Inspection Reports for Little Angel Care Home
2570 Keystone Ave, Reno, NV 89503, NV, 89503
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Inspection Report
Annual Inspection
Census: 5
Capacity: 5
Deficiencies: 2
Aug 14, 2024
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, specifically the failure to designate a secondary person responsible for infection control and the lack of required infection control training for that person. The facility received a grade of A overall.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure a secondary person responsible for the infection control program was identified. | Severity: 2 |
| Facility lacked a secondary infection control person with the required infection control training. | Severity: 2 |
Report Facts
Resident census: 5
Total licensed capacity: 5
Infection control training hours required: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marilou A Reyes | Administrator | Named as primary infection control person and responsible for plan of correction implementation |
Inspection Report
Complaint Investigation
Census: 5
Capacity: 5
Deficiencies: 4
Dec 12, 2023
Visit Reason
The inspection was conducted as a complaint investigation triggered by complaint #NV00069663 alleging roaches and bed bugs in the facility.
Findings
The complaint of roaches and bed bugs was not substantiated due to lack of evidence. However, deficiencies were found including unsecured medications in a kitchen cabinet, an incomplete infection control plan lacking designation of responsible persons, and staff lacking required infection control training.
Complaint Details
Complaint #NV00069663 alleging roaches and bed bugs was investigated but not substantiated due to lack of evidence.
Severity Breakdown
F: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Medications were found unsecured in a kitchen cabinet, failing to ensure medications were secured and safe from access by residents or visitors. | F |
| The facility failed to develop a comprehensive infection control program and policies to prevent and control infections, lacking designation of responsible persons and current evidence-based guidelines. | F |
| The facility failed to designate a primary and secondary person responsible for the infection control program. | F |
| Staff lacked the required infection control and prevention training. | F |
Report Facts
Number of residents present: 5
Total licensed capacity: 5
Severity level 2 deficiencies: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marilou A Reyes | Administrator | Named as responsible for implementing corrective actions |
Inspection Report
Annual Inspection
Census: 4
Capacity: 5
Deficiencies: 2
Sep 5, 2023
Visit Reason
This inspection was conducted as an annual State Licensure 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 had deficiencies including burnt-out hallway bathroom lights posing a safety hazard and failure to ensure medication profile reviews were properly signed by the administrator for two residents.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Hallway bathroom lights were not adequately functioning with burnt out bulbs, creating a safety hazard. | Severity: 2 |
| Medication profile reviews for two residents were completed but lacked administrator initials acknowledging medication accuracy. | Severity: 2 |
Report Facts
Licensed beds: 5
Residents present: 4
Residents reviewed: 4
Employee files reviewed: 4
Medication reviews missing initials: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marilou A Reyes | Administrator | Administrator confirmed medication review deficiencies and signed plan of correction |
Inspection Report
Annual Inspection
Census: 4
Deficiencies: 8
Jan 6, 2023
Visit Reason
The inspection was conducted as a result of a State Licensure annual survey combined with a complaint investigation at the facility on 01/06/23.
Findings
The facility received a grade of B with multiple deficiencies identified including insufficient staffing with only one caregiver on site, failure to submit waivers for residents receiving skilled nursing services, lack of timely physical examinations and medication reviews, failure to conduct monthly smoke detector tests and fire drills, and missing physician orders for medications.
Complaint Details
One complaint (#NV00066733) was investigated with substantiated allegations that a resident was bedfast without an exemption on file and that only one caregiver was on site providing care. Other allegations regarding leaking toilet, rodent poison, and caregiver yelling were not substantiated due to lack of evidence.
Severity Breakdown
Level 2: 7
Deficiencies (8)
| Description | Severity |
|---|---|
| Insufficient number of caregivers on duty to assist a resident in a timely manner after a fall. | Level 2 |
| Failure to ensure smoke detectors were tested and fire alarms conducted monthly. | — |
| Admission or retention of residents receiving skilled nursing services without submitting required waivers. | Level 2 |
| Failure to ensure annual physical examinations including review of systems were completed for residents. | Level 2 |
| Medication profile reviews were not performed timely and lacked administrator initials acknowledging medication changes. | Level 2 |
| Failure to obtain physician orders for medications for one resident. | Level 2 |
| Failure to document symptoms treated for as-needed medications on the Medication Administration Record. | Level 2 |
| Failure to obtain initial and annual Standard Physician Assessment and Placement Determinations for a resident. | Level 2 |
Report Facts
Residents present: 4
Employee files reviewed: 3
Resident files reviewed: 4
Medication reviews late: 2
Residents receiving skilled nursing without waiver: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marilou A Reyes | Administrator | Named in relation to findings on staffing, medication reviews, and other deficiencies |
Inspection Report
Complaint Investigation
Census: 4
Deficiencies: 0
Jul 20, 2022
Visit Reason
The inspection was conducted as a complaint State Licensure survey initiated on 07/20/22 and finalized on 07/28/22, triggered by complaint #NV00066684 with multiple allegations against the facility.
Findings
The investigation included observations, interviews, and document reviews. None of the five allegations were substantiated, and no regulatory deficiencies were identified. The facility received a grade of A and no further action was necessary.
Complaint Details
Complaint #NV00066684 included five allegations: untreated pressure sores leading to death, witnessing abuse of a roommate, inadequate dinner meals, presence of rodents and cockroaches, and excessive heat in the facility. All allegations were investigated and found unsubstantiated due to lack of evidence.
Report Facts
Sample size: 5
Inspection Report
Annual Inspection
Census: 4
Deficiencies: 3
Mar 21, 2022
Visit Reason
This inspection was conducted as a State Licensure annual survey at the facility in accordance with Nevada Administrative Code (NAC) Chapter 449, Residential Facility for Groups.
Findings
The facility received a grade of A but had several deficiencies including maintenance issues with a sliding screen door, cleanliness problems in the kitchen oven, and failure to ensure a resident received a physical examination prior to admission.
Severity Breakdown
2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| The sliding screen door leading to the backyard was difficult to slide open and needed replacement. | 2 |
| The kitchen oven interior door had a buildup of old encrusted spills and splatters and needed cleaning. | 2 |
| One of five sampled residents did not have a documented physical examination prior to admission; the exam was approximately 3 months late. | 2 |
Report Facts
Census: 4
Resident files reviewed: 4
Employee files reviewed: 4
Residents sampled: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marilou A Reyes | Administrator | Named as responsible for ensuring plan of correction implementation and involved in corrective actions |
Inspection Report
Annual Inspection
Census: 4
Deficiencies: 1
Jun 4, 2021
Visit Reason
This inspection was conducted as a State Licensure annual survey at the facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. One deficiency was identified related to the failure to ensure that one of four sampled residents received a physical examination prior to admission.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 4 sampled residents received a physical examination prior to admission (Resident #3). | 2 |
Report Facts
Residents reviewed: 4
Employees reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marilou A Reyes | Administrator | Signed the report and responsible for implementing the plan of correction |
Inspection Report
Routine
Census: 3
Capacity: 5
Deficiencies: 0
Sep 29, 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 components of an Infection Control and Prevention Plan including staff training, PPE inventory, screening practices, and response plans. No regulatory deficiencies were identified.
Report Facts
Licensed beds: 5
Census: 3
Inspection Report
Annual Inspection
Census: 4
Deficiencies: 0
Jun 12, 2020
Visit Reason
This inspection was conducted as a State Licensure annual survey in accordance with Nevada Administrative Code (NAC) Chapter 449, 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: 4
Employee files reviewed: 3
Inspection Report
Annual Inspection
Census: 5
Capacity: 5
Deficiencies: 0
May 12, 2016
Visit Reason
This Statement of Deficiencies was generated as a result of an annual State Licensure survey conducted in the facility on 5/12/16 by the authority of NRS 449.0307.
Findings
There were no deficiencies identified. The facility is in substantial compliance with the regulations and received a grade of A.
Report Facts
Resident files reviewed: 5
Employee files reviewed: 4
Inspection Report
Complaint Investigation
Census: 5
Deficiencies: 0
Apr 19, 2016
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding allegations of facility staffing and a resident fall.
Findings
The complaint allegations could not be substantiated. No regulatory deficiencies were identified during the investigation.
Complaint Details
Complaint #NV00045478 included allegations of facility staffing and a resident fall, both of which were not substantiated after investigation.
Report Facts
Sample size: 5
Inspection Report
Re-Inspection
Deficiencies: 0
May 5, 2014
Visit Reason
This document is a required grading re-survey conducted from 2014-04-22 to 2014-05-05 as a state licensure survey by the Division of Public and Behavioral Health.
Findings
The facility received a re-survey grade of A with no deficiencies identified during the inspection.
Inspection Report
Annual Inspection
Census: 4
Capacity: 5
Deficiencies: 6
Feb 20, 2014
Visit Reason
The inspection was conducted as a State Licensure annual grading survey to assess compliance with regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of C with multiple deficiencies identified including failure to secure oxygen tanks, incomplete physician assessments for residents with Alzheimer's disease, missing pre-admission physical examination, unsecured medications, unsecured resident and employee files, and incomplete tuberculosis testing documentation.
Severity Breakdown
Severity: 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to secure oxygen tanks in a rack or to the wall, with observations of unsecured tanks in Bedroom #1 and the garage. | Severity: 2 |
| Facility failed to provide current physician assessments for 2 of 4 residents with Alzheimer's disease. | Severity: 2 |
| Facility failed to ensure 1 of 5 residents received a pre-admission physical examination. | Severity: 2 |
| Facility failed to ensure medications were secured in a locked cabinet; observed medications on a table in caregiver room not locked. | Severity: 2 |
| Facility failed to ensure resident and employee files were secured in a locked cabinet; files were observed unlocked on kitchen floor and in file cabinet. | Severity: 2 |
| Facility failed to ensure 3 of 4 residents complied with tuberculosis testing requirements; documentation errors and missing chest x-ray noted. | Severity: 2 |
Report Facts
Residents present: 4
Licensed capacity: 5
Unsecured oxygen tanks: 4
Residents missing physician assessments: 2
Residents missing pre-admission physical exam: 1
Residents non-compliant with TB testing: 3
Inspection Report
Annual Inspection
Census: 4
Capacity: 5
Deficiencies: 6
Feb 20, 2014
Visit Reason
This document is a State Licensure annual grading survey conducted to assess compliance with regulatory requirements for a residential facility for group beds for elderly and disabled persons.
Findings
The facility received a grade of C with multiple deficiencies identified including unsecured oxygen tanks, lack of current physician assessments for residents with Alzheimer's disease, missing pre-admission physical examination for one resident, unsecured medications and resident files, and incomplete tuberculosis testing documentation.
Severity Breakdown
Level 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to secure oxygen tanks in a rack or to the wall. | Level 2 |
| Administrator must provide current physician's assessment for 2 of 4 residents with Alzheimer's disease. | Level 2 |
| Failed to ensure 1 of 5 residents received a physical prior to admission. | Level 2 |
| Failed to ensure medications were secured in a locked cabinet. | Level 2 |
| Failed to ensure resident files were secured in a locked cabinet. | Level 2 |
| Failed to ensure 3 of 4 residents complied with tuberculosis testing requirements. | Level 2 |
Report Facts
Facility licensed capacity: 5
Census: 4
Grade: C
Deficiency severity: 2
Inspection Report
Annual Inspection
Census: 4
Capacity: 5
Deficiencies: 0
Dec 10, 2012
Visit Reason
This document is a result of an annual State Licensure survey conducted at the facility on 12/10/12 to assess compliance with state regulations.
Findings
The facility received a grade of A with no regulatory deficiencies identified. Four resident files and three employee files were reviewed during the survey.
Report Facts
Resident files reviewed: 4
Employee files reviewed: 3
Inspection Report
Annual Inspection
Census: 3
Capacity: 5
Deficiencies: 3
Nov 30, 2011
Visit Reason
This document is an annual State Licensure survey conducted at Little Angel Care Home LLC on 11/30/2011 to assess compliance with state regulations for residential care facilities.
Findings
The facility received a grade of A. Deficiencies were identified related to restraint definitions, failure to ensure full bed rails were used properly on one resident, failure to submit required paperwork, and failure to obtain a plan of care for a resident receiving hospice care.
Severity Breakdown
Severity: 2 Scope: 1: 1
Severity: 1 Scope: 1: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 3 residents were not restrained by the use of full bed rails (Resident #1). | Severity: 2 Scope: 1 |
| Failure to submit the required paperwork to the Bureau of Health Care Quality and Compliance. | Severity: 1 Scope: 1 |
| Failure to obtain a copy of the plan of care for a resident receiving hospice care (Resident #1). | Severity: 1 Scope: 1 |
Report Facts
Deficiencies identified: 3
Facility licensed capacity: 5
Resident census: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Monica A. Reyes | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
Inspection Report
Annual Inspection
Census: 3
Capacity: 5
Deficiencies: 2
Nov 30, 2011
Visit Reason
This annual State Licensure survey was conducted to assess compliance with state regulations for the residential facility for group beds for elderly and disabled persons.
Findings
The facility received a grade of A but was cited for two deficiencies: failure to submit required paperwork to retain a bedfast resident receiving hospice care, and failure to obtain a copy of the plan of care for a resident receiving hospice care.
Severity Breakdown
Severity: 1: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to submit the required paperwork to the Bureau of Health Care Quality and Compliance requesting a waiver to retain a bedfast person receiving hospice care for 1 of 3 residents (Resident #1). | Severity: 1 |
| Failed to obtain a copy of the plan of care for a resident receiving hospice care (Resident #1). | Severity: 1 |
Report Facts
Licensed capacity: 5
Census: 3
Inspection Report
Annual Inspection
Census: 5
Capacity: 5
Deficiencies: 2
Nov 16, 2010
Visit Reason
This document is an annual State Licensure survey conducted at the facility to assess compliance with state regulations for residential care facilities.
Findings
The facility received a grade of A but was found deficient in maintaining the premises clean and well maintained, including the backyard area and kitchen cleanliness. Specific issues included discarded furniture and debris in the backyard and accumulated grease and missing grout in the kitchen.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure the premises were clean and well maintained, including discarded furniture and debris in the backyard and improperly fitting window screen. | Severity: 2 |
| Kitchen area was not clean allowing for sanitary preparation of food, including accumulated grease on stove top and missing grout from kitchen tiles around sink. | Severity: 2 |
Report Facts
Licensed beds: 5
Resident census: 5
Inspection Report
Annual Inspection
Census: 5
Capacity: 5
Deficiencies: 6
Nov 6, 2009
Visit Reason
This document is the result of an annual State Licensure survey conducted at the facility on 11/06/2009 to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of B and was found deficient in several areas including personnel background checks, smoking policy posting, medication administration and records, PRN medication records, and tuberculosis testing compliance.
Severity Breakdown
1: 3
2: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 4 caregivers met background check requirements (Employee #3 did not show evidence of an FBI background check). | 2 |
| Facility failed to ensure that its smoking policy was posted in a common area of the facility. | 1 |
| Facility failed to ensure that 3 of 5 residents received medications as prescribed (Residents #1, #3 and #4). | 2 |
| Facility failed to ensure the medication administration record (MAR) was accurate for 3 of 5 residents (Residents #1, #3 and #4). | 1 |
| Administrator did not ensure that 'as needed' (PRN) medication records were used by the facility for 2 of 5 residents with prescriptions for PRN medications (Residents #1 and #3). | 1 |
| Facility failed to ensure 1 of 5 residents complied with tuberculosis testing requirements (Resident #3), which affected all residents. | 2 |
Report Facts
Residents present: 5
Licensed capacity: 5
Caregivers reviewed: 4
Resident files reviewed: 5
Discharged resident files reviewed: 1
Residents with medication administration issues: 3
Residents with PRN medication record issues: 2
Residents with tuberculosis testing noncompliance: 1
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