Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Re-Inspection
Census: 38
Capacity: 45
Deficiencies: 11
Jan 27, 2025
Visit Reason
This inspection was a State Licensure mandatory re-grading survey conducted at the facility on 01/27/2025 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, including issues with administrator responsibilities, first aid and CPR supplies, medication administration, medication storage security, weights training, privacy protections, cultural competency training, preferred name/pronoun policies, and annual resident assessments. All deficiencies referenced previous plans of correction from the survey dated 08/14/2024.
Severity Breakdown
D: 7
E: 2
C: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Administrator's Responsibilities-Complete Rec - Ensure that the records of the facility are complete and accurate. | D |
| First Aid & CPR - A first-aid kit must be available at the facility with required contents. | D |
| Medication Administration - Responsibilities of administrator, caregiver and employees regarding medication assistance. | D |
| Medication/OTCS, Supplements, Change Order - Proper administration and documentation of medications and supplements. | D |
| Administration of Medication Maintenance - Maintain accurate medication logs and records including refusals and mistakes. | E |
| Medication: Storage - Facility failed to ensure resident medications were kept secured for 1 of 15 self-administering residents (Room #158). | D |
| Weights - Training/Consent - Caregivers must be trained and residents must consent to being weighed. | E |
| Duties of licensed facility to protect - Maintain confidentiality and privacy of patients or residents. | C |
| Cultural Competency Training - Facility must provide cultural competency training to agents or employees providing care. | D |
| Preferred Name/Pronoun Policies - Facility must develop policies to ensure patients or residents are addressed by preferred names and pronouns. | D |
| Annual Assessment of History of Each Resident - Administrator must conduct annual assessments and physical examinations of residents. | D |
Report Facts
Licensed beds: 45
Resident census: 38
Self-administering residents: 15
Residents files reviewed: 10
Employee files reviewed: 15
Severity 2 Scope: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsay Gray | Director of Heath and Wellness | Signed the report and plan of correction |
| Business Office Manager (BOM) | Confirmed medications were unsecured in Room #158 |
Inspection Report
Annual Inspection
Census: 37
Capacity: 45
Deficiencies: 12
Aug 14, 2024
Visit Reason
Annual State Licensure survey conducted at the facility to assess compliance with Nevada Administrative Code for Residential Facility for Groups.
Findings
The facility received a grade of D with multiple deficiencies identified including incomplete resident records, inadequate first aid supplies, medication administration errors, unsecured medications, lack of resident consents for weight measurements, missing cultural competency training for staff, and failure to protect resident privacy and preferred name/pronoun policies.
Severity Breakdown
A: 1
C: 1
D: 7
E: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Administrator failed to ensure complete and accurate records for 1 of 10 residents (Resident #2) regarding home health care plans. | D |
| Facility failed to maintain contents of first aid kit, lacking CPR device, disposable gloves, and thermometer. | D |
| Failed to complete Ultimate User Agreement after change of condition for 1 of 10 residents (Resident #3). | D |
| Medication administration errors including missing physician orders and unavailable medications for residents #6 and #7. | D |
| Medication Administration Record (MAR) inaccurate for 4 of 10 residents with missing or incorrect medication documentation. | E |
| Resident medications not secured in 7 of 16 resident rooms with self-administering residents. | D |
| Over-the-counter medication bottle lacked prescriber's name for 1 of 10 residents (Resident #6). | A |
| Facility failed to obtain resident or representative consent for monthly weight measurements for all residents. | E |
| Facility failed to maintain confidentiality policies regarding sexual orientation, gender identity, and HIV status and failed to ensure privacy during care. | C |
| Facility failed to provide required cultural competency training timely for 6 of 20 sampled employees. | D |
| Facility failed to develop policies to ensure residents are addressed by preferred name and pronoun in accordance with gender identity or expression. | D |
| Facility failed to obtain an initial Standard Physician Assessment and Placement Determination for 1 of 10 residents with dementia (Resident #7). | D |
Report Facts
Resident files reviewed: 10
Employee files reviewed: 20
Facility grade: D
Licensed capacity: 45
Current census: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick Charles Ward | Executive Director | Signed report and involved in corrective actions |
Inspection Report
Renewal
Census: 38
Capacity: 41
Deficiencies: 12
Jan 8, 2024
Visit Reason
This inspection was a State Licensure regrading survey conducted by the Division of Public and Behavioral Health in accordance with NAC 449, Residential Facility for Groups, to assess compliance for license renewal.
Findings
The facility received a grade of A with several regulatory deficiencies identified, including issues with elder abuse training, medication storage security, annual resident assessments, and cultural competency training. Corrective actions were accepted for all deficiencies.
Severity Breakdown
E: 2
D: 8
F: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Elder Abuse Training - failure to ensure required annual training to recognize and prevent abuse of older persons. | E |
| Permits - failure to comply with NAC 446 on food service permits and inspections. | E |
| First Aid & CPR - failure to ensure administrators or caregivers trained within 30 days of employment. | D |
| Residents Requiring Use of Oxygen - failure to ensure compliance with monitoring and safety requirements for residents using oxygen. | D |
| Medication Administration - failure to ensure accuracy and proper reporting of medication administration. | D |
| Medication Administration Maintenance - failure to maintain proper medication logs and records. | D |
| Medication Storage - failure to secure resident medications in one resident's room; medications found unsecured in unlocked bathroom cabinet. | D |
| Medication Storage - failure to label medications properly and keep in original containers until administration. | D |
| Maintenance and Contents of Separate File - failure to maintain locked, confidential resident files with required documentation. | D |
| Cultural Competency Training - failure to conduct required annual cultural competency training for employees providing care. | F |
| Annual Assessment of History of Each Resident - failure to ensure annual provider placement determination completed for one resident with Alzheimer's disease. | D |
| Infection Control Required Training - failure to conduct required infection control training. | F |
Report Facts
Licensed capacity: 41
Census: 38
Resident rooms with unsecured medications: 1
Resident files reviewed: 6
Employee files reviewed: 7
Inspection Report
Renewal
Capacity: 41
Deficiencies: 0
Jan 8, 2024
Visit Reason
The inspection was conducted as a Bed Increase State Licensure Survey to approve licensure for four additional Residential Facility for Group beds providing assisted living services for elderly or disabled persons.
Findings
The survey found no regulatory deficiencies and approved the application for four additional beds. No further action was necessary.
Report Facts
Total licensed beds: 41
Additional beds requested: 4
Inspection Report
Annual Inspection
Census: 37
Capacity: 45
Deficiencies: 12
Aug 7, 2023
Visit Reason
Annual State Licensure survey conducted in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility was found deficient in multiple areas including elder abuse training, food service and kitchen sanitation, medication administration and storage, oxygen safety, infection control training, cultural competency training, tuberculosis testing, and resident assessment documentation.
Severity Breakdown
E: 2
D: 8
F: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure 5 of 12 employees received initial elder abuse training prior to beginning work and annually thereafter. | E |
| Kitchen refrigeration units not holding proper temperature; multiple non-food contact surfaces dirty; paper towel dispenser in disrepair. | E |
| Failed to ensure 1 of 6 employees had required CPR and first aid training within 30 days of hire. | D |
| Oxygen tank unsecured in resident room posing safety hazard. | D |
| Failed to ensure medication reviews for accuracy and appropriateness completed at least every six months for some residents; pharmacy recommendations not addressed. | D |
| Medication Administration Record inaccurate for 2 of 10 sampled residents. | D |
| Resident medications unsecured in resident rooms where residents self-administer medications. | D |
| Medications not labeled with resident's name and prescribing provider for 2 of 10 sampled residents. | D |
| Failed to maintain complete resident files including timely tuberculosis testing documentation for 3 of 10 sampled residents. | D |
| Failed to ensure cultural competency training completed timely for 6 of 8 sampled employees. | F |
| Failed to obtain Physician Placement Determination Statement for 3 of 10 sampled residents to determine appropriate facility placement. | D |
| Primary and secondary infection control staff lacked required infection control training. | F |
Report Facts
Facility licensed beds: 45
Current census: 37
Employee files reviewed: 15
Resident files reviewed: 10
Severity 2 deficiencies: 10
Severity E deficiencies: 2
Severity F deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick Ward | Administrator | Signed the Statement of Deficiencies report |
| Employee #1 | Failed elder abuse training timely; lacked infection control training; Administrator | |
| Employee #2 | Director of Resident Care | Lacked timely CPR/first aid training and infection control training |
| Employee #3 | Lacked cultural competency training | |
| Employee #4 | Lacked cultural competency training | |
| Employee #5 | Lacked cultural competency training | |
| Employee #6 | Lacked cultural competency training | |
| Employee #9 | Lacked cultural competency training | |
| Employee #11 | Lacked cultural competency training |
Inspection Report
Re-Inspection
Census: 37
Capacity: 41
Deficiencies: 8
Feb 16, 2023
Visit Reason
This inspection was a State Licensure mandatory regrading survey conducted by the Division of Public and Behavioral Health in accordance with NAC 449 for Residential Facility for Groups.
Findings
The facility received a grade of A with several regulatory deficiencies identified, including misrepresentation in advertising, medical care documentation, medication administration, maintenance of resident files, and caregiver training. Corrective actions and plans of correction were referenced with completion dates mostly in late 2022 and early 2023.
Severity Breakdown
F: 3
E: 2
D: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Qualifications of Caregivers - Age, English, Training requirements not fully met. | F |
| Advertising and promotional materials misrepresented services by stating 24/7 nursing staff when only care staff were provided. | D |
| Medical care of resident after illness not fully compliant with required physician examinations and instructions. | D |
| Medication administration responsibilities not fully met as per regulations. | D |
| Maintenance and contents of separate resident files not fully compliant with confidentiality and documentation requirements. | D |
| Maintenance and contents of separate resident files not fully compliant with evidence of compliance with chapter 441A of NRS. | E |
| Elderly care training for caregivers not fully completed within required timeframe. | E |
| Cultural Competency Training for staff not fully completed; training planned and scheduled. | F |
Report Facts
Licensed beds: 41
Resident census: 37
Severity level 2: 1
Completion dates: Dec 28, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick Ward | Executive Director | Named as facility representative and interviewed regarding advertising deficiency |
Inspection Report
Annual Inspection
Census: 34
Capacity: 41
Deficiencies: 7
Oct 20, 2022
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation at the facility.
Findings
The facility received a grade of C with multiple deficiencies identified including failure to ensure annual caregiver training, incomplete annual physical examinations for residents, delayed ultimate user agreements, incomplete physician assessments, missing tuberculosis testing documentation, inadequate initial caregiver training, and lack of cultural competency training for employees.
Complaint Details
Two complaints were investigated. Complaint #NV00065883 with multiple allegations including medication errors, cleanliness, odors, and unauthorized medications was not substantiated due to lack of evidence. Complaint #NV00066208 alleging improper care and medication administration was also not substantiated due to lack of evidence.
Severity Breakdown
Level 2: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to ensure 4 of 4 sampled employees with over a year of employment received eight hours of annual caregiver training. | Level 2 |
| Facility failed to ensure a physical examination including a review of systems was completed annually for 1 of 10 sampled residents. | Level 2 |
| Facility failed to ensure an ultimate user agreement was completed timely for 1 of 10 sampled residents. | Level 2 |
| Facility failed to obtain and ensure accuracy of a Standard Physician Assessment and Placement Determination for 3 of 5 residents. | Level 2 |
| Facility failed to ensure 4 of 10 sampled residents met tuberculosis testing requirements including two-step TB tests upon admission and timely annual tests. | Level 2 |
| Facility failed to ensure 4 of 6 employees received four hours of initial caregiver training within 60 days of hire. | Level 2 |
| Facility failed to ensure employees received cultural competency training within 30 days of hire for 10 of 10 employees who worked greater than 30 days. | Level 2 |
Report Facts
Licensed beds: 41
Census: 34
Complaints investigated: 2
Employees lacking annual training: 4
Residents lacking annual physical exam: 1
Residents lacking ultimate user agreement: 1
Residents lacking physician assessment: 3
Residents lacking TB testing compliance: 4
Employees lacking initial caregiver training: 4
Employees lacking cultural competency training: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick Ward | Executive Director | Signed the report and mentioned in relation to training and oversight. |
| Human Resources Director | Confirmed findings related to caregiver training and cultural competency training deficiencies. | |
| Clinical Specialist | Confirmed findings related to resident physical exams, ultimate user agreements, physician assessments, and TB testing. |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 41
Deficiencies: 14
Feb 17, 2022
Visit Reason
The inspection was conducted as a grading re-survey State Licensure Survey and complaint investigation triggered by complaint #NV00065742 alleging issues such as call lights not answered promptly, residents left in soiled garments, unmet oxygen needs, dining room closure due to lack of staff, and residents left alone for long periods.
Findings
The facility received a grade of A. The complaint allegations were not substantiated due to lack of evidence. Several deficiencies were identified related to caregiver qualifications, personnel file documentation including TB screening and CPR certification, health and sanitation, medication administration and storage, resident medical care, and maintenance of resident files.
Complaint Details
Complaint #NV00065742 was investigated with allegations including call lights not answered promptly, residents left in soiled garments, unmet oxygen needs, dining room closure due to lack of staff, and residents left alone for long periods. The complaint was not substantiated due to lack of evidence.
Severity Breakdown
D: 10
F: 2
E: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Qualifications of Caregiver - Medication Training not met as per NAC 449.196. | D |
| Personnel File - TB Screening not completed within required timeframe for 1 of 6 sampled employees. | D |
| Personnel File - 1st Aid & CPR certification not current for 1 of 6 sampled employees. | D |
| Health and Sanitation - Garbage containers not maintained as required. | D |
| Health and Sanitation - Facility premises not well maintained. | D |
| Permits - Facility did not comply with NAC 446 on Food Service permits and inspections. | F |
| Rights of Residents - Facility did not ensure a safe and comfortable environment. | F |
| Residents Requiring Use of Oxygen - Facility failed to meet requirements for oxygen use and monitoring. | D |
| Medical Care of Resident After Illness - Facility failed to obtain required physical examination results. | D |
| Medication Administration - Responsibilities of administrator and caregivers not fully met. | E |
| Medication/OTCs, Supplements, Change Order - Facility failed to comply with medication administration requirements. | D |
| Medication Storage - Medications not stored in locked, secure areas as required. | D |
| Maintenance and Contents of Separate File - Facility failed to ensure 1 of 6 sampled residents met TB testing requirements. | D |
| Maintenance and Contents of Separate File - Facility failed to maintain required resident evaluations for activities of daily living. | D |
Report Facts
Licensed capacity: 41
Census: 34
Number of resident files reviewed: 6
Number of employee personnel files reviewed: 6
Severity 2 deficiencies: 3
Severity 1 Scope: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick Ward | Administrator | Signed report and confirmed findings related to TB screening and CPR certification deficiencies |
| Employee #1 | Identified as Resident Assistant/Medication Technician with deficiencies in TB screening and CPR certification |
Inspection Report
Annual Inspection
Census: 32
Capacity: 41
Deficiencies: 14
Oct 27, 2021
Visit Reason
This inspection was conducted as a result of an annual State Licensure survey combined with a complaint investigation at the facility.
Findings
The facility received a grade of D with multiple deficiencies identified including medication management training gaps, incomplete TB screenings, late CPR and first aid training, uncovered garbage dumpsters, unsanitary exterior grounds, food service violations, failure to screen visitors for COVID-19 symptoms, missing physician orders for oxygen use, missing annual physical exams, unsigned Ultimate User Agreements for medication administration, medication availability issues, unsecured self-administered medications, and late annual ADL assessments.
Complaint Details
One complaint was investigated (Complaint #NV00064754) with five allegations including lack of a Registered Nurse, understaffing, untimely call light response, resident fall with prolonged pain, and medication errors. None of the allegations were substantiated due to lack of evidence.
Severity Breakdown
Level 2: 13
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 8 employees completed required annual medication management training on time. | Level 2 |
| Failed to ensure tuberculosis (TB) screening was completed within required timeframe for 4 of 8 employees. | Level 2 |
| Failed to ensure 2 of 8 employees completed CPR and first aid training within 30 days of employment. | Level 2 |
| Failed to ensure garbage dumpsters were covered and lids closed. | Level 2 |
| Failed to ensure exterior grounds were free of refuse and well maintained. | Level 2 |
| Failed to ensure kitchen and dining services complied with food service standards including sanitizing dishwashing machine and proper handwashing. | Level 2 |
| Failed to screen visitors for temperature and COVID-19 symptoms upon entry. | Level 2 |
| Failed to obtain physician's order for oxygen and post oxygen use signage for 1 resident. | Level 2 |
| Failed to ensure 1 of 10 sampled residents received an annual physical examination. | Level 2 |
| Failed to ensure Ultimate User Agreement was signed upon admission for 4 of 10 sampled residents. | Level 2 |
| Failed to ensure medication was available onsite for 1 of 10 sampled residents. | Level 2 |
| Failed to ensure self-administered medications were secured for 1 resident. | Level 2 |
| Failed to ensure 2 of 10 sampled residents met tuberculosis testing documentation requirements. | Level 2 |
| Failed to ensure annual Activities of Daily Living (ADL) assessments were completed timely for 2 of 10 sampled residents. | Level 2 |
Report Facts
Facility licensed beds: 41
Resident census: 32
Complaint allegations: 5
Employees reviewed: 8
Resident files reviewed: 10
Deficiency severity Level 2: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patrick Ward | Executive Director | Signed the inspection report |
| Employee #6 | Director of Resident Care | Named in medication management training deficiency and TB screening deficiency |
| Employee #1 | Lead Medication Technician | Named in TB screening deficiency |
| Employee #2 | Resident Assistant | Named in CPR and first aid training deficiency |
| Employee #3 | Resident Assistant | Named in TB screening deficiency and Ultimate User Agreement deficiency |
| Employee #4 | Resident Assistant | Named in TB screening deficiency |
| Employee #5 | Resident Assistant | Named in CPR and first aid training deficiency and Ultimate User Agreement deficiency |
Inspection Report
Routine
Census: 37
Capacity: 41
Deficiencies: 0
Sep 16, 2020
Visit Reason
This inspection was conducted as a State Licensure COVID-19 Infection Control and Prevention Plan Survey to assess the facility's compliance with infection control requirements.
Findings
The facility had documented and ready-to-implement components of an Infection Control and Prevention Plan including visitor screening, emergency staffing plans, PPE inventory, staff training, and resident COVID-19 response protocols. No regulatory deficiencies were identified.
Report Facts
Licensed beds: 41
Census: 37
Inspection Report
Annual Inspection
Census: 34
Capacity: 41
Deficiencies: 0
Dec 2, 2015
Visit Reason
This inspection was conducted as an annual State Licensure survey combined with a complaint investigation regarding infection control.
Findings
The facility was found to be in substantial compliance with no deficiencies identified. The complaint regarding infection control was not substantiated.
Complaint Details
Complaint #NV00043950 alleging infection control was investigated through observation, interviews, and policy review, and was not substantiated.
Report Facts
Resident files reviewed: 10
Employee files reviewed: 15
Inspection Report
Annual Inspection
Census: 37
Capacity: 41
Deficiencies: 0
Sep 18, 2014
Visit Reason
This document is the result of an annual State Licensure survey conducted at the facility on 09/18/2014 to assess compliance with state regulations for assisted living services.
Findings
The facility received a grade of A with no regulatory deficiencies identified at the time of the survey.
Report Facts
Resident files reviewed: 10
Employee files reviewed: 10
Inspection Report
Annual Inspection
Census: 34
Capacity: 34
Deficiencies: 3
Aug 29, 2013
Visit Reason
The inspection was conducted as a State Licensure annual grading survey from 08/22/13 to 08/29/13 to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A. Deficiencies were identified related to food service permits, kitchen sanitation, and resident file maintenance, including critical violations such as a dishwasher not sanitizing properly and incomplete tuberculosis screening documentation for residents.
Severity Breakdown
SS=C: 1
Severity: 1: 1
Severity: 2: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Permits - Comply with NAC 446 on Food Service including storage of food, adequate supplies, permits, and inspections. | SS=C |
| High temperature dishwasher was not sanitizing at the time of inspection; wash temperature 170°F and final rinse 150°F observed. | Severity: 1 Scope: 3 |
| Resident file maintenance failed for 5 of 10 residents regarding tuberculosis testing documentation and confidentiality of information. | Severity: 2 Scope: 2 |
Report Facts
Census: 34
Total Capacity: 34
Deficiency Count: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeanne Jones | Executive Director | Signed the plan of correction |
Inspection Report
Annual Inspection
Census: 34
Capacity: 34
Deficiencies: 2
Aug 29, 2013
Visit Reason
This document is a State Licensure annual grading survey conducted from 8/22/13 to 8/29/13 to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A but had deficiencies including a critical violation where the high temperature dishwasher was not sanitizing properly, and issues with resident tuberculosis testing documentation for 5 of 10 residents.
Severity Breakdown
Severity: 1: 1
Severity: 2: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| The high temperature dishwasher was not sanitizing at the time of inspection; wash temperature was 170°F and final rinse temperature was 150°F. | Severity: 1 |
| Failure to maintain a separate resident file with evidence of tuberculosis testing compliance as required by NAC 441A; 5 of 10 residents lacked proper measurement results or read dates. | Severity: 2 |
Report Facts
Resident files reviewed: 10
Employee files reviewed: 10
Critical violations: 1
Residents non-compliant with tuberculosis testing: 5
Inspection Report
Renewal
Capacity: 34
Deficiencies: 0
Feb 20, 2013
Visit Reason
This State Licensure survey was conducted as a result of a Bed Increase survey to request licensure for five additional Residential Facility for Group beds for elderly and disabled persons providing Assisted Living services, Category II.
Findings
No regulatory deficiencies were identified during the survey. No further action is necessary.
Report Facts
Licensed beds: 34
Requested additional beds: 5
Inspection Report
Annual Inspection
Census: 30
Capacity: 34
Deficiencies: 0
Aug 28, 2012
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at the facility on 08/28/2012.
Findings
The facility received a grade of A with no regulatory deficiencies identified. Ten resident files and ten employee files were reviewed during the survey.
Report Facts
Resident files reviewed: 10
Employee files reviewed: 10
Inspection Report
Complaint Investigation
Capacity: 34
Deficiencies: 0
May 2, 2011
Visit Reason
This document is a Statement of Deficiencies generated as a result of a complaint investigation conducted from 10/8/10 through 5/2/11 regarding neglect related to monitoring a resident for changes in medical condition.
Findings
The investigation reviewed Resident #1's medical records and interviews, finding no regulatory deficiencies and concluding the allegation of neglect was unsubstantiated. No further action was necessary.
Complaint Details
Complaint intake #NV00026636 alleged neglect in monitoring a resident's medical condition leading to resident death. The allegation was unsubstantiated after review.
Report Facts
Licensed facility beds: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Lizarraga | RN. HFS. II | Named as complaint intake contact |
Inspection Report
Annual Inspection
Census: 30
Capacity: 34
Deficiencies: 2
Jul 8, 2010
Visit Reason
This document is an annual State Licensure survey conducted to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A but was cited for deficiencies including critical food safety violations in the kitchen and failure to obtain annual physical examinations for residents as required by regulations.
Severity Breakdown
2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Critical violations in kitchen food storage and sanitation including improper storage of pastry dish and bacon, soiled equipment, and damaged cutting boards. | 2 |
| Failure to obtain annual physical examination for 1 of 10 residents reviewed (Resident #9). | 2 |
Report Facts
Resident files reviewed: 10
Employee files reviewed: 10
Discharged resident files reviewed: 1
Inspection Report
Annual Inspection
Deficiencies: 3
Jul 16, 2009
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at Classic Residence by Hyatt on 07/16/2009 to assess compliance with state regulations.
Findings
The inspection identified multiple deficiencies related to personnel files, employee training, and kitchen compliance with health standards. Specific issues included missing tuberculosis testing documentation for one employee, lack of current first aid and CPR certification for another, and several kitchen sanitation and maintenance problems.
Severity Breakdown
2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure that 1 of 11 employees complied with tuberculosis testing requirements (Employee #10). | 2 |
| Failed to ensure that 1 of 9 caregivers was trained in first aid and cardiopulmonary resuscitation (Employee #3). | 2 |
| Commercial kitchen did not comply with standards: sausage held at improper temperature, chemical spray bottles stored improperly, damaged refrigerator door gaskets, soiled dish area walls, and inadequate lighting due to burned out bulbs. | 2 |
Report Facts
Employees reviewed: 11
Caregivers reviewed: 9
Severity 2 deficiencies: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #10 | Failed tuberculosis testing compliance | |
| Employee #3 | Lacked current first aid and CPR certification |
Inspection Report
Annual Inspection
Census: 8
Deficiencies: 4
Jul 16, 2009
Visit Reason
The inspection was conducted as an annual State Licensure survey of a Residential Facility for Group beds providing care to persons with Alzheimer's disease, Category II residents.
Findings
No regulatory deficiencies were identified initially, but several deficiencies were later cited related to personnel files, tuberculosis testing, first aid and CPR certification, and kitchen safety and sanitation standards.
Severity Breakdown
F: 1
2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Personnel file did not include required health certificates for employees. | F |
| Facility failed to ensure 1 of 11 employees complied with tuberculosis testing requirements. | 2 |
| Personnel file for a caregiver lacked current first aid and CPR certification. | 2 |
| Facility did not ensure commercial kitchen compliance with standards: improper food temperature, chemical storage, damaged refrigerator door gaskets, soiled dish area, and inadequate lighting. | 2 |
Report Facts
Employees reviewed: 11
Caregivers reviewed: 9
Severity level 2 deficiencies: 3
Severity level F deficiencies: 1
Inspection Report
Annual Inspection
Census: 27
Capacity: 34
Deficiencies: 3
Jul 10, 2008
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility on 7/10/08, completed on 7/22/08, to assess compliance with state regulations for residential facilities for elderly and disabled persons.
Findings
The inspection identified deficiencies including failure to conduct the required annual inspection of the automatic sprinkler system, inadequate cleanliness and sanitation in the kitchen area, and improper refrigeration temperatures in one of the freezers in the assisted living unit.
Severity Breakdown
Level 1: 1
Level 2: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| The facility's automatic sprinkler system had not been inspected annually; the last inspection was on 6/26/07 and the inspection tag had expired. | Level 1 |
| The kitchen was not properly cleaned, with food residue and hardened liquid spills on refrigerator/freezer bottoms, dirty food preparation counters, mold in caulking and walls, improper stacking of wet plastic containers, and other sanitation issues. | Level 2 |
| One of four freezers in the assisted living satellite kitchen was not maintained at the appropriate temperature; thermometer showed 11 degrees Fahrenheit and raspberry sherbet was melting. | Level 2 |
Report Facts
Licensed capacity: 34
Census: 27
Freezer temperature: 11
Freezer temperature: 5
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