Inspection Reports for Saint Jean Senior Care
6924 Acoma Ct, Las Vegas, NV 89145, NV, 89145
Back to Facility Profile
Inspection Report
Annual Inspection
Census: 5
Capacity: 10
Deficiencies: 4
May 21, 2025
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 several areas including failure to develop person-centered service plans for all residents, failure to ensure an annual physical examination for one resident, failure to obtain a mental illness endorsement while retaining a resident with mental illness, and lack of policies and documentation regarding preferred names, pronouns, gender identity, and sexual orientation. The facility received a grade of B.
Severity Breakdown
Severity: 2: 3
Severity: 1: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to develop a person-centered service plan for 5 of 5 residents. | Severity: 2 |
| Failed to ensure 1 of 5 residents received an annual physical examination. | Severity: 2 |
| Failed to obtain an endorsement for Mental Illness and retained 1 of 5 residents with an MI diagnosis. | Severity: 2 |
| Failed to develop policies and revise resident records to reflect preferred names, pronouns, gender identity or expression, and sexual orientation. | Severity: 1 |
Report Facts
Licensed capacity: 10
Census: 5
Resident files reviewed: 5
Employee files reviewed: 4
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Prescila Barcelon | Administrator | Acknowledged deficiencies and involved in corrective actions |
Inspection Report
Re-Inspection
Census: 6
Capacity: 10
Deficiencies: 8
Jun 12, 2024
Visit Reason
This inspection was a State Licensure 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 A with several deficiencies identified, including failure to complete background checks for two employees, lack of in-person CPR and first aid training for one employee, and other administrative and safety-related issues. Corrective actions were planned or completed for all deficiencies.
Severity Breakdown
2: 2
D: 3
F: 2
E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure background checks were completed through the Nevada Automated Background Check System for 2 of 5 employees. | 2 |
| Failure to ensure one employee received CPR and first aid training with the required in-person component. | 2 |
| Failure to maintain premises clean and well maintained (corrected on previous survey). | F |
| Failure to maintain separate locked resident files with required documentation. | D |
| Failure to install operational alarms on all doors that may be used to exit the facility (new owners informed to install alarm). | F |
| Failure to obtain endorsement for care of persons with mental illnesses; owners not pursuing endorsement and social services notified. | D |
| Failure to display the placard conspicuously within 24 hours after receipt. | D |
| Failure to ensure infection control personnel completed required 15 hours of training; certificates on file. | E |
Report Facts
Licensed beds: 10
Census: 6
Employees reviewed: 5
Resident files reviewed: 2
Severity 2 deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Prescila Barcelon | Administrator | Named as Administrator involved in findings and corrective actions |
| Employee 4 | Caregiver | Failed background check and CPR/in-person first aid training |
| Employee 5 | Caregiver | Failed background check at time of survey, completed later |
Inspection Report
Annual Inspection
Census: 7
Capacity: 10
Deficiencies: 8
Apr 8, 2024
Visit Reason
This inspection was conducted as an annual State Licensure survey of the residential facility for groups, in accordance with Nevada Administrative Code Chapter 449.
Findings
The facility was found deficient in several areas including failure to provide required in-person CPR and first aid training for employees, a leaking toilet, failure to read a TB skin test within the required timeframe, a non-functioning exit door alarm, lack of endorsement for mental illness care, failure to post the current survey grade placard, incomplete infection control training for designated staff, and incomplete background checks for some employees.
Severity Breakdown
2: 6
1: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to ensure 4 of 4 employees received CPR and first aid training with the required in-person component. | 2 |
| Facility failed to ensure a toilet was not leaking in the hallway bathroom. | 2 |
| Facility failed to ensure 1 of 7 residents' TB skin test was read within 72 hours, rendering the result invalid. | 2 |
| Facility failed to ensure an exit door sounded an audible alarm upon opening. | 2 |
| Facility failed to obtain an endorsement for Mental Illness and admitted and retained a resident with an MI diagnosis without it. | 2 |
| Facility failed to ensure the most current grade placard was posted; the 2022 placard was displayed instead of the current 2024 placard. | 1 |
| Facility failed to ensure primary and secondary infection control staff completed 15 hours of infection control training from an approved organization. | 2 |
| Facility failed to ensure background checks were completed through the Nevada Automated Background Check System for 2 of 4 employees. | 2 |
Report Facts
Facility licensed capacity: 10
Resident census: 7
Employees reviewed: 4
Resident files reviewed: 7
Survey grade: C
Severity 2 deficiencies: 6
Severity 1 deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Prescila Barcelon | Administrator | Acknowledged CPR and first aid training deficiencies and other findings during inspection |
| Employee #1 | Administrator | Failed to complete required in-person CPR and first aid training; identified as primary infection control staff lacking required training |
| Employee #2 | Caregiver | Failed to complete required in-person CPR and first aid training; identified as secondary infection control staff lacking required training; lacked background check for facility |
| Employee #3 | Caregiver | Failed to complete required in-person CPR and first aid training |
| Employee #4 | Caregiver | Failed to complete required in-person CPR and first aid training; lacked background check for facility; refused to retake fingerprinting and quit |
Inspection Report
Complaint Investigation
Deficiencies: 5
Nov 15, 2023
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #NV00069676, involving review of resident and employee files, observations, interviews, and document reviews to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found deficient in multiple areas including failure to ensure annual caregiver training, failure to obtain background checks every 5 years for employees, missing controlled medication tablets, failure to maintain medication receiving logs, and failure to ensure annual Alzheimer's training for employees providing dementia care.
Complaint Details
Complaint #NV00069676 was verified. The investigation included observation of residents' physical appearance, medication storage, staffing, supplies, meal observation, facility tour, interviews with residents, caregivers, hospice nurse, and administrator, and review of clinical records, policies, staff schedules, and menus.
Severity Breakdown
Level 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 3 caregivers received eight hours of annual elderly and disabled training. | Level 2 |
| Failure to ensure 1 of 3 employees obtained a background check every 5 years through the Nevada Automated Background Check System. | Level 2 |
| Failure to ensure all tablets of Oxycodone prescribed to a resident were onsite and accounted for; 18 tablets were unaccounted for. | Level 2 |
| Failure to maintain a medication receiving log for a medication received at the facility for 1 of 5 residents. | Level 2 |
| Failure to ensure three hours of annual Alzheimer's training was completed by 2 of 3 employees providing care to residents with dementia. | Level 2 |
Report Facts
Complaint count: 1
Sample size: 5
Sample size: 3
Missing medication tablets: 18
Medication order quantity: 90
Training hours required: 8
Training hours required: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Caregiver | Failed to complete annual elderly and disabled training and background check; last training completed 06/11/22; background check missing within last 5 years. |
| Employee #1 | Caregiver | Acknowledged medication administration; failed to maintain medication receiving log; lacked documented Alzheimer's training. |
Inspection Report
Annual Inspection
Census: 4
Capacity: 10
Deficiencies: 0
Apr 12, 2023
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. Four resident files and three employee files were reviewed, and no further action was necessary.
Report Facts
Licensed capacity: 10
Census: 4
Inspection Report
Re-Inspection
Census: 8
Capacity: 10
Deficiencies: 8
May 18, 2022
Visit Reason
This inspection was a mandatory regrading survey conducted at the facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to be in compliance with no deficiencies cited and received a grade of A. Several regulatory requirements related to administrator responsibilities, caregiver qualifications, medication administration, record maintenance, and dementia care training were reviewed.
Severity Breakdown
C: 1
D: 6
E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Administrator's Responsibilities - Designation - NAC 449.194 Responsibilities of administrator. | C |
| Qualifications of Caregivers-Age-Eng-Training - NAC 449.196 Qualifications and training of caregivers. | D |
| Personnel File - TB Screening - NAC 449.200 Personnel files. | D |
| Medication Administration-Accuracy & Report - NAC 449.2742 Administration of medication: Responsibilities of administrator, caregiver and employees of facility. | E |
| Medication/OTCS, Supplements, Change Order - NAC 449.2742 - Administration of medication: Responsibilities of administrator, caregiver and employees of facility. | D |
| Administration of Medication Maintenance - NAC 449.2744 Administration of medication: Maintenance and contents of logs and records. | D |
| Maintenance and Contents of Separate File - NAC 449.2749 Maintenance and contents of separate file for each resident; confidentiality of information. | D |
| Care to Persons with Dementia - NAC 449.2768 Residential facility which provides care to persons with dementia: Training for employees. | D |
Report Facts
Licensed beds: 10
Census: 8
Resident files reviewed: 5
Employee files reviewed: 2
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 8
Apr 5, 2022
Visit Reason
The inspection was an annual State Licensure and infection control survey initiated on 04/05/22 in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of C with multiple deficiencies identified including failure to designate an employee in charge during the Administrator's absence, incomplete annual caregiver training documentation, missing annual tuberculosis screenings for employees and residents, incomplete medication reviews for residents, medication administration errors, and inaccurate medication administration records.
Severity Breakdown
Level 1: 1
Level 2: 7
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to designate in writing one or more employees to be in charge of the facility during the Administrator's absence. | Level 1 |
| Failed to ensure eight hours of annual Caregiver training was completed for 1 of 4 employees (Employee #1). | Level 2 |
| Failed to ensure tuberculosis (TB) screenings were completed annually for 1 of 4 employees (Employee #3). | Level 2 |
| Failed to ensure a medication review was completed every six months for 5 of 10 residents (Residents #1, #7, #8, #9, and #10). | Level 2 |
| Failed to ensure medications were administered to a resident as ordered by the physician for 1 of 10 residents (Resident #1). | Level 2 |
| Failed to ensure the Medication Administration Record (MAR) accurately documented the administration of medications for 2 of 10 residents (Resident #7 and Resident #8). | Level 2 |
| Failed to ensure a 2-step Tuberculosis (TB) test was completed for 1 of 10 residents (Resident #5). | Level 2 |
| Failed to ensure annual Alzheimer's training was completed for 1 of 4 employees (Employee #1). | Level 2 |
Report Facts
Residents missing medication reviews: 5
Residents with inaccurate MAR documentation: 2
Employees missing annual caregiver training: 1
Employees missing annual TB screening: 1
Residents missing 2-step TB test: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Prescila Barcelon | Administrator | Named as the Administrator who acknowledged deficiencies and implemented corrective actions. |
| Employee #1 | Administrator | Failed to complete annual caregiver training and annual Alzheimer's training. |
| Employee #3 | Failed to have annual TB screening documentation; involved in medication administration and MAR corrections. | |
| Employee #4 | Designated as Employee In-charge in the absence of the Administrator. |
Inspection Report
Complaint Investigation
Census: 8
Deficiencies: 0
Sep 7, 2021
Visit Reason
The inspection was conducted as a result of a State Licensure complaint investigation survey triggered by complaint #NV00064662 with three allegations.
Findings
The investigation found all three allegations unsubstantiated after interviews with residents, staff, the facility administrator, the resident's public guardian, and medical care provider, as well as record reviews and observations.
Complaint Details
Complaint #NV00064662 with three allegations: 1) Water not offered to a resident, 2) Failure to assess and monitor a resident, and 3) Possible medication overdose. All allegations were unsubstantiated based on interviews, record reviews, and observations.
Report Facts
Sample size: 1
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 3
Jun 7, 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 but had several regulatory deficiencies including failure to ensure background checks for one employee, incomplete medication reviews for four residents, and unsafe storage of toxic substances accessible to residents.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 5 employees met background check requirements; missing fingerprint submission and clearance letter for Employee #4. | Level 2 |
| Failure to ensure medication reviews were completed every six months for 4 of 8 residents. | Level 2 |
| Failure to ensure toxic substances were inaccessible to residents; laundry room door was unlocked with chemicals accessible. | Level 2 |
Report Facts
Number of resident files reviewed: 8
Number of employee files reviewed: 5
Facility licensed bed capacity: 10
Current census: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Prescila Barcelon | Administrator | Confirmed missing fingerprint submission and clearance letter for Employee #4; involved in corrective actions |
| Employee #4 | Caregiver lacking required background check documentation | |
| Employee #1 | Acknowledged laundry room door should be locked when toxic substances are stored |
Inspection Report
Renewal
Census: 6
Capacity: 10
Deficiencies: 0
Sep 29, 2020
Visit Reason
This inspection was a voluntary State Licensure re-survey initiated at the facility in accordance with Nevada Administrative Code Chapter 449 for 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.
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 3
Apr 26, 2016
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility to assess compliance with regulations for a Residential Facility for Group beds for elderly and disabled persons and/or persons with Alzheimer's disease.
Findings
The facility received a grade of A. Deficiencies were identified related to medication administration, medication storage, and resident file maintenance concerning tuberculosis testing. Specific issues included failure to ensure one resident received medications as prescribed, unsecured medication storage including expired medication, and incomplete tuberculosis testing documentation for two residents.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 10 residents received medications as prescribed. | Severity: 2 |
| Failed to ensure medications were stored securely, including expired medication found in unsecured cabinet. | Severity: 2 |
| Failed to ensure 2 of 10 residents met tuberculosis testing requirements with complete documentation. | Severity: 2 |
Report Facts
Residents present: 10
Total licensed capacity: 10
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #4 | Acknowledged medication delivery and secured medications; acknowledged missing tuberculosis test documentation | |
| Employee #2 | In charge of spot checking medication storage cabinet to ensure compliance | |
| Employee #3 | Instructed on how to review resident information files for tuberculosis testing compliance |
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 3
Apr 26, 2016
Visit Reason
This annual State Licensure survey was conducted on 4/26/16 by the Division of Public and Behavioral Health to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A but had several deficiencies including failure to administer medications as prescribed to one resident, unsecured medication storage including expired medication, and incomplete tuberculosis testing documentation for two residents.
Severity Breakdown
2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 10 residents received medications as prescribed (Resident #1). | 2 |
| Failed to ensure medications were stored securely; medications found unsecured in hallway cabinet including expired hydrocortisone cream. | 2 |
| Failed to ensure 2 of 10 residents met tuberculosis testing requirements; missing documented evidence of injection and read dates and completion of second step test (Residents #2 and #3). | 2 |
Report Facts
Residents present: 10
Total licensed capacity: 10
Medications not on site: 2
Expired medication: 1
Residents with incomplete TB testing: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #4 acknowledged medication and documentation deficiencies and secured medications |
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 4, 2015
Visit Reason
This document is a required grading re-survey conducted on 6/4/15 as part of a state licensure survey by the Division of Public and Behavioral Health.
Findings
The facility received a re-survey grade of A with no deficiencies identified during this inspection.
Notice
Deficiencies: 0
May 18, 2015
Visit Reason
The document serves as a sanction notice informing St. Jean Senior Care of imposed monetary penalties due to repeat deficiencies identified in a prior survey dated 3/1/15.
Findings
The Division of Public and Behavioral Health is imposing a $300 monetary penalty for a repeat deficiency at TAG Y0050 cited in the survey dated 3/1/15. The notice outlines the statutory authority, penalty details, appeal rights, and payment instructions.
Report Facts
Monetary penalty amount: 300
Penalty reduction percentage: 25
Appeal deadline: 10
Penalty payment due days: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Minou Nelson | Health Facilities Inspector III | Signed the sanction notice |
| Kyle Devine | Bureau Chief | Referenced as Bureau Chief in the sanction notice |
Inspection Report
Renewal
Census: 10
Capacity: 10
Deficiencies: 11
Mar 31, 2015
Visit Reason
This State Licensure survey was conducted as a required State Licensure resurvey on 3/31/15 to assess compliance with regulatory requirements for a residential facility for persons with Alzheimer's disease.
Findings
The facility was found deficient in multiple areas including administrator oversight, elder abuse training, personnel files, medication administration, medication destruction, medication container storage, tuberculosis testing, Alzheimer's facility door alarms, dangerous items accessibility, and dementia training. The facility received a grade of D and several repeat deficiencies from prior surveys were noted.
Severity Breakdown
Level 2: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight and guidance to ensure residents received needed services and protective supervision. | Level 2 |
| Facility failed to ensure 1 of 6 employees received elder abuse training prior to providing care and failed to implement Plan of Correction for employee checklist. | Level 2 |
| Facility failed to ensure 4 of 6 employees completed required pre-employment physical examination and initial 2-Step Tuberculosis testing. | Level 2 |
| Facility failed to ensure 3 of 6 employees met background check requirements. | Level 2 |
| Facility failed to ensure 2 of 7 residents were administered medications following doctor's order. | Level 2 |
| Facility failed to ensure discontinued medication of 1 of 7 residents was destroyed. | Level 2 |
| Facility failed to keep medication belonging to 1 of 7 residents in its original container. | Level 2 |
| Facility failed to ensure 3 of 7 residents met tuberculosis testing requirements. | Level 2 |
| Facility failed to ensure Alzheimer's facility door alarm was operational at all times. | Level 2 |
| Facility failed to ensure dangerous items were inaccessible to residents. | Level 2 |
| Facility failed to ensure 3 of 6 employees completed dementia training within first 40 hours of employment. | Level 2 |
Report Facts
Census: 10
Total Capacity: 10
Deficiencies cited: 11
Inspection Report
Renewal
Census: 10
Capacity: 10
Deficiencies: 11
Mar 31, 2015
Visit Reason
This document is a State Licensure resurvey conducted on 3/31/2015 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 D with multiple deficiencies including failure to provide adequate oversight by the administrator, incomplete elder abuse training for employees, incomplete tuberculosis testing, medication administration errors, failure to destroy discontinued medications, unsecured dangerous items, and incomplete dementia training for employees.
Severity Breakdown
Level 2: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight and guidance to ensure residents received needed services and protective supervision. | Level 2 |
| Facility failed to ensure 1 of 6 employees received elder abuse training prior to providing care and failed to implement Plan of Correction regarding employee checklist. | Level 2 |
| Facility failed to ensure 4 of 6 employees completed required pre-employment physical examination and initial 2-Step Tuberculosis testing. | Level 2 |
| Facility failed to ensure 3 of 6 employees met background check requirements. | Level 2 |
| Facility failed to ensure 2 of 7 residents were administered medications following doctor's order. | Level 2 |
| Facility failed to ensure discontinued medication of 1 of 7 residents was destroyed. | Level 2 |
| Facility failed to keep medication belonging to 1 of 7 residents in its original container. | Level 2 |
| Facility failed to ensure 3 of 7 residents met tuberculosis testing requirements. | Level 2 |
| Facility failed to ensure the door alarm was operational at all times. | Level 2 |
| Facility failed to ensure dangerous items were not accessible to residents. | Level 2 |
| Facility failed to ensure 3 of 6 employees completed at least two hours of Alzheimer's training within the first 40 hours of employment. | Level 2 |
Report Facts
Residents present: 10
Total licensed capacity: 10
Employees reviewed: 6
Resident files reviewed: 7
Severity 2 deficiencies: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Caregiver | Failed to complete elder abuse training and Alzheimer's training |
| Employee #3 | Caregiver | Failed to complete elder abuse training, tuberculosis testing, background check, and Alzheimer's training |
| Employee #4 | Caregiver | Failed to complete tuberculosis testing and background check |
| Employee #5 | Caregiver | Failed to complete tuberculosis testing and background check |
| Employee #6 | Administrator | Failed to complete Alzheimer's training |
| Caregiver #2 | Caregiver | Involved in medication administration errors and door alarm observation |
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 15
Mar 5, 2015
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation initiated by the Division of Public and Behavioral Health.
Findings
The facility received a grade of D with multiple deficiencies identified including unqualified staff caring for residents, incomplete medication administration records, and failure to ensure required training and documentation for caregivers and employees. Some allegations in complaints were substantiated while others were not.
Complaint Details
Complaint #NV00041806 contained three allegations: unqualified staff caring for residents (substantiated), resident safety/falls (not substantiated), and incomplete Medication Administration Record (not substantiated). Complaint #NV00041878 contained three allegations related to inappropriate level of care, insufficient food, and insufficient supplies; none were substantiated.
Severity Breakdown
Level 1: 2
Level 2: 13
Deficiencies (15)
| Description | Severity |
|---|---|
| Administrator failed to ensure residents received needed services and protective supervision. | Level 2 |
| Caregivers failed to complete required initial medication management training. | Level 2 |
| Employees failed to receive annual training in recognition, prevention, and response to elder abuse. | Level 2 |
| Administrator failed to maintain monthly staffing schedule for at least six months. | Level 1 |
| Facility failed to ensure employees met tuberculosis testing and physical examination requirements. | Level 2 |
| Facility failed to ensure employees met background check requirements. | Level 2 |
| Facility failed to ensure one caregiver was trained in first aid and CPR. | Level 2 |
| Facility failed to ensure residents received initial or annual physical examinations. | Level 2 |
| Medication administration records were incomplete or inaccurate for some residents. | Level 1 |
| Medications were observed unsecured and not stored properly. | Level 2 |
| Facility failed to keep medications in original labeled containers and secure medications properly. | Level 2 |
| Facility failed to keep medications belonging to residents in their original containers. | Level 2 |
| Facility failed to maintain separate resident files with required documentation for tuberculosis testing. | Level 2 |
| Facility failed to ensure dangerous items were inaccessible to residents. | Level 2 |
| Facility failed to ensure employees received dementia training within required timeframes. | Level 2 |
Report Facts
Number of resident files reviewed: 9
Number of employee files reviewed: 5
Number of discharged resident files reviewed: 2
Number of former employee files reviewed: 1
Number of caregivers required to complete initial medication training: 6
Number of residents with incomplete physical exams: 2
Number of residents with incomplete medication administration records: 3
Number of employees lacking elder abuse training: 2
Number of employees lacking tuberculosis testing documentation: 4
Number of employees lacking background checks: 2
Number of employees lacking first aid and CPR training: 1
Number of residents with medications observed unsecured: 1
Number of residents with medications not in original containers: 1
Number of residents lacking annual TB testing: 5
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 14
Mar 5, 2015
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation initiated by the Division of Public and Behavioral Health.
Findings
The facility received a grade of D with multiple deficiencies identified including unqualified staff, incomplete training, missing documentation, medication administration errors, unsecured medications, and unsafe storage of dangerous items. Several complaints were substantiated while others were not. Repeat deficiencies from prior surveys were noted.
Complaint Details
Complaint #NV00041806 was substantiated with three allegations including unqualified staff. Complaint #NV00041878 contained three allegations but was not substantiated.
Severity Breakdown
Level 1: 2
Level 2: 12
Deficiencies (14)
| Description | Severity |
|---|---|
| Administrator failed to ensure residents received needed services and protective supervision. | Level 2 |
| Two caregivers lacked required initial medication management training and one administered medication prior to training. | Level 2 |
| Two employees failed to receive annual elder abuse training. | Level 2 |
| Administrator failed to maintain complete monthly staffing schedules with shift times and retention for six months. | Level 1 |
| Four employees lacked required tuberculosis testing and pre-employment physical examinations. | Level 2 |
| Two employees failed to meet background check requirements. | Level 2 |
| One caregiver lacked current first aid and CPR certification. | Level 2 |
| Two residents lacked initial or annual physical examinations as required. | Level 2 |
| Medication administration records were inaccurate for three residents. | Level 1 |
| Medications were not stored securely; multiple medications were found unsecured in resident rooms. | Level 2 |
| Medication for one resident was not kept in original container. | Level 2 |
| Five residents' files lacked required tuberculosis test documentation. | Level 2 |
| Dangerous items such as knives were accessible to residents. | Level 2 |
| Two employees lacked required dementia training within first 40 hours of employment. | Level 2 |
Report Facts
Number of residents: 10
Number of employee files reviewed: 5
Number of resident files reviewed: 9
Number of discharged resident files reviewed: 2
Number of former employee files reviewed: 1
Number of medication administration records inspected: 10
Number of residents with inaccurate MARs: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Lacked annual elder abuse training and incomplete tuberculosis testing | |
| Employee #2 | Lacked initial medication management training, Alzheimer's training, and background check issues | |
| Employee #3 | Lacked annual elder abuse training and current CPR certification; acknowledged medication discrepancies | |
| Employee #4 | Lacked pre-employment physical examination and tuberculosis testing | |
| Employee #6 | Administered medication prior to training, lacked Alzheimer's training, background check issues, and incomplete tuberculosis testing |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 3
Mar 28, 2014
Visit Reason
This inspection was conducted as a mandatory grading re-survey and annual State Licensure survey from 2014-03-24 through 2014-03-28 to assess compliance with state regulations for the facility.
Findings
The facility received a grade of A but had deficiencies including failure to ensure one employee met background check requirements, admission of a bedfast resident without exemption, and incomplete documentation of PRN medication administration for five residents.
Severity Breakdown
Severity: 2: 2
Severity: 1: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 employees met background check requirements of NRS 449. | Severity: 2 |
| Failed to ensure a resident who was bedfast was not admitted to the facility. | Severity: 2 |
| Failed to ensure PRNs were documented accurately for 5 of 9 residents; medication administration records missing information on PRN results. | Severity: 1 |
Report Facts
Residents reviewed: 9
Employee files reviewed: 4
Residents with PRN documentation issues: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Named in background check deficiency and interview confirming missing state and FBI clearance |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 3
Mar 24, 2014
Visit Reason
The inspection was a mandatory grading re-survey and annual State Licensure survey conducted from 3/24/14 through 3/28/14 to assess compliance with state regulations for a residential facility for persons with Alzheimer's disease.
Findings
The facility received a grade of A but had deficiencies including failure to ensure background checks for one employee, admission of a bedfast resident without exemption, and incomplete documentation of PRN medication administration for several residents.
Severity Breakdown
Severity: 1: 1
Severity: 2: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Personnel file background check missing state or FBI clearance for one employee. | Severity: 2 |
| Facility admitted a bedfast resident without obtaining an exemption as required by policy. | Severity: 2 |
| Medications administration records for PRNs lacked documentation on results for 5 of 9 residents. | Severity: 1 |
Report Facts
Residents present: 9
Licensed capacity: 10
Employees reviewed: 4
Resident files reviewed: 9
Residents with PRN documentation issues: 5
Loading inspection reports...
