Inspection Reports for Holy Family Home Care
3235 Delna Dr, Sparks, NV 89431, NV, 89431
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Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 0
Aug 19, 2024
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the survey. The facility received a grade of A and no further action is necessary.
Report Facts
Resident files reviewed: 8
Employee files reviewed: 4
Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 1
Aug 1, 2023
Visit Reason
This inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to have deficiencies related to infection control training, specifically the Owner and Administrator had not completed the required 15 hours of infection control training. The facility received an overall grade of A.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The primary and secondary infection control persons lacked the required 15 hours of infection control training from approved nationally recognized organizations. | Severity: 2 |
Report Facts
Resident census: 8
Total licensed capacity: 8
Deficiency severity: 2
Deficiency scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nelia Buendia | Administrator | Named as the assistant Infection Control Manager lacking required training |
| Owner/Caregiver | Named as the primary Infection Control Manager lacking required training |
Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 2
Oct 26, 2022
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but had deficiencies including an incomplete Ultimate User Agreement for medication administration for one resident and failure to complete Activities of Daily Living (ADL) assessments on admission and/or annually for all eight residents.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure an ultimate user agreement was completed for 1 of 8 residents; the form was incomplete with no selection made by the resident. | Severity: 2 |
| Failed to ensure Activities of Daily Living (ADL) assessments were completed on admission and/or annually for 8 of 8 residents. | Severity: 2 |
Report Facts
Residents present: 8
Licensed capacity: 8
Resident files reviewed: 8
Employee files reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nelia Buendia | Administrator | Named as Laboratory Director's or Provider/Supplier Representative who signed the report |
Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 0
Nov 22, 2021
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the survey. The facility received a grade of A and no further action is necessary.
Report Facts
Resident files reviewed: 8
Employee files reviewed: 3
Inspection Report
Follow-Up
Census: 8
Capacity: 8
Deficiencies: 0
Sep 14, 2020
Visit Reason
This was a follow-up State Licensure COVID-19 Infection Control and Prevention Plan Survey conducted to assess the facility's compliance with infection control measures during the COVID-19 pandemic.
Findings
The facility maintained adequate infection control practices including PPE availability, staff training, screening procedures, and quarantine plans. No regulatory deficiencies were identified during this follow-up survey.
Report Facts
Licensed beds: 8
Census: 8
N95 Fit tested staff: 4
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 5
Aug 26, 2020
Visit Reason
This inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of B with several deficiencies identified including late fingerprint renewal for an employee, failure to maintain cleanliness and repairs in the facility, late medication profile review for a resident, missing initial ADL assessment for a resident, and failure to display the current letter grade placard.
Severity Breakdown
Level 2: 4
Level 1: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 employees met background check requirements; fingerprint renewal was over three months late. | Level 2 |
| Facility failed to maintain interior premises free of spiders, repair torn screens, clean HVAC filter, and maintain bathroom shower. | Level 2 |
| Administrator failed to ensure medication profile review was performed at least every six months for 1 of 7 residents; review was two weeks late. | Level 2 |
| Failed to ensure 1 of 7 residents received an activities of daily living (ADL) assessment upon admission. | Level 2 |
| Failed to display the letter grade from the last annual State Licensure survey; outdated placard was displayed. | Level 1 |
Report Facts
Residents present: 7
Licensed capacity: 8
Employee files reviewed: 4
Resident files reviewed: 7
Inspection Report
Routine
Census: 7
Capacity: 8
Deficiencies: 0
Aug 25, 2020
Visit Reason
This inspection was conducted as a State Licensure COVID-19 Infection Control and Prevention Plan Survey to evaluate the facility's compliance with infection control requirements.
Findings
No regulatory deficiencies were identified; however, the facility did not have a complete Infection Control and Prevention Plan documented. Resources were provided and the Administrator committed to having a documented plan ready for follow-up by 09/08/20.
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 0
Feb 12, 2020
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility to assess compliance with NAC 449, Residential Facilities 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: 4
Inspection Report
Complaint Investigation
Census: 7
Capacity: 8
Deficiencies: 0
Oct 29, 2019
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding an allegation that a resident eloped from the facility on 09/21/19.
Findings
The complaint investigation included observations, interviews, and file reviews, and concluded that the allegation could not be substantiated. No deficiencies were identified during the investigation.
Complaint Details
Complaint #NV00058955 with the allegation that a resident eloped from the facility on 09/21/19 was investigated and found to be unsubstantiated.
Report Facts
Complaint count: 1
Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 0
Apr 1, 2019
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility in accordance with NAC 449, Residential Facilities for Groups.
Findings
No regulatory deficiencies were identified during the survey. The facility received a grade of A, and no further action is necessary.
Report Facts
Resident files reviewed: 8
Employee files reviewed: 4
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 2
May 24, 2016
Visit Reason
This inspection was conducted as an annual State Licensure survey to assess compliance with regulations for a residential facility for elderly and disabled persons and/or persons with mental illnesses.
Findings
The facility received a grade of A. Deficiencies were identified related to caregiver medication training and mental illness training, specifically the failure to ensure employees had current and documented annual training certificates.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure 2 of 5 employees received eight hours of annual training in the management of medication. | Severity: 2 |
| Failure to ensure 1 of 5 employees received 8 hours of training concerning care for residents suffering from mental illnesses within 60 days of hire. | Severity: 2 |
Report Facts
Number of residents present: 7
Total licensed capacity: 8
Number of employees reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Caregiver | Medication training certificate expired and lacked current evidence |
| Employee #3 | Caregiver | Lacked documented evidence of mental illness training within 60 days of hire |
| Employee #4 | Acknowledged expired certificates | |
| Employee #5 | Administrator | Medication training certificate expired and lacked current evidence |
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 2
May 24, 2016
Visit Reason
This annual State Licensure survey was conducted to assess compliance with state regulations for a residential facility for group beds for elderly and disabled persons and/or persons with mental illnesses.
Findings
The facility received a grade of A but was found deficient in ensuring that employees received required annual medication management training and mental illness care training. Specifically, 2 of 5 employees lacked current annual medication training certificates, and 1 of 5 employees lacked required mental illness training within 60 days of hire.
Severity Breakdown
Level 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 5 employees received eight hours of annual training in the management of medication; medication training certificates expired and no current certificates were documented. | Level 2 |
| Failed to ensure 1 of 5 employees received eight hours of training concerning care for residents with mental illnesses within 60 days of hire. | Level 2 |
Report Facts
Number of employees reviewed: 5
Number of resident files reviewed: 7
Facility licensed capacity: 8
Current census: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Caregiver | Named in medication training deficiency due to expired certificate |
| Employee #5 | Administrator | Named in medication training deficiency due to expired certificate |
| Employee #3 | Caregiver | Named in mental illness training deficiency due to lack of documented training within 60 days of hire |
| Employee #4 | Acknowledged expired certificates and missing documentation |
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 3
Apr 3, 2014
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure grading survey conducted on 4/3/14 to assess compliance with regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A but had several deficiencies including failure to complete required annual medication management training, unsecured oxygen tanks in resident rooms, and admitting a resident with Alzheimer's disease without the required endorsement. The facility agreed to corrective actions including scheduling training and securing oxygen tanks.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Administrator failed to complete the required 8 hours of annual medication management refresher training. | Severity: 2 |
| Facility failed to ensure oxygen tanks were secured in a rack or to the wall in 1 of 4 resident rooms. | Severity: 2 |
| Facility admitted a resident with Alzheimer's disease without an Alzheimer's disease endorsement on its license. | Severity: 2 |
Report Facts
Licensed beds: 8
Resident census: 7
Employee files reviewed: 5
Resident files reviewed: 7
Oxygen tanks unsecured: 5
Inspection Report
Complaint Investigation
Capacity: 8
Deficiencies: 1
Aug 1, 2013
Visit Reason
The inspection was conducted as a complaint investigation following allegations of verbal abuse of a resident at the facility between 7/16/13 and 8/1/13.
Findings
The investigation substantiated the allegation that a staff member verbally abused a resident by calling them 'fat' and being verbally abusive when residents asked for assistance.
Complaint Details
Complaint #NV00036253: The allegation of verbal abuse of a resident was substantiated.
Severity Breakdown
Severity: 3: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The administrator failed to ensure that residents were not verbally abused by staff, as evidenced by a staff member calling a resident 'fat' and being verbally abusive. | Severity: 3 |
Report Facts
Licensed capacity: 8
Residents involved: 1
Severity level: 3
Scope: 1
Inspection Report
Complaint Investigation
Capacity: 8
Deficiencies: 1
Jul 16, 2013
Visit Reason
This inspection was conducted as a result of a complaint investigation regarding an allegation of verbal abuse of a resident.
Findings
The investigation substantiated that one of seven residents was verbally abused by a staff member who called the resident 'fat' and was verbally abusive when residents asked for assistance.
Complaint Details
Complaint #NV00036253: The allegation of verbal abuse of a resident was substantiated.
Severity Breakdown
Severity: 3: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The administrator failed to ensure that one of seven residents was not verbally abused by a staff member. | Severity: 3 |
Report Facts
Residents involved: 7
Licensed capacity: 8
Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 2
Apr 23, 2013
Visit Reason
This State Licensure survey was conducted as an annual survey on 4/23/13 to assess compliance with state regulations for the facility licensed for group beds for elderly and disabled persons.
Findings
The facility received a grade of A but had deficiencies including failure to obtain appropriate mental health training for caring for a resident with mental illness and failure to ensure one caregiver received annual elder abuse training.
Severity Breakdown
Severity: 2: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility was caring for a resident with a history of mental illness without appropriate endorsement and training. | Severity: 2 |
| Administrator failed to ensure 1 of 4 caregivers received annual training in recognition, prevention, and response to elder abuse. | — |
Report Facts
Census: 8
Total Capacity: 8
Caregivers: 4
Resident: 1
Caregiver: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in failure to ensure caregiver training |
Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 2
Apr 23, 2013
Visit Reason
This document is the result of an annual State Licensure survey conducted at the facility on 4/23/2013 to assess compliance with state regulations for residential facilities.
Findings
The facility received a grade of A but had deficiencies including caring for a resident with a mental illness without appropriate endorsement or training, and failure to ensure one caregiver received annual elder abuse training as required by Nevada Revised Statutes.
Severity Breakdown
Severity: 2: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility was caring for a resident with a history of mental illness without appropriate endorsement and necessary training (Resident #3). | Severity: 2 |
| Administrator failed to ensure one of four caregivers received annual training in recognition, prevention, and response to elder abuse (Employee #1). | — |
Report Facts
Resident files reviewed: 8
Employee files reviewed: 4
Caregivers: 4
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 0
May 3, 2012
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted from 2012-04-26 to 2012-05-03 at the facility.
Findings
No deficiencies were identified during the survey. The facility received a grade of A.
Report Facts
Resident files reviewed: 7
Employee files reviewed: 5
Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 0
Mar 14, 2011
Visit Reason
This document is the result of an annual State Licensure survey conducted at the facility on 03/14/2011 to assess compliance with state regulations for a Residential Facility for Group beds for elderly and disabled persons.
Findings
No regulatory deficiencies were identified during the inspection. The facility received a grade of A and no further action was necessary.
Report Facts
Resident files reviewed: 8
Employee files reviewed: 4
Inspection Report
Annual Inspection
Census: 6
Capacity: 8
Deficiencies: 1
Mar 25, 2010
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 3/25/2010 at Holy Family Home Care.
Findings
The facility received a grade of A. One deficiency was identified related to medication administration where the facility failed to ensure that 1 of 6 residents received brand name medications as prescribed.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure that 1 of 6 residents received brand name medications as prescribed (Resident #5 - Bengay Cream, Joint Flex Patch, Lacrilube). | 2 |
Report Facts
Licensed beds: 8
Resident census: 6
Resident files reviewed: 6
Employee files reviewed: 5
Discharged resident files reviewed: 1
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