Inspection Reports for Duncan Manor Care Home

The inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.

The facility received a grade of A but had regulatory deficiencies including improper medication storage and non-functioning audible alarms on exit doors. Corrective actions were implemented and completed by 12/13/2024.

The inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.

The facility received a grade of A. One deficiency was identified related to personnel files: one of three employees did not have a current background check completed through the Nevada Automated Background Check System as required by Nevada Revised Statute.

Annual State Licensure and infection control survey conducted at the facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.

The facility received a grade of A but had regulatory deficiencies including failure to ensure COVID-19 screening of visitors, improper administration of over-the-counter medications not according to physician orders, and improper labeling and storage of medications.

This Statement of Deficiencies was generated as a result of a grading resurvey conducted at the facility on 03/29/22 in accordance with Nevada Administrative Code, Chapter 449, Residential Facilities for Groups.

The facility received a grade of A with no regulatory deficiencies identified. Two resident records and four employee records were reviewed during the survey.

The inspection was conducted as an annual State Licensure and infection control survey in accordance with Nevada Administrative Code, Chapter 449, Residential Facilities for Groups.

The facility received a grade of B with several regulatory deficiencies identified, including failure to ensure two-step tuberculosis testing for employees and residents, poor maintenance of the facility exterior with trash and debris present, lack of audible alarm on an exit door, and unsecured toxic substances accessible to residents.

This inspection was a COVID-19 focused infection control State Licensure survey conducted to assess the facility's compliance with infection control practices during the COVID-19 pandemic.

The facility was found to have implemented many infection control measures such as visitor screening, hand hygiene, social distancing, and cleaning protocols. However, a deficiency was identified as the facility did not have any employee medically cleared and fit tested to wear an N95 mask, despite prior guidance recommending at least one caregiver be fit tested.

The inspection was conducted as a result of a complaint investigation at the facility on 07/30/2020, triggered by Complaint #61258 with four allegations.

The investigation included observations, interviews, and record reviews. All four allegations were found to be unsubstantiated and no regulatory deficiencies were identified. No further action was necessary.

Complaint #61258 with four allegations was investigated and found unsubstantiated. Allegations included staff dragging a resident, failure to report abuse, resident privacy concerns, and restrictions on resident's spouse removing the resident from the facility.

The inspection was conducted as an annual State Licensure survey of the facility in accordance with Nevada Administrative Code, Chapter 449, Residential Facilities for Groups.

The facility received a grade of A but had several regulatory deficiencies related to medication administration, medication record accuracy, and securing toxic substances. Deficiencies included missing ultimate user agreement for medication, incomplete medication administration records, and unsecured toxic substances.

This inspection was a regrading State Licensure survey initiated and completed on 2/19/2020 to assess compliance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.

The facility received a grade of A but had several deficiencies including failure to ensure tuberculosis (TB) testing was completed for some employees and residents, incomplete personnel files, improper handling of resident money, inadequate written policies on admissions, and deficiencies in medication administration and record keeping.

The inspection was conducted as a State Licensure wellness check survey at a residential facility for groups to ensure compliance and to inform the facility representative of the need to immediately renew their license.

The surveyor informed the facility that failure to renew the license could result in a civil penalty of $10,000 if six residents remain in the facility after January 31, 2019. No specific deficiencies were cited in this report.

The inspection was conducted as a result of a complaint investigation completed at the facility on 3/27/18, involving two complaints regarding staff safety concerns and patient care issues.

The investigation included observations, interviews, and medical record reviews. Both complaints were not substantiated, and no regulatory deficiencies were identified. No further action was necessary.

Two complaints were investigated. Complaint #NV00052428 involved concerns about staff safety after an assault incident and was not substantiated. Complaint #NV00052423 involved patient complaints about pain management, delayed nurse response, IV pump alarms, and room temperature, all of which were not substantiated.

This inspection was conducted as an annual State Licensure survey to assess compliance with regulatory requirements for the Duncan Manor Group Home.

The facility received a grade of B and was found deficient in several areas including personnel files lacking tuberculosis and background check documentation, failure to provide scheduled resident activities, incomplete medication reviews for residents, and unsecured resident files.

This inspection was a required grading re-survey conducted for state licensure purposes at Duncan Manor Group Home on 9/22/2016.

The facility received a re-survey grade of A. Deficiencies were identified related to incomplete background checks for an employee, lack of prior written authorization for handling a resident's ATM card, failure to document the basic rate of services in a resident's file, and failure to maintain accurate records of resident funds withdrawals.

The Division of Public and Behavioral Health is imposing sanctions and monetary penalties on Duncan Manor Group Home due to repeat deficiencies cited in a prior survey dated 1/21/16.

The facility received monetary penalties totaling $600 for repeat deficiencies at TAG Y105 and TAG Y176. The facility also received a grade of D and is required to submit a grading system re-survey application with a $600 fee, which has not been submitted.

The inspection was conducted as a complaint investigation initiated on 7/21/16 regarding the facility's failure to have a supervising administrator while operating a licensed residential facility for groups.

The facility was found to have substantiated allegations of failing to have a licensed administrator on staff from 7/1/16 to 8/9/16. The owner was actively seeking a licensed administrator but had not yet hired one by the time of the follow-up call on 8/9/16.

Complaint #NV00046673 was substantiated. The allegation that the facility failed to have a supervising administrator while operating a licensed facility for groups was confirmed.

This report is a Statement of Deficiencies generated as a result of a required grading re-survey conducted on 5/5/16 following a prior survey. The re-survey was conducted to assess compliance with state licensure requirements and to verify correction of previous deficiencies.

The facility received a re-survey grade of D. Multiple deficiencies were identified including failure of the administrator to provide necessary staff oversight, inadequate caregiver training hours, failure to provide elder abuse training, incomplete background checks for employees, presence of insects and rodents, non-compliance with written policies, failure to ensure resident rights and dignity, unsecured medication storage, and failure to display the required grading placard. Many deficiencies were repeat findings from the prior annual survey.

This document is a Statement of Deficiencies generated as a result of a required grading re-survey conducted on 5/5/2016 at Duncan Manor Group Home to assess compliance with state licensure requirements.

The facility received a re-survey grade of D with multiple deficiencies identified including failure to provide adequate staff oversight, incomplete employee training, lack of background checks, presence of insects and rodents, failure to follow facility policies, failure to treat residents with dignity and respect, unsecured medications, and failure to display the current grading placard.

This inspection was an annual State Licensure survey conducted on 1/26/16 to assess compliance with regulations for a residential facility for elderly and disabled persons.

The facility received a grade of D with multiple deficiencies identified, including failures in caregiver training, personnel file requirements, health and safety standards, and fire safety. Several employees lacked required training and documentation, and the facility had issues with insects and rodents as well as maintenance problems.

This annual State Licensure survey was conducted to assess compliance with state regulations for the Duncan Manor Group Home, a residential facility for elderly and disabled persons.

The facility received a grade of D with multiple deficiencies identified including lack of required employee training, incomplete personnel files, failure to maintain a pest-free and well-maintained environment, non-working emergency lights, and incomplete resident tuberculosis testing documentation.

This document is a Statement of Deficiencies generated as a result of an annual State Licensure grading survey conducted on 1/20/15 to assess compliance with regulatory requirements for a residential facility for elderly and disabled persons.

The facility was found deficient in several areas including personnel files lacking current CPR certification for some employees, health and sanitation issues such as a non-operable dishwasher and soiled carpets, incomplete and inaccurate medication administration records for multiple residents, and failure to ensure employees assessed residents' medication needs. The facility received a grade of B.

This annual State Licensure grading survey was conducted to assess compliance with state regulations for Duncan Manor Group Home, a residential facility for elderly and disabled persons.

The facility received a grade of B with several regulatory deficiencies identified, including expired CPR and First Aid certifications for employees, unclean and poorly maintained premises, incomplete and inaccurate medication administration records for multiple residents, improper administration of PRN medications, and failure to obtain a chronic illness endorsement for a resident with chronic conditions.

This inspection was a required grading re-survey conducted as a result of a previous inspection to verify corrections and compliance with state licensure regulations.

The facility was found to have deficiencies related to incomplete and inaccurate record keeping by the administrator and medication administration records. These deficiencies were repeat issues from a prior annual state licensure survey.

This document is a required grading re-survey conducted as a State Licensure survey to assess compliance with regulations at Duncan Manor Group Home.

The facility received a re-survey grade of A. Deficiencies were identified related to incomplete and inaccurate facility records and medication administration records (MAR). These deficiencies were repeat findings from the prior annual State Licensure survey.

The inspection was conducted as a result of a complaint investigation initiated on 2013-09-27 regarding an allegation that a caregiver was physically abusive toward a resident.

The complaint was unsubstantiated after interviews with the resident, the alleged caregiver, and other residents. No regulatory deficiencies were identified and no further action was required.

Complaint #NV00036890 was unsubstantiated. The allegation that a caregiver was physically abusive was not substantiated through interviews conducted by an Elder Rights Specialist and other investigative steps.

The Division of Public and Behavioral Health is imposing sanctions on the facility due to repeat deficiencies identified in a prior survey conducted on 8/9/12, as detailed in the attached survey and Plan of Correction.

The facility was found to have repeat deficiencies at TAG Y 920, resulting in the imposition of monetary penalties totaling $300.00. The sanctions are based on the severity and scope of the deficiencies as defined by Nevada Administrative Code.

This document is a State Licensure annual grading survey conducted on 8/1/13 to assess compliance with regulatory requirements for a residential facility for elderly and disabled persons.

The facility received a grade of D with multiple deficiencies identified including incomplete and inaccurate records, missing pre-employment physicals, inadequate health and sanitation maintenance, failure to ensure residents received required physical examinations, medication administration errors, and improper medication storage and labeling.

This document is a State Licensure annual grading survey conducted to assess compliance with regulatory requirements for Duncan Manor Group Home.

The facility received a grade of D with multiple deficiencies identified including incomplete and inaccurate records, missing pre-employment physicals for employees, poor health and sanitation conditions, failure to ensure residents received required physical examinations, medication administration errors, improper medication storage, and missing tuberculosis testing for a resident.

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 and/or persons with mental illness.

The facility received a grade of B with several deficiencies identified including failure to ensure fire extinguishers were inspected and recharged, incomplete physical examinations for residents, medication administration errors, failure to notify physicians of missed medications, inaccurate medication administration records, and unsecured medication storage.

This document is an annual State Licensure survey conducted on 8/9/2012 to assess compliance with state regulations for Duncan Manor Group Home, a residential facility for elderly or disabled persons and/or persons with mental illness.

The facility received a grade of B with multiple deficiencies identified including expired fire extinguisher tags, failure to ensure residents received required physical examinations, medication administration errors, failure to notify physicians of missed medications, inaccurate medication administration records, and unsecured medication storage.

The inspection was an annual State Licensure survey conducted on 7/22/11 to assess compliance with state regulations for a residential facility for elderly and disabled persons and/or persons with mental illness.

The facility received a grade of A. Deficiencies were identified related to maintaining cleanliness and orderliness of the premises, providing a written program of activities for residents, and preparing a comprehensive medication plan including training for caregivers.

This document is an annual State Licensure survey conducted on 7/22/2011 to assess compliance with state regulations for a residential facility for group beds for elderly and disabled persons and/or persons with mental illness.

The facility received a grade of A but had deficiencies including failure to maintain clean and well-maintained premises, failure to provide an appropriate calendar of daily activities, and failure to prepare a comprehensive medication plan including all required components.

The Bureau conducted a grading resurvey at Duncan Manor Group Home on 3/24/11, which led to the imposition of sanctions and monetary penalties due to deficiencies found during the survey.

The facility received a grade of B for their survey, with specific deficiencies detailed in the Statement of Deficiencies (Attachment A). The Plan of Correction submitted was reviewed and deemed acceptable.

This document is a Statement of Deficiencies generated as a result of a required grading re-survey conducted on 3/24/11 to assess compliance with state licensure regulations for a residential facility for elderly and disabled persons.

The facility was found deficient in maintaining complete personnel files, including missing employee personal information, tuberculosis testing, reference checks, background checks, and mental illness training. Several deficiencies were repeat findings from a prior survey on 8/19/10.

This document is a required grading re-survey conducted as a State Licensure survey to assess compliance with regulations at Duncan Manor Group Home.

The facility received a re-survey grade of B with multiple deficiencies identified related to personnel files, tuberculosis testing, reference checks, background checks, and mental illness training. Several deficiencies were repeat findings from a prior survey conducted on 8/19/10.

This document is the result of an annual State Licensure survey conducted on 8/19/2010 to assess compliance with state regulations for Duncan Manor Group Home, a residential facility for elderly and disabled persons and/or persons with mental illness.

The facility received a grade of D with multiple deficiencies noted including failure to provide required caregiver training, incomplete tuberculosis testing and background checks for employees, hazards in the facility, improper medication administration and storage, inaccurate medication records, and failure to maintain proper resident files. Several deficiencies were repeat citations from prior surveys.

This report documents a required grading re-survey conducted at Duncan Manor Group Home to assess compliance with state licensure regulations.

The facility received a survey grade of A but had deficiencies including failure to display the grading placard, incomplete background checks for 2 of 3 caregivers, and lack of first aid and CPR certification for 1 of 3 caregivers. These deficiencies were repeat findings from previous surveys.

The Health Division is notifying the facility of its intent to impose sanctions and monetary penalties due to deficiencies cited in a prior survey dated December 17, 2008.

The facility was assessed monetary penalties totaling $900 for repeat deficiencies at specific tags cited in the previous survey. The notice outlines the statutory authority, penalty amounts, appeal rights, and payment instructions.

This was an annual State Licensure survey conducted to assess compliance with state regulations for a residential facility for elderly and disabled persons and/or persons with mental illness.

The facility was found deficient in multiple areas including caregiver qualifications, training, personnel file requirements, health and sanitation, medication administration records, resident physical examinations, and tuberculosis testing. Several deficiencies were repeat findings from prior surveys.

The inspection was conducted as an annual state licensure survey combined with a complaint investigation at Duncan Manor Group Home.

The facility was found deficient in multiple areas including caregiver qualifications and training, personnel file documentation, health and sanitation, medication administration, resident physical examinations, and record keeping. Several deficiencies were repeat findings from a prior survey.

Two complaints were investigated during the survey. Complaint #NV00017347 was substantiated without deficiencies. Complaint #NV00017737 was unsubstantiated.