timely manner.
Findings
The investigation included interviews with several residents and a call light test in Resident #1's room. No complaints or deficiencies were found, and the allegation was unsubstantiated.
Complaint Details
Complaint #NV00039540 regarding quality of care and treatment (call lights) was investigated and found unsubstantiated after resident interviews and call light testing.
Report Facts
Licensed capacity: 150
Inspection Report
Complaint Investigation
Capacity: 150
Deficiencies: 0
Jul 24, 2014
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding an allegation that visitors at the facility were not notified of an ongoing gastro-intestinal outbreak.
Findings
The investigation found that the facility took appropriate containment and prevention measures during the outbreak, including working with the Division of Public and Behavioral Health, posting notices, increased sanitizing, and closing the kitchen temporarily. No deficiencies were noted and the allegation was unsubstantiated.
Complaint Details
Complaint #NV00039538 contained one allegation regarding infection control which was not substantiated after investigation.
Report Facts
Total licensed capacity: 150
Inspection Report
Complaint Investigation
Capacity: 150
Deficiencies: 2
Feb 28, 2014
Visit Reason
This document is a complaint investigation conducted from 9/12/13 through 2/28/13 regarding regulatory compliance at a residential facility licensed for 150 beds.
Findings
The investigation substantiated complaint #NV00036732 and identified deficiencies related to medication administration and destruction, including missing inhaler medication and failure to destroy expired medications for one resident.
Complaint Details
Complaint #NV00036732 was substantiated with deficiencies cited under TAGs Y878 and Y885, and an additional deficiency under TAG Y9999.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Medication administration deficiencies related to over-the-counter medications and supplements requiring physician approval and proper documentation. | — |
| Medication destruction deficiencies where expired medications were not destroyed for one resident. | Severity: 2 |
Report Facts
Licensed capacity: 150
Complaint investigation period: 170
Residents with reviewed files: 8
Residents with medication destruction issue: 1
Inspection Report
Complaint Investigation
Census: 120
Capacity: 150
Deficiencies: 3
Feb 28, 2014
Visit Reason
This amended Statement of Deficiencies was generated as a result of a complaint investigation conducted from 9/12/13 through 2/28/13 at the facility.
Findings
The facility was found to have multiple deficiencies including failure to administer medications as prescribed for 1 of 8 residents, failure to indicate order changes on medication containers for 2 residents, failure to destroy expired medications for 1 resident, and failure to conspicuously display the current grade placard.
Complaint Details
Complaint #NV00036732 was substantiated based on findings related to medication administration and other regulatory violations.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 8 residents received medications as prescribed and did not indicate order change on medication containers for 2 residents. | SS=E |
| Failed to destroy expired medications for 1 of 8 residents. | SS=D |
| Failed to post the current grade placard in a conspicuous location in the facility. | — |
Report Facts
Licensed capacity: 150
Current census: 120
Residents reviewed: 8
Severity 2 deficiencies: 2
Inspection Report
Annual Inspection
Capacity: 114
Deficiencies: 3
Oct 17, 2013
Visit Reason
This State Licensure survey was conducted as a result of the annual licensure grading of the facility from 10/16/13 through 10/17/13 by the Division of Public and Behavioral Health.
Findings
The facility received a grade of A but had several deficiencies including failure to ensure caregivers received required annual training hours, failure to comply with medication administration regulations for one resident, and failure to provide required dementia care training to employees. Some deficiencies were repeats from a prior survey.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure that 3 of 3 caregivers received eight hours of annual training. | Severity: 2 |
| Facility failed to comply with medication administration requirements as 1 of 8 residents' medications were not at maintenance level and required medical assessment before administration. | Severity: 2 |
| Facility failed to ensure that 3 of 3 employees completed at least 3 hours of dementia care training annually. | Severity: 2 |
Report Facts
Licensed capacity: 114
Alzheimer's beds: 30
Resident files reviewed: 8
Employee files reviewed: 7
Caregivers not meeting training: 3
Residents with medication issue: 1
Employees not meeting dementia training: 3
Inspection Report
Annual Inspection
Capacity: 114
Deficiencies: 3
Oct 16, 2013
Visit Reason
This State Licensure survey was conducted from 10/16/13 through 10/17/13 as an annual inspection of a residential facility licensed for group beds for elderly and disabled persons, including beds for persons with Alzheimer's disease.
Findings
The facility received a grade of A but had several deficiencies including failure to ensure caregivers received required annual training, medication administration errors, and insufficient dementia training for employees. These deficiencies were repeats from a prior 6/12/13 inspection.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure that 3 of 3 caregivers received eight hours of annual training. | Severity: 2 |
| Failure to comply with medication administration regulations; 1 of 8 residents' medications were not at maintenance level and lacked required medical assessment. | Severity: 2 |
| Failure to ensure a minimum of 3 hours of dementia training annually for 3 of 3 employees. | Severity: 2 |
Report Facts
Licensed capacity: 114
Beds for persons with Alzheimer's disease: 30
Caregivers reviewed: 3
Residents medication reviewed: 8
Employees reviewed for dementia training: 3
Inspection Report
Complaint Investigation
Capacity: 150
Deficiencies: 1
Sep 16, 2013
Visit Reason
This Statement of Deficiencies was generated as a result of a complaint investigation conducted on the facility from 09/06/13 to 09/13/13 in accordance with 42 CFR, Chapter IV, Section 482.1 to 482.57.
Findings
The facility was found to have failed to ensure suspected abuse was reported immediately or within 24 hours as mandated by NRS 200.5093. Complaint #NV00036353 was substantiated.
Complaint Details
Complaint #NV00036353 was substantiated.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure suspected abuse was reported immediately or within 24 hours mandated by NRS 200.5093. | Severity: 2 |
Report Facts
Total licensed capacity: 150
Severity level: 2
Scope: 1
Inspection Report
Complaint Investigation
Capacity: 150
Deficiencies: 1
Sep 16, 2013
Visit Reason
The inspection was conducted as a result of a complaint investigation from 09/06/2013 to 09/13/2013 regarding suspected abuse at the facility.
Findings
The facility was found to have failed to ensure that suspected abuse was reported immediately or within 24 hours as mandated by NRS 200.5093. The complaint #NV00036353 was substantiated.
Complaint Details
Complaint #NV00036353 was substantiated.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure suspected abuse was reported immediately or within 24 hours mandated by NRS 200.5093. | Severity: 2 |
Report Facts
Licensed capacity: 150
Severity level: 2
Scope: 1
Inspection Report
Capacity: 126
Deficiencies: 0
Jan 15, 2013
Visit Reason
This State Licensure survey was conducted as a result of a Bed Increase survey at the facility on 1/15/13.
Findings
No regulatory deficiencies were identified during the survey. No further action is necessary.
Report Facts
Licensed beds: 96
Licensed beds: 30
Requested additional beds: 24
Inspection Report
Capacity: 120
Deficiencies: 0
May 16, 2012
Visit Reason
This report was generated as a result of a Bed Increase survey conducted from 2012-01-19 to 2012-05-16 to evaluate licensure for additional beds at the facility.
Findings
No regulatory deficiencies were identified during the survey. No further action is necessary.
Report Facts
Licensed beds: 96
Licensed beds: 24
Requested additional beds: 6
Inspection Report
Annual Inspection
Census: 87
Capacity: 96
Deficiencies: 4
May 15, 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 5/15/12.
Findings
The facility received a grade of A. Deficiencies were identified related to caregiver medication training, food service permits and compliance, medication administration records, and medication labeling.
Severity Breakdown
Severity: 1: 1
Severity: 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure that 4 of 15 caregivers had completed medication management training as required by NRS 449.037(6). | Severity: 2 |
| Facility failed to ensure the kitchen complied with the standards of NAC 446, including improper cooling and storage of leftover beef stew and cleaning and sanitation issues. | Severity: 2 |
| Medication administration record (MAR) was inaccurate for 5 of 20 residents, including missing signatures and undocumented medications. | Severity: 1 |
| Medications were not plainly labeled for 2 of 20 residents, failing to meet medication labeling requirements. | Severity: 2 |
Report Facts
Licensed capacity: 96
Census: 87
Caregivers not trained: 4
Residents with inaccurate MAR: 5
Residents with unlabeled medications: 2
Inspection Report
Annual Inspection
Census: 87
Capacity: 120
Deficiencies: 4
May 15, 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 5/15/2012.
Findings
The facility received a grade of A but had several deficiencies including failure to ensure medication management training for some caregivers, critical food service violations, inaccurate medication administration records for some residents, and failure to properly label medications.
Severity Breakdown
Level 1: 1
Level 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure that 4 of 15 caregivers had completed medication management training as required. | Level 2 |
| Kitchen failed to comply with standards including improperly cooled leftover beef stew and sanitation issues such as excessively soiled microwave and refrigerator floor. | Level 2 |
| Medication administration record (MAR) was inaccurate for 5 of 20 residents with missing documentation of medication administration. | Level 1 |
| Medications were not plainly labeled for 2 of 20 residents. | Level 2 |
Report Facts
Caregivers lacking medication training: 4
Residents with inaccurate MAR: 5
Residents with unlabeled medications: 2
Facility licensed capacity: 120
Census at time of survey: 87
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 12, 2012
Visit Reason
A visit was made to the facility on 3/12/12 to investigate a complaint (#30983) regarding resident neglect.
Findings
The investigation found that a Norovirus outbreak occurred at the facility starting January 2012, contributing to Resident #1's death. The facility failed to ensure adequate supervision and hydration for Resident #1, leading to dehydration and eventual death. The facility also failed to monitor and provide necessary services to prevent dehydration.
Complaint Details
Complaint #NV00030983 was substantiated regarding resident neglect. The investigation revealed lack of quality care contributed to Resident #1's death.
Severity Breakdown
Severity: 4: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents are not abused, neglected, or exploited by staff or others. | Severity: 4 Scope: 1 |
Report Facts
Severity level: 4
Scope: 1
Date of complaint investigation visit: Mar 12, 2012
Date of survey completion: Mar 13, 2012
Number of servers delivering meals: 8
Number of residents served: 190
Resident fever: 104.2
Date resident died: Feb 7, 2012
Duration of Norovirus outbreak: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Stated she cared for Resident #1 on PM shifts of 1/22/12, 1/23/12, and 1/24/12 |
| LPN #1 | Licensed Practical Nurse | Interviewed on 3/13/12 regarding care of Resident #1 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 12, 2012
Visit Reason
A visit was made to the facility on 3/12/12 to investigate a complaint (#30983) regarding resident neglect.
Findings
The investigation found that the facility failed to ensure a resident (Resident #1) was not neglected by staff during a Norovirus outbreak from January to March 2012. Resident #1, who required supervision and encouragement during meals, was isolated and not adequately monitored for food and fluid intake, leading to dehydration, hospitalization, and eventual death.
Complaint Details
Complaint #NV00030983 was substantiated regarding resident neglect.
Severity Breakdown
Severity: 4: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The administrator failed to ensure a resident was not neglected by staff during isolation for Norovirus, resulting in dehydration and hospitalization. | Severity: 4 |
Report Facts
Severity level: 4
Scope: 1
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Oct 12, 2011
Visit Reason
This document is a Statement of Deficiencies generated as a result of a complaint investigation initiated on 2011-10-10 and completed on 2011-10-12 at Cascades of the Sierra, a residential facility.
Findings
The complaint regarding quality of care and neglect was not substantiated after interviews with residents, staff, family members, and observations of resident rooms and records. The investigation included interviews and review of wellness records and medication administration.
Complaint Details
Complaint #NV00029443 alleged quality of care and neglect. The allegation was not substantiated through record review, interviews, and observations conducted during the investigation.
Report Facts
Licensed capacity: 120
Inspection Report
Annual Inspection
Census: 77
Capacity: 120
Deficiencies: 14
Jun 23, 2011
Visit Reason
This Statement of Deficiencies was generated as a result of an annual State Licensure survey conducted at the facility on 6/23/11.
Findings
The facility received a grade of B and multiple deficiencies were identified including food service violations, safety requirements, medication administration issues, medication destruction, and assisted living endorsement compliance.
Severity Breakdown
Severity: 1: 1
Severity: 2: 4
Deficiencies (14)
| Description | Severity |
|---|---|
| Raw chicken juice was split onto multiple soda syrup 'bag in the boxes' including corresponding syrup bag ports and dispensing tubes. | — |
| Eggs were stored over ready-to-eat vegetables in the walk-in refrigerator. | — |
| A spray bottle of water was not labeled and/or identified in the dishwashing area. | — |
| Multiple uncovered and unprotected food items were stored in the walk-in refrigerator and freezer. | — |
| A server was observed slicing and handling ready-to-eat bread with bare hands. | — |
| The bulk ice scoop was stored with the handle contacting the ice. | — |
| Kitchen refuse/garbage was stored in an area designated for soda syrup 'bag in the boxes' contaminated by seepage from the garbage. | — |
| The hood vents over the cook's line were soiled with grease and debris. | — |
| The floor beneath the under-counter reach-in refrigerator was excessively soiled with debris in the back room of the Bistro. | — |
| The automatic handwashing sink faucet near the food preparation area was in disrepair. | Severity: 2 |
| The facility failed to respond to auditory alarms for 1 of 2 sampled alarms activated (public bathroom 3rd floor). | Severity: 2 |
| The facility was unable to administer PRN medications as prescribed for 2 of 20 residents because their PRN medications were not available in the facility. | Severity: 2 |
| The facility did not destroy medications for 2 of 20 residents after medications were discontinued, expired, or after a resident had been transferred. | Severity: 2 |
| The facility was advertising and promoting assisted living services without an endorsement. | Severity: 1 |
Report Facts
Licensed capacity: 120
Census: 77
Residents reviewed: 20
Employee files reviewed: 12
Resident files reviewed: 20
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 13, 2010
Visit Reason
This document is a statement of deficiencies generated as a result of a required grading re-survey conducted at the facility on 08/13/2010 by the Bureau of Health Care Quality and Compliance under the authority of NRS 449.150.
Findings
The facility received a re-survey grade of A and no further regulatory deficiencies were identified during this re-survey.
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Jul 9, 2010
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 7/9/10 under the authority of NRS 449.150, Powers of the Health Division.
Findings
The complaint #NV00025777 was investigated and found to be not substantiated. No deficiencies were cited in this report.
Complaint Details
Complaint #NV00025777 was investigated and determined to be not substantiated.
Report Facts
Licensed capacity: 120
Inspection Report
Annual Inspection
Census: 60
Capacity: 120
Deficiencies: 19
Jun 15, 2010
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 6/15/2010 at Cascades of the Sierra, a residential facility for elderly and disabled persons including persons with Alzheimer's disease.
Findings
The facility received a grade of D with multiple deficiencies identified including personnel file issues, health and sanitation problems, emergency drill and smoke detector testing failures, medication administration and storage violations, and resident file documentation deficiencies.
Severity Breakdown
Severity: 1: 1
Severity: 2: 15
Deficiencies (19)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 15 employees complied with tuberculosis testing requirements. | Severity: 2 |
| Failed to ensure all emergency lights were functioning on the third floor of the A tower. | Severity: 2 |
| Kitchen failed to comply with food service standards including critical violations such as dented cans and multiple sanitation and equipment issues. | Severity: 2 |
| Failed to conduct monthly evacuation drills on an irregular schedule for 2 of the past 12 months. | Severity: 2 |
| Failed to ensure smoke detectors were tested monthly for 12 out of the past 12 months. | Severity: 2 |
| Failed to ensure 2 of 15 caregivers received first aid and CPR training within 30 days of employment. | Severity: 2 |
| Failed to ensure oxygen tanks were secured in a rack or to the wall in 3 of 6 resident rooms using oxygen. | Severity: 2 |
| Failed to ensure 3 of 15 residents received an initial physical examination. | Severity: 2 |
| Failed to obtain or sign ultimate user agreements for medication administration for 15 of 15 residents. | Severity: 1 |
| PRN medications were not available for 2 of 15 residents. | Severity: 2 |
| Failed to administer medications as prescribed for 2 of 15 residents due to unavailable medications and failed to obtain orders for continuation of routine medications for 1 resident. | Severity: 2 |
| Failed to obtain clarification when medication label did not match current order for 1 of 15 residents. | — |
| Failed to destroy discontinued medications for 2 of 15 residents. | Severity: 2 |
| Medication administration record was inaccurate for 1 of 15 residents. | — |
| Failed to ensure medications belonging to 8 of 9 residents not requiring assistance were secured in their apartments. | Severity: 2 |
| Failed to ensure refrigerated insulin for 3 of 3 insulin-dependent diabetics was secured in locked boxes inside refrigerators. | Severity: 2 |
| Failed to ensure 6 of 15 residents complied with tuberculosis testing requirements. | Severity: 2 |
| Failed to provide proper discharge documentation for a resident. | — |
| Facility allowed a resident to remain after an intravenous catheter was inserted for intravenous antibiotic therapy, contrary to regulations. | Severity: 2 |
Report Facts
Residents files reviewed: 15
Employee files reviewed: 15
Discharged resident files reviewed: 1
Licensed capacity: 120
Current census: 60
Oxygen rooms with unsecured tanks: 3
Residents missing initial physical exam: 3
Residents missing tuberculosis compliance: 6
Caregivers missing first aid/CPR training: 2
Residents with unavailable PRN medications: 2
Residents with unavailable medications: 2
Residents with discontinued medications not destroyed: 2
Residents with inaccurate MAR: 1
Residents with unsecured medications in apartments: 8
Insulin dependent diabetics with unsecured insulin: 3
Months missing evacuation drills on irregular schedule: 2
Months missing smoke detector testing: 0
Report
File
JHZU11_SoD.pdf
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