Inspection Reports for Forget Me Not Home Care
5513 Flora Spray St, Las Vegas, NV 89130, NV, 89130
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: 6
Capacity: 7
Deficiencies: 3
Oct 14, 2024
Visit Reason
This inspection was conducted as an annual State Licensure survey of the residential facility for groups in accordance with Nevada Administrative Code Chapter 449.
Findings
The facility received a grade of A but was cited for several deficiencies including unsanitary conditions in the laundry room, failure to obtain initial placement assessments for all six residents, and failure to ensure required annual infection control training for designated staff.
Severity Breakdown
Level 1: 1
Level 2: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Laundry room was not kept in a sanitary manner; lint was found on walls, pipes, and behind washer and dryer. | Level 2 |
| Failed to ensure an initial placement assessment was obtained for 6 of 6 residents. | Level 1 |
| Failed to ensure primary infection control specialist, secondary infection control designee, and unlicensed caregiver completed annual infection control training from a nationally recognized organization. | Level 2 |
Report Facts
Residents reviewed: 6
Employee files reviewed: 3
Beds licensed: 7
Residents present: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lawrence D O'Shea | Administrator | Signed the report as Administrator. |
| Employee #1 | Administrator and primary infection control specialist | Named in infection control training deficiency. |
| Employee #2 | Caregiver and infection control specialist designee | Named in infection control training deficiency. |
| Employee #3 | Unlicensed Caregiver | Named in infection control training deficiency. |
Inspection Report
Annual Inspection
Census: 7
Capacity: 7
Deficiencies: 0
Oct 25, 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
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: 7
Employee files reviewed: 3
Inspection Report
Annual Inspection
Census: 7
Capacity: 7
Deficiencies: 0
Oct 25, 2022
Visit Reason
The 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
The facility received a grade of A with no regulatory deficiencies identified. Seven resident files and three employee files were reviewed, and no further action was necessary.
Report Facts
Resident files reviewed: 7
Employee files reviewed: 3
Inspection Report
Annual Inspection
Census: 7
Capacity: 7
Deficiencies: 4
Oct 28, 2021
Visit Reason
This inspection was conducted as a State Licensure annual survey and infection control survey for a residential facility for groups, to assess compliance with Nevada Administrative Code Chapter 449.
Findings
The facility received a grade of A but was found deficient in several areas including admitting a bedfast resident without a waiver, failure to complete six-month medication reviews for multiple residents, inaccurate medication administration records, and incomplete initial and annual Activities of Daily Living (ADL) assessments for most residents.
Severity Breakdown
Level 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure a bedfast resident was not admitted and retained without an exemption waiver. | Level 2 |
| Facility failed to ensure medication reviews were completed at least once every six months for 4 of 7 sampled residents. | Level 2 |
| Medication Administration Record (MAR) was inaccurate for 1 of 7 sampled residents; medications were signed as administered on a future date. | Level 2 |
| Facility failed to ensure 5 of 7 residents had an initial and/or annual Activities of Daily Living (ADL) assessment completed as required. | Level 2 |
Report Facts
Residents sampled: 7
Employee files reviewed: 3
Beds licensed: 7
Residents present: 7
Inspection Report
Abbreviated Survey
Census: 7
Capacity: 7
Deficiencies: 1
Nov 9, 2020
Visit Reason
The inspection was a COVID-19 focused infection control State Licensure survey conducted to assess the facility's compliance with infection control practices during the COVID-19 pandemic.
Findings
The facility had implemented multiple infection control measures including signage, screening, hand hygiene, and cleaning protocols. However, the facility failed to have N95 masks in supply and staff were not medically cleared or fit tested to wear N95 masks, despite prior infection control guidance recommending this.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to implement safe infection control practices related to COVID-19 by not having N95 masks available and staff not medically cleared and fit tested to wear N95 masks. | Severity: 2 |
Report Facts
Licensed beds: 7
Census: 7
PPE inventory: 55
PPE inventory: 2
PPE inventory: 50
PPE inventory: 2
Plan of correction completion date: Nov 11, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lawrence O'Shea | Administrator | Signed as Laboratory Director or Provider/Supplier Representative |
Inspection Report
Annual Inspection
Census: 6
Capacity: 7
Deficiencies: 7
Dec 11, 2019
Visit Reason
The inspection was conducted as the Annual Grading State Licensure Survey for the residential facility, in accordance with Nevada Administrative Code, Chapter 449.
Findings
The facility received a grade of C with multiple regulatory deficiencies identified, including failures in caregiver training, tuberculosis screening, medication administration discrepancies, improper medication labeling, unsecured dangerous items, and inadequate training related to Alzheimer's care.
Severity Breakdown
Level 2: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 3 employees had at least eight hours of annual training within the past twelve months. | Level 2 |
| Failed to ensure 1 of 4 employees had tuberculosis (TB) testing; lacked initial 2-step TB testing results. | Level 2 |
| Failed to ensure medications were administered per physician's instructions for 3 of 6 residents, with discrepancies in medication orders and MAR. | Level 2 |
| Failed to ensure medications were clearly labeled with the name of the resident and the name of the physician for 1 of 6 residents. | Level 2 |
| Failed to ensure tools and dangerous items were securely stored and inaccessible to residents; shed was unlocked containing sharp garden tools. | Level 2 |
| Failed to ensure toxic substances were in a locked area and not accessible to residents; cleaning supplies and chemicals were found unlocked in multiple areas. | Level 2 |
| Failed to ensure 1 of 4 employees obtained annual training related to providing care for persons with Alzheimer's disease. | Level 2 |
Report Facts
Licensed beds: 7
Resident census: 6
Employees reviewed: 4
Residents reviewed: 6
Facility grade: C
Inspection Report
Annual Inspection
Census: 7
Deficiencies: 4
Jan 8, 2019
Visit Reason
This inspection was conducted as a State Licensure annual survey of the residential facility in accordance with Chapter 449.
Findings
The facility received an annual survey grade of B with multiple deficiencies identified including unclean kitchen surfaces, missing annual physical exam for one resident, incomplete medication administration records, and unsafe storage of toxic substances accessible to residents.
Severity Breakdown
Level 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Food preparation area was not clean to allow for sanitary preparation of food; kitchen cabinets and handles were sticky with grease and dust accumulated above the stove. | Level 2 |
| Annual physical exam was not completed for 1 of 7 residents (Resident #6). | Level 2 |
| Medication Administration Record (MAR) was incomplete for 1 of 7 residents receiving PRN medications; missing purpose and documentation of administration. | Level 2 |
| Toxic substances were accessible to residents; cleaning solution found in unlocked cabinet and other chemicals in unlocked closet. | Level 2 |
Report Facts
Residents present: 7
Resident files reviewed: 7
Employee files reviewed: 5
Survey grade: B
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dennis O'Shea | Administrator | Administrator signed the report and is referenced in corrective actions |
Inspection Report
Annual Inspection
Census: 7
Capacity: 7
Deficiencies: 4
Jan 12, 2018
Visit Reason
The inspection was conducted as an annual State Licensure survey of the facility on 01/12/2018 to assess compliance with regulatory requirements.
Findings
The facility was found to have multiple deficiencies related to medication storage, non-functional door alarms, unsecured dangerous items, and accessible toxic substances. The facility received a grade of B and corrective actions were planned and implemented.
Severity Breakdown
Severity: 2 Scope 3: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Medications were not stored securely; PRN medications and Aspirin were found in unlocked cabinets and drawers. | Severity: 2 Scope 3 |
| Alarms on two doors leading outside were not functional; laundry room door was unlocked. | Severity: 2 Scope 3 |
| Knives and scissors were not locked up and accessible to residents, posing a danger. | Severity: 2 Scope 3 |
| Toxic substances such as fabric softener and detergent were accessible in an unlocked cabinet; laundry door was not locked. | Severity: 2 Scope 3 |
Report Facts
Resident census: 7
Total licensed capacity: 7
Employee files reviewed: 5
Resident files reviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dennis O'Shea | Administrator | Signed as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Complaint Investigation
Census: 6
Deficiencies: 0
Nov 20, 2017
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding allegations of misappropriation of property at the facility.
Findings
The complaint was investigated through observations, interviews, and record reviews, and the allegation of misappropriation of property was not substantiated. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00050796 alleging misappropriation of property was investigated and found to be unsubstantiated.
Report Facts
Complaint count: 1
Sample size: 1
Inspection Report
Complaint Investigation
Census: 7
Deficiencies: 0
Apr 12, 2016
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by Complaint #NV00045620, which included allegations of a person sleeping in the closet and improper infection control practices.
Findings
The investigation included observations, interviews, and record reviews, and found no regulatory deficiencies. The allegations were not substantiated and no further action was necessary.
Complaint Details
Complaint #NV00045620 included two allegations: 1) a person sleeping in the closet, and 2) improper infection control. Both allegations could not be substantiated after investigation.
Report Facts
Sample size: 6
Inspection Report
Annual Inspection
Census: 6
Capacity: 7
Deficiencies: 0
Jan 28, 2016
Visit Reason
This Statement of Deficiencies was generated as a result of an annual State Licensure survey conducted in the facility on 01/28/16 by the authority of NRS 449.150, Powers of the Health Division.
Findings
The facility received a grade of A. No deficiencies were identified during the survey.
Report Facts
Licensed beds: 7
Census: 6
Inspection Report
Re-Inspection
Census: 5
Capacity: 7
Deficiencies: 4
Mar 3, 2015
Visit Reason
This State Licensure survey was conducted as a result of a requested grading resurvey for State Licensure conducted on 3/3/15.
Findings
The facility received a grade of B. Deficiencies were identified related to elder abuse training, tuberculosis testing, background checks, and failure to display the current grade placard. Several deficiencies were repeat from 1/5/15.
Severity Breakdown
Severity: 2: 3
Severity: 1: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 4 employees received annual elder abuse training (Employee #3). | Severity: 2 |
| Facility failed to ensure 3 of 4 employees were compliant with tuberculosis testing requirements (Employees #1, #3, and #4). | Severity: 2 |
| Facility failed to ensure 3 of 4 employees received state and FBI background check results (Employees #1, #2, #3, and #4). | Severity: 2 |
| Facility failed to display the most current grade placard dated 1/25/15 with a grade of B in a conspicuous public area. | Severity: 1 |
Report Facts
Licensed capacity: 7
Census: 5
Deficiencies cited: 4
Inspection Report
Renewal
Census: 5
Capacity: 7
Deficiencies: 4
Mar 3, 2015
Visit Reason
This inspection was a requested grading resurvey for State Licensure conducted on 3/3/2015 at Forget Me Not Home Care, a residential facility for group beds for elderly or disabled persons.
Findings
The facility received a grade of B. Deficiencies were identified related to failure to ensure annual elder abuse training for one employee, non-compliance with tuberculosis testing requirements for three employees, lack of state and FBI background check results for three employees, and failure to display the current grade placard in a public area.
Severity Breakdown
Severity: 2: 3
Severity: 1: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 employees received annual elder abuse training (Employee #3). | Severity: 2 |
| Failed to ensure 3 of 4 employees were compliant with tuberculosis testing requirements (Employees #1, #3, and #4). | Severity: 2 |
| Failed to ensure 3 of 4 employees received state and FBI background check results (Employees #1, #2, #3, and #4). | Severity: 2 |
| Failed to display the current grade placard in a conspicuous public area of the residential facility. | Severity: 1 |
Report Facts
Licensed capacity: 7
Current census: 5
Employees reviewed: 4
Resident files reviewed: 3
Repeat deficiencies: 3
Grade received: B
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Named in elder abuse training, tuberculosis testing, and background check deficiencies | |
| Employee #1 | Named in tuberculosis testing and background check deficiencies | |
| Employee #4 | Named in tuberculosis testing and background check deficiencies | |
| Employee #2 | Named in background check deficiency |
Inspection Report
Annual Inspection
Census: 5
Capacity: 7
Deficiencies: 5
Jan 5, 2015
Visit Reason
This document is the result of an annual State Licensure survey conducted at the facility on 01/05/2015 to assess compliance with state regulations for residential care facilities.
Findings
The facility received a grade of B with several deficiencies identified, including failure to ensure elder abuse training for one employee, incomplete tuberculosis and physical compliance for all employees, lack of state and FBI background checks for all employees, missing first aid and CPR certification for one employee, and incomplete tuberculosis screening documentation for two residents.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 employees received elder abuse training prior to working with residents (Employee #2). | Severity: 2 |
| Failed to ensure 4 of 4 employees were compliant with tuberculosis and physical requirements. | Severity: 2 |
| Failed to ensure 4 of 4 employees received state and FBI background check results. | Severity: 2 |
| Failed to ensure 1 of 4 employees were trained in first aid and cardiopulmonary resuscitation (CPR) (Employee #2). | Severity: 2 |
| Failed to ensure 2 of 5 residents met tuberculosis screening requirements. | Severity: 2 |
Report Facts
Licensed beds: 7
Current census: 5
Employees reviewed: 4
Residents reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Failed elder abuse training, lacked first aid and CPR certification, lacked documented pre-employment physical, and lacked state and FBI background check results | |
| Employee #3 | Acknowledged lack of elder abuse training for Employee #2 and lack of documentation for TB tests and background checks | |
| Employee #1 | Lacked documented evidence of pre-employment physical and background check results; submitted new fingerprints in November 2014 but results not received | |
| Employee #4 | Lacked documented evidence of pre-employment physical, annual TB test, and background check results |
Inspection Report
Annual Inspection
Census: 5
Capacity: 7
Deficiencies: 5
Jan 5, 2015
Visit Reason
This visit was an annual State Licensure survey conducted to assess compliance with regulatory requirements for a residential facility for elderly or disabled persons.
Findings
The facility received a grade of B and several deficiencies were identified related to elder abuse training, personnel file documentation including physicals, tuberculosis testing, background checks, and CPR certification.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 4 employees received elder abuse training prior to working with residents. | Severity: 2 |
| Failure to ensure 4 of 4 employees were compliant with tuberculosis (TB) and physicals requirements. | Severity: 2 |
| Failure to ensure 4 of 4 employees received state and FBI background checks. | Severity: 2 |
| Failure to ensure 1 of 4 employees were trained in first aid and CPR. | Severity: 2 |
| Failure to ensure 2 of 5 residents met tuberculosis screening requirements. | Severity: 2 |
Report Facts
Licensed capacity: 7
Census: 5
Employees reviewed: 4
Residents reviewed: 5
Inspection Report
Re-Inspection
Census: 5
Capacity: 7
Deficiencies: 0
Jan 28, 2014
Visit Reason
This document is a State Licensure re-survey conducted at the facility on 1/28/14 by the authority of NRS 449.150.
Findings
No deficiencies were identified during this re-survey. The facility received a grade of A.
Report Facts
Licensed beds: 7
Census: 5
Inspection Report
Annual Inspection
Census: 4
Capacity: 7
Deficiencies: 7
Aug 14, 2013
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted from 2013-05-22 to 2013-08-14 at Forget Me Not Home Care, a residential facility for elderly and disabled persons.
Findings
The facility received a grade of C with multiple deficiencies identified including failure to maintain clean and hazard-free premises, improper oxygen tank storage, failure to request medical exemptions for residents, failure to ensure residents received required physical exams, medication administration errors, failure to obtain tuberculosis testing, and failure to obtain a chronic illness endorsement while retaining a resident with chronic illness.
Severity Breakdown
Level 2: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to ensure premises was clean, well maintained and free of hazards including uncovered oxygen tanks, unsecured wall openings, cluttered patio and smoking near oxygen tanks. | Level 2 |
| Facility failed to remove oxygen tanks and equipment for a resident no longer residing at the facility; oxygen tanks stored uncovered and accessible to residents who smoke. | Level 2 |
| Facility failed to request a medical exemption for a resident with a urostomy who was not capable of independently managing care. | Level 2 |
| Facility failed to ensure two residents received required physical examinations after admission or due to significant change in condition. | Level 2 |
| Facility failed to administer medications as prescribed for two residents, including incorrect dosage documentation and failure to obtain physician orders. | Level 2 |
| Facility failed to obtain required tuberculosis test for one resident requiring a second step TB skin test. | Level 2 |
| Facility failed to obtain chronic illness endorsement and failed to move a resident to an appropriate facility as required by physician. | Level 2 |
Report Facts
Licensed beds: 7
Resident census: 4
Deficiency count: 7
Inspection Report
Annual Inspection
Census: 5
Capacity: 7
Deficiencies: 6
May 24, 2012
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with state regulations for a residential facility for elderly or disabled persons.
Findings
The facility received a grade of B with several deficiencies identified including personnel file issues related to tuberculosis testing, health and sanitation concerns, improper use of restraints, incomplete physical examinations, and medication administration and storage problems.
Severity Breakdown
Severity: 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 employees complied with tuberculosis testing requirements (missing evidence of a two-step TB skin test). | Severity: 2 |
| Facility failed to ensure premises were clean and well maintained (toaster oven dirty and drain cover unsecured in master bedroom shower). | Severity: 2 |
| Failed to ensure mechanical restraints were not used on 1 of 5 residents (resident #1 had full bedrails). | Severity: 2 |
| Failed to ensure 1 of 5 residents received a physical examination upon admission (Resident 4). | Severity: 2 |
| Failed to ensure 2 of 5 residents received medications as prescribed (Resident #3 and #4). | Severity: 2 |
| Failed to ensure refrigerated medications were secured properly (2 bottles of Milk of Magnesia and suppositories located on refrigerator door). | Severity: 2 |
Report Facts
Licensed beds: 7
Residents present: 5
Employees reviewed: 4
Resident files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Saverio | Administrator | Signed as Laboratory Director or Provider/Supplier Representative |
Inspection Report
Annual Inspection
Census: 5
Capacity: 7
Deficiencies: 6
May 24, 2012
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with state regulations for a residential facility for elderly or disabled persons.
Findings
The facility received a grade of B with multiple deficiencies identified, including failure to ensure tuberculosis testing compliance for one employee, unclean and poorly maintained premises, use of mechanical restraints on a resident, failure to provide required physical examinations for residents, medication administration errors, and unsecured refrigerated medications.
Severity Breakdown
Severity: 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 employees complied with tuberculosis testing requirements (missing two-step TB skin test). | Severity: 2 |
| Facility premises were not clean and well maintained (dirty toaster oven and unsecured drain cover in master bedroom shower). | Severity: 2 |
| Use of mechanical restraints on 1 of 5 residents (full bedrails on Resident #1). | Severity: 2 |
| Failed to ensure 1 of 5 residents received a physical examination upon admission (Resident #4). | Severity: 2 |
| Failed to ensure 2 of 5 residents received medications as prescribed (Resident #3 and #4). | Severity: 2 |
| Failed to ensure refrigerated medications were secured (Milk of Magnesia and suppositories on refrigerator door). | Severity: 2 |
Report Facts
Licensed capacity: 7
Census: 5
Employee files reviewed: 4
Resident files reviewed: 5
Inspection Report
Capacity: 6
Deficiencies: 0
Mar 22, 2012
Visit Reason
This State Licensure survey was conducted as a result of a Bed Increase survey to request licensure for one additional Residential Facility for Group bed for elderly or disabled persons, Category II residents.
Findings
No regulatory deficiencies were identified during the survey. No further action is necessary.
Report Facts
Licensed capacity: 6
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 4
Jun 1, 2011
Visit Reason
This document is the result of an annual State Licensure survey conducted on 06/01/2011 at Forget Me Not Home Care LLC, a residential facility licensed for six beds for elderly and disabled persons.
Findings
The facility received a grade of A but had several deficiencies related to personnel files, tuberculosis testing, first aid and CPR certification, and facility cleanliness and maintenance.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Personnel file did not include proof of annual tuberculosis (TB) testing for Employee #1. | Severity: 2 |
| Personnel file failed to ensure 1 of 5 caregivers was trained in first aid and CPR; Employee #1 was overdue for training. | Severity: 2 |
| Facility failed to maintain clean and well-maintained premises; observed large garbage bags stored improperly. | Severity: 2 |
| Resident files failed to ensure 2 of 4 residents complied with tuberculosis testing requirements. | Severity: 2 |
Report Facts
Number of residents present: 4
Total licensed capacity: 6
Number of employees reviewed: 5
Number of resident files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Richard Uy Bengkee | Administrator | Named in plan of correction and responsible for final review and implementation |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 4
Jun 1, 2011
Visit Reason
This document is the result of an annual State Licensure survey conducted on 6/1/2011 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 found deficient in several areas including personnel tuberculosis testing, first aid and CPR certification, cleanliness and maintenance of the premises, and resident tuberculosis testing compliance.
Severity Breakdown
2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 5 employees complied with tuberculosis testing requirements (no proof of annual one step following the 2 step TB test). | 2 |
| Failed to ensure 1 of 5 caregivers were trained in first aid and cardiopulmonary resuscitation (overdue for training). | 2 |
| Failed to ensure the premises was clean and well maintained (two large garbage bags full of empty cans and plastic bottles were left uncovered and open). | 2 |
| Failed to ensure 2 of 4 residents complied with tuberculosis testing requirements (second step not completed). | 2 |
Report Facts
Number of employees reviewed: 5
Number of resident files reviewed: 4
Facility licensed capacity: 6
Current census: 4
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 6
Jun 25, 2010
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction generated as a result of an annual State Licensure survey conducted on 2010-06-25 at Forget Me Not Home Care LLC.
Findings
The facility received an annual survey grade of B with multiple deficiencies identified including improper refrigeration temperatures, incomplete fire drill records, failure to inspect fire extinguishers annually, incomplete smoke detector testing, improper storage of oxygen tanks, and an expired business license.
Severity Breakdown
Level 1: 2
Level 2: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Perishable foods not refrigerated at 40 degrees Fahrenheit or less; freezer failed to maintain temperature below 0 degrees for 1 or 3 freezers. | Level 2 |
| Monthly evacuation fire drills were not conducted on an irregular schedule for 5 of the past 12 months. | Level 1 |
| Portable fire extinguishers were not inspected, recharged, and tagged annually as required. | Level 2 |
| Smoke detectors were not tested 6 out of the past 12 months as required. | Level 2 |
| Oxygen tanks were not properly secured in a rack or to the wall in 1 of 3 resident rooms using oxygen. | Level 2 |
| Facility business license had expired on 2010-05-31 and was not immediately posted upon receipt. | Level 1 |
Report Facts
Licensed beds: 6
Current census: 5
Fire drill months missed: 5
Smoke detector test months missed: 6
Fire extinguishers inspected: 0
Oxygen tanks unsecured: 3
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 6
Jun 25, 2010
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility to assess compliance with regulatory requirements.
Findings
The facility received an annual survey grade of B with multiple deficiencies identified including failure to maintain freezer temperatures, incomplete emergency evacuation drills, lack of annual fire extinguisher inspections, incomplete smoke detector testing, unsecured oxygen tanks, and an expired business license.
Severity Breakdown
Severity: 1: 2
Severity: 2: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to maintain freezer temperature below 0 degrees Fahrenheit for 1 or 3 freezers. | Severity: 2 |
| Monthly evacuation drills were not conducted on an irregular schedule for 5 of the past 12 months. | Severity: 1 |
| Two of two facility fire extinguishers were not inspected annually. | Severity: 2 |
| Smoke detectors were not tested for 6 out of the past 12 months. | Severity: 2 |
| Three oxygen tanks were not secured in a rack or to the wall in one resident room. | Severity: 2 |
| Facility's business license had expired on 5/31/10. | Severity: 1 |
Report Facts
Licensed beds: 6
Residents present: 5
Freezers not maintained below 0°F: 1
Fire extinguishers not inspected: 2
Months without evacuation drills on irregular schedule: 5
Months smoke detectors not tested: 6
Oxygen tanks unsecured: 3
Inspection Report
Complaint Investigation
Census: 6
Deficiencies: 1
May 10, 2010
Visit Reason
This document is a Statement of Deficiencies generated as a result of a complaint investigation conducted from 04/29/2010 through 05/10/2010 at Forget Me Not Home Care LLC.
Findings
The facility admitted a person who was bedfast without the required waiver, violating NAC 449.2702. The complaint #NV00024661 was substantiated. The facility was found to have admitted a bedfast resident without proper authorization and was required to monitor such residents closely.
Complaint Details
Complaint #NV00024661 was substantiated regarding admission of a bedfast resident without proper waiver.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Admission of a bedfast resident without a waiver as required by NAC 449.2702. | Severity: 2 |
Report Facts
Census: 6
Date range of investigation: Investigation conducted from 04/29/2010 through 05/10/2010
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 1
May 10, 2010
Visit Reason
The inspection was conducted as a result of a complaint investigation from 04/29/2010 through 05/10/2010 regarding the facility's admission practices.
Findings
The facility admitted a person who was bedfast, which is against the admission policy for the residential facility. The complaint #NV00024661 was substantiated.
Complaint Details
Complaint #NV00024661 was substantiated based on observation, interview, and record review.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility admitted a person who was bedfast, violating admission policy. | Severity: 2 |
Report Facts
Licensed beds: 6
Census: 6
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 4
Jun 25, 2009
Visit Reason
This document is the result of an annual State Licensure survey conducted at the facility on June 25, 2009, to assess compliance with state regulations for residential facilities for elderly and disabled persons.
Findings
The facility received a grade of A but was found deficient in several areas including failure to ensure annual inspection of fire extinguishers, proper medication labeling, maintenance of resident files, tuberculosis testing compliance, and required mental illness training for caregivers.
Severity Breakdown
1: 2
2: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure that 1 of 1 facility fire extinguishers was inspected annually. | 1 |
| Failure to ensure medications were plainly labeled for 1 of 4 residents (Resident #2). | 2 |
| Failure to maintain resident files properly and ensure compliance with tuberculosis testing for 2 of 4 residents (Resident #1 and #4). | 2 |
| Failure to ensure that 2 of 3 caregivers received required training regarding care of residents with mental illness. | 1 |
Report Facts
Deficiencies cited: 4
Facility licensed beds: 6
Residents present: 4
Caregivers lacking training: 2
Residents with medication labeling issues: 1
Residents non-compliant with TB testing: 2
Inspection Report
Annual Inspection
Census: 3
Capacity: 5
Deficiencies: 4
Sep 17, 2008
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with regulations for a residential facility for elderly and disabled persons.
Findings
The facility was found deficient in medication administration reviews, tuberculosis testing, annual activities of daily living assessments, and discharge documentation for residents. Several resident files lacked timely or complete documentation as required by regulations.
Severity Breakdown
Severity: 1: 3
Severity: 2: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| The facility did not ensure 2 of 3 resident medication regimens were reviewed every six months. | Severity: 1 |
| The facility did not ensure 1 of 3 residents met tuberculosis (TB) testing requirements. | Severity: 2 |
| The facility did not ensure 2 of 3 residents had evidence of annual activities of daily living (ADL) assessments. | Severity: 1 |
| The facility did not ensure the file for a discharged resident contained information concerning the discharge. | Severity: 1 |
Report Facts
Resident census: 3
Total licensed capacity: 5
Deficiency scope: 3
Deficiency scope: 2
Deficiency scope: 3
Deficiency scope: 1
Inspection Report
Annual Inspection
Census: 3
Capacity: 6
Deficiencies: 10
Sep 17, 2008
Visit Reason
Annual state licensure survey conducted to assess compliance with Nevada Administrative Code (NAC) 449, Residential Facility for Groups Regulations.
Findings
The facility was found deficient in multiple areas including caregiver training, personnel files, tuberculosis documentation, background checks, hazard-free environment, resident eligibility, medication administration, medication storage, and resident file maintenance.
Severity Breakdown
Level 1: 3
Level 2: 6
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure 8 hours of annual training related to resident needs for 1 of 3 employees. | Level 2 |
| Failed to ensure required tuberculosis documentation for 3 of 3 employees. | Level 2 |
| Failed to meet background check requirements for criminal history for 2 of 3 employees. | Level 2 |
| Failed to ensure the facility was free of hazards; towels on floor without non-skid backing presented slipping hazard. | Level 2 |
| Failed to ensure 2 of 3 residents complied with eligibility requirements. | Level 2 |
| Failed to ensure an ultimate user agreement was signed for 1 of 3 residents. | Level 1 |
| Failed to administer medication as prescribed for 1 of 3 residents (Docusate Sodium given daily instead of as needed). | Level 2 |
| Failed to document specific times for medication administration on MAR for 3 of 3 residents. | Level 1 |
| Failed to ensure medication cabinet was kept locked when employee was out of the kitchen. | Level 2 |
| Failed to perform annual evaluation of residents' ability to perform activities of daily living for 3 of 3 residents. | Level 1 |
Report Facts
Total licensed beds: 6
Current census: 3
Employees reviewed: 3
Residents reviewed: 3
Background check deficiency repeat: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Failed to have documented 8 hours annual training, incomplete TB documentation, and incomplete background check | |
| Employee #2 | Incomplete TB documentation | |
| Employee #3 | Incomplete TB documentation and background check |
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