Inspection Reports for Fairway Residential Care Home
3817 Fairway Cir, Las Vegas, NV 89108, NV, 89108
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 4
Capacity: 10
Deficiencies: 2
Dec 9, 2024
Visit Reason
The inspection was conducted as an annual State Licensure survey of the facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but was found deficient in developing person-centered service plans for all four residents and in ensuring six-month medication reviews were initialed and dated by the Administrator within 72 hours for three residents.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure a person-centered service plan was developed including the required components for 4 of 4 residents. | Severity: 2 |
| Failure to ensure six-month Medication Reviews were initialed and dated by the Administrator within 72 hours for 3 of 4 residents. | Severity: 2 |
Report Facts
Licensed beds: 10
Residents present: 4
Residents with deficient service plans: 4
Residents with deficient medication reviews: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Geoffrey Gomez | Administrator | Acknowledged deficiencies related to person-centered service plans and medication reviews |
Inspection Report
Annual Inspection
Census: 4
Capacity: 10
Deficiencies: 4
Dec 5, 2023
Visit Reason
This inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but had several deficiencies including unclean kitchen utensils and refrigerator surfaces, incomplete tuberculosis screening documentation for one resident, non-functional audible alarms on exit doors, and incomplete infection control training for designated employees.
Severity Breakdown
2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| The kitchen was not properly cleaned and sanitized; food debris and sticky substance found in utensil storage and dust on refrigerator top. | 2 |
| Failed to ensure a two-step tuberculosis screening was completed for one resident; second step TB test lacked documented result and read date. | 2 |
| Facility failed to ensure all exit doors had working audible alarms; front door alarm was turned off. | 2 |
| Primary and secondary infection control designees did not complete required 15 hours of infection control training. | 2 |
Report Facts
Licensed beds: 10
Resident census: 4
Deficiencies cited: 4
Infection control training hours required: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Geoffrey Gomez | Administrator | Administrator confirmed findings related to TB screening, kitchen sanitation, door alarms, and infection control training |
Inspection Report
Annual Inspection
Census: 5
Capacity: 10
Deficiencies: 0
Dec 22, 2022
Visit Reason
This inspection was conducted as an annual State Licensure and infection control survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the survey. The facility received a grade of A and no further action was necessary.
Report Facts
Resident files reviewed: 5
Employee files reviewed: 3
Inspection Report
Annual Inspection
Census: 7
Capacity: 10
Deficiencies: 0
Nov 15, 2021
Visit Reason
This inspection was conducted as an annual State Licensure and infection control survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
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.
Report Facts
Resident files reviewed: 7
Employee files reviewed: 3
Inspection Report
Complaint Investigation
Census: 8
Capacity: 10
Deficiencies: 0
Apr 13, 2021
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding visitor denial due to COVID-19 vaccination status.
Findings
The complaint alleging denial of visitors due to lack of COVID-19 vaccination was unsubstantiated based on interviews and record reviews. No regulatory deficiencies were identified.
Complaint Details
One complaint (#NV00063504) with one allegation was investigated and found unsubstantiated. The allegation that the facility denied visitors entry due to not being vaccinated was not supported by evidence.
Report Facts
Sample size: 5
Facility grade: A
Inspection Report
Routine
Census: 9
Capacity: 10
Deficiencies: 2
Nov 17, 2020
Visit Reason
This inspection was a COVID-19 focused infection control State Licensure survey conducted to assess compliance with infection control practices during the COVID-19 pandemic.
Findings
The facility had implemented several infection control measures such as visitor screening, staff PPE use, and cleaning protocols, but failed to have a comprehensive COVID-19 infection control plan and lacked N95 masks with no staff medically cleared or fit tested to wear them. Infection control guidance and recommendations were provided to the facility.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to implement a comprehensive COVID-19 infection control plan including standard and transmission-based precautions, visitor and staff screening, education and monitoring of PPE use, and staffing policies during emergencies. | Severity: 2 |
| Facility did not have N95 masks available and staff were not medically cleared or fit tested to wear N95 masks as recommended. | Severity: 2 |
Report Facts
Licensed beds: 10
Census: 9
Hand sanitizer bottles: 3
Gloves: 750
Disposable masks: 150
KN95 masks: 20
Non-contact thermometers: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Geoffrey Gomez | Administrator | Named as Administrator and signer of the report |
| Employee #1 | Caregiver | Assigned caregiver medically cleared and fit tested to wear N95 mask |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 2
Dec 11, 2019
Visit Reason
The inspection was conducted as the Annual Grading State Licensure Survey for the facility in accordance with Nevada Administrative Code, Chapter 449, Residential Facilities for Groups.
Findings
The facility received a grade of A. Deficiencies were identified related to securing oxygen tanks and medication labeling. The facility failed to ensure oxygen tanks were properly secured in two closets and medications for 3 of 9 residents were not labeled with the resident's and physician's names.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Oxygen tanks were not secured in one resident room closet and one caregiver's room closet. | Severity: 2 |
| Medications were not labeled with the name of the resident and the name of the physician for 3 of 9 residents. | Severity: 2 |
Report Facts
Resident files reviewed: 9
Employee files reviewed: 3
Residents with unlabeled medications: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Geoffrey Gomez | Administrator | Named as the facility administrator signing the report |
Inspection Report
Re-Inspection
Deficiencies: 9
May 7, 2019
Visit Reason
This inspection was a required State Licensure grading re-survey conducted in the facility to assess compliance with Nevada Administrative Code 449 for Residential Facilities for Groups.
Findings
The facility received a re-survey grade of B with multiple deficiencies identified including overcrowded bedrooms, expired fire extinguisher inspection, lack of annual tuberculosis testing documentation for residents, non-functional door alarms on exit doors, unsecured kitchen knives accessible to residents, and medication storage issues.
Severity Breakdown
Level 2: 4
Level D: 3
Level F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Residents shared a bedroom with more than two other residents; Bedroom #1 had four beds all occupied. | Level 2 |
| Fire extinguisher in laundry room was not inspected annually; last inspection was over a year prior. | Level D |
| Bedroom doors with locks did not open with a single motion from inside unless lock provides security and can be operated without a key. | Level D |
| Use of certain areas as bedrooms prohibited; no specific findings detailed. | Level D |
| Caregivers failed to ensure residents received annual tuberculosis testing or documentation of positive TB test for two residents. | Level 2 |
| Resident files lacked evaluation of ability to perform activities of daily living upon admission. | Level F |
| Three of four exit doors were not alarmed when opened, including main front door and bedroom #1 exit door. | Level 2 |
| Knives and sharp items in kitchen drawer were accessible to residents due to unlocked drawer. | Level 2 |
| Medication storage requirements not fully met; medications must be stored in locked, cool, dry areas. | Level F |
Report Facts
Beds in Bedroom #1: 4
Fire extinguisher last inspection date: Feb 21, 2018
Residents lacking annual TB test: 2
Exit doors without alarms: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Geoffrey Gomez | Administrator | Acknowledged bedroom overcrowding, fire extinguisher issues, door alarm deficiencies, TB test documentation discrepancies, and unlocked kitchen drawer; responsible for monitoring compliance and corrective actions. |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 8
Jan 3, 2019
Visit Reason
The inspection was an annual survey conducted to assess compliance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups providing care to residents with Alzheimer's disease.
Findings
The facility was found deficient in multiple areas including bedroom door locks, use of rooms as bedrooms, resident activities, oxygen equipment monitoring, medication storage, resident file documentation for tuberculosis screening and ADL assessments, and door alarms for Alzheimer's care. The facility received a grade of C.
Severity Breakdown
2: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Bedroom door #3 did not have a single motion lock as required. | 2 |
| A bedroom was used without a door, having only a curtain, which is prohibited. | 2 |
| Activities scheduled on the activity calendar were not followed and residents were not encouraged to participate. | 2 |
| Two oxygen tanks were unsecured in Resident #2's closet and Resident #3 lacked a documented physician order for oxygen use. | 2 |
| Medications were not properly secured; expired medications were left unattended and caregiver's room contained unsecured medications accessible to residents. | 2 |
| Two residents did not have completed two-step tuberculosis screening at the time of admission. | 2 |
| Activities of Daily Living (ADL) assessments were not completed initially or annually for 7 of 9 residents. | 2 |
| Alzheimer's facility door alarms were not operational on two doors leading to the front yard. | 2 |
Report Facts
Residents present: 9
Total licensed capacity: 10
Deficiency severity count: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Geoffrey Gomez | Administrator | Administrator verified deficiencies and provided corrective action plans |
| Caregiver #1 | Mentioned in relation to medication storage and activity participation deficiencies |
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 0
Aug 20, 2018
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding allegations that residents were left unattended.
Findings
The complaint was investigated and found unsubstantiated. Observations showed residents were well groomed and cared for by caregiver staff, with 24/7 caregiver services provided. No deficiencies were identified.
Complaint Details
Complaint Number NV00054259 was investigated and found unsubstantiated. The allegations of residents left unattended were unsubstantiated.
Report Facts
Census: 10
Inspection Report
Annual Inspection
Census: 5
Capacity: 10
Deficiencies: 4
Apr 14, 2016
Visit Reason
This inspection was an annual State Licensure survey conducted to assess compliance with regulations for a residential facility for residents with Alzheimer's disease.
Findings
The facility received a grade of B with several deficiencies identified including failure to perform timely background checks on employees, exterior facility hazards, improper administration of injections, and non-functioning door alarms.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 3 employees had a background check performed at least once every 5 years. | Severity: 2 |
| Facility exterior hazards including cinder block walls with barbed wire presenting potential harm or escape risk. | Severity: 2 |
| Residents requiring intramuscular injections were not administered by a qualified medical professional. | Severity: 2 |
| Two exit doors had non-functioning alarms due to dead batteries. | Severity: 2 |
Report Facts
Licensed capacity: 10
Census: 5
Deficiencies cited: 4
Inspection Report
Annual Inspection
Census: 5
Capacity: 10
Deficiencies: 4
Apr 14, 2016
Visit Reason
This annual State Licensure survey was conducted on 4/14/16 by the Division of Public and Behavioral Health to assess compliance with state regulations for the licensed residential care home.
Findings
The facility received a grade of B with several deficiencies identified including failure to perform timely background checks on employees, hazards related to unsecured exterior walls and fencing, improper administration of required injections by non-medical staff, and non-functioning door alarms on exit doors.
Severity Breakdown
2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 3 employees had a background check performed at least once every 5 years. | 2 |
| Failed to ensure the exterior of the facility was free of hazards including unsafe cinder block walls and unsecured pool access. | 2 |
| Failed to ensure residents requiring intramuscular injections were administered by a medical professional not employed by the facility. | 2 |
| Failed to ensure two exit doors had working alarms; alarms were non-operational due to dead batteries. | 2 |
Report Facts
Licensed beds: 10
Current census: 5
Employee files reviewed: 3
Resident files reviewed: 5
Inspection Report
Annual Inspection
Census: 5
Capacity: 10
Deficiencies: 1
May 14, 2015
Visit Reason
Annual State Licensure grading survey conducted to assess compliance with regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but was found deficient in ensuring dangerous items such as knives, matches, firearms, and tools were inaccessible to residents. Specifically, a lighter and lancets were found accessible to residents, which was acknowledged by a caregiver.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure dangerous items were inaccessible to residents, including a lighter on a resident's dresser and lancets in a nightstand drawer. | Severity: 2 |
Report Facts
Resident files reviewed: 5
Employee files reviewed: 4
Facility licensed beds: 10
Resident census: 5
Deficiency scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver #4 | Acknowledged the deficiency regarding dangerous items accessibility |
Inspection Report
Annual Inspection
Census: 5
Capacity: 10
Deficiencies: 1
May 14, 2015
Visit Reason
This annual State Licensure grading survey was conducted to assess compliance with regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but was found deficient for failing to ensure dangerous items such as a lighter and lancets were inaccessible to residents, posing a safety risk.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure dangerous items (lighter and lancets) were inaccessible to residents. | 2 |
Report Facts
Licensed capacity: 10
Census: 5
Severity level: 2
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver #4 acknowledged the deficiency but no full name provided |
Inspection Report
Complaint Investigation
Census: 5
Deficiencies: 3
Aug 27, 2014
Visit Reason
The inspection was conducted as a complaint investigation initiated by the Division of Public and Behavioral Health on 8/27/14 regarding an allegation that the facility failed to contact the responsible party after a resident fell.
Findings
The investigation substantiated the complaint that the facility failed to notify the resident's family after a fall and failed to complete an incident report. Additionally, the facility did not ensure immediate medical attention was provided after the injury, resulting in a fractured hip being diagnosed later.
Complaint Details
Complaint #NV00039921 contained one allegation that the facility failed to contact the responsible party after a resident fell. The complaint was substantiated.
Severity Breakdown
Severity: 2: 2
Severity: 3: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to notify the resident's family after a fall occurred. | Severity: 2 |
| Facility failed to ensure an incident report was completed after a resident sustained a fall. | Severity: 2 |
| Facility failed to ensure a resident received immediate medical attention after an injury. | Severity: 3 |
Report Facts
Census: 5
Date of fall incident: Jul 3, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver #1 | Interviewed regarding the fall incident and lack of notification and documentation |
Inspection Report
Complaint Investigation
Census: 5
Deficiencies: 3
Aug 27, 2014
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated by the Division of Public and Behavioral Health on 8/27/14 regarding failure to contact the responsible party after a resident fall.
Findings
The facility was found to have failed to notify the resident's family after a fall, failed to complete an incident report after a resident sustained a fall, and failed to ensure immediate medical attention after the injury. The complaint was substantiated with deficiencies identified.
Complaint Details
Complaint #NV00039921 contained one allegation that the facility failed to contact the responsible party after a resident fell. The complaint was substantiated.
Severity Breakdown
Level D: 2
Level G: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify the resident's family after a fall incident. | Level D |
| Failure to complete an incident report after a resident sustained a fall. | Level D |
| Failure to ensure immediate medical attention after injury to resident. | Level G |
Report Facts
Census: 5
Severity Level D Deficiencies: 2
Severity Level G Deficiencies: 1
Inspection Report
Annual Inspection
Census: 5
Capacity: 10
Deficiencies: 3
May 12, 2014
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 5/12/14 to assess compliance with regulatory requirements for a residential facility for persons with Alzheimer's disease.
Findings
The facility received a grade of A but had several deficiencies including failure to renew background checks for one employee, poor health and sanitation conditions such as strong urine odor and maintenance issues, and failure to ensure operational alarms on exit doors. The administrator acknowledged these deficiencies and corrective actions were planned.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 4 employees met background check requirements; fingerprints background check not renewed for Employee #3. | Severity: 2 |
| Facility failed to maintain clean and well-maintained interior and exterior; strong urine odor, unusable mattress, broken dresser drawer, paint peeling, standing water, lint on ceiling fan, hole in bathroom wall. | Severity: 2 |
| Failure to ensure 1 of 3 exit doors had alarms that operated when the door was opened; front exit door alarm not activated during multiple observations. | Severity: 2 |
Report Facts
Number of residents present: 5
Total licensed capacity: 10
Number of employee files reviewed: 4
Number of resident files reviewed: 5
Inspection Report
Annual Inspection
Census: 5
Capacity: 10
Deficiencies: 3
May 12, 2014
Visit Reason
This annual State Licensure survey was conducted on 5/12/14 by the Division of Public and Behavioral Health to assess compliance with state regulations for a residential care home providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but had several deficiencies including failure to ensure background check renewal for one employee, poor facility cleanliness and maintenance with strong urine odor and physical damages, and failure to have operational door alarms on one exit door. All deficiencies were acknowledged by the Administrator.
Severity Breakdown
2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 employees met background check renewal requirements. | 2 |
| Facility interior and exterior were not clean or well maintained, including strong urine odor, unusable mattress, broken dresser drawer, uncovered air duct with peeling paint, standing water, exposed outlet, lint on ceiling fan, and hole in bathroom wall. | 2 |
| Failed to ensure 1 of 3 exit doors had operational alarms activated when opened. | 2 |
Report Facts
Licensed beds: 10
Current census: 5
Employee files reviewed: 4
Resident files reviewed: 5
Deficiencies severity 2: 3
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 3
May 7, 2013
Visit Reason
This document is a State Licensure grading survey conducted as an annual inspection of the Fairway Residential Care Home on 5/7/2013 to assess compliance with state regulations.
Findings
The facility received a grade of A but had several deficiencies including failure to maintain clean and well-maintained premises, failure to ensure residents received required physical examinations, and failure to maintain proper tuberculosis testing documentation. These deficiencies were repeat findings from a prior survey.
Severity Breakdown
2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure the premises was clean and well maintained, including grease and grime under stove hood, dust behind dryer, non-working ceiling fan with exposed wires, dust on ceiling vents, missing light covers, peeling paint, broken windows, and unusable furniture scattered in yard. | 2 |
| Facility failed to ensure 4 of 8 residents received a physical examination due to significant change in condition (Residents #3, #4, #5, #7). | 2 |
| Facility failed to ensure 1 of 8 residents complied with tuberculosis testing requirements (Resident #1 needed new two-step TB test). | 2 |
Report Facts
Residents present: 8
Total licensed beds: 10
Deficiencies cited: 3
Employee files reviewed: 4
Resident files reviewed: 8
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 3
May 7, 2013
Visit Reason
This document is the result of an annual State Licensure survey conducted on 5/7/13 to assess compliance with state regulations for a residential facility for group beds.
Findings
The facility received a grade of A but had several deficiencies including failure to maintain cleanliness and premises, incomplete physical examinations for residents, and inadequate tuberculosis testing documentation. All deficiencies were assigned severity level 2 with varying scopes.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure the premises was clean and well maintained, including excessive grease and grime under stove hood, dust behind dryer, non-working ceiling fan, dust on ceiling vents, missing ceiling light covers, peeling paint, broken windows, and scattered unusable furniture in yard. | Severity: 2 |
| Facility failed to ensure 4 of 8 residents received a physical examination due to significant change in condition; missing physicals for residents #3, #4, #5, and #7 for 2012 and/or 2013. | Severity: 2 |
| Facility failed to ensure 1 of 8 residents complied with tuberculosis testing requirements; Resident #1 needs new two-step TB test as 7/29/11 reading did not document results. | Severity: 2 |
Report Facts
Licensed beds: 10
Resident census: 8
Deficiency severity: 3
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 3
May 30, 2012
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at Fairway Residential Care Home on 05/30/2012.
Findings
The facility was found deficient in tuberculosis testing compliance for employees, periodic physical examinations for residents, and maintenance of resident files related to tuberculosis testing. The facility received a grade of A.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 5 employees complied with tuberculosis testing requirements. | Severity: 2 |
| Failed to ensure 1 of 8 residents received required periodic physical examinations. | Severity: 2 |
| Failed to ensure 2 of 8 residents complied with tuberculosis testing documentation requirements. | Severity: 2 |
Report Facts
Census: 8
Total Capacity: 10
Employees reviewed: 5
Resident files reviewed: 8
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 3
May 30, 2012
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 5/30/2012 at Fairway Residential Care Home.
Findings
The facility received a grade of A but was found deficient in several areas including personnel tuberculosis testing compliance, periodic physical examinations for residents, and maintenance of resident files related to tuberculosis testing.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 5 employees complied with tuberculosis testing requirements (Employee #3 missing positive TB test and Employee #5 missing annual signs and symptoms). | Severity: 2 |
| Failed to ensure 1 of 8 residents received a physical examination due to a significant change in condition (Resident #2 did not obtain a physical in 2011 and Resident #6 did not obtain a physical in 2010). | Severity: 2 |
| Failed to ensure 2 of 8 residents complied with tuberculosis testing requirements (Resident #1 missing 2 Step TB Test and Resident #8 had annual TB test obtained a year and three months after second step). | Severity: 2 |
Report Facts
Number of employees reviewed: 5
Number of resident files reviewed: 8
Facility licensed capacity: 10
Current census: 8
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 14, 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 7/14/11 by the Health Division under state licensure authority.
Findings
The facility received a re-survey grade of A and no deficiencies were identified during this inspection.
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 7
Jun 1, 2011
Visit Reason
This document is the result of an annual State Licensure survey conducted on 06/01/2011 to assess compliance with regulations for Fairway Residential Care Home.
Findings
The facility received a grade of C with multiple deficiencies identified including failure to secure oxygen tanks, incomplete annual physical examinations for residents, improper medication destruction and storage, unsecured resident files, and failure to secure dangerous items and toxic substances. Corrective actions were implemented and monitored by the administrator.
Severity Breakdown
1: 1
2: 6
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to secure oxygen tanks in a rack or to the wall. | 2 |
| Failed to ensure 1 of 8 residents received an annual physical examination. | 2 |
| Failed to destroy medications after they were discontinued, expired, or after resident transfer. | 2 |
| Failed to ensure medications were kept in a locked area; medications for discharged residents found unsecured. | 2 |
| Failed to keep resident files locked; files were observed unlocked in a rolling file cabinet. | 1 |
| Failed to ensure dangerous items (knives, scissors, razors) were inaccessible to residents. | 2 |
| Failed to ensure toxic substances were inaccessible to residents; toxic substances found unsecured in multiple locations. | 2 |
Report Facts
Residents present: 8
Total licensed capacity: 10
Resident files reviewed: 8
Employee files reviewed: 6
Residents not receiving annual physical exam: 1
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 7
Jun 1, 2011
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at the facility on 6/1/2011 to assess compliance with state regulations.
Findings
The facility received a grade of C and was found deficient in multiple areas including failure to secure oxygen tanks, failure to ensure annual physical examinations for residents, improper medication destruction and storage, unsecured resident files, and failure to keep dangerous items and toxic substances inaccessible to residents.
Severity Breakdown
1: 1
2: 6
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to secure oxygen tanks in a rack or to the wall (two oxygen tanks in master bedroom closet and one unsecured in medication room). | 2 |
| Failed to ensure 1 of 8 residents received an annual physical examination. | 2 |
| Did not destroy medications after they were discontinued, expired, or after resident transfer. | 2 |
| Failed to ensure medications were kept in a locked area (medications for discharged residents found unsecured in living room filing cabinet). | 2 |
| Failed to keep resident files locked (files for 8 of 8 residents found in unlocked rolling file cabinet). | 1 |
| Failed to ensure dangerous items (scissors and razors) were inaccessible to residents (found in master bathroom and caregiver's bathroom). | 2 |
| Failed to ensure toxic substances were inaccessible to residents (found in caregiver's bathroom, under kitchen sink cabinet, and unlocked shed). | 2 |
Report Facts
Resident files reviewed: 8
Employee files reviewed: 6
Facility grade: C
Inspection Report
Annual Inspection
Census: 7
Capacity: 10
Deficiencies: 3
May 19, 2010
Visit Reason
This State Licensure survey was conducted as an annual inspection of the Fairway Residential Care Home on 05/19/2010 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in several areas including caregiver training, personnel background checks, resident file maintenance, and tuberculosis testing compliance. Some deficiencies were repeat findings from a prior survey.
Severity Breakdown
F: 2
E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure that 5 of 5 caregivers received eight hours of annual training related to Alzheimer's disease. | F |
| Failed to ensure 3 of 5 caregivers met background check requirements, including fingerprinting and repeat checks. | F |
| Failed to maintain resident files properly and ensure tuberculosis testing compliance for residents #5 and #7. | E |
Report Facts
Census: 7
Total Capacity: 10
Caregivers not trained: 5
Caregivers not background checked: 3
Residents non-compliant with TB testing: 2
Inspection Report
Annual Inspection
Census: 7
Capacity: 10
Deficiencies: 3
May 19, 2010
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 5/19/2010 at Fairway Residential Care Home.
Findings
The survey identified deficiencies related to caregiver training, personnel background checks, and resident tuberculosis testing compliance. Specifically, caregivers did not receive the required annual training, background checks were incomplete or outdated, and some residents lacked required tuberculosis testing documentation.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure that 5 of 5 caregivers received eight hours of annual training. | Severity: 2 |
| Facility failed to ensure 3 of 5 caregivers met background check requirements, including failure to repeat background checks after 5 years and failure to have fingerprints rolled within 10 days after hire. | Severity: 2 |
| Facility failed to ensure 2 of 7 residents complied with tuberculosis testing requirements, a repeat deficiency from a prior survey. | Severity: 2 |
Report Facts
Licensed beds: 10
Residents present: 7
Caregivers reviewed: 5
Resident files reviewed: 7
Employee files reviewed: 5
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 26, 2009
Visit Reason
This document is a required grading re-survey conducted at the facility on August 26, 2009, as part of a State Licensure survey by the Health Division.
Findings
No regulatory deficiencies were identified during this re-survey, and the facility received a grade of A.
Notice
Deficiencies: 0
Jul 30, 2009
Visit Reason
The Health Division is notifying the facility of its intent to impose sanctions based on deficiencies found during a prior survey and imposing monetary penalties accordingly.
Findings
The facility received sanctions based on the severity and scope of deficiencies as defined by Nevada regulations, including monetary penalties totaling $800. The facility also received a grade of D and is required to submit a grading system re-survey application with a fee.
Report Facts
Monetary penalties: 800
Monetary penalty: 300
Monetary penalty: 800
Fee: 500
Working days: 11
Working days: 10
Days: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Chambers | Health Facilities Surveyor III | Signed the notice of intent to impose sanctions. |
| Marla L. McDade Williams | Bureau Chief | Authorized the notice of intent to impose sanctions. |
Inspection Report
Annual Inspection
Census: 7
Capacity: 10
Deficiencies: 8
May 19, 2009
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation on 5/19/09 at the Fairway Res Care Home.
Findings
The facility was found deficient in multiple areas including improper handling of residents' money without written consent, inadequate record keeping for residents' funds, failure to obtain legal guardianship documentation, lack of rate agreements for residents, failure to obtain ultimate user agreements for medication administration, medication administration errors, failure to notify physicians of missed medications, and non-compliance with tuberculosis testing requirements. The complaint was substantiated and the facility received a grade of D.
Complaint Details
Complaint #21628 was substantiated, leading to identification of multiple deficiencies related to residents' money handling, legal guardianship, rate agreements, medication administration, and tuberculosis testing.
Severity Breakdown
Level 1: 3
Level 2: 5
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to ensure written consent was received from residents for handling their money. | Level 1 |
| Facility failed to provide separate and accurate record keeping for residents' money. | Level 1 |
| Facility failed to ensure documentary evidence of efforts to obtain legal guardians prior to becoming representative payee. | Level 2 |
| Facility failed to provide a rate agreement for 5 of 7 residents. | Level 2 |
| Facility failed to ensure ultimate user agreement was obtained for medication administration for 6 of 7 residents. | Level 1 |
| Facility failed to ensure medications were administered as prescribed for 2 of 7 residents. | Level 2 |
| Facility failed to notify physician within 12 hours of missed medication doses for 2 of 7 residents. | Level 2 |
| Facility failed to ensure compliance with tuberculosis testing for 2 of 7 residents, affecting all residents. | Level 2 |
Report Facts
Residents present: 7
Total licensed beds: 10
Residents files reviewed: 7
Employee files reviewed: 5
Residents without rate agreement: 5
Residents without ultimate user agreement: 6
Residents with medication administration errors: 2
Residents with missed medication physician notification failures: 2
Residents non-compliant with tuberculosis testing: 2
Inspection Report
Annual Inspection
Census: 6
Capacity: 10
Deficiencies: 12
Jul 16, 2008
Visit Reason
The inspection was conducted as an annual state licensure survey combined with a complaint investigation at the facility on July 15-16, 2008.
Findings
The facility was found deficient in multiple areas including failure to document evacuation drills and smoke detector tests for 3 of 12 months, failure to obtain written permission for opening resident mail, restricting resident movement by locking doors, inadequate protective supervision for residents, lack of documented annual physicals and medication reviews, medication administration discrepancies, missing tuberculosis testing documentation, missing annual activities of daily living assessments, and incomplete personnel files for employees.
Complaint Details
Seven complaints were investigated during the survey; four were substantiated (CPT #14684, #15123, #15336, #15353) and three were unsubstantiated (CPT #06548, #15082, #16559).
Severity Breakdown
Severity: 2: 11
Severity: 3: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to document evacuation drills on an irregular monthly schedule for 3 of 12 months. | Severity: 2 |
| Failed to document monthly smoke detector tests for 3 of 12 months. | Severity: 2 |
| Failed to obtain a resident's written permission for opening mail for 1 resident. | Severity: 2 |
| Failed to allow residents capable to enter and leave the facility at will; doors locked with a bike-like cable lock. | Severity: 2 |
| Failed to provide necessary protective supervision for 2 of 6 residents. | Severity: 3 |
| Failed to provide documented annual physicals for 6 of 6 residents. | Severity: 2 |
| Failed to review resident medications every six months for 2 of 6 residents. | Severity: 2 |
| Medication label from pharmacy did not match medication administration record for 1 resident. | Severity: 2 |
| Failed to provide instructions for medication administration reflecting current physician orders for 1 resident. | Severity: 2 |
| Failed to provide Tuberculin testing documentation for 6 of 6 residents. | Severity: 2 |
| Failed to document annual activities of daily living assessments for 4 of 6 residents. | Severity: 2 |
| Personnel files were not up to date with required information for 5 of 5 employees, including expired Tuberculin testing, missing training, missing references, and missing certifications. | Severity: 2 |
Report Facts
Total beds: 10
Census: 6
Complaints investigated: 7
Deficiency severity counts: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Named in findings related to locked doors restricting resident movement and personnel file deficiencies. | |
| Employee #4 | Named in findings related to locked doors restricting resident movement. | |
| Employee #6 | Named in incident report of resident elopement. | |
| Employee #7 | Caregiver | Named in incident report of resident elopement. |
| Employee #8 | Caregiver | Named in incident report of resident elopement. |
Inspection Report
Annual Inspection
Census: 6
Capacity: 10
Deficiencies: 11
Jul 15, 2008
Visit Reason
The inspection was conducted as a result of the annual state licensure survey and complaint investigation at the facility on July 15-16, 2008.
Findings
The survey identified multiple regulatory deficiencies including failure to perform emergency drills and smoke detector tests on a regular schedule, failure to obtain resident permission for mail opening, failure to allow residents to enter and leave the facility at will, inadequate protective supervision for residents, lack of documented annual physicals, medication administration errors, incomplete resident files, and personnel files not up to date. Several complaints were investigated with some substantiated findings.
Complaint Details
Seven complaints were investigated during the survey; four were substantiated (CPT #14684, #15123, #15336, #15353) and three were unsubstantiated (CPT #06548, #15082, #16559).
Severity Breakdown
Severity: 2: 10
Severity: 3: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to document evacuation drills on an irregular monthly schedule for 3 of 12 months. | Severity: 2 |
| Failed to document monthly smoke detector tests for 3 of 12 months. | Severity: 2 |
| Failed to obtain a resident's written permission for opening mail. | Severity: 2 |
| Failed to allow capable residents to enter and leave the facility at will; doors locked with cable lock restricting movement. | Severity: 2 |
| Failed to provide necessary protective supervision for 2 of 6 residents requiring it. | Severity: 3 |
| Failed to provide documented annual physical examinations for 6 of 6 residents. | Severity: 2 |
| Failed to review resident medications every six months for 2 of 6 residents. | Severity: 2 |
| Medication administration record did not match medication container label for 1 of 6 residents. | Severity: 2 |
| Failed to provide instructions for medication administration reflecting current physician orders for 1 of 6 residents. | Severity: 2 |
| Failed to provide Tuberculin testing documentation for 6 of 6 residents. | Severity: 2 |
| Personnel files not up to date for 5 of 5 employees, including missing TB tests, training, physical exams, and background checks. | Severity: 2 |
Report Facts
Total licensed beds: 10
Resident census: 6
Complaints investigated: 7
Months missing documentation: 3
Residents lacking annual physicals: 6
Residents lacking medication review: 2
Employees with incomplete personnel files: 5
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