Inspection Reports for Fernley Estates
1130 Chisholm Trail, Fernley, NV 89408, Fernley, NV
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 9, 2024, found multiple deficiencies including issues with timely CPR training, medication administration, tuberculosis testing, activities of daily living assessments, nondiscrimination statements, and physician placement determinations for residents with dementia. Earlier inspections showed a pattern of similar deficiencies related to staff training (CPR, elder abuse, dementia care), medication management, tuberculosis testing, and resident placement assessments, with no enforcement actions or fines listed in the available reports. Complaint investigations were mostly unsubstantiated, with one regrading complaint investigation in 2021 resulting in a grade of A but noting several deficiencies in training, personnel files, and safety measures. The facility’s inspection grades have fluctuated over time, with some improvement in training and documentation noted in recent years, though issues persist. There is no clear trend of consistent improvement or worsening, but the facility continues to have recurring challenges in staff training and medication management.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% worse than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
68% occupied
Based on a July 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Annual Inspection
Census: 49
Capacity: 72
Deficiencies: 7
Date: Jul 9, 2024
Visit Reason
This inspection was conducted as a State Licensure annual survey of Fernley Estates, a Residential Facility for Groups, to assess compliance with Nevada Administrative Code Chapter 449.
Findings
The facility was found to have multiple regulatory deficiencies including failure to ensure timely CPR training for an employee, medication administration errors, late tuberculosis testing, delayed activities of daily living assessments, incomplete nondiscrimination statement on the website, and late physician placement determinations for residents with dementia.
Deficiencies (7)
Failed to ensure 1 of 15 employees had required CPR and first aid training within 30 days of hire.
Failed to ensure medication was onsite to administer prescribed dosage for 1 of 15 sampled residents (Resident #4).
Failed to ensure Medication Administration Record (MAR) was accurate for 1 of 15 sampled residents (Resident #11).
Failed to ensure annual tuberculosis (TB) test was completed timely for 1 of 15 sampled residents (Resident #7).
Failed to ensure initial Activities of Daily Living (ADL) assessment was completed timely for 1 of 15 sampled residents (Resident #12).
Failed to post a current and complete nondiscrimination statement prominently on the Internet website used to market the facility.
Failed to ensure initial physician placement determinations were completed timely by a provider for residents with a diagnosis of dementia prior to admission for 1 of 25 sampled residents (Resident #12).
Report Facts
Employees reviewed: 15
Resident files reviewed: 15
Deficiencies cited: 7
Days late for TB test: 30
Days late for physician placement: 53
Inspection Report
Re-Inspection
Census: 48
Capacity: 72
Deficiencies: 10
Date: Mar 14, 2024
Visit Reason
This Statement of Deficiencies was generated as a result of a mandatory regrading survey conducted at the facility on 03/14/24 in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. Several regulatory deficiencies were identified related to administrator responsibilities, elder abuse training, personnel file requirements including TB screening, first aid and CPR training, medication storage, maintenance of resident files, dementia care training, cultural competency training, and annual resident assessments.
Deficiencies (10)
Administrator's Responsibilities-Complete Rec - NAC 449.194 Responsibilities of administrator to ensure records are complete and accurate.
Elder Abuse Training - NRS 449.093 Training to recognize and prevent abuse of older persons required for applicants, licensees, administrators, and employees.
Personnel File - TB Screening - NAC 449.200 Personnel files must include health certificates as required.
First Aid & CPR - NAC 449.231 Administrator or caregiver must be trained in first aid and CPR within 30 days of employment.
Written Policy on Admissions - NAC 449.2702 A person may not reside in the facility if physician or Bureau determines non-compliance with eligibility.
Medication: Storage - NAC 449.2748 Medication must be stored in locked areas with specific requirements for refrigeration and resident self-administration.
Maintenance and Contents of Separate File - NAC 449.2749 Separate resident files must be maintained and locked for at least 5 years after discharge.
Care to Persons with Dementia - NAC 449.2768 Training requirements for employees providing care to residents with dementia.
Cultural Competency Training - R016-20 Facility must conduct cultural competency training for employees providing care.
Annual Assessment of History of Each Resident - NRS 449.1845 Administrator must conduct annual assessments and ensure qualified providers conduct physical exams and assessments.
Report Facts
Licensed capacity: 72
Census: 48
Files reviewed: 10
Files reviewed: 6
Survey date: Mar 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Belle Alto | Administrator | Named as Laboratory Director or Provider/Supplier Representative signing the report |
Inspection Report
Re-Inspection
Census: 47
Capacity: 72
Deficiencies: 11
Date: Jan 2, 2024
Visit Reason
This Statement of Deficiencies was generated as a result of a mandatory regrading survey conducted at the facility on 01/02/2024 in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of C with multiple deficiencies identified including failure to ensure timely elder abuse training, tuberculosis testing, CPR and first aid training, medication storage security, proper resident placement, and completion of required dementia and cultural competency training for employees. Several residents lacked proper placement assessments and documentation.
Deficiencies (11)
Failed to ensure 1 of 6 employees received timely annual elder abuse training (Employee #2).
Failed to ensure 1 of 6 employees met tuberculosis (TB) testing requirements (Employee #2).
Failed to ensure 1 of 6 employees had required CPR and first aid training within 30 days of hire (Employee #2).
Failed to ensure a resident was placed in the appropriate memory care setting (Resident #4).
Failed to ensure resident medications were kept secured for 1 of 7 resident rooms with self-administering medication (Room #210).
Failed to ensure 1 of 9 residents met TB testing requirements including second step TB test (Resident #6).
Failed to ensure 1 of 6 employees had employee file documentation present at the facility (Employee #2).
Failed to ensure 1 of 2 employees completed required additional three hours of dementia training by hire anniversary date (Employee #2).
Failed to ensure cultural competency training was completed timely for 1 of 6 employees required to obtain it (Employee #2).
Failed to ensure standard placement determination were completed by a provider upon admission and annually for 2 of 9 residents (Resident #1 and #8).
Failed to ensure infection control required training was completed.
Report Facts
Facility licensed capacity: 72
Census: 47
Employees reviewed: 6
Residents reviewed: 9
Resurvey fee: 600
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura A Higman | Administrator | Signed report as Administrator |
| Employee #2 | Vice President of Operations | Named in multiple findings including failure to complete elder abuse training, TB testing, CPR and first aid training, dementia training, cultural competency training, and lack of employee file documentation |
Inspection Report
Annual Inspection
Census: 48
Capacity: 72
Deficiencies: 19
Date: Sep 14, 2023
Visit Reason
This inspection was a State Licensure annual survey conducted in accordance with Nevada Administrative Code (NAC) Chapter 449 for a Residential Facility for Groups.
Findings
The facility received a grade D with multiple deficiencies identified including failure to ensure timely elder abuse training, tuberculosis testing, CPR/First Aid training, physical exams, medication administration reviews, medication storage, dementia care training, cultural competency training, infection control training, and standard placement assessments for residents with dementia.
Deficiencies (19)
Failed to ensure 4 of 15 employees received initial elder abuse training prior to beginning work and annually thereafter.
Failed to ensure 2 of 15 employees met tuberculosis testing requirements.
Failed to ensure 4 of 15 employees had required CPR and first aid training within 30 days of hire.
Failed to ensure physical examinations were completed prior to admission or annually for 4 of 15 residents.
Failed to ensure medication profile review was reviewed and initialed by physician within 72 hours for 1 of 10 sampled residents.
Failed to ensure resident medications were kept secured for 1 of 10 sampled residents.
Failed to ensure tuberculosis testing requirements were met for 1 of 15 sampled residents.
Failed to ensure annual Activities of Daily Living (ADL) assessment was completed for 1 of 10 residents.
Failed to ensure hospice Plan of Care was obtained and retained for 1 of 10 sampled residents receiving hospice care.
Failed to have a policy addressing dangerous and toxic items in the memory care unit.
Failed to ensure dangerous items were inaccessible to residents in memory care unit for 1 of 12 occupied rooms.
Failed to ensure toxic substances were inaccessible to residents in memory care unit for 5 of 12 occupied rooms.
Failed to ensure 2 of 12 employees received four hours of initial caregiver training within 60 days of hire.
Failed to ensure 2 of 15 employees providing care to residents with dementia received two hours of dementia training within 40 hours of hire.
Failed to ensure 3 of 10 employees providing care to residents with dementia received eight hours of dementia training within 90 days of hire.
Failed to ensure 2 of 2 employees providing care to residents with dementia completed required three hours of annual dementia training by hire anniversary date.
Failed to ensure cultural competency training was completed timely for 3 of 14 employees required to obtain it.
Failed to ensure standard placement assessments were completed by a provider initially upon admission and annually thereafter for 6 of 10 residents with dementia not residing in memory care.
Primary infection control staff lacked required infection control training.
Report Facts
Deficiencies cited: 19
Facility licensed capacity: 72
Census: 48
Researched employee sample size: 15
Resident sample size: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kailin Peitz | Administrator | Named in relation to findings and responsible for ensuring compliance and training goals. |
| Employee #1 | Administrator | Primary infection control staff lacking required infection control training. |
| Employee #2 | Failed elder abuse training, caregiver training, cultural competency training, dementia training. | |
| Employee #3 | Failed elder abuse training, caregiver training, cultural competency training, dementia training. | |
| Employee #4 | Failed annual dementia training. | |
| Employee #7 | Failed elder abuse training. | |
| Employee #11 | Failed CPR/First Aid training and annual dementia training. | |
| Employee #12 | Failed caregiver training, dementia training, cultural competency training. | |
| Employee #14 | Failed elder abuse training and tuberculosis testing. | |
| Employee #15 | Failed cultural competency training. |
Inspection Report
Annual Inspection
Census: 46
Capacity: 72
Deficiencies: 3
Date: Aug 11, 2022
Visit Reason
This inspection was conducted as a State Licensure annual survey of Fernley Estates, a Residential Facility for Groups, to assess compliance with Nevada Administrative Code Chapter 449.
Findings
The survey identified multiple regulatory deficiencies including failure to discharge a resident receiving skilled nursing without an approved exemption, medication administration errors, and improper labeling of over-the-counter medications lacking resident and physician names.
Deficiencies (3)
Facility failed to discharge a resident receiving skilled nursing for wound care without an approved exemption from the State of Nevada.
Medication was not administered as prescribed; discrepancy between physician order and medication administration record for Resident #6.
Over-the-counter medications lacked resident and/or physician names on labels for Residents #3 and #10.
Report Facts
Deficiencies cited: 3
Resident files reviewed: 15
Employee files reviewed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Higman | Administrator | Named as the facility administrator who submitted exemption waiver and involved in corrective actions |
Inspection Report
Re-Inspection
Census: 49
Capacity: 72
Deficiencies: 9
Date: Dec 22, 2021
Visit Reason
This Statement of Deficiencies was generated as a result of a mandatory regrading survey conducted at the facility on 12/22/21 in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Complaint Details
The facility received a regrading/complaint investigation grade of A. The findings and conclusions of the investigation do not prohibit other criminal or civil investigations or actions.
Findings
The facility received a regrading/complaint investigation grade of A. Several regulatory deficiencies were identified including administrator responsibilities, elder abuse training, personnel file issues such as background checks and TB screening, health and sanitation maintenance, laundry services, maintenance of resident files, Alzheimer’s care safety standards, and dementia care training requirements.
Deficiencies (9)
Administrator failed to designate employees to be in charge during administrator absence with proper access and posting.
Failure to provide required training to recognize and prevent abuse of older persons.
Personnel file lacked required health certificates and background check documentation for one employee.
Facility failed to maintain a complete list of current employees on the criminal history check website for one employee.
Facility premises were not adequately maintained in terms of cleanliness and landscaping.
Laundry and linen services did not meet regulatory requirements for sanitary washing and finishing.
Maintenance and contents of separate resident files were not properly maintained and secured.
Residents were not safe from toxic substances in an unlocked bathroom cabinet in the memory care unit.
Employees providing care to residents with dementia did not complete required dementia care training.
Report Facts
Licensed capacity: 72
Census: 49
Number of resident files reviewed: 15
Number of employee files reviewed: 9
Severity 2 deficiency count: 2
Severity 1 deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Higman | Administrator | Signed the report and confirmed issues related to background checks |
| Employee #3 | Wellness Director | Named in deficiency related to background check and toxic substances accessibility |
Inspection Report
Annual Inspection
Census: 32
Capacity: 72
Deficiencies: 10
Date: Jul 29, 2021
Visit Reason
This inspection was a State Licensure annual survey conducted in accordance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.
Findings
The facility received a grade of C with multiple deficiencies identified including failure to designate an employee in charge during the administrator's absence, incomplete elder abuse training for employees, late tuberculosis screenings and incomplete pre-employment physicals, incomplete background checks, maintenance issues with furniture and laundry room sanitation, medication administration documentation errors, late resident tuberculosis testing, unsafe access to toxic substances in the memory care unit, and incomplete dementia care training for an employee.
Deficiencies (10)
Failed to designate in writing one or more employees to oversee the facility during the Administrator's absence.
Failed to ensure 2 of 9 sampled employees completed training to recognize and prevent the abuse of older persons within required timeframes.
Failed to ensure tuberculosis screenings were completed within required timeframe for 3 of 9 employees and pre-employment physicals were incomplete for 5 of 9 employees.
Failed to maintain a complete list of current employees on the established Internet website for criminal history checks for 1 of 9 sampled employees.
Failed to ensure a cushioned bench in the memory care unit was in good repair for resident use.
Failed to ensure the laundry room in the memory care unit was clean and free of lint and debris, and soiled and clean laundry were separated.
Failed to initial a medication profile review for 1 of 10 sampled residents.
Failed to ensure 2 of 10 sampled residents met tuberculosis testing requirements in accordance with Nevada Administrative Code.
Failed to ensure residents were safe from toxic substances in the memory care unit; alcohol-based hand sanitizer was accessible and residents were not assessed for proper use of soap dispensers.
Failed to ensure an employee completed required hours of continuing education in providing care to residents with dementia.
Report Facts
Facility licensed capacity: 72
Resident census: 32
Deficiency severity counts: 10
Resurvey application fee: 600
Employees sampled: 9
Residents sampled: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Higman | Designated Manager | Named as Designated Manager who acknowledged deficiencies and provided confirmations during the inspection |
| Employee #1 | Administrator | Failed to complete dementia care training and was not entered into background check system properly |
| Employee #3 | Wellness Director | Failed to complete elder abuse training timely and had incomplete pre-employment physical documentation |
| Employee #5 | Director of Environmental Services | Failed to complete elder abuse training timely and had late TB screening |
| Designated Manager | Provided multiple confirmations and acknowledgments of deficiencies during inspection |
Inspection Report
Routine
Census: 37
Capacity: 72
Deficiencies: 3
Date: Jan 20, 2021
Visit Reason
This inspection was conducted as a State Licensure COVID-19 Focused Infection Control Survey to assess compliance with infection control and prevention regulations in a residential facility for groups.
Findings
The facility had six COVID-19 positive residents and two COVID positive staff members at the time of the survey. The facility failed to provide a safe environment by not fit testing staff for N95 masks, not providing adequate staff education on PPE doffing, and not following CDC symptom-based or test-based strategies for staff return to work after COVID infection.
Deficiencies (3)
Failure to have staff fit tested for N95 respirator masks.
Failure to provide staff education on the appropriate procedure for doffing of PPE for 3 of 3 employees.
Failure to follow CDC symptom-based or test-based strategy to determine when a staff member was able to return to work.
Report Facts
Licensed beds: 72
Current census: 37
COVID positive residents: 6
COVID positive staff: 2
PPE stock quantities: 1500
PPE stock quantities: 135000
PPE stock quantities: 770
PPE stock quantities: 10250
PPE stock quantities: 90
PPE stock quantities: 10
PPE stock quantities: 56
PPE stock quantities: 36
PPE stock quantities: 60
PPE stock quantities: 248
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Simons | MSL Director Quality Assurance | Signed the report |
| Vice President of Operations | Provided key information on fit testing failures, PPE use, and staff return to work policies | |
| Administrator Designee | Provided information on staff training and PPE procedures | |
| Resident Assistant | Interviewed regarding PPE use and training | |
| Wellness Director | Interviewed regarding PPE doffing procedures | |
| Maintenance Director | COVID positive staff member allowed to work without proper clearance |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 72
Deficiencies: 0
Date: Jan 5, 2021
Visit Reason
This inspection was conducted as a complaint investigation triggered by two complaints alleging noncompliance with COVID-19 guidelines and staff exposure risks.
Complaint Details
Two complaints were investigated: Complaint #NV00062864 alleging staff not following COVID-19 guidelines and lack of PPE accessibility, and Complaint #NV00062867 alleging a COVID-19 positive resident assistant attended to COVID-19 negative residents. Both complaints were not substantiated.
Findings
The investigation found that the complaints could not be substantiated based on interviews, observations, and document reviews. The facility had adequate PPE supplies, implemented COVID-19 protocols including quarantining residents, staff testing, and use of PPE, but had not completed N95 fit testing for all employees. No regulatory deficiencies were identified.
Report Facts
Licensed beds: 72
Current census: 43
COVID-19 positive residents: 6
Staff diagnosed with COVID-19: 8
PPE Inventory - gloves: 133300
PPE Inventory - reusable gowns: 237
PPE Inventory - disposable gowns: 2060
PPE Inventory - aprons: 13714
PPE Inventory - ponchos: 400
PPE Inventory - surgical masks: 18540
PPE Inventory - KN95 masks: 3320
PPE Inventory - NIOSH KN95 masks: 880
PPE Inventory - hair covers: 940
PPE Inventory - goggles: 20
PPE Inventory - shoe covers: 1200
PPE Inventory - face shields: 482
PPE Inventory - safety glasses: 82
PPE Inventory - disinfectant wipes: 288
PPE Inventory - hand sanitizer gallons: 163
Inspection Report
Renewal
Census: 48
Capacity: 72
Deficiencies: 0
Date: Oct 15, 2020
Visit Reason
This inspection was a State Licensure re-grading survey conducted to assess compliance with NAC 449 for a Residential Facility for Groups, including endorsement for persons with Alzheimer's disease.
Findings
The facility was found to be in compliance with no deficiencies identified and received a grade of A. Several regulatory areas such as personnel files, medication administration, oxygen use, and Alzheimer's care standards were reviewed with no new deficiencies cited.
Report Facts
Resident files reviewed: 10
Employee files reviewed: 6
Inspection Report
Annual Inspection
Census: 52
Capacity: 66
Deficiencies: 3
Date: Jul 25, 2017
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 07/25/17 to assess compliance with regulatory requirements for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A but was found deficient in medication administration and storage practices, including failure to administer medications as prescribed and failure to secure medications properly. Additionally, the facility failed to ensure proper documentation of tuberculosis testing for one resident.
Deficiencies (3)
Facility failed to administer medications as prescribed by a physician and label medication containers with a change sticker for 3 of 15 sampled residents.
Facility failed to ensure medications were stored securely, with several over-the-counter medications found unsecured in residents' rooms.
Facility failed to maintain a separate file for each resident with documented evidence of a completed second step tuberculosis test prior to admission for 1 of 15 residents.
Report Facts
Licensed capacity: 66
Census: 52
Sampled residents: 15
Employee files reviewed: 12
Residents with medication administration issues: 3
Residents with tuberculosis documentation issues: 1
Inspection Report
Renewal
Census: 48
Capacity: 66
Deficiencies: 6
Date: Jul 21, 2016
Visit Reason
The inspection was conducted as an annual State Licensure survey and re-licensure primary inspection of the facility.
Findings
The facility received a grade of B with multiple deficiencies identified including failure to ensure required tuberculosis testing for employees and residents, unsecured oxygen tanks, late physical examinations for residents, missed medication documentation, and medication not being on site for residents.
Deficiencies (6)
Facility failed to ensure 4 out of 10 employees met the required 2-Step Tuberculosis Skin Test.
Facility failed to ensure oxygen tanks in 3 of 12 rooms were secured.
Facility failed to ensure 1 of 15 residents received a timely pre-admission or annual physical examination.
Facility failed to ensure the reason for missed medication was documented for 1 of 5 residents.
Facility failed to ensure medication was on site for 1 of 15 residents.
Facility failed to ensure 5 of 10 residents met tuberculosis testing requirements including two-step TB tests and signs and symptoms screening upon admission.
Report Facts
Employees not meeting TB test requirements: 4
Rooms with unsecured oxygen tanks: 3
Residents with late physical exams: 1
Residents with missed medication documentation: 1
Residents with medication not on site: 1
Residents not meeting TB test requirements: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adrianne Miranda | Designated Manager | Signed the document as authorized person |
| Vice President of Operations | Acknowledged findings related to TB testing and physical exams | |
| Acting Administrator | Acknowledged findings related to unsecured oxygen tanks and medication not on site | |
| Medication Technician | Acknowledged findings related to missed medication documentation |
Inspection Report
Annual Inspection
Census: 48
Capacity: 66
Deficiencies: 6
Date: Jul 21, 2016
Visit Reason
This annual State Licensure survey was conducted to assess compliance with state regulations for Fernley Estates, a residential facility licensed for 66 beds, including care for elderly, disabled, and Alzheimer's residents.
Findings
The facility received a grade of B with multiple deficiencies identified, including failure to ensure required tuberculosis testing for employees and residents, unsecured oxygen tanks in resident rooms, delayed or missing physical examinations for residents, and medication administration documentation and availability issues.
Deficiencies (6)
Facility failed to ensure 4 out of 10 employees met the required 2-Step Tuberculosis Skin Test.
Facility failed to ensure oxygen tanks in 3 of 12 rooms were secured.
Facility failed to ensure 1 of 15 residents received a timely pre-admission or annual physical examination.
Facility failed to ensure the reason for missed medication was documented for 1 of 5 residents.
Facility failed to ensure medication was on site for 1 of 15 residents.
Facility failed to ensure 5 of 10 residents met tuberculosis testing requirements and signs and symptoms screening upon admission.
Report Facts
Resident files reviewed: 15
Employee files reviewed: 10
Oxygen tanks unsecured: 6
Residents with TB deficiencies: 5
Employees lacking TB testing: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vice President of Operations | Vice President of Operations | Acknowledged findings related to tuberculosis testing and physical examination deficiencies |
| Medication Technician | Medication Technician | Acknowledged findings related to missed medication documentation |
| Acting Administrator | Acting Administrator | Acknowledged findings related to unsecured oxygen tanks and medication availability |
Inspection Report
Re-Inspection
Census: 33
Capacity: 66
Deficiencies: 1
Date: Aug 4, 2015
Visit Reason
This inspection was a required grading re-survey conducted as a State Licensure survey by the Division of Public and Behavioral Health on 8/4/15.
Findings
The facility received a re-survey grade of A. The survey identified deficiencies related to Elder Abuse Training where 3 of 8 employees failed to complete required training prior to providing care.
Deficiencies (1)
Facility failed to ensure 3 of 8 employees completed the Elder Abuse Prevention training before providing care.
Report Facts
Employees not trained: 3
Total employees reviewed: 8
Resident census: 33
Total licensed capacity: 66
Inspection Report
Re-Inspection
Census: 33
Capacity: 66
Deficiencies: 1
Date: Aug 4, 2015
Visit Reason
This Statement of Deficiencies was generated as a result of a required grading re-survey conducted in the facility on 8/4/15 by the Division of Public and Behavioral Health.
Findings
The facility failed to ensure that 3 of 8 employees completed the required Elder Abuse Prevention training before providing care. The Administrator acknowledged the findings and was unaware that the training was required on or before the date of hire.
Deficiencies (1)
Failed to ensure 3 of 8 employees completed the Elder Abuse Prevention training before providing care.
Report Facts
Licensed capacity: 66
Census: 33
Employees reviewed: 8
Resident files reviewed: 10
Employees not trained: 3
Inspection Report
Annual Inspection
Census: 30
Capacity: 66
Deficiencies: 5
Date: Jun 17, 2015
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual survey conducted at Fernley Estates on 06/17/2015 by the authority of NRS 449.0307, Division of Public and Behavioral Health.
Findings
The facility was found deficient in multiple areas including personnel files lacking required tuberculosis and physical examination documentation, failure to ensure employees obtained first aid and CPR certification within 30 days of hire, expired food items in the kitchen, unsecured oxygen tanks, and medication administration errors. The facility received a grade of B.
Deficiencies (5)
Personnel files lacked required tuberculosis (TB) and physical examination documentation for 5 out of 10 employees.
Personnel files lacked certification for first aid and CPR within 30 days of hire for 5 out of 10 employees.
The kitchen failed to comply with food service standards; multiple potentially hazardous foods were expired in the walk-in refrigerator.
Oxygen tanks were unsecured in one resident room.
Medication administration errors including failure to receive prescribed medications as ordered for sampled residents.
Report Facts
Licensed capacity: 66
Current census: 30
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Lacked documented physical examination and TB test prior to employment; hired 8/11/14 | |
| Employee #2 | Dietary Services Manager | Lacked documented physical examination and TB test prior to employment; hired 5/9/14 |
| Employee #3 | Medication Technician | Lacked documented physical examination prior to employment; hired 7/1/14 |
| Employee #4 | Wellness Director | Lacked documented physical examination prior to employment; hired 5/19/14 |
| Employee #5 | Administrator | Lacked documented physical examination and CPR certification within 30 days of hire; hired 1/6/14 |
| Employee #8 | Lacked documented evidence of current certification to perform first aid and CPR; hired 5/14/15 |
Inspection Report
Annual Inspection
Census: 30
Capacity: 66
Deficiencies: 5
Date: Jun 17, 2015
Visit Reason
This document is a State Licensure annual survey conducted on 6/17/2015 to assess compliance with regulatory requirements for Fernley Estates, a residential facility for groups.
Findings
The facility received a grade of B with deficiencies identified in personnel files regarding tuberculosis and physical examinations, late first aid and CPR certifications, expired foods in the kitchen, unsecured oxygen tanks, and medication administration errors for two residents.
Deficiencies (5)
Failed to ensure 5 out of 10 employees met tuberculosis and pre-employment physical examination requirements.
Failed to ensure 5 of 10 employees obtained first aid and CPR certification within 30 days of hire.
Failed to ensure the kitchen complied with food service standards; multiple potentially hazardous foods were expired in the walk-in refrigerator.
Failed to secure oxygen tanks in a rack or to the wall in 1 of 11 resident rooms using oxygen.
Failed to ensure 2 out of 10 sampled residents received medications as prescribed.
Report Facts
Licensed capacity: 66
Current census: 30
Employees reviewed: 10
Resident files reviewed: 11
Expired food items: 5
Residents with medication errors: 2
Inspection Report
Complaint Investigation
Census: 28
Capacity: 66
Deficiencies: 0
Date: Apr 21, 2015
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated by the Division of Public and Behavioral Health on 4/21/15 regarding four allegations related to the facility's care and services.
Complaint Details
Complaint #NV00042343 contained four allegations which were all unsubstantiated: 1) Services not provided per physician orders; 2) Medications given by untrained caregivers; 3) Inappropriate discharge; 4) Failure to monitor and treat pressure sores.
Findings
The complaint investigation found that none of the four allegations—failure to provide services per physician orders, medications given by untrained caregivers, inappropriate discharge, and failure to monitor and treat pressure sores—could be substantiated. The facility followed normal policies and procedures, and no regulatory deficiencies were identified.
Report Facts
Licensed beds: 66
Current census: 28
Medication technicians certified: 8
Medication dosage limit: 2
Inspection Report
Original Licensing
Capacity: 66
Deficiencies: 0
Date: Jul 7, 2014
Visit Reason
This document is the result of an initial State licensure survey conducted on 7/7/2014 for the facility requesting licensure as a Residential Facility for Group with 66 beds.
Findings
No regulatory deficiencies were identified during this initial licensure survey.
Report Facts
Licensed beds: 66
Employee files reviewed: 6
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