Inspection Reports for Pleasant Care Group Home III
795 Sienna Station Way, Reno, NV 89512, NV, 89512
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Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 1
Aug 22, 2024
Visit Reason
The inspection was conducted as an Annual State Licensure survey of the facility on 08/22/2024 by the Division of Public and Behavioral Health in accordance with NAC 449 for Residential Facility for Groups.
Findings
The facility was found to lack an infection control program and policy at the time of the survey, which had the potential to affect the entire residential census. The Administrator was initially unaware of the requirement but subsequently developed a program and policy based on CDC guidelines and other professional resources.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility lacked an infection control policy to carry out the infection control program as required by regulation. | Severity: 2 |
Report Facts
Licensed beds: 6
Current census: 4
Employee files reviewed: 3
Resident files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Freda Castro | Administrator | Named as Administrator who confirmed lack of infection control program and later developed the policy |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 5
Sep 28, 2023
Visit Reason
This inspection was an Annual State Licensure survey conducted to assess compliance with regulations for a Residential Facility for Groups.
Findings
The facility was found deficient in several areas including personnel files lacking current pre-employment physicals, failure to maintain clean and clutter-free premises, missing timely annual physical examinations for residents, untimely medication profile reviews, and failure to obtain required mental illness endorsement for admitting residents with mental illness diagnoses.
Severity Breakdown
Level 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Personnel file failed to have a current pre-employment physical for 1 of 2 employees. | Level 2 |
| Facility failed to maintain clean side yards free of weeds and stored items; dryer lint trap had accumulation of lint. | Level 2 |
| Resident #1 did not have a timely annual general physical examination for 2023. | Level 2 |
| Medication profile reviews were not performed timely at least every six months for Resident #1 and Resident #4. | Level 2 |
| Facility lacked mental illness endorsement to admit and retain residents with mental illness diagnoses (Resident #1 and Resident #6). | Level 2 |
Report Facts
Licensed beds: 6
Census: 6
Deficiencies cited: 5
Inspection Report
Re-Inspection
Census: 6
Capacity: 6
Deficiencies: 8
Mar 13, 2023
Visit Reason
This inspection was a grading re-survey State Licensure survey conducted to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was licensed for six beds and had a census of six residents at the time of the survey. Four resident files and four employee files were reviewed. The facility received a grade of A with no regulatory deficiencies identified and no further action necessary.
Severity Breakdown
D: 6
F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| First Aid & CPR - A first-aid kit must be available at the facility with specified contents. | D |
| Medication/OTCS, Supplements, Change Order - Administration of medication must follow physician's written approval and instructions. | D |
| Medication - Destruction - Medication must be destroyed properly in presence of a witness and documented. | D |
| Medication: Storage - Medication must be stored in a locked, cool, and dry area with protections against misuse. | F |
| Medication: Storage - Medication must be plainly labeled and kept in original container until administered. | D |
| Maintenance and Contents of Separate File - A separate file must be maintained for each resident and kept locked and protected. | D |
| Cultural Competency Training - Facility must conduct cultural competency training for employees providing care. | D |
| Annual Assessment of History of Each Resident - Administrator must conduct annual assessments and ensure qualified health care provider examinations. | F |
Report Facts
Licensed beds: 6
Census: 6
Resident files reviewed: 4
Employee files reviewed: 4
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 8
Jan 23, 2023
Visit Reason
This inspection was conducted as an Annual State Licensure survey of the facility to assess compliance with Nevada Administrative Code 449 for Residential Facility for Groups.
Findings
The facility received a grade of C with multiple deficiencies identified including incomplete first aid kit contents, medication administration errors, improper medication storage, failure to destroy discontinued medications, incomplete resident files including tuberculosis testing and physician assessments, and late cultural competency training for an employee.
Severity Breakdown
Level D: 6
Level F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| First aid kit lacked a shield or mask for administering cardiopulmonary resuscitation (CPR). | Level D |
| Medication administration failure: PRN medication triamcinolone acetonide 1% topical ointment was not available on site for Resident #3. | Level D |
| Discontinued medication benzonatate 100 mg was not destroyed and remained in Resident #3's medication bin. | Level D |
| Medications were not secured properly; unsecured medication found in refrigerator for 6 of 6 residents. | Level F |
| Over-the-counter medication for Resident #6 lacked physician's name and resident's name on the label. | Level D |
| Resident #5 lacked timely two-step tuberculosis testing as required. | Level D |
| Cultural competency training for Employee #1 was completed late. | Level D |
| Incomplete or missing Standard Physician Assessment and Placement Determination for Residents #2, #3, #4, and #5. | Level F |
Report Facts
Facility licensed beds: 6
Resident census: 6
Survey completion date: Jan 23, 2023
Medication deficiencies: 4
Resident files reviewed: 6
Employee files reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Freda Castro | Administrator | Named as facility administrator responsible for corrective actions and signature on report |
| Employee #1 | Administrator | Mentioned in relation to late cultural competency training |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 0
Mar 16, 2022
Visit Reason
This inspection was conducted as an Annual State Licensure survey of the facility to assess compliance with NAC 449, Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the survey. The facility received a grade of A and no further action is necessary.
Report Facts
Resident files reviewed: 6
Employee files reviewed: 4
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 3
Jun 3, 2021
Visit Reason
This inspection was conducted as an Annual State Licensure survey of the residential facility for groups to assess compliance with NAC 449 regulations.
Findings
The facility received a grade of A but had deficiencies including failure to ensure timely medication profile reviews by a qualified professional for some residents, incomplete tuberculosis testing documentation for some residents, and inadequate initial caregiver training documentation for one employee.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure medication profile review by a physician, pharmacist, or registered nurse at least once every six months for 3 of 6 sampled residents. | Level 2 |
| Failure to maintain complete tuberculosis testing documentation for 2 of 6 sampled residents, including missing or late TB tests and lack of read dates. | Level 2 |
| Failure to ensure one of four employees received four hours of initial caregiver training within 60 days of hire. | Level 2 |
Report Facts
Residents sampled: 6
Employees sampled: 4
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Freda T Castro | Administrator | Named as Administrator responsible for medication review and training compliance |
| Employee #3 | Caregiver | Failed to receive required initial caregiver training within 60 days of hire |
| Employee #4 | Acknowledged deficiencies in medication review and tuberculosis testing documentation |
Inspection Report
Routine
Census: 6
Capacity: 6
Deficiencies: 0
Sep 28, 2020
Visit Reason
This inspection was conducted as a State Licensure COVID-19 Infection Control and Prevention Plan Survey to assess the facility's compliance with infection control requirements during the COVID-19 pandemic.
Findings
The facility demonstrated comprehensive infection control practices including visitor screening, use of PPE, cleaning protocols, and isolation procedures for suspected or confirmed COVID-19 cases. No regulatory deficiencies were identified.
Report Facts
Licensed beds: 6
Residents present: 6
Inspection Report
Routine
Census: 6
Capacity: 6
Deficiencies: 0
Aug 31, 2020
Visit Reason
This inspection was conducted as a State Licensure COVID-19 Infection Control and Prevention Plan Survey to assess 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 at the time of the survey. Guidance was provided and the Administrator committed to having a plan documented and ready for follow-up by 09/10/20.
Report Facts
Licensed beds: 6
Census: 6
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 3
Jun 11, 2020
Visit Reason
This inspection was conducted as an Annual State licensure survey of the facility to assess compliance with regulatory requirements for a Residential Facility for Groups.
Findings
The facility was found to have deficiencies including failure to ensure background checks for 2 employees, maintenance issues such as damaged drywall and black marks in common areas, and inaccuracies in the Medication Administration Record for one resident. The facility received a grade of A.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 4 employees met background check requirements, lacking fingerprint submission and clearance letters. | Severity: 2 |
| Failed to maintain the common hallway and outside premises free of debris; damaged drywall, black marks on walls and doors, loose sink faucet, and clutter in backyard. | Severity: 2 |
| Medication Administration Record was inaccurate for 1 of 6 residents; MAR did not match physician's order for lorazepam dosage. | Severity: 2 |
Report Facts
Number of employees reviewed: 4
Number of resident files reviewed: 6
Number of residents present: 6
Total licensed capacity: 6
Severity 2 deficiencies: 3
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 4
May 25, 2018
Visit Reason
This inspection was conducted as a result of a State Licensure annual survey of the facility to assess compliance with regulations for Residential Facility for Groups.
Findings
The facility received a grade of A. Deficiencies were identified related to the Administrator's late renewal of Medication Management training, failure to ensure annual physical exams for residents, failure to complete and acknowledge medication profile reviews every six months for multiple residents, and failure to ensure tuberculosis testing was completed for some residents.
Severity Breakdown
Level 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Administrator failed to complete and pass an approved Medication Management course annually, with renewal 12 days late. | Level 2 |
| Resident #6 did not receive a timely annual physical examination in 2017. | Level 2 |
| Medication profile reviews were not completed and acknowledged in writing by the Administrator or Designee every six months for 5 of 6 residents. | Level 2 |
| Tuberculosis testing was not completed for 3 of 6 residents, including lack of evidence of annual TB testing or symptom screening. | Level 2 |
Report Facts
Number of residents present: 6
Total licensed capacity: 6
Days late for Medication Management training renewal: 12
Number of residents with missing medication profile reviews: 5
Number of residents missing tuberculosis testing: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Freda T Castro | Administrator | Named in relation to late Medication Management training and oversight of medication profile reviews and resident care |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 0
Apr 19, 2016
Visit Reason
This document reports on an annual State Licensure survey conducted at the facility on 04/19/2016 to assess compliance with regulatory requirements.
Findings
The facility received a grade of A with no regulatory deficiencies identified at the time of the survey. Five resident files and four employee files were reviewed during the inspection.
Report Facts
Resident files reviewed: 5
Employee files reviewed: 4
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 2
May 6, 2015
Visit Reason
This inspection was an annual State Licensure survey conducted to assess compliance with regulatory requirements for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A but was found deficient in tuberculosis (TB) screening requirements for one of four employees and in maintaining proper resident files for TB testing compliance for one of five residents.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 4 employees complied with Tuberculosis (TB) screening requirement. | Severity: 2 |
| Failure to ensure 1 of 5 residents met the requirements concerning tuberculosis (TB) testing documentation. | Severity: 2 |
Report Facts
Number of employees reviewed: 4
Number of resident files reviewed: 5
Number of employees non-compliant with TB screening: 1
Number of residents non-compliant with TB testing documentation: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Named in deficiency for incomplete TB screening documentation | |
| Employee #1 | Acknowledged findings related to TB screening and resident file deficiencies |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 0
Mar 26, 2014
Visit Reason
This document reports the results of an annual State Licensure survey conducted at the facility on 3/26/2014 by the Division of Public and Behavioral Health.
Findings
The facility was found to be in compliance with regulations, received a grade of A, and no deficiencies were cited in this report.
Report Facts
Resident files reviewed: 4
Employee files reviewed: 3
Inspection Report
Complaint Investigation
Capacity: 6
Deficiencies: 1
Dec 23, 2013
Visit Reason
This inspection was conducted as a complaint investigation regarding an allegation of failure to provide protective supervision to a resident.
Findings
The facility failed to provide necessary protective supervision to a resident diagnosed with increased confusion and dementia, resulting in the resident eloping from the facility during early morning hours on 7/8/13. The allegation was substantiated.
Complaint Details
Complaint #NV0037438 regarding failure to provide protective supervision to a resident was substantiated.
Severity Breakdown
3: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide a resident diagnosed with increased confusion and dementia necessary protective supervision. | 3 |
Report Facts
Licensed capacity: 6
Severity level: 3
Inspection Report
Original Licensing
Capacity: 6
Deficiencies: 0
Apr 26, 2013
Visit Reason
This document is the result of an initial State licensure survey conducted from 4/24/13 to 5/3/13 for Pleasant Care Group Home III, LLC, requesting licensure for six Residential Facility for Groups beds for elderly and disabled persons.
Findings
No deficiencies were identified during this initial licensing survey.
Report Facts
Licensed beds: 6
Category I residents: 1
Category II residents: 5
Report
File
MRWC11_SoD.pdf
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