Inspection Reports for Pleasant Care Group Home II
3238 Jamestown Ct, Sparks, NV 89431, NV, 89431
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Inspection Report
Re-Inspection
Census: 7
Capacity: 7
Deficiencies: 0
Dec 2, 2024
Visit Reason
This inspection was a grading resurvey State Licensure survey conducted by the Division of Public and Behavioral Health in accordance with NAC 449 for Residential Facility for Groups.
Findings
The facility was found compliant with no deficiencies identified at the time of the survey and received a grade of A. Multiple regulatory requirements were reviewed including staffing schedules, supervision and treatment of residents, medical care, medication administration, patient rights, discrimination policies, preferred name/pronoun policies, annual resident assessments, infection control program, and caregiver training.
Report Facts
Licensed beds: 7
Resident census: 7
Resident files reviewed: 5
Employee files reviewed: 5
Training hours: 15
Training retention period: 3
Inspection Report
Annual Inspection
Census: 7
Capacity: 7
Deficiencies: 12
Aug 26, 2024
Visit Reason
This inspection was an annual State Licensure survey conducted by the Division of Public and Behavioral Health to assess compliance with NAC 449 for Residential Facility for Groups.
Findings
The facility was found deficient in multiple areas including failure to maintain accurate staffing schedules, lack of person-centered service plans for all residents, delayed initial physical examinations, incomplete medication administration reviews, failure to inform residents of their rights upon admission, lack of nondiscrimination statement with complaint contact information, absence of policies and documentation reflecting residents' preferred names and pronouns, delayed placement determinations, and deficiencies in infection control program designation and training.
Severity Breakdown
Level 1: 4
Level 2: 8
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to maintain an accurate staffing schedule including times, staff type, and days worked. | Level 1 |
| Failure to develop person-centered service plans for all 7 residents. | Level 2 |
| Failure to ensure timely initial general physical examination for Resident #5. | Level 2 |
| Failure to ensure six-month pharmacy profile review for Residents #4 and #7. | Level 2 |
| Failure to review and initial medication profile within 72 hours for Resident #3. | Level 2 |
| Failure to inform residents of their rights upon admission for all 7 residents. | Level 1 |
| Failure to post nondiscrimination statement with Division contact information for complaints. | Level 1 |
| Failure to develop policies and update resident records to reflect preferred name, pronoun, gender identity or expression, and sexual orientation for all residents. | Level 1 |
| Failure to obtain timely initial Standard Physician Assessment and Placement Determination for Resident #5. | Level 2 |
| Failure to designate primary and secondary persons responsible for infection control program. | Level 2 |
| Failure to ensure primary and secondary infection control persons completed required infection control training. | Level 2 |
| Failure to ensure 4 of 5 employees completed required infection control training annually. | Level 2 |
Report Facts
Resident files reviewed: 7
Employee files reviewed: 5
Facility licensed beds: 7
Current census: 7
Days late for initial physical exam: 19
Medication profile review frequency: 6
Infection control training hours required: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Freda Castro | Administrator | Named as primary person responsible for infection control and involved in multiple findings. |
| Gerome Andres | Assistant Manager | Named as secondary person responsible for infection control. |
Inspection Report
Annual Inspection
Census: 7
Capacity: 7
Deficiencies: 2
Jul 5, 2023
Visit Reason
This inspection was conducted as an annual State Licensure survey of the Pleasant Care Group Home 2 facility to assess compliance with NAC 449, Residential Facility for Groups regulations.
Findings
The facility was found to have deficiencies including allowing residents receiving skilled nursing care without proper waivers, and failure to post required state contact information for discrimination complaints. The facility received a grade of A overall.
Severity Breakdown
Level 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure residents receiving skilled nursing services were not admitted or allowed to remain without a bedfast waiver for 3 of 7 residents. | Level 2 |
| Facility failed to post prominently the State contact information for filing complaints related to prohibited discrimination. | Level 2 |
Report Facts
Residents reviewed: 7
Employee files reviewed: 3
Beds licensed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Freda T Castro | Administrator | Named as facility administrator responsible for corrective actions |
Inspection Report
Annual Inspection
Census: 7
Capacity: 7
Deficiencies: 0
Aug 12, 2021
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility.
Findings
The facility was licensed for seven beds and had a census of seven residents at the time of the survey. Seven resident files and three employee files were reviewed. The facility received a grade of A with no deficiencies identified and no further action necessary.
Inspection Report
Routine
Census: 6
Capacity: 7
Deficiencies: 0
Sep 28, 2020
Visit Reason
The inspection was conducted as a State Licensure COVID-19 Infection Control and Prevention Plan Survey to assess the facility's compliance with COVID-19 related infection control requirements.
Findings
The facility demonstrated comprehensive infection control measures including visitor screening, use of PPE, cleaning protocols, and isolation plans for suspected or confirmed COVID-19 cases. No regulatory deficiencies were identified during the survey.
Report Facts
Licensed beds: 7
Residents present: 6
Inspection Report
Routine
Census: 6
Capacity: 7
Deficiencies: 0
Aug 31, 2020
Visit Reason
This inspection was conducted as a State Licensure COVID-19 Infection Control and Prevention Plan Survey to evaluate the facility's compliance with infection control requirements.
Findings
No regulatory deficiencies were identified; however, the facility did not have a documented Infection Control and Prevention Plan. The Administrator verbalized that a plan would be documented and ready for follow-up review by 09/10/20, including key components such as visitor screening, emergency staffing, PPE use, and COVID-19 response protocols.
Report Facts
Licensed beds: 7
Census: 6
Inspection Report
Annual Inspection
Census: 6
Capacity: 7
Deficiencies: 0
Jul 9, 2020
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility in accordance with NAC 449, Residential Facility for Groups.
Findings
The facility received a grade of A with no deficiencies identified during the survey. No further action is necessary.
Inspection Report
Annual Inspection
Census: 7
Capacity: 7
Deficiencies: 4
Jul 30, 2018
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility to assess compliance with regulatory requirements.
Findings
The facility received a grade of A. Deficiencies were identified related to personnel files lacking pre-employment physical and tuberculosis testing, failure to post a current activities calendar, and incomplete activities of daily living (ADL) assessments upon admission and annually for residents.
Severity Breakdown
Level 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to obtain a pre-employment physical and Tuberculosis (TB) Test for 1 of 4 employees. | Level 2 |
| Facility failed to post a current activities calendar in a common area notifying residents of major activities. | Level 2 |
| Facility failed to ensure ADL assessments were completed upon admission for 3 of 7 residents. | Level 2 |
| Facility failed to perform an annual ADL evaluation for 1 of 7 residents residing longer than a year. | Level 2 |
Report Facts
Residents present: 7
Total licensed capacity: 7
Employees reviewed: 4
Resident files reviewed: 7
Inspection Report
Annual Inspection
Census: 7
Capacity: 7
Deficiencies: 1
Jul 27, 2017
Visit Reason
This inspection was an annual State Licensure survey conducted to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A; however, a deficiency was identified related to tuberculosis testing documentation for one resident. Specifically, the facility failed to ensure proper documentation of TB signs and symptoms evaluation for Resident #1.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure proper documentation of tuberculosis signs and symptoms evaluation for Resident #1. | 2 |
Report Facts
Resident files reviewed: 7
Employee files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Freda T Castro | Administrator | Signed the report and mentioned as facility administrator responsible for tuberculosis documentation |
Inspection Report
Annual Inspection
Census: 7
Capacity: 7
Deficiencies: 1
Jul 27, 2017
Visit Reason
This annual State Licensure survey was conducted to assess compliance with state regulations for the facility licensed as a Residential Facility for Group beds for elderly and disabled persons.
Findings
The facility received a grade of A. One deficiency was identified related to failure to ensure tuberculosis testing documentation for one resident (Resident #1).
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 7 residents met the requirements concerning tuberculosis (TB) testing due to lack of documentation of a TB signs and symptoms evaluation for Resident #1. | 2 |
Report Facts
Resident files reviewed: 7
Employee files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 confirmed the tuberculosis testing deficiency |
Inspection Report
Complaint Investigation
Census: 7
Deficiencies: 0
Oct 17, 2016
Visit Reason
The inspection was conducted as a complaint investigation following allegation #NV00047101 regarding resident verbal abuse.
Findings
The investigation included observations, interviews, and policy reviews, and found no regulatory deficiencies. The complaint could not be substantiated and no further action was necessary.
Complaint Details
Complaint #NV00047101 alleging resident verbal abuse was investigated and found to be unsubstantiated.
Report Facts
Sample size: 7
Complaint count: 1
Inspection Report
Complaint Investigation
Census: 7
Deficiencies: 0
Sep 23, 2016
Visit Reason
The inspection was conducted as a complaint investigation initiated on 2016-09-09 and completed on 2016-09-23 regarding an allegation that resident medications were not given according to physician instruction.
Findings
The complaint was investigated through observations, interviews, and record reviews, and the allegation was not substantiated. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00046674 alleged that resident medications were not given according to physician instruction; this allegation was not substantiated.
Report Facts
Sample size: 5
Complaint count: 1
Inspection Report
Annual Inspection
Census: 7
Capacity: 7
Deficiencies: 4
Jun 27, 2016
Visit Reason
This inspection was conducted as an annual State Licensure survey of a residential facility for elderly and disabled persons and/or persons with mental illnesses or chronic illnesses.
Findings
The facility received a grade of A but was found deficient in several areas including failure to maintain safe hot water temperatures, incomplete annual physical examinations for residents, and improper administration and documentation of medications.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure hot water in bathrooms was at safe temperature. | Severity: 2 |
| Facility failed to ensure 1 of 7 residents completed required annual physical examination. | Severity: 2 |
| Facility failed to ensure 'as needed' medications were administered properly for 1 of 7 residents. | Severity: 2 |
| Facility failed to maintain accurate medication administration records and proper documentation. | Severity: 2 |
Report Facts
Residents present: 7
Total licensed capacity: 7
Hot water temperature: 128
Hot water temperature: 137
Deficiency severity count: 4
Medication quantity: 120
Medication quantity: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda L. Cushta | Administrator | Named in multiple findings related to hot water temperature, physical exams, and medication administration |
Inspection Report
Annual Inspection
Census: 7
Capacity: 7
Deficiencies: 4
Jun 27, 2016
Visit Reason
This inspection was an annual State Licensure survey conducted on 6/27/2016 to assess compliance with state regulations for a Residential Facility for Group beds for elderly and disabled persons.
Findings
The facility received a grade of A but was cited for several deficiencies including unsafe hot water temperatures in bathrooms, failure to ensure one resident completed the required annual physical examination, and multiple medication administration issues involving improper administration and incomplete medication records for one resident.
Severity Breakdown
Level 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Hot water in the sink of Bathrooms #1, #2 and #3 registered 128 to 137 degrees Fahrenheit, exceeding safe temperature limits. | Level 2 |
| One of seven residents failed to complete the required annual physical examination. | Level 2 |
| Failed to ensure 'as needed' medications were administered following doctor's orders for one resident; medications were administered routinely instead of PRN. | Level 2 |
| Medication Administration Record (MAR) was incomplete and inaccurate for one resident, with repeated identical times, reasons, and results recorded instead of actual administration details. | Level 2 |
Report Facts
Deficiencies cited: 4
Resident census: 7
Total licensed capacity: 7
Inspection Report
Re-Inspection
Census: 6
Capacity: 7
Deficiencies: 1
Aug 5, 2015
Visit Reason
This inspection was a required grading re-survey conducted by the State Licensure survey authority to evaluate compliance with medication administration regulations.
Findings
The facility failed to ensure the Medication Administration Record (MAR) was accurate and consistent with medication labels and physician orders for 1 of 7 residents. Specific inaccuracies were found between medication bottle labels and the MAR for Resident #6.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain accurate and consistent Medication Administration Records (MAR) with medication labels and physician orders for Resident #6. | Severity: 2 |
Report Facts
Residents present: 6
Total licensed beds: 7
Severity level: 2
Scope: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Acknowledged findings on 8/5/15 |
Inspection Report
Annual Inspection
Census: 6
Capacity: 7
Deficiencies: 8
Jun 3, 2015
Visit Reason
This document is an annual State Licensure survey conducted to assess compliance with regulatory requirements for a residential facility for elderly and disabled persons.
Findings
The facility was found deficient in several areas including personnel files lacking pre-employment physical examinations and background checks, inadequate lighting in bedrooms, medication administration errors, and failure to post required rates. The facility received a grade of C.
Severity Breakdown
Severity: 2: 7
Severity: 1: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Personnel files lacked documented evidence of pre-employment physical examinations for some employees. | Severity: 2 |
| Personnel files lacked evidence of required background checks for some employees. | Severity: 2 |
| The facility failed to keep the exterior free from garbage and refuse. | Severity: 2 |
| The facility failed to maintain adequate electrical lighting in bedrooms. | Severity: 2 |
| The administrator failed to ensure all medication was administered correctly for one resident. | Severity: 2 |
| Medication administration records were inaccurate or incomplete for several residents. | Severity: 2 |
| The facility failed to ensure employees received required mental illness training within 60 days of hire. | Severity: 2 |
| The facility failed to post required rates as per Nevada Revised Statute. | Severity: 1 |
Report Facts
Census: 6
Total Capacity: 7
Employees reviewed: 3
Resident MARs inspected: 6
Inspection Report
Annual Inspection
Census: 7
Capacity: 7
Deficiencies: 6
Apr 3, 2014
Visit Reason
The inspection was an annual State Licensure grading survey conducted on 4/3/14 to assess compliance with state regulations for a residential facility licensed for elderly and disabled persons.
Findings
The facility received a grade of B with several deficiencies identified including failure to ensure caregivers received required annual training, failure to maintain clean and sanitary conditions, and failure to ensure proper endorsement and training for employees caring for residents with mental illness and chronic illness.
Severity Breakdown
Severity: 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| One of three caregivers failed to receive eight hours of annual training related to caregiving needs. | Severity: 2 |
| One of three employees failed to receive annual training in elder abuse recognition and prevention. | Severity: 2 |
| Facility premises were not clean and well maintained; grease build-up behind stove and heavy urine odor in a resident's bedroom. | Severity: 2 |
| Sprinkler system was impaired and not in working order as of 12/3/13. | Severity: 2 |
| One of three employees failed to receive eight hours of training concerning care for residents with mental illnesses. | Severity: 2 |
| Facility admitted a resident with a chronic illness without proper endorsement and failed to ensure one of three employees received required training for chronic illness care. | Severity: 2 |
Report Facts
Number of residents present: 7
Total licensed capacity: 7
Deficiency severity count: 6
Inspection Report
Annual Inspection
Census: 7
Capacity: 7
Deficiencies: 6
Apr 3, 2014
Visit Reason
This inspection was conducted as an annual State Licensure grading survey in accordance with NRS 449.0307, Powers of the Health Division.
Findings
The facility received a grade of B with multiple deficiencies identified including failure to ensure caregivers received required annual training, failure to maintain the facility clean and well maintained, sprinkler system impairments, and admission of a resident without required chronic illness endorsement.
Severity Breakdown
Severity: 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure that 1 of 3 caregivers received eight hours of annual training (Employee #1). | Severity: 2 |
| Failed to ensure 1 of 3 employees received annual training in recognition, prevention and response to elder abuse (Employee #3). | Severity: 2 |
| Facility was not clean and well maintained; grease build-up behind stove and cabinets, heavy urine odor and sticky floor in Resident #6's bedroom. | Severity: 2 |
| Sprinkler system was tagged with impairments on 12/3/13 and was not in working order. | Severity: 2 |
| Failed to ensure 1 of 3 employees received 8 hours of mental illness training (Employee #2). | Severity: 2 |
| Admitted a resident with a chronic illness without a chronic illness endorsement (Resident #2). | Severity: 2 |
Report Facts
Census: 7
Total Capacity: 7
Deficiencies cited: 6
Inspection Report
Annual Inspection
Census: 6
Capacity: 7
Deficiencies: 0
Apr 25, 2013
Visit Reason
This State Licensure survey was conducted as an annual survey of the facility on 04/25/2013 by the Health Division under the authority of NRS 449.150.
Findings
No deficiencies were identified during the inspection. The facility received a grade of A. Six resident files and three employee files were reviewed.
Report Facts
Resident files reviewed: 6
Employee files reviewed: 3
Report
File
08-24-2022_51641_TBKY11_SOD.pdf
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