Inspection Report
Annual Inspection
Census: 97
Capacity: 108
Deficiencies: 2
Nov 19, 2024
Visit Reason
This inspection was conducted as an annual State Licensure survey of the residential facility for groups, to assess compliance with Nevada Administrative Code Chapter 449.
Findings
The facility received a grade of A but had regulatory deficiencies including a kitchen equipment violation where a convection oven was not under the ventilation hood, and failure to perform six-month medication reviews for one sampled resident.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The kitchen and supportive dining services failed to comply with NAC 446 standards; specifically, a single deck convection oven was not located under the ventilation hood. | Severity: 2 |
| Failure to perform medication reviews every six months for one of 20 sampled residents (Resident #4). | Severity: 2 |
Report Facts
Resident files reviewed: 20
Employee files reviewed: 10
Licensed capacity: 108
Current census: 97
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Aragon | General Manager | Named in relation to oversight of medication reviews and plan of correction |
Inspection Report
Annual Inspection
Census: 100
Capacity: 108
Deficiencies: 10
Nov 28, 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
The facility received a grade of D with multiple deficiencies identified including failure to ensure proper oversight by the acting Administrator, incomplete annual caregiver training, missing annual TB testing for some employees, failure to maintain proper medication administration agreements for residents, expired medication not destroyed timely, and incomplete cultural competency training for employees.
Severity Breakdown
Level 2: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Facility failed to ensure the acting Administrator was prepared to provide oversight and direction; lacked posted non-discrimination statement and complaint information; Maintenance Director unaware of posting requirements and unable to locate resident record. | Level 2 |
| Failed to ensure annual caregiver training was completed for 1 of 10 sampled employees. | Level 2 |
| Failed to ensure 3 of 10 sampled employees completed annual tuberculin (TB) testing or TB Signs and Symptoms Review. | Level 2 |
| Failed to ensure a dryer was free from excessive lint in the laundry room. | Level 2 |
| Failed to ensure an annual physical examination was completed for 1 of 20 residents. | Level 2 |
| Failed to ensure Ultimate User Agreements authorizing medication administration were signed and updated for 6 of 20 residents. | Level 2 |
| Failed to ensure expired medication was destroyed for 1 of 20 residents. | Level 2 |
| Failed to ensure 1 of 20 sampled residents received tuberculin (TB) testing prior to admission. | Level 2 |
| Failed to ensure 1 of 10 sampled employees had initial training in caregiving for elderly or disabled persons within 60 days of hire. | Level 2 |
| Failed to ensure 6 of 10 sampled employees were in compliance with initial cultural competency training requirements. | Level 2 |
Report Facts
Residents reviewed: 20
Employees reviewed: 10
Facility grade: D
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Conaway | General Manager | Signed the inspection report |
| Maintenance Director | Designated acting Administrator during inspection; involved in findings related to oversight and posting of required information | |
| Office Manager | Unable to provide documentation for annual caregiver training and TB testing for certain employees | |
| Caregiver | Confirmed ultimate user agreements were not signed or updated for several residents | |
| Senior Caregiver | Indicated annual physical examination was not completed for a resident | |
| Business Manager | Unable to provide evidence of initial cultural competency training for several employees |
Inspection Report
Annual Inspection
Census: 101
Capacity: 108
Deficiencies: 4
Nov 30, 2022
Visit Reason
The inspection was conducted as a State Licensure Annual Grading survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. Deficiencies were identified related to caregiver training, elder abuse training, CPR training, and cultural competency training compliance for certain employees.
Severity Breakdown
2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure caregiver training was completed annually for 1 of 10 employees (Employee #10). | 2 |
| Facility failed to ensure elder abuse training was completed annually for 1 of 10 employees (Employee #10). | 2 |
| Facility failed to ensure cardiopulmonary resuscitation (CPR) training was completed within 30 days of hire for 1 of 10 employees (Employee #9). | 2 |
| Facility failed to submit an application for a cultural competency training program and ensure 10 of 10 employees were in compliance with annual cultural competency training; training was conducted by a non-approved program. | 2 |
Report Facts
Residents present: 101
Total licensed capacity: 108
Employees reviewed: 10
Residents files reviewed: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #10 | Named in deficiencies for failure to complete annual caregiver training and elder abuse training | |
| Employee #9 | Named in deficiency for failure to complete CPR training within 30 days of hire | |
| David Conaway | General Manager | Signed the report and responsible for compliance |
Report
File
Notice
Report
File
Sanction_Sanction
Report
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signed.pdf
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