Inspection Reports for Covenant Of Love
1213 Balzar Ave., Las Vegas, NV 89106, NV, 89106
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 2
Aug 15, 2024
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility in accordance with Nevada Administrative Code (NAC), Chapter 449, Residential Facilities for Groups.
Findings
The facility was found deficient for failing to develop person-centered service plans for all six residents and failing to obtain annual or initial placement assessments for all six residents. The facility received a grade of A despite these deficiencies.
Severity Breakdown
C: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to develop a person-centered service plan for 6 of 6 residents. | C |
| Facility failed to ensure an annual placement assessment and/or initial placement assessment was obtained for 6 of 6 residents. | C |
Report Facts
Residents present: 6
Total licensed capacity: 6
Resident files reviewed: 6
Employee files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rustirer Kiper Armstrong | Assistant | Signed the inspection report |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 15
Dec 20, 2023
Visit Reason
This inspection was a mandatory grading re-survey conducted as a State Licensure Survey in accordance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.
Findings
The facility was found to have several deficiencies related to administrator responsibilities, elder abuse training, personnel files, medication administration, medical care documentation, medication storage, and maintenance of resident files. The facility received an annual survey grade of A.
Severity Breakdown
D: 7
C: 3
F: 1
2: 2
E: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Administrator failed to ensure that the records of the facility are complete and accurate. | D |
| Failure to ensure elder abuse training was completed as required for staff and administrators. | D |
| Personnel files lacked required TB screening and health certificates. | D |
| Personnel files lacked current certification for first aid and CPR for caregivers. | F |
| Failure to post and maintain a calendar of activities for residents as required. | C |
| Failure to review and maintain medical condition records and prescriptions for residents as required. | D |
| Failure to maintain written records of all accidents, injuries, and illnesses of residents. | D |
| Failure to obtain and maintain annual or more frequent physical examinations for residents. | D |
| Medication change label was not placed on a medication package for one resident, failing to identify the change in dosage. | 2 |
| Medication Administration Record (MAR) was inaccurate for one resident; second daily dose of medication was administered but not documented. | 2 |
| Medication storage did not comply with labeling and container requirements. | E |
| Failure to maintain separate locked files for each resident containing all required records for at least 5 years after discharge. | D |
| Failure to develop and carry out policies to prevent discrimination and post nondiscrimination statements as required. | C |
| Failure to conduct cultural competency training for employees providing care to residents as required. | D |
| Failure to develop policies ensuring residents are addressed by preferred name and pronoun and to adapt records accordingly. | C |
Report Facts
Licensed beds: 6
Census: 6
Resident files reviewed: 3
Employee files reviewed: 2
Severity 2 deficiencies: 2
Severity D deficiencies: 7
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 14
Aug 9, 2023
Visit Reason
Annual State Licensure survey completed at the facility on 08/09/23 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 incomplete resident records, missing elder abuse training for employees, missing tuberculosis tests, inaccurate medication administration records, lack of posted activity calendar, missing incident reports for resident injuries, and failure to post a current non-discrimination statement. Plans of correction were implemented with completion dates mostly in October 2023.
Severity Breakdown
Level 1: 3
Level 2: 10
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 6 resident records was complete and accurate, missing required documents for Resident #1. | Level 2 |
| Failed to ensure 1 of 5 employees had annual elder abuse training (Employee #3). | Level 2 |
| Failed to ensure 1 of 5 employees had a two-step or annual tuberculosis test (Employee #5). | Level 2 |
| Failed to ensure 4 of 5 employees met requirements for first aid and CPR training (Employees #1, #2, #3, #4). | Level 2 |
| Failed to ensure a current Activity Calendar was posted; no calendar for August 2023. | Level 1 |
| Failed to provide documented evidence of medical condition review for Resident #1, including diagnoses and physician orders. | Level 2 |
| Failed to document an injury for Resident #4 including date, time, description, and staff response. | Level 2 |
| Failed to ensure initial physical examination was completed for Resident #1. | Level 2 |
| Medication Administration Records (MAR) inaccurate for Residents #1, #2, and #5. | Level 2 |
| Medications not kept in original containers and improperly labeled for Residents #1 and #2. | Level 2 |
| Failed to ensure annual tuberculosis test for Resident #6 was completed and documented. | Level 2 |
| Failed to post a current non-discrimination statement prominently in the facility. | Level 1 |
| Failed to ensure initial cultural competency training for Employee #4. | Level 2 |
| Failed to develop policies and revise resident records to reflect preferred name, pronoun, and gender identity as required by regulation. | Level 1 |
Report Facts
Residents present: 6
Total licensed capacity: 6
Deficiencies cited: 13
Employee files reviewed: 5
Resident files reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Administrator | Named in findings related to first aid/CPR training and medication administration |
| Employee #2 | Caregiver | Named in findings related to resident records, medication administration, and training |
| Employee #3 | Caregiver | Named in findings related to elder abuse training, medication administration, and missing activity calendar |
| Employee #4 | Caregiver | Named in findings related to first aid/CPR training and cultural competency training |
| Employee #5 | Administrator | Named in findings related to tuberculosis testing |
| Charlene Bynum | Executive Director | Signed report and named in plan of correction responsibilities |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 7
Jul 5, 2022
Visit Reason
This inspection was conducted as an annual and infection control State Licensure survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility was found deficient in several areas including failure to ensure annual tuberculosis testing for employees, inadequate maintenance of the facility exterior, failure to obtain annual physical examinations for residents, medication administration errors, lack of written instructions for PRN medications, incomplete resident files regarding TB testing, and failure to provide a cultural competency training program.
Severity Breakdown
Level 2: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 2 sampled employees had an annual tuberculosis (TB) test. | Level 2 |
| Failed to ensure the exterior of the facility was maintained, including inoperable mailbox, debris, and damaged stucco siding. | Level 2 |
| Failed to obtain an annual physical examination for 3 of 3 sampled residents. | Level 2 |
| Failed to ensure medications were administered per physician's orders for 1 of 6 sampled residents. | Level 2 |
| Failed to ensure written instructions indicating specific symptoms for PRN medication administration for 1 of 6 sampled residents. | Level 2 |
| Failed to ensure 1 of 6 sampled residents met TB testing requirements; lacked documented annual TB test. | Level 2 |
| Failed to submit or provide documented evidence of a cultural competency training program for employees. | Level 2 |
Report Facts
Number of beds: 6
Census: 6
Deficiencies cited: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charlene W Bynum | Executive Director | Named in relation to responsibility for corrective actions and acknowledged facility deficiencies |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 0
Sep 16, 2021
Visit Reason
This inspection was conducted as an annual and infection control State Licensure survey in accordance with Nevada Administrative Code, Chapter 449, Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the survey. The facility received a grade of A and was provided guidance on nondiscrimination, privacy, cultural competency, and complaint policies.
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 0
Jun 11, 2021
Visit Reason
The inspection was conducted as a result of a Complaint and Facility Reported Incident Investigation at the facility from 04/28/21 through 06/11/21, investigating two complaints and one facility reported incident.
Findings
Two complaints with multiple allegations were investigated and found to be unsubstantiated. One facility reported incident was substantiated but with no regulatory deficiencies identified. Overall, no regulatory deficiencies were found and no further action was necessary.
Complaint Details
Complaint #NV00061199 with one allegation was unsubstantiated regarding the Owner being named as a beneficiary on a resident's life insurance policy. Complaint #NV00064058 with two allegations was unsubstantiated regarding resident safety and the Owner being set up as a Representative Payee on a resident's Social Security benefits. Facility Reported Incident #5709 was substantiated with no regulatory deficiencies; it involved a resident found deceased with vitamin supplements under the bed.
Report Facts
Complaint count: 2
Facility reported incident count: 1
Sample size: 3
Inspection Report
Abbreviated Survey
Census: 5
Capacity: 6
Deficiencies: 0
Oct 8, 2020
Visit Reason
The inspection was a focused COVID-19 infection control survey conducted to assess compliance with infection prevention measures in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
No residents or staff tested positive or showed symptoms of COVID-19. The facility implemented screening, temperature checks, social distancing, and sanitization protocols. Infection control policies and procedures were reviewed and found adequate. No deficiencies were identified.
Report Facts
Fluid ounce bottles of sanitizer: 3
Gloves: 200
Surgical masks: 100
Gowns: 5
Electronic temporal thermometers: 2
Inspection Report
Annual Inspection
Census: 6
Capacity: 12
Deficiencies: 7
Oct 31, 2019
Visit Reason
This inspection was a grading re-survey and State Licensure Survey conducted in accordance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups. The survey was initiated on 10/31/2019.
Findings
The facility received an annual survey grade of A. Several regulatory deficiencies were identified including issues with elder abuse training compliance, facility temperature maintenance, bathroom supplies, resident activities, medical care evaluations, medication storage security, and maintenance of resident files.
Severity Breakdown
D: 3
F: 4
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure elder abuse training was completed annually by required employees. | D |
| Facility failed to maintain inside temperature between 68 and 82 degrees Fahrenheit; thermostat was set at 77 but actual temperature was 63 degrees. | F |
| Residents did not have adequate toilet articles; corrective actions included installation of air-hand dryers and ensuring supplies. | F |
| Failure to provide at least 10 hours per week of scheduled activities suited to residents' interests and capacities. | F |
| Failure to obtain and maintain up-to-date annual physical and mental evaluations of residents, including documentation of Activities of Daily Living (ADL) assessments. | D |
| Medication storage was unsecured; medication cabinet door was cracked open with keys in the doorknob and not in line of sight of caregiver. | F |
| Failure to maintain separate locked files for each resident containing all required documentation and evaluations, retained for at least 5 years. | D |
Report Facts
Licensed beds: 12
Current census: 6
Severity 2 deficiencies: 2
Scheduled activity hours: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charlene W Bynum | Executive Director | Signed the inspection report. |
| Employee #4 | Named in elder abuse training deficiency and corrective action. |
Inspection Report
Annual Inspection
Deficiencies: 3
Oct 8, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulations related to nutrition, special diets, medication administration, and caregiver requirements at the facility.
Findings
The facility demonstrated compliance with requirements for providing special diets as prescribed by physicians or dietitians, serving nutritious meals at appropriate intervals, and administering medications according to physician orders. Corrective action plans include ongoing monitoring, education, and collaboration with physicians to ensure continued compliance.
Severity Breakdown
Level D: 1
Level F: 1
Level G: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Nutrition and Service of Food - Special Diet: Records of modifications to menus for special diets must be kept on file for at least 90 days. | Level D |
| Service of Food - Nutritious Meals; Frequency: Meals must be nutritious, served appropriately, and at regular intervals with snacks available unless prohibited by physician. | Level F |
| Medication/OTCS, Supplements, Change Order: Administration of medications must follow physician orders with timely retrieval of written prescriptions and proper documentation. | Level G |
Report Facts
Medication order retrieval timeframe: 5
Medication audit frequency: 7
Medication training hours: 16
Plan of correction monitoring period: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charlene W Bynum | Executive Director; Assistant to Administrator | Signed the report and involved in monitoring meal preparation and medication administration compliance. |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 3
Jun 16, 2016
Visit Reason
The inspection was conducted as an annual State Licensure Grading survey of a residential facility for elderly and disabled persons, including persons with chronic and mental illnesses.
Findings
The facility was found to have multiple deficiencies including disrepair in bathrooms and bedrooms, failure to maintain oxygen equipment properly, and failure to ensure physician's orders for medication administration were obtained for residents. The facility received a grade of A.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility premises were not well maintained; bathrooms and bedrooms had brown rust, residue, dilapidated caulking, cracked tiles, worn and soiled towels, broken light covers, flickering bulbs, and dirty rugs. | Level 2 |
| Oxygen tank was removed from the facility when not in use but was stored improperly in the closet near the dining room. | Level 2 |
| Failure to ensure physician's orders were obtained for administration of medication ordered on an as-needed basis for 3 of 5 residents. | Level 2 |
Report Facts
Licensed beds: 6
Residents present: 5
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Verified findings of disrepair and reviewed medication labels and records | |
| Employee #4 | Verified findings of disrepair |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 3
Jun 16, 2016
Visit Reason
The inspection was conducted as an annual State Licensure Grading survey at the facility on 6/16/16 by the Division of Public and Behavioral Health.
Findings
The facility received a grade of A but had regulatory deficiencies including failure to maintain the premises in good repair, improper storage of an unused oxygen tank, and lack of physician's orders specifying symptoms for administration of as-needed medications for three residents.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure the premises were well maintained and free from disrepair, including rust and residue on toilets, cracked tiles, worn and soiled towels, broken light covers, flickering bulbs, and a torn rug. | Level 2 |
| Facility failed to ensure an oxygen tank was removed from the facility when not in use; oxygen tank stored in closet for approximately one week with no residents using oxygen. | Level 2 |
| Facility failed to ensure physician's orders were obtained for specific symptoms for administration of as-needed medications for 3 of 5 residents. | Level 2 |
Report Facts
Residents present: 5
Licensed capacity: 6
Residents' records reviewed: 5
Employee records reviewed: 4
Repeat deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 and Employee #4 verified findings of disrepair; Employee #3 indicated towels were often soiled and paper towels often ran out; Employee #3 reviewed medication labels and records verifying lack of symptom documentation for PRN medications. |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 4
Jul 25, 2013
Visit Reason
This document is a State Licensure annual grading survey conducted on 7/25/13 to evaluate compliance with regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A but was found deficient in several areas related to medical care, medication administration, and record keeping. Deficiencies included failure to ensure annual physical exams for residents, incomplete medication orders, missed medication doses, and inaccurate medication administration records.
Severity Breakdown
Severity: 2 Scope: 1: 2
Severity: 2 Scope: 2: 1
Severity: 1 Scope: 3: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 6 residents received a physical examination due to missing 2013 annual physical. | Severity: 2 Scope: 1 |
| Failure to ensure 2 of 6 residents received medications as prescribed, including missing proof of order change and missing doctor's order. | Severity: 2 Scope: 2 |
| Failure to notify physician within 12 hours after resident refused or missed medication dose for 1 of 6 residents. | Severity: 2 Scope: 1 |
| Failure to maintain accurate medication administration records for 5 of 6 MARs inspected, including incorrect dosages documented. | Severity: 1 Scope: 3 |
Report Facts
Residents reviewed: 6
Employee files reviewed: 5
Discharged resident files reviewed: 1
Facility licensed capacity: 6
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 4
Jul 25, 2013
Visit Reason
This document is a State Licensure annual grading survey conducted at the facility on 7/25/2013 to assess compliance with state regulations for a Residential Facility for Group beds for elderly and disabled persons.
Findings
The facility received a grade of A but had several deficiencies including failure to ensure one resident received a required annual physical exam, failure to administer medications as prescribed for two residents, failure to notify a physician after a resident refused or missed medication doses, and inaccuracies in medication administration records for five residents.
Severity Breakdown
Severity: 2: 3
Severity: 1: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 6 residents received a physical examination due to a significant change in physical condition (Resident #6 missing 2013 annual physical). | Severity: 2 |
| Failure to ensure 2 of 6 residents received medications as prescribed (Resident #3 missing proof of order change and Allergy Relief order; Resident #6 missing discontinued order for Proair Inhale). | Severity: 2 |
| Failure to notify 1 of 6 resident's physicians after refusing and missing a dose of medication (Resident #6 refused and missed TRIAMT/HCTZ doses). | Severity: 2 |
| Failure to maintain accurate medication administration records for 5 of 6 residents inspected, including undocumented dosages for PRN medications and discrepancies in medication dosages on MAR. | Severity: 1 |
Report Facts
Residents present: 6
Total licensed capacity: 6
Residents with medication administration record inaccuracies: 5
Residents with medication administration deficiencies: 2
Residents with missed physician notification: 1
Residents missing annual physical examination: 1
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 4
Jul 10, 2012
Visit Reason
The inspection was conducted as an annual State Licensure survey to assess compliance with regulatory requirements for a residential facility for elderly or disabled persons.
Findings
The facility received a grade of A but was found deficient in maintaining personnel files with required health certificates, ensuring pre-employment physicals for employees, obtaining physical examinations for residents prior to admission, and maintaining resident files with required tuberculosis testing documentation.
Severity Breakdown
Severity 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Personnel files lacked required health certificates for employees as per NAC 441A. | Severity 2 |
| Failed to ensure 3 of 5 employees had pre-employment physicals completed after hire. | Severity 2 |
| Failed to ensure 2 of 6 residents received physical examinations prior to admission. | Severity 2 |
| Failed to ensure 2 of 6 residents complied with tuberculosis testing requirements (pre-admission 2-step TB test). | Severity 2 |
Report Facts
Residents present: 6
Licensed capacity: 6
Employees reviewed: 5
Resident files reviewed: 6
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 4
Jul 10, 2012
Visit Reason
This document is the result of an annual State Licensure survey conducted on 7/10/2012 to assess compliance with state regulations for a residential facility for group beds for elderly or disabled persons.
Findings
The facility received a grade of A but had deficiencies related to personnel files missing required health certificates, failure to ensure pre-employment physicals were completed prior to hire for 3 of 5 employees, failure to ensure 2 of 6 residents received physical examinations prior to admission, and failure to obtain pre-admission 2-Step tuberculosis tests for 2 residents.
Severity Breakdown
F: 1
2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Personnel files missing required health certificates pursuant to NAC 441A. | F |
| Failed to ensure 3 of 5 employees completed pre-employment physicals prior to hire. | 2 |
| Failed to ensure 2 of 6 residents received a physical examination prior to admission. | 2 |
| Failed to ensure 2 of 6 residents complied with tuberculosis testing requirements by not obtaining pre-admission 2-Step TB test. | 2 |
Report Facts
Number of residents present: 6
Total licensed capacity: 6
Number of employee files reviewed: 5
Number of resident files reviewed: 6
Number of employees non-compliant with pre-employment physicals: 3
Number of residents without physical exam prior to admission: 2
Number of residents without pre-admission 2-Step TB test: 2
Inspection Report
Complaint Investigation
Capacity: 6
Deficiencies: 0
Aug 11, 2011
Visit Reason
The inspection was conducted as a complaint investigation initiated on 2011-07-25 regarding an allegation of sexual assault at the facility.
Findings
The allegation of sexual assault was not substantiated after review of police and incident reports, and interviews with police, facility staff, the owner, case workers, and the resident involved.
Complaint Details
Complaint #NV00028811 regarding a sexual assault was investigated and found not substantiated based on police reports, facility incident reports, and multiple interviews. The Las Vegas Metropolitan Police Department closed the case with no charges filed.
Report Facts
Licensed capacity: 6
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 24, 2011
Visit Reason
This document is a statement of deficiencies generated as a result of a required grading re-survey conducted at the facility on 02/24/2011 by the authority of NRS 449.150.
Findings
The facility received a re-survey grade of A and no deficiencies were identified during this inspection.
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 8
Apr 23, 2010
Visit Reason
The inspection was conducted as a result of a complaint investigation on 04/23/2010 at the facility Covenant of Love.
Findings
Multiple deficiencies were identified including failure to have proper endorsements for mental and chronic illness care, failure to document menu substitutions, failure to provide scheduled activities, inaccurate medication administration records, and lack of required training for caregivers on mental illness and chronic illness care.
Complaint Details
Complaint #NV00025116 was substantiated.
Severity Breakdown
Level 1: 3
Level 2: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility licensed for six residents; census was five at time of survey. Complaint #NV00025116 was substantiated. | — |
| Facility failed to obtain necessary training and endorsements to care for residents with mental and chronic illnesses. | Level 2 |
| Facility failed to document and retain menu substitutions for at least 90 days. | Level 1 |
| Facility failed to provide at least 10 hours of scheduled activities per week for all residents. | Level 2 |
| Facility failed to create and post a calendar of weekly activities. | Level 1 |
| Medication administration records were inaccurate for all residents reviewed. | Level 1 |
| Facility failed to provide required mental illness training to employees within 60 days of employment. | Level 2 |
| Facility failed to provide required chronic illness (HIV) training to employees within 60 days of employment. | Level 2 |
Report Facts
Licensed capacity: 6
Census: 5
Residents with mental illness: 5
Residents with chronic illness: 1
Deficiency severity Level 2: 4
Deficiency severity Level 1: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Miguela M. Suarez | Administrator | Signed as Laboratory Director or Provider/Supplier Representative |
| Miguela M. Suarez | Administrator | Named in corrective action plans for ensuring compliance with training and documentation requirements |
Inspection Report
Complaint Investigation
Census: 5
Capacity: 6
Deficiencies: 7
Apr 23, 2010
Visit Reason
This inspection was conducted as a complaint investigation triggered by complaint #NV00025116 to assess compliance with state licensure requirements for a residential facility for elderly and disabled persons.
Findings
The facility was found to be caring for residents with mental and chronic illnesses without the required license endorsements or staff training. Additional deficiencies included failure to document menu substitutions, inadequate scheduled activities and activity calendars, inaccurate medication administration records, and lack of evidence of caregiver training for mental illness and chronic illness care.
Complaint Details
Complaint #NV00025116 was substantiated based on findings of deficiencies related to licensing endorsements, training, activities, food service documentation, and medication administration.
Severity Breakdown
Level 1: 3
Level 2: 4
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility cared for 5 residents with mental illnesses and 1 with chronic illness without required license endorsements or training. | Level 2 |
| Failed to document and retain menu substitutions for at least 90 days. | Level 1 |
| Failed to provide at least 10 hours of scheduled activities for residents. | Level 2 |
| Failed to create and post a calendar of weekly activities for residents. | Level 1 |
| Medication administration records were inaccurate; residents initialed their own MAR instead of caregivers. | Level 1 |
| Failed to provide evidence that caregivers had been trained in care of residents with mental illnesses. | Level 2 |
| Failed to provide evidence that caregivers had been trained in care of residents with chronic illnesses (HIV). | Level 2 |
Report Facts
Licensed capacity: 6
Current census: 5
Deficiency severity counts: 7
Scheduled activity hours required: 10
Menu substitution retention period: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 mentioned in relation to failure to document menu substitutions and lack of activity calendar; no full name provided. |
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