Inspection Reports for Sachele Senior Guest Home II
3397 El Camino Real, Las Vegas, NV 89121, NV, 89121
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Inspection Report
Annual Inspection
Census: 9
Capacity: 9
Deficiencies: 1
Dec 9, 2024
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 received a grade of A. One regulatory deficiency was identified related to infection control training where one of three employees lacked documented evidence of completing infection control training through a nationally recognized course.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure one of three employees received infection control training through a nationally recognized course. | 2 |
Report Facts
Employees reviewed: 3
Resident files reviewed: 9
Facility licensed beds: 9
Census: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rowena Pace | Administrator | Acknowledged the deficiency regarding infection control training for Employee #3 |
| Employee #3 | Caregiver | Employee who lacked documented infection control training |
Inspection Report
Annual Inspection
Census: 7
Capacity: 9
Deficiencies: 1
Dec 12, 2023
Visit Reason
This inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. One regulatory deficiency was identified related to infection control training where the primary infection control designee had not completed the required 15 hours of training at the time of the survey.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure the primary infection control designee completed 15 hours of infection control training. | 2 |
Report Facts
Licensed beds: 9
Resident census: 7
Infection control training hours required: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rowena G. Pace | Administrator | Named as the primary infection control designee who had not completed required training at time of survey |
Inspection Report
Complaint Investigation
Census: 9
Deficiencies: 0
Apr 27, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation in accordance with Nevada Administrative Code (NAC) 449 for Residential Facility for Groups.
Findings
The complaint was unsubstantiated with no regulatory deficiencies identified. Observations, interviews, and record reviews were conducted without finding any violations or issues requiring further action.
Complaint Details
One complaint (NV00068316) was investigated and found to be unsubstantiated.
Report Facts
Sample size: 3
Inspection Report
Annual Inspection
Census: 9
Capacity: 9
Deficiencies: 0
Dec 15, 2022
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to have no regulatory deficiencies and received a grade of A. Nine resident files and three employee files were reviewed during the survey.
Report Facts
Resident files reviewed: 9
Employee files reviewed: 3
Inspection Report
Annual Inspection
Census: 6
Capacity: 9
Deficiencies: 1
Dec 2, 2021
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. One deficiency was identified related to failure to ensure one resident completed the required two-step tuberculosis testing, with the administrator acknowledging the missing documentation.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure one resident had completed two-step tuberculosis testing; missing documented evidence of second step TB test for Resident #6. | Severity: 2 |
Report Facts
Resident census: 6
Total licensed capacity: 9
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rowena G. Pace | Administrator | Named as Administrator acknowledging deficiency and signing report |
Inspection Report
Abbreviated Survey
Census: 6
Capacity: 9
Deficiencies: 0
Nov 18, 2020
Visit Reason
A focused COVID-19 infection control survey was conducted to investigate regulatory compliance with infection control and prevention measures in accordance with Nevada Administrative Code (NAC) Chapter 449.
Findings
The facility demonstrated compliance with infection control practices including screening, PPE use, disinfection, social distancing, and staff training. No residents or employees had COVID-19 symptoms or positive results. No regulatory deficiencies were cited.
Report Facts
PPE stock: 2000
PPE stock: 1000
PPE stock: 300
PPE stock: 200
PPE stock: 10
PPE stock: 2
Residents tested: 6
Staff tested: 3
Non-contact temporal thermometers: 5
Inspection Report
Annual Inspection
Capacity: 9
Deficiencies: 0
Jan 8, 2020
Visit Reason
The inspection was conducted as a State licensure survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facilities for Groups, including a review of the facility's licensed bed capacity and recent approval for a bed increase.
Findings
No regulatory deficiencies were identified during the inspection. The facility is licensed for nine Category II beds following approval of a three-bed increase, and no further action is necessary.
Report Facts
Licensed beds: 9
Inspection Report
Complaint Investigation
Census: 4
Deficiencies: 0
Sep 24, 2019
Visit Reason
The inspection was conducted as a result of a State licensure complaint investigation regarding allegations of neglect and substandard quality of care at the facility.
Findings
The investigation included observations, interviews, and medical record reviews, and found no regulatory deficiencies. The allegations could not be substantiated and no further action was necessary.
Complaint Details
One complaint (#NV00058298) was investigated with two allegations: neglect of a resident and substandard quality of care. Both allegations were not substantiated.
Report Facts
Sample size: 5
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 3
Jul 25, 2019
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but had deficiencies including improper food storage with spoiled and unlabeled food items, failure to maintain an annual bedfast waiver for a resident, and unlocked toxic chemicals accessible to residents.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Food was not stored appropriately; freezers and refrigerator were overpacked, food items were unlabeled, and some food was spoiled or expired. | Severity: 2 |
| Failure to ensure a bedfast waiver was completed annually for one resident who was bedfast and receiving hospice services. | Severity: 2 |
| Toxic chemicals (paint primer) were stored in an unlocked cabinet accessible to residents. | Severity: 2 |
Report Facts
Resident files reviewed: 6
Employee files reviewed: 3
Facility licensed beds: 6
Census: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rowena Pace | RFA | Laboratory Director's or Provider/Supplier Representative's signature on the report |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 5
Jul 12, 2018
Visit Reason
The inspection was conducted as an annual State Licensure survey of the facility on 07/12/2018 to assess compliance with regulatory requirements for a residential facility for elderly and disabled persons.
Findings
The facility was found to have multiple deficiencies including failure to maintain clean and well-maintained premises, improper food storage, inadequate housing for live-in staff, medication labeling discrepancies, and unsecured medication storage. Corrective actions were planned and implemented for each deficiency.
Severity Breakdown
Level 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure the interior and exterior premises were clean and well-maintained, including dirty refrigerator and freezer, dusty furniture, and improper storage of food and materials. | Level 2 |
| Facility failed to ensure open bottles of salad dressing and mayonnaise were refrigerated after opening. | Level 2 |
| Facility failed to provide a bed and bedroom for a live-in staff member who was sleeping on a recliner in a resident's room. | Level 2 |
| Medication label did not match the physician's order for Aspirin for Resident #1. | Level 2 |
| Medication for Resident #3 was not stored in a locked container as required; found unsecured on kitchen counter. | Level 2 |
Report Facts
Deficiencies cited: 5
Census: 6
Total Capacity: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rowena Pace | Administrator | Named as the administrator responsible for corrective actions and compliance. |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 1
Oct 8, 2015
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 10/8/15 at Sachele Senior Guest Home 2.
Findings
The facility received a grade of A. One deficiency was identified related to dementia training for employees, specifically that 1 of 5 employees did not receive the required ten hours of training within the first three months of employment.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to ensure 1 of 5 employees received ten hours of training in care for persons with Alzheimer's disease within the first three months of employment. | Severity: 2 |
Report Facts
Employees reviewed: 5
Resident census: 6
Total capacity: 6
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 1
Oct 8, 2015
Visit Reason
This annual State Licensure survey was conducted on 10/8/15 by the Division of Public and Behavioral Health to assess compliance with state regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A; however, one deficiency was identified related to dementia training where one of five employees did not complete the required ten hours of training within the first three months of employment.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 5 employees received ten hours of training in care for persons with Alzheimer's disease within the first three months of employment. | 2 |
Report Facts
Employees reviewed: 5
Resident files reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Named in deficiency for incomplete dementia training | |
| Employee #3 | Acknowledged Employee #1's incomplete training |
Inspection Report
Annual Inspection
Census: 6
Capacity: 9
Deficiencies: 3
Sep 22, 2014
Visit Reason
The inspection was conducted as a State Licensure annual grading survey to assess compliance with regulations for a Residential Facility for Group beds providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but had several deficiencies including failure to meet personnel file background check requirements, inadequate maintenance of the interior building, and unsecured gates in the Alzheimer's facility yard.
Severity Breakdown
2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Personnel file background check requirements not met; error on FBI background investigation and no result recorded in employee file. | 2 |
| Facility failed to ensure the interior building was maintained. | 2 |
| Facility yard gate was unlocked, providing direct access to the street, failing to secure the Alzheimer's facility yard. | 2 |
Report Facts
Licensed capacity: 9
Census: 6
Inspection Report
Annual Inspection
Census: 6
Capacity: 9
Deficiencies: 3
Sep 22, 2014
Visit Reason
This document is a State Licensure annual grading survey conducted to assess compliance with regulatory requirements for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but had several deficiencies including failure to ensure one employee met background check requirements, maintenance issues creating a tripping hazard, and failure to secure the gate in the Alzheimer's endorsed facility.
Severity Breakdown
2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 5 employees met background check requirements of NRS 449. | 2 |
| Facility failed to ensure the interior building was maintained; buckled floor planks creating a tripping hazard. | 2 |
| Failed to ensure the gate in an Alzheimer's endorsed facility was secured; lock on South gate was unlocked providing direct access to the street. | 2 |
Report Facts
Licensed beds: 9
Residents present: 6
Employees reviewed: 5
Resident files reviewed: 6
Severity 2 deficiencies: 3
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 1
Sep 10, 2013
Visit Reason
The inspection was conducted as a State Licensure annual grading survey to assess compliance with health and sanitation regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but was found deficient in maintaining the premises clean and well maintained, specifically due to a broken window and exposed nails on the side of the house. The broken window was replaced and the hazardous materials removed.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure the premises was clean and well maintained, including a broken window and exposed nails on the side of the house. | Severity: 2 |
Report Facts
Licensed beds: 6
Resident census: 5
Deficiency severity: 2
Deficiency scope: 3
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 1
Sep 10, 2013
Visit Reason
This document is a State Licensure annual grading survey conducted at the facility on 09/10/2013 to assess compliance with health and safety regulations.
Findings
The facility received a grade of A but was found deficient for failing to maintain the premises clean and well maintained, specifically noting a broken window and exposed nails on the side of the house.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure the premises was clean and well maintained (broken window on side of house and exposed nails in wood stacked by side of house). | 2 |
Report Facts
Licensed beds: 6
Resident census: 5
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 1
Sep 25, 2012
Visit Reason
The inspection was conducted as an annual State Licensure survey to assess compliance with regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but was found deficient for failing to ensure dangerous items were inaccessible to residents, specifically a razor found in an unsecured cabinet accessible to 6 of 6 residents.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure dangerous items such as knives, matches, firearms, tools, and other hazardous items were inaccessible to residents, evidenced by a razor found in an unsecured cabinet in the hallway bathroom. | Severity: 2 |
Report Facts
Residents present: 6
Licensed capacity: 6
Deficient residents: 6
Deficiency scope: 3
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 1
Sep 25, 2012
Visit Reason
This document is the result of an annual State Licensure survey conducted at the facility on 9/25/2012 to assess compliance with state regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of A but was found deficient for failing to ensure dangerous items were inaccessible to residents, specifically a razor found in an unsecured cabinet in the hallway bathroom accessible to all six residents.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure dangerous items (razor) were inaccessible to residents. | Severity: 2 |
Report Facts
Resident census: 6
Total licensed capacity: 6
Employee files reviewed: 5
Resident files reviewed: 6
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 0
Oct 18, 2011
Visit Reason
The inspection was conducted as an annual State Licensure survey to assess compliance with regulatory requirements for the facility licensed to provide care to persons with Alzheimer's disease.
Findings
The facility received a grade of A with no regulatory deficiencies cited during this survey. Five resident and five employee files were reviewed.
Report Facts
Resident files reviewed: 5
Employee files reviewed: 5
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 4
Sep 23, 2010
Visit Reason
This document is the result of an annual licensure survey conducted at Sachele Senior Guest Home 2 on 09/23/2010 to assess compliance with state regulations for residential facilities.
Findings
The facility received a grade of B with several deficiencies identified, including inadequate laundry room enclosure, bathroom privacy and lock issues, and failure to secure dangerous items accessible to residents.
Severity Breakdown
Level 1: 1
Level 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Laundry room was not situated in a room or enclosure; the dryer was located on the backyard patio. | Level 1 |
| Public restroom lacked a single motion lock allowing privacy; door knob lock was reversed allowing locking only from outside. | Level 2 |
| Bathroom door locks did not open with a single motion from inside; one bathroom had a lock installed backwards creating risk of locking a resident inside. | Level 2 |
| Dangerous items (tools, shovel, scissors, box cutter) were stored unlocked in backyard shed accessible to all 6 residents. | Level 2 |
Report Facts
Deficiencies cited: 4
Resident census: 6
Total licensed capacity: 6
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