Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 4
Capacity: 10
Deficiencies: 0
Apr 3, 2025
Visit Reason
This inspection was conducted as an annual State Licensure and infection control 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.
Inspection Report
Annual Inspection
Census: 4
Capacity: 10
Deficiencies: 3
Apr 1, 2024
Visit Reason
This 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 but was cited for several deficiencies including failure to ensure six-month medication reviews were initialed and dated by the Administrator within 72 hours for 3 residents, failure to complete an annual Activities of Daily Living (ADL) assessment for one resident, and failure to ensure primary and secondary infection control designees completed required 15 hours of infection control training.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure six-month Medication Reviews were initialed and dated by the Administrator within 72 hours for 3 of 4 residents. | Level 2 |
| Failed to ensure an annual Activities of Daily Living (ADL) Assessment was completed for 1 of 4 residents. | Level 2 |
| Failed to ensure primary and secondary infection control designees completed 15 hours of infection control training from a nationally recognized organization. | Level 2 |
Report Facts
Licensed beds: 10
Current census: 4
Deficiencies cited: 3
Infection control training hours required: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cherry Daelto | Administrator | Named in relation to medication review deficiencies and signature on report |
| Employee #2 | Caregiver | Primary infection control designee lacking required training |
| Employee #3 | Caregiver | Secondary infection control designee lacking required training |
Inspection Report
Annual Inspection
Census: 6
Capacity: 10
Deficiencies: 1
Mar 22, 2023
Visit Reason
The inspection was conducted as an annual State Licensure and infection control survey of the facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility failed to ensure that a six month medication review with recommendations was completed for 3 of 6 residents (Residents #4, #5, and #6). The facility received a grade of A despite this deficiency.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a six month medication review with recommendations was completed for 3 of 6 residents (Residents #4, #5, and #6). | Severity: 2 |
Report Facts
Licensed beds: 10
Census: 6
Residents reviewed: 6
Employee files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cherry Daelto | Administrator | Signed the report and named as facility administrator |
Inspection Report
Annual Inspection
Census: 5
Capacity: 10
Deficiencies: 5
Mar 15, 2022
Visit Reason
This inspection was conducted as an annual State Licensure and infection control survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of B with several regulatory deficiencies identified, including lack of current medication management training and CPR certification for some employees, missing physical examination for one resident, incomplete tuberculosis testing for another resident, and insufficient dementia care training for one employee.
Severity Breakdown
2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure caregivers had evidence of current Medication Management training for 2 of 4 employees (E3 and E4). | 2 |
| Failed to ensure caregivers had current Cardiopulmonary Resuscitation (CPR) training for 2 of 4 employees (E3 and E4). | 2 |
| Failed to ensure all admitted residents had a current physical examination for 1 of 5 residents (Resident #2). | 2 |
| Failed to ensure all residents had a documented 2-Step Tuberculosis (TB) skin test for 1 of 5 residents (Resident #1). | 2 |
| Failed to ensure caregivers had at least eight hours of current documented annual Caregiver training including at least three hours of Alzheimer's training for 1 of 4 employees (Employee #1). | 2 |
Report Facts
Licensed beds: 10
Current census: 5
Employees reviewed: 4
Residents reviewed: 5
Training hours completed: 16.75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Caregiver | Named in findings for lack of current Medication Management and CPR training |
| Employee #4 | Caregiver | Named in findings for lack of current Medication Management and CPR training |
| Employee #1 | Caregiver | Named in finding for lack of current annual caregiver training including Alzheimer's training |
| Rosalie K. Bacal | RFA | Signed as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Annual Inspection
Census: 3
Deficiencies: 4
May 20, 2021
Visit Reason
This inspection was conducted as a State Licensure annual survey of the residential facility to assess compliance with regulatory requirements.
Findings
The facility received an annual survey grade of A. Deficiencies were identified related to elder abuse training for employees, failure to obtain a bedfast waiver for one resident, incomplete annual activities of daily living (ADL) screening for one resident, and failure to ensure initial elder care training for one employee.
Severity Breakdown
E: 1
D: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 4 employees received annual training to care for elderly and disabled residents. | E |
| Failed to obtain a bedfast waiver for 1 of 3 residents. | D |
| Failed to complete an annual activities of daily living (ADL) screening for 1 of 3 residents. | D |
| Failed to ensure 1 of 4 employees received four hours of initial training to care for elderly and disabled residents. | D |
Report Facts
Census: 3
Employees reviewed: 4
Residents reviewed: 3
Inspection Report
Abbreviated Survey
Census: 4
Capacity: 10
Deficiencies: 2
May 14, 2020
Visit Reason
This inspection was a focused COVID-19 infection control survey conducted to assess compliance with infection control policies and procedures during the COVID-19 pandemic.
Findings
The facility failed to conduct temperature checks and COVID-19 screening for visitors prior to entry, lacked an infection control policy, and did not ensure a staff member was awake on duty at all times. Three residents and one employee tested positive for COVID-19. The Administrator was the sole caregiver during the survey and reported staffing challenges due to resignations and positive COVID-19 cases among staff.
Severity Breakdown
Severity: 2 Scope: 3: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| No temperature check or COVID-19 screening questions were conducted prior to inspector entry; facility lacked an infection control policy. | Severity: 2 Scope: 3 |
| Facility did not ensure a staff member was awake and on duty at all times; Administrator admitted to sleeping about three hours on the couch. | Severity: 2 Scope: 3 |
Report Facts
Residents tested positive for COVID-19: 3
Employees tested positive for COVID-19: 1
Licensed capacity: 10
Census at time of survey: 4
Staff to resident ratio prior to COVID-19 outbreak: 2.5
Cost per COVID-19 test: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rosalie K Bacal | Administrator / Sole Caregiver | Named as the Administrator and sole caregiver responsible for infection control and staffing during the survey. |
Inspection Report
Annual Inspection
Census: 6
Capacity: 10
Deficiencies: 3
Dec 12, 2019
Visit Reason
The inspection was conducted as a required re-grading and annual State Licensure survey for the Residential Facility for Groups under Nevada Administrative Code Chapter 449.
Findings
The facility received a grade of A but had several regulatory deficiencies including falsified medication management training for one employee, failure to ensure timely tuberculosis testing for two residents, and unsecured scissors and razors in a common bathroom.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 6 employees received initial 16 hour medication management training; medication management certificate was falsified. | Level 2 |
| Facility failed to ensure 2 of 6 residents received timely tuberculosis testing; second step tests were 10 and 11 months late. | Level 2 |
| Facility failed to ensure scissors and razors were secured in a common bathroom, posing a safety risk to residents. | Level 2 |
Report Facts
Licensed beds: 10
Current census: 6
Deficiencies cited: 3
Inspection Report
Complaint Investigation
Census: 7
Capacity: 10
Deficiencies: 11
Oct 23, 2019
Visit Reason
This inspection was conducted as a complaint investigation initiated on 2019-09-16 and finalized on 2019-10-23, based on complaint #NV00058209 with four allegations regarding resident care and staffing.
Findings
The facility was found to have substantiated deficiencies including failure to turn or reposition residents timely, lack of assigned night shift staff, and unqualified staff. Additional deficiencies included missing elder abuse training, incomplete personnel files, inadequate staff background checks, missing first aid/CPR training, failure to properly document resident turning and pressure sore care, lack of bedfast waiver for a resident, inaccurate medication administration records, insufficient Alzheimer's care staffing and training, and staff working 24-hour shifts.
Complaint Details
Complaint #NV00058209 with four allegations: 1) Residents not turned or repositioned timely (substantiated); 2) No assigned staff for night shift (substantiated); 3) Infection control practices not followed (not substantiated); 4) Facility did not have qualified staff (substantiated).
Severity Breakdown
Level 1: 1
Level 2: 10
Deficiencies (11)
| Description | Severity |
|---|---|
| Residents were not turned or repositioned in a timely manner. | Level 2 |
| Facility did not have assigned staff for the night shift. | Level 2 |
| Facility did not have qualified staff including missing elder abuse training for employees. | Level 2 |
| Facility failed to ensure employees had pre-employment physicals and TB tests. | Level 2 |
| Facility failed to ensure employees had completed background checks. | Level 2 |
| Facility failed to ensure employees had first aid and CPR training within 30 days of hire. | Level 2 |
| Facility failed to ensure one resident was turned every two hours to prevent pressure sores and failed to document turning. | Level 2 |
| Facility failed to obtain a bedfast waiver for a resident requiring it. | Level 2 |
| Medication Administration Record was inaccurate for a resident, listing medications via PEG tube incorrectly. | Level 1 |
| Facility failed to ensure at least one staff member was awake and on duty during night shifts and failed to prevent staff working 24-hour shifts. | Level 2 |
| Facility failed to ensure caregivers received required Alzheimer's/dementia training within 40 hours of employment. | Level 2 |
Report Facts
Licensed beds: 10
Residents present: 7
Sample size: 6
Severity 2 deficiencies: 10
Severity 1 deficiencies: 1
Employee terminations: 3
Training completion deadline: Nov 22, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rosalie Kowatch | Administrator | Named as Administrator involved in interviews and acknowledged deficiencies. |
| Employee #1 | Failed to have elder abuse training and pre-employment physical/TB test; terminated 10/23/2019. | |
| Employee #2 | Lacked complete TB test documentation and background clearance letter; scheduled for new physical and fingerprinting. | |
| Employee #3 | Lacked elder abuse training and first aid training; scheduled for new CPR/First aid training; employee file missing. | |
| Employee #4 | Considered volunteer; lacked elder abuse, background check, first aid/CPR, and Alzheimer's training; terminated 10/23/2019. |
Inspection Report
Re-Inspection
Census: 6
Capacity: 6
Deficiencies: 8
Mar 28, 2019
Visit Reason
This inspection was a State Licensure re-grading survey conducted to assess compliance with Nevada Administrative Code for a Residential Facility for Groups.
Findings
The facility received a grade of A with several regulatory deficiencies identified, including issues with medication administration accuracy, incomplete tuberculin testing for residents, and documentation discrepancies. The facility maintained cleanliness and safety measures, including proper staffing and secured outdoor areas.
Severity Breakdown
C: 1
D: 3
E: 1
F: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Staffing schedule was not maintained monthly as required. | C |
| Premises were not maintained clean and well kept. | F |
| Failure to ensure medications were documented and administered accurately per physician's orders for two residents. | D |
| Medication container labeling was not compliant; medications were not plainly labeled with resident's name and prescribing physician. | E |
| Failure to ensure tuberculin testing was completed for two residents; missing 2-step tuberculin tests. | D |
| Swimming pool was not properly secured with a lock at all times. | F |
| At least one staff member was not awake and on duty at all times during the night shift. | F |
| Outdoor yard area was not properly secured and maintained for safety. | F |
Report Facts
Facility licensed beds: 6
Current census: 6
Severity 2 deficiencies: 3
Severity 3 deficiencies: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rosalie K. Bacal | Administrator | Named in relation to medication error findings and overall facility administration |
Inspection Report
Annual Inspection
Census: 4
Deficiencies: 12
Jan 10, 2019
Visit Reason
This inspection was a State Licensure annual survey conducted to assess compliance with regulations for the residential facility.
Findings
The facility received an annual survey grade of D with multiple deficiencies identified including failure to maintain staffing schedules, inadequate health and sanitation, lack of monthly fire drills, admission of a bedfast resident without proper endorsement, medication administration errors, unlabeled medications, incomplete resident files, unsecured swimming pool and exterior gates, and failure to ensure awake overnight staff.
Severity Breakdown
Level 1: 1
Level 2: 10
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to maintain a monthly staffing schedule and retain schedules for the previous six months. | Level 1 |
| Facility failed to ensure the backyard was free of garbage and debris. | Level 2 |
| Failed to conduct monthly fire drills and smoke detector checks. | — |
| Admitted and retained a bedfast resident without endorsement to provide accommodations and care. | Level 2 |
| Failed to obtain an exemption for a bedfast resident. | Level 2 |
| Failed to ensure a medication review was conducted for one resident. | Level 2 |
| Medication Administration Record (MAR) was inaccurate for two residents. | Level 2 |
| Failed to ensure over the counter medications and supplements were plainly labeled for two residents. | Level 2 |
| Failed to ensure two residents met tuberculosis testing requirements. | Level 2 |
| Failed to ensure a swimming pool was locked and inaccessible to residents. | Level 2 |
| Failed to ensure a caregiver was awake overnight. | Level 2 |
| Failed to ensure an exterior gate was properly locked. | Level 2 |
Report Facts
Census: 4
Survey Grade: D
Deficiency Severity Level 1: 1
Deficiency Severity Level 2: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rosalie K. Bacal | Administrator | Named in relation to multiple findings including staffing schedule, fire drills, medication administration, and staffing issues. |
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 14, 2018
Visit Reason
This document is a Statement of Deficiencies generated as a result of a required grading re-survey conducted on 02/14/18 by the Division of Public and Behavioral Health.
Findings
No deficiencies were identified during this re-survey, and the facility received a re-survey grade of A.
Loading inspection reports...
