Inspection Reports for Olive Grove Residential Care Facility
9446 Back Bay Cir, Las Vegas, NV 89123, NV, 89123
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 3
Capacity: 4
Deficiencies: 1
Apr 7, 2025
Visit Reason
The 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 regulatory deficiencies related to the care and placement of a resident with dementia who required Alzheimer's disease endorsement, which the facility lacked. The facility received a grade of A overall.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident with dementia was appropriately placed according to the Physician Placement Determination; the facility lacked Alzheimer's Disease endorsement and was not equipped to provide required care. | Severity: 2 |
Report Facts
Licensed beds: 4
Resident census: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marina Vaughn | Administrator | Signed the report and responsible for corrective actions |
Inspection Report
Renewal
Census: 3
Capacity: 4
Deficiencies: 9
Sep 6, 2024
Visit Reason
This inspection was a mandatory State Licensure regrading survey conducted as part of the facility's license renewal process in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but had several regulatory deficiencies including expired food items, missing physician orders for two residents, incomplete personnel files, and medication storage issues. Corrective actions were planned and assigned to the Administrator.
Severity Breakdown
D: 4
E: 3
F: 2
C: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Qualifications of Caregiver - Med Training requirements not fully met. | D |
| Personnel files incomplete including background checks and first aid/CPR certification. | D |
| Health and sanitation issues including odors, hazards, insects, dirt. | F |
| Service of Food - Expired food items found in pantry and refrigerator. | F |
| Posting requirements for license, rates, and contact information not fully met. | C |
| Medication Administration - Missing physician orders for 2 of 3 residents. | E |
| Medication Storage - Medications must be stored in locked, cool, dry areas. | D |
| Maintenance and contents of separate resident files incomplete or not fully compliant. | E |
| Infection Control Required Training not fully documented or completed as required. | D |
Report Facts
Licensed beds: 4
Current census: 3
Expired food items: 4
Residents with missing physician orders: 2
Training hours required: 16
Annual medication training hours: 8
Infection control training hours: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Alan Domondon | Manager | Signed as Laboratory Director's or Provider/Supplier Representative on report |
Inspection Report
Complaint Investigation
Census: 3
Deficiencies: 0
May 31, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 05/31/2024.
Findings
The complaint was unsubstantiated with no regulatory deficiencies identified. The investigation included observations, interviews, and record reviews, and the facility received an A grade.
Complaint Details
Complaint #NV00071315 was investigated and found to be unsubstantiated with no regulatory deficiencies identified.
Report Facts
Sample size: 4
Inspection Report
Annual Inspection
Census: 2
Capacity: 4
Deficiencies: 14
Apr 3, 2024
Visit Reason
This inspection was conducted as an annual State Licensure survey of the Olive Grove Residential Care Facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of D with multiple deficiencies identified including failure to ensure annual medication management training for employees, incomplete personnel files, lack of background checks, expired food items, inadequate signage, medication administration issues, improper medication storage, missing tuberculosis testing documentation, missing activities of daily living assessments, failure to post current grade placard, and incomplete infection control training.
Severity Breakdown
Level 1: 2
Level 2: 11
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 1 employees administering medications received annual medication management training. | Level 2 |
| Failed to ensure 1 of 2 employees had a complete personnel file. | Level 2 |
| Failed to ensure background checks were completed through Nevada Automated Background Check System for 2 of 2 employees. | Level 2 |
| Failed to ensure 1 of 1 employees met CPR and first aid training requirements; CPR training lacked in-person component. | Level 2 |
| Failed to keep premises free from insects; ants observed on kitchen counter. | Level 2 |
| Failed to ensure food was not expired and suitable for residents; multiple expired food items found. | Level 2 |
| Failed to post required signage including current license, administrator's license, and designated representative information. | Level 1 |
| Failed to ensure current Ultimate User Agreement for medication administration was obtained for 1 of 2 residents. | Level 2 |
| Failed to ensure physician orders were available and medications were properly labeled for 1 of 2 residents; discrepancies in medication orders and labeling noted. | Level 2 |
| Failed to ensure medications were stored in a locked area; resident's medications found unsecured in resident's room without physician assessment for self-administration. | Level 2 |
| Failed to ensure residents met tuberculosis testing requirements; missing annual and admission TB tests for 2 residents. | Level 2 |
| Failed to ensure residents had activities of daily living (ADL) assessments; missing initial and annual ADL assessments for 2 residents. | Level 2 |
| Failed to display the most current grade placard; outdated placard with incorrect grade posted. | Level 1 |
| Failed to ensure primary infection control staff completed required 15 hours of infection control training. | Level 2 |
Report Facts
Facility licensed beds: 4
Current census: 2
Deficiency severity Level 2: 11
Deficiency severity Level 1: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Alyn Domondon | Owner/Director | Named as Laboratory Director's or Provider/Supplier Representative signing the report |
| Employee #1 | Caregiver | Named in medication management training, background check, CPR training, and medication administration deficiencies |
| Employee #2 | Administrator | Named in personnel file and background check deficiencies |
Inspection Report
Annual Inspection
Census: 2
Capacity: 4
Deficiencies: 5
Mar 16, 2023
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation at Olive Grove Residential Care Facility in accordance with Nevada Administrative Code Chapter 449.
Findings
The facility received a grade of B with one complaint investigated and found unsubstantiated. Several regulatory deficiencies were identified including failure to ensure caregiver medication training, incomplete background checks, expired food items, unsecured medications, and lack of cultural competency training for staff.
Complaint Details
One complaint (#NV00067802) was investigated and found unsubstantiated with no regulatory deficiencies identified.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 3 employees received initial medication management training as required by NAC 449.196. | Severity: 2 |
| Failed to ensure background checks were current and completed under the facility's Nevada Automated Background Check System for 3 of 3 employees; repeat deficiency. | Severity: 2 |
| Failed to ensure food was not expired; two loaves of bread expired on 03/04/23 and 03/15/23 were found. | Severity: 2 |
| Failed to ensure medications were secured; unsecured cough medicine in refrigerator and unsecured medication bin under bathroom sink. | Severity: 2 |
| Failed to post a non-discrimination sign and ensure staff were trained in cultural competency for 2 of 3 employees. | Severity: 2 |
Report Facts
Licensed beds: 4
Current census: 2
Employees reviewed: 3
Resident files reviewed: 2
Discharged resident files reviewed: 1
Expired bread items: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Alyn Domondon | Director/Owner | Signed the report and responsible for facility oversight |
| Employee #3 | Failed to have required 16-hour medication management training at time of inspection | |
| Employee #1 | Background check not completed under correct facility account and lacked cultural competency training prior to survey | |
| Employee #2 | Administrator | Background check expired and lacked cultural competency training prior to survey; no longer active employee as of April 1, 2023 |
Inspection Report
Re-Inspection
Census: 3
Capacity: 4
Deficiencies: 5
Jul 5, 2022
Visit Reason
This Statement of Deficiencies was generated as a result of a Grading resurvey conducted at the facility on 07/05/22 in accordance with Nevada Administrative Code, Chapter 449, Residential Facilities for Groups.
Findings
The facility received a grade of B with multiple deficiencies identified including failure to ensure safe infection control practices during the COVID-19 pandemic, incomplete personnel background checks, inadequate elder abuse training, poor health and sanitation maintenance, lack of scheduled activities for residents, and medication administration review deficiencies.
Severity Breakdown
Level 2: 4
Level 3: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure safe infection control practices and maintain a safe environment in response to COVID-19, including lack of N95 masks, no infection control plan, and no fit testing or medical clearance for N95 mask use. | Level 2 |
| Failure to provide fingerprinting results for one employee (Employee #2) as required for background checks. | Level 2 |
| Failure to ensure the interior of the facility was maintained, including a non-flushing toilet and multiple holes in drywall in a hallway bathroom. | Level 2 |
| Failure to ensure activities were available as scheduled; no supplies for word play and Bingo, and activities only provided on Mondays and Wednesdays despite schedule. | Level 2 |
| Failure to ensure medication review for residents was conducted every six months as required. | Level 3 |
Report Facts
Facility licensed beds: 4
Census: 3
Deficiency severity counts: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Caregiver | Named in deficiencies related to infection control, background checks, elder abuse training, and activities |
| Mary Alyn Domondon | Operation Manager/Owner | Signed the report and plan of correction |
Inspection Report
Annual Inspection
Census: 3
Capacity: 4
Deficiencies: 6
Apr 11, 2022
Visit Reason
The inspection was an annual State Licensure and infection control survey conducted to assess compliance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility was found deficient in multiple areas including infection control practices related to COVID-19, employee training on elder abuse, personnel background checks, facility maintenance, lack of group activities for residents, and medication administration reviews. Corrective actions were planned and implemented for each deficiency.
Severity Breakdown
Level 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure safe infection control practices during the COVID-19 pandemic, including lack of mask wearing and absence of N-95 masks and COVID-19 policy. | Level 2 |
| Failure to ensure employee completed elder abuse training prior to providing care. | Level 2 |
| Failure to ensure employee fingerprinting and background check clearance within 10 days of hire. | Level 2 |
| Failure to maintain the interior and exterior of the facility, including holes in drywall, dead bird on premises, and loose kitchen chair legs. | Level 2 |
| Failure to provide group activities suited to residents' interests and capacities; missing activities calendar. | Level 2 |
| Failure to ensure medication reviews were completed every six months for residents. | Level 2 |
Report Facts
Licensed beds: 4
Residents present: 3
Deficiency severity counts: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Olivia Parnell | Administrator | Named as responsible for oversight and corrective actions |
| Employee #2 | Named in findings related to infection control, elder abuse training, background checks, and group activities |
Inspection Report
Annual Inspection
Census: 3
Capacity: 8
Deficiencies: 3
Jun 15, 2021
Visit Reason
The inspection was conducted as a State Licensure annual survey and focused COVID-19 Infection Control Survey to assess compliance with regulations for a Residential Facility for Groups.
Findings
The facility received an annual survey grade of A. Deficiencies were identified related to failure to ensure annual Elder Abuse training for one employee, failure to ensure initial/annual CPR training for two employees, and failure to ensure initial/annual activities of daily living assessments for three residents.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 3 employees had annual Elder Abuse training. | Severity: 2 |
| Failure to ensure 2 of 3 employees had initial/annual CPR training. | Severity: 2 |
| Failure to ensure 3 of 3 residents had initial/annual activities of daily living assessments. | Severity: 2 |
Report Facts
Licensed beds: 8
Residents present: 3
Employees reviewed: 3
Residents reviewed: 3
Inspection Report
Annual Inspection
Census: 2
Capacity: 8
Deficiencies: 1
Aug 11, 2020
Visit Reason
The inspection was conducted as a State Licensure annual survey combined with a focused COVID-19 Infection Control Survey to assess regulatory compliance with Chapter 449, Residential Facility for Groups.
Findings
The facility was found to have no residents or staff positive for COVID-19 and received an annual survey grade of A. However, a deficiency was identified related to the admission and retention of a bedfast resident without a proper exemption, which is against licensing policy.
Severity Breakdown
Severity: 2 Scope: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to ensure that a bedfast resident was not admitted or allowed to remain without a bedfast exemption as required by NAC 449.2702 and NRS 449.0302. | Severity: 2 Scope: 2 |
Report Facts
Licensed beds: 8
Residents present: 2
Inventory counts: 6
Inventory counts: 100
Inventory counts: 12
Inventory counts: 400
Inventory counts: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Olivia Parnell | Administrator | Named as responsible person for corrective action and monitoring |
Inspection Report
Annual Inspection
Census: 1
Capacity: 8
Deficiencies: 5
Jun 11, 2019
Visit Reason
This inspection was conducted as a State Licensure annual survey of the Olive Grove Residential Care Facility to assess compliance with regulations for residential facilities for groups.
Findings
The facility was found deficient in several areas including caregiver medication management training, CPR certification, pharmacy medication review, medication administration record accuracy, and annual activities of daily living assessments. The facility received an annual survey grade of B.
Severity Breakdown
Level 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 16 hours of initial medication administration training was completed for 1 of 2 caregivers. | Level 2 |
| Failed to ensure cardiopulmonary resuscitation (CPR) training was up to date for 1 of 2 caregivers. | Level 2 |
| Failed to ensure a pharmacy review was completed every six months for 1 of 1 resident. | Level 2 |
| Failed to ensure medications on the Medication Administration Record were signed off for three days and a new medication was inventoried for 1 of 1 resident. | Level 2 |
| Failed to ensure an activities of daily living assessment was completed yearly for 1 resident. | Level 2 |
Report Facts
Licensed beds: 8
Current census: 1
Deficiency severity: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Olivia Parnell | Administrator | Named as responsible for corrective actions and monitoring compliance |
| Caregiver #1 | Failed to complete required medication management training and did not sign medication administration records | |
| Caregiver #2 | CPR certification expired and failed to submit updated certification copy |
Inspection Report
Renewal
Census: 2
Capacity: 4
Deficiencies: 3
Jul 27, 2016
Visit Reason
The inspection was conducted as an annual State Licensure survey for re-licensure of the Olive Grove Residential Care Facility.
Findings
The facility received a grade of A. Deficiencies were found related to employee training and documentation, including failure to ensure tuberculosis health certificates, annual caregiver training, and chronic illness training were properly documented for some employees.
Severity Breakdown
2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 employees met tuberculosis (TB) training requirements; lacked documented evidence of a pre-employment physical examination for Employee #2. | 2 |
| Failed to ensure 1 of 4 caregivers received eight hours of annual training; Employee #4 lacked documented evidence of 2016 annual caregiver training. | 2 |
| Failed to ensure 2 of 4 caregivers received required training in providing care to residents with chronic illnesses; Employees #3 and #4 lacked documented evidence of chronic illness training. | 2 |
Report Facts
Number of employees reviewed: 4
Number of resident files reviewed: 2
Licensed capacity: 4
Current census: 2
Inspection Report
Annual Inspection
Census: 2
Capacity: 4
Deficiencies: 3
Jul 25, 2016
Visit Reason
This inspection was conducted as an annual State Licensure survey of Olive Grove Residential Care Facility to assess compliance with state regulations.
Findings
The facility received a grade of A but was found deficient in personnel file documentation, including missing pre-employment physical examination for one employee and lack of required caregiver training and chronic illness training documentation for multiple employees.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 employees met tuberculosis (TB) training requirements; missing pre-employment physical examination for Employee #2. | Severity: 2 |
| Failed to ensure 1 of 4 caregivers received eight hours of annual training in 2016 (Employee #4). | Severity: 2 |
| Failed to ensure 2 of 4 caregivers received required training in providing care to residents with chronic illnesses (Employees #3 and #4). | Severity: 2 |
Report Facts
Number of residents present: 2
Total licensed capacity: 4
Number of employee files reviewed: 4
Number of resident files reviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Caregiver | Missing pre-employment physical examination and TB training documentation |
| Employee #3 | Caregiver | Missing documented evidence of chronic illness training |
| Employee #4 | Caregiver | Missing eight hours of annual training and chronic illness training documentation; acknowledged missing documentation |
Inspection Report
Original Licensing
Capacity: 4
Deficiencies: 0
Sep 5, 2013
Visit Reason
This document is the result of an initial State licensure survey conducted to license the facility for four Residential Facility for Group beds for elderly and disabled persons, Category 2 residents.
Findings
No deficiencies were found at the time of inspection. Two employee files were reviewed. No further action is required.
Report Facts
Total licensed capacity: 4
Employee files reviewed: 2
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