Inspection Reports for Peace of Mind

4354 E Harmon Ave, Las Vegas, NV 89121, NV, 89121

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Deficiencies per Year

20 15 10 5 0
2019
2022
2023
2024
High Moderate

Census Over Time

0 4 8 12 16 Oct '19 Oct '22 Apr '23 Aug '23 May '24 Sep '24
Census Capacity
Inspection Report Complaint Investigation Census: 10 Deficiencies: 0 Sep 17, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 09/17/24, in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
Three complaints were investigated; two were unsubstantiated with no regulatory deficiencies identified, and one was substantiated without deficiencies. Overall, no regulatory deficiencies were found and no further action was necessary.
Complaint Details
Three complaints were investigated: Complaint #NV00071957 and #NV00072142 were unsubstantiated with no deficiencies; Complaint #NV00072146 was substantiated without deficiencies.
Report Facts
Sample size: 5 Employee files reviewed: 7 Complaints investigated: 3
Inspection Report Complaint Investigation Census: 8 Capacity: 10 Deficiencies: 2 Jul 9, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation and Facility Reported Incident State Licensure survey at the facility on 07/09/24, investigating one complaint and two Facility Reported Incidences.
Findings
The facility was found to have substantiated one complaint involving failure to provide oversight for an Alzheimer's resident transported alone via Uber and failure to provide written and verbal discharge notification to the resident's next of kin. No regulatory deficiencies were found related to one substantiated FRI without deficient practice and one unsubstantiated FRI.
Complaint Details
One complaint (#NV00071375) was substantiated involving failure to provide oversight and failure to notify next of kin prior to discharge. Two Facility Reported Incidences were investigated: one substantiated without deficient practice and one unsubstantiated.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
DescriptionSeverity
Failure to ensure oversight of an Alzheimer's resident who was transported alone in an Uber to the receiving facility without staff accompaniment.Severity: 2
Failure to ensure written and verbal notification was given to the next of kin prior to discharge of a resident.Severity: 2
Report Facts
Licensed beds: 10 Census: 8 Sample size: 5
Employees Mentioned
NameTitleContext
Trina M AndersonAdministratorNamed as the Administrator and signatory on the report
Inspection Report Annual Inspection Census: 8 Capacity: 10 Deficiencies: 5 May 15, 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 was found deficient in multiple areas including failure to ensure timely tuberculosis testing for residents and employees, lack of audible alarm on an exit door, failure to develop person-centered service plans for all residents, and failure to complete required six-month medication reviews for most residents. The facility received a grade of B.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
DescriptionSeverity
Failed to ensure 3 of 8 residents received required two-step or annual tuberculosis tests.Severity: 2
Failed to ensure a door leading to the outside was equipped with an audible alarm; alarm was turned off.Severity: 2
Failed to ensure an annual tuberculosis test was completed for 1 of 7 employees.Severity: 2
Failed to develop person-centered service plans for all 8 residents.Severity: 2
Failed to ensure medication reviews were completed every six months for 7 of 8 residents.Severity: 2
Report Facts
Residents reviewed: 8 Employee files reviewed: 7 Facility grade: B
Inspection Report Annual Inspection Census: 8 Capacity: 10 Deficiencies: 5 Apr 15, 2024
Visit Reason
The inspection was conducted as a result of an annual survey, complaint investigation, and Facility Reported Incident State Licensure survey at the facility on 04/15/24.
Findings
The facility was found to have multiple deficiencies including failure to maintain cleanliness and sanitation, inaccurate medication administration records for residents, unsecured toxic substances accessible to residents, failure to provide cultural competency training within required timeframes for employees, and lack of initial placement assessments for all residents. Several deficiencies were repeat findings from previous surveys.
Complaint Details
One complaint (#NV00070725) was investigated and found unsubstantiated. Three Facility Reported Incidences (FRI #9663, #9681, #9699) were substantiated without deficient practice.
Severity Breakdown
Level 2: 5
Deficiencies (5)
DescriptionSeverity
Facility and outside area were not clean and well maintained, including spills in refrigerator, cluttered counters, dust accumulation, and cluttered outside area.Level 2
Medication Administration Record (MAR) included inaccurate documentation for 2 of 8 residents' medications, with caregivers initialing administration without giving medication.Level 2
Toxic substances such as sink and drain cleaner and air freshener were unsecured and accessible to residents.Level 2
One of five employees failed to receive cultural competency training within 30 days of hire.Level 2
Initial placement assessments were not obtained for 8 of 8 residents.Level 2
Report Facts
Licensed beds: 10 Current census: 8 Employee files reviewed: 5 Resident files reviewed: 8 Complaints investigated: 1 Facility Reported Incidences investigated: 3
Inspection Report Routine Census: 7 Capacity: 10 Deficiencies: 10 Aug 7, 2023
Visit Reason
The inspection was a Mandatory Grading resurvey conducted to assess compliance with Nevada Administrative Code, Chapter 449, for Residential Facilities for Groups.
Findings
The facility received a grade of B with multiple deficiencies identified including issues with medication administration documentation, incomplete tuberculosis testing, lack of door alarms, unsecured toxic substances, and incomplete employee training related to dementia care and cultural competency.
Severity Breakdown
Level F: 6 Level E: 2 Level D: 3
Deficiencies (10)
DescriptionSeverity
Failed to ensure Medication Administration Record (MAR) was accurate for 3 of 7 residents.Level F
Failed to ensure 1 of 7 residents received a two-step tuberculosis (TB) test.Level F
Failed to ensure a door leading out from the facility was alarmed.Level F
Failed to ensure toxic substances were locked away from residents.Level F
Failed to ensure employees providing care to persons with dementia completed required training.Level D
Failed to ensure cultural competency training was conducted for employees providing care.Level F
Personnel files lacked required health certificates and certifications (e.g., TB screening, First Aid & CPR).Level E
Facility premises were not well maintained; interior, exterior, and landscaping issues noted.Level F
Failed to maintain proper medical care records of residents after illness or injury.Level D
Medication storage issues including unlocked medications and improper labeling.Level F
Report Facts
Licensed beds: 10 Resident census: 7 Deficiencies cited: 11 Severity Level F deficiencies: 6 Severity Level E deficiencies: 2 Severity Level D deficiencies: 3
Employees Mentioned
NameTitleContext
Trina M AndersonAdministratorNamed in relation to acknowledgment of medication administration deficiencies and facility operations
Inspection Report Annual Inspection Census: 8 Capacity: 10 Deficiencies: 17 May 18, 2023
Visit Reason
This inspection was conducted as a result of an annual and complaint State Licensure and infection control survey at the facility on 05/18/23, including investigation of one verified complaint.
Findings
The facility was found deficient in multiple areas including employee training, personnel file documentation, medication administration and storage, facility maintenance, resident care documentation, and safety standards for Alzheimer's care. Several employees lacked required training and certifications, resident files were incomplete, medications were improperly stored or documented, and safety alarms and hazardous items were not properly secured.
Complaint Details
One complaint (#NV00068393) was investigated and verified. The investigation included observation of resident's skin condition and medication security, interviews with residents and caregivers, and record review. Deficiencies related to medication incident reporting and medication storage were cited.
Severity Breakdown
Level 2: 16
Deficiencies (17)
DescriptionSeverity
Failed to ensure 1 of 6 employees had initial elder abuse training.Level 2
Failed to ensure 3 of 6 employees had required pre-employment physicals, TB tests, or annual signs and symptoms.Level 2
Failed to ensure 2 of 6 employees were trained in CPR and first aid.Level 2
Facility was not well maintained; kitchen cabinets had peeling paint and food debris, vent had heavy dust buildup.Level 2
Failed to ensure incident report contained necessary information after injury for 1 of 9 residents.Level 2
Failed to ensure 1 of 9 residents signed an ultimate user agreement for medications.Level 2
Failed to ensure physician orders were obtained, medication was on site, and MAR matched prescription labels for 7 of 9 residents.Level 2
Failed to ensure medications were secured; padlock on laundry room door was not latched and contained resident medications.Level 2
Failed to ensure medications were kept in original containers; medications pre-poured in cup.Level 2
Failed to ensure 5 of 9 residents had two-step tuberculosis tests documented.Level 2
Failed to ensure 5 of 9 residents had activities of daily living assessments.Level 2
Back door alarm was not operating.Level 2
Failed to ensure sharp objects were secured; broken cabinet lock and unsecured scissors found.Level 2
Failed to ensure medications were secured; padlock on laundry room door repeatedly not latched.Level 2
Failed to ensure 1 of 6 employees had two hours of initial Alzheimer's training within first 40 hours of employment.Level 2
Failed to ensure 1 of 6 employees had three hours of annual Alzheimer's training by date of hire.Level 2
Failed to post nondiscrimination sign and ensure cultural competency training for 5 of 6 employees.Level 2
Report Facts
Licensed beds: 10 Current census: 8 Employees reviewed: 6 Residents reviewed: 9 Deficiencies cited: 16
Employees Mentioned
NameTitleContext
Employee #6Failed initial elder abuse training, CPR and first aid training, and Alzheimer's training
Employee #1Missing pre-employment physical and annual signs and symptoms
Employee #4Expired CPR and first aid, missing annual signs and symptoms, no longer employed as of 06/07/23
Employee #3Missing three hours of annual Alzheimer's training
Inspection Report Complaint Investigation Census: 10 Deficiencies: 0 Apr 18, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 04/18/23 in accordance with Nevada Administrative Code Chapter 449.
Findings
The complaint was unsubstantiated after review of six resident files, observations, and interviews with staff and residents. No regulatory deficiencies were identified.
Complaint Details
Complaint #NV00068059 was investigated and found to be unsubstantiated.
Report Facts
Sample size: 6
Employees Mentioned
NameTitleContext
CaregiverInterviewed during complaint investigation
OwnerInterviewed during complaint investigation
Registered NurseInterviewed during complaint investigation
Inspection Report Complaint Investigation Census: 8 Deficiencies: 4 Feb 7, 2023
Visit Reason
The inspection was conducted as a complaint investigation triggered by two substantiated complaints regarding health and sanitation and medication administration at the facility.
Findings
The facility was found to have multiple deficiencies including failure to maintain cleanliness with pet feces present, failure to complete incident reports for a resident's fall and hospital transfer, failure to ensure medications were on site for ten days for a resident, and failure to notify a physician after a resident missed medications.
Complaint Details
Two complaints were investigated; Complaint #NV00067904 and Complaint #NV00067557 were both substantiated. The investigation included observations, interviews, and record reviews related to cleanliness, resident care, and medication administration.
Severity Breakdown
Level 2: 4
Deficiencies (4)
DescriptionSeverity
Facility failed to ensure the premises were clean and well maintained; dried dog feces found on bedroom floor.Level 2
Facility failed to complete incident reports for a resident's fall and hospital transfer.Level 2
Facility failed to ensure medications were on site for ten days for one resident.Level 2
Facility failed to notify a physician after a resident missed medications for ten days.Level 2
Report Facts
Complaints investigated: 2 Sample size: 5
Employees Mentioned
NameTitleContext
Maegan PadillaOwnerNamed as Owner involved in interviews and findings related to incident reporting and medication administration.
Inspection Report Complaint Investigation Census: 8 Deficiencies: 0 Oct 12, 2022
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 10/12/22, triggered by complaint #NV00066938 with six allegations.
Findings
The complaint investigation found all six allegations to be unsubstantiated after observations, interviews, and record reviews. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00066938 with six allegations was investigated and found unsubstantiated. Allegations included misuse of resident narcotics, falsification of medication records, failure to change soiled incontinent pads, overmedication at night, physical abuse, and lack of current CPR certification among staff.
Report Facts
Complaint allegations: 6 Census: 8
Inspection Report Annual Inspection Census: 8 Capacity: 10 Deficiencies: 0 Jul 13, 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 A with no regulatory deficiencies identified. Eight resident files and six employee files were reviewed, and no further action was necessary.
Inspection Report Original Licensing Census: 7 Capacity: 10 Deficiencies: 0 Oct 11, 2019
Visit Reason
The inspection was conducted as a full State Licensure survey for a change of ownership, with the facility requesting licensure for ten Residential Facility for Group beds with endorsement to provide care for elderly or disabled persons and persons with Alzheimer's disease or related dementia.
Findings
The facility received a grade of A with no regulatory deficiencies identified. Seven resident records and five employee records were reviewed during the survey.
Report Facts
Resident records reviewed: 7 Employee records reviewed: 5

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