Inspection Reports for Shepherd Care Home
5319 Stampa Ave, Las Vegas, NV 89146, NV, 89146
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Re-Inspection
Census: 10
Capacity: 10
Deficiencies: 7
Jun 4, 2025
Visit Reason
This inspection was a mandatory regrading State Licensure survey conducted at the facility in accordance with Nevada Administrative Code (NAC) Chapter 449.
Findings
No regulatory deficiencies were identified during the inspection. The facility received a grade of A and no further action was necessary.
Severity Breakdown
F: 4
C: 1
D: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Administrator's Responsibilities - Oversight - NAC 449.194 Responsibilities of administrator. | F |
| Administrator's Responsibilities-Complete Records - NAC 449.194 Responsibilities of administrator. | C |
| Health & Sanitation - Maintain Interior/Exterior - NAC 449.209 Health and sanitation. | F |
| Service of Food-Nutritious Meals; Frequency - NAC 449.2175 Service of food. | F |
| Bedrooms - Floor space - NAC 449.218 Bedrooms: Floor space; windows and doors; privacy; storage space; bedding; personal furnishings; lighting. | D |
| Residents Requiring Use of Oxygen - NAC 449.2712 Residents requiring use of oxygen. | D |
| Medication: Storage - NAC 449.2748 Medication: Storage; duties upon discharge, transfer and return of resident. | F |
Report Facts
Licensed beds: 10
Census: 10
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 7
Feb 5, 2025
Visit Reason
The 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 administrator oversight, incomplete employee records, improper storage and sanitation issues in the backyard, expired and improperly defrosted food, inadequate bedroom floor space for one resident, improper oxygen canister storage, and unsecured medication storage. The facility received a grade of C.
Severity Breakdown
F: 4
C: 1
D: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight and supervision to ensure facility compliance and maintenance. | F |
| Employee records were incomplete and inaccurate for 3 of 4 employees. | C |
| Backyard was cluttered with debris and broken furniture, not well maintained. | F |
| Food was expired, improperly defrosted, and lacked proper labeling. | F |
| A bedroom occupied by a single resident did not meet minimum floor space and storage requirements. | D |
| Oxygen canisters were improperly stored and unsecured in a hallway closet. | D |
| Medications stored in refrigerator were not properly secured in a locked container. | F |
Report Facts
Licensed beds: 10
Residents present: 9
Employee files reviewed: 4
Resident files reviewed: 9
Facility grade: C
Severity 2 deficiencies: 4
Inspection Report
Renewal
Census: 7
Capacity: 10
Deficiencies: 9
May 29, 2024
Visit Reason
This inspection was a mandatory State Licensure re-grading survey conducted to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of B with multiple deficiencies identified including incomplete employee records, missing background checks, expired CPR training, lack of physician orders for medications, improper medication storage, and failure to complete required infection control training. Several deficiencies were repeats from the prior annual survey.
Severity Breakdown
F: 5
D: 4
C: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure 3 of 5 employee records were complete and accurate, including missing tuberculin tests, mental illness training, pre-physical exams, and cultural competency training. | F |
| Failed to ensure 4 of 5 employees were fingerprinted within 10 days of hire and had background check clearance. | F |
| Failed to ensure 1 of 5 employees received CPR and first aid training before expiration. | F |
| Failed to ensure physician order for medications for 1 of 4 residents; unsecured medication without order observed. | D |
| Failed to maintain complete medication administration records including type, date/time, refusals, instructions, changes, and errors. | F |
| Failed to store medications in locked areas and protect medications from misuse. | F |
| Failed to maintain separate locked files for each resident containing all required records. | D |
| Failed to ensure the secondary infection control designee completed required 15 hours of infection control training. | D |
| Failed to operate the facility under proper supervision as required by NRS 449.186. | C |
Report Facts
Facility licensed beds: 10
Resident census: 7
Employee records reviewed: 5
Resident files reviewed: 4
Severity 2 deficiencies: 6
Severity 1 deficiency: 1
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 13
Feb 6, 2024
Visit Reason
This annual State Licensure survey was conducted to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of D with multiple deficiencies identified including failure to notify change of administrator, incomplete employee records, missing background checks, incomplete resident medical and medication records, unsecured medications, and lack of infection control training for the designated staff.
Severity Breakdown
Level 1: 2
Level 2: 11
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to notify the Division after the former Administrator passed away and no application for new Administrator was submitted. | Level 1 |
| Incomplete and inaccurate employee records for two caregivers including missing physical exams, TB tests, and training documentation. | Level 2 |
| Failure to ensure fingerprinting and background checks were completed within 10 days of hire for three employees. | Level 2 |
| Failure to ensure one employee had current first aid and CPR certification. | Level 2 |
| Failure to ensure annual physical examination was completed for one resident. | Level 2 |
| Failure to ensure six-month medication review was completed for one resident. | Level 2 |
| Failure to ensure Administrator initialed six-month medication reviews within 72 hours for two residents. | Level 2 |
| Failure to ensure medications were on site, change labels applied, physician orders obtained, and medications administered as prescribed for multiple residents. | Level 2 |
| Failure to maintain accurate Medication Administration Records (MAR) for multiple residents. | Level 2 |
| Failure to secure medications properly; unsecured medications found in resident rooms and common areas. | Level 2 |
| Failure to ensure initial two-step tuberculosis tests for two residents. | Level 2 |
| Failure to inform nine residents of their rights upon admission. | Level 1 |
| Failure to ensure the primary infection control designee completed required 15 hours of infection control training. | Level 2 |
Report Facts
Deficiencies cited: 13
Facility licensed beds: 10
Resident census: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tess Pascual | Owner/Provider | Named as responsible for ensuring plan of correction implementation. |
| Administrator Designee | Named in multiple findings including lack of current administrator license, incomplete employee records, missing medication reviews, and infection control training. | |
| Employee #3 | Administrator Designee/Caregiver | Mentioned in relation to missing background checks, medication administration, infection control training, and employee record deficiencies. |
| Employee #4 | Caregiver | Mentioned in relation to missing employee records and medication administration. |
| Employee #5 | Caregiver | Mentioned in relation to missing employee records and temporary employment status. |
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 6
Feb 8, 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 was found deficient in several areas including failure to complete background checks for employees, maintaining a clean and clutter-free backyard, obtaining waivers for bedfast residents, incomplete medication administration records, improper medication labeling, and lack of cultural competency training for employees.
Severity Breakdown
2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure a background check was initiated and completed through the Nevada Automated Background Check System (NABS) upon hire for 1 of 4 employees. | 2 |
| Failed to ensure the backyard was free of garbage and debris; multiple broken items and trash were noted throughout the backyard. | 2 |
| Failed to ensure a waiver was obtained to maintain residents who were bedfast for 2 of 8 residents. | 2 |
| Failed to ensure the Medication Administration Record (MAR) was properly documented for 3 of 8 residents; MARs did not list the year, month, or date. | 2 |
| Failed to ensure all medications were properly labeled with resident's name, prescribing physician, and directions for use for 1 of 8 residents. | 2 |
| Failed to submit an application for a cultural competency training program and ensure 4 of 4 employees were in compliance with annual cultural competency training requirements. | 2 |
Report Facts
Residents present: 8
Total licensed capacity: 10
Employees reviewed: 4
Residents reviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tess Pascual | Owner/Provider | Named as Owner/Provider responsible for plan of correction and confirmed findings |
Inspection Report
Re-Inspection
Census: 9
Capacity: 10
Deficiencies: 0
May 11, 2022
Visit Reason
This inspection was a State Licensure mandatory grading resurvey conducted to assess compliance 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. Guidance was provided on nondiscrimination policies, privacy protections, cultural competency training, and complaint policies.
Report Facts
Resident files reviewed: 8
Employee files reviewed: 3
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 5
Feb 7, 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 was found deficient in multiple areas including failure to implement safe infection control practices related to COVID-19, incomplete tuberculosis (TB) testing and monitoring for employees and residents, lack of required medication reviews for residents, and failure to provide required training for caregivers related to care for persons with intellectual disabilities.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to implement safe infection control practices for COVID-19, including lack of screening questions, temperature checks, and mask usage by employees. | Severity: 2 |
| Failure to ensure 2 of 3 sampled employees had complete tuberculosis (TB) testing and monitoring documentation. | Severity: 2 |
| Failure to ensure medication reviews were completed at least once every six months for 5 of 9 sampled residents. | Severity: 2 |
| Failure to ensure 6 of 9 sampled residents met tuberculosis (TB) testing requirements, including initial two-step TB tests within five days of admission and annual TB tests. | Severity: 2 |
| Failure to ensure 3 of 3 sampled employees completed four hours of training related to care for persons with intellectual disabilities within 60 days of hire. | Severity: 2 |
Report Facts
Facility licensed capacity: 10
Resident census: 9
Employees reviewed: 3
Residents reviewed: 9
Deficiencies with medication reviews: 5
Deficiencies with TB testing: 6
Deficiencies with caregiver training: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tess Pascual | Provider | Signed the report as the provider. |
| Owner | Acknowledged deficiencies related to infection control, TB testing, medication reviews, and training. |
Inspection Report
Re-Inspection
Census: 4
Capacity: 10
Deficiencies: 5
Apr 14, 2021
Visit Reason
This inspection was conducted as a State Licensure Change of Ownership grading re-survey for Shepherd Care Home to be licensed for ten Residential Facility for Group beds.
Findings
The facility received a grade of A. Several regulatory deficiencies were identified related to administrator oversight, health and sanitation, laundry and linen services, kitchen equipment, and food storage.
Severity Breakdown
F: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Administrator's Responsibilities - Oversight - NAC 449.194 Responsibilities of administrator. | F |
| Health & Sanitation - odors, hazards, insects, dirt - NAC 449.209 Health and sanitation. | F |
| Laundry & Linen Services Provided - NAC 449.213 Laundry and linen services. | F |
| Kitchens - Equipment Works; Clean And Sanitary - NAC 449.217 Kitchens; storage of food; adequate supplies of food; permits; inspections. | F |
| Storage of Food - Perishable Foods Refrigerated - NAC 449.217 Kitchens; storage of food; adequate supplies of food; permits; inspections. | F |
Report Facts
Licensed beds: 10
Census: 4
Inspection Report
Original Licensing
Census: 4
Capacity: 10
Deficiencies: 6
Feb 23, 2021
Visit Reason
The inspection was conducted as a State Licensure Change of Ownership full survey and focused COVID-19 Infection Control Survey for Shepherd Care Home, which requested licensing for ten Residential Facility for Group beds for elderly or disabled persons and others.
Findings
The facility failed to implement safe infection control practices, including caregivers not wearing face masks properly and failure to ensure social distancing among residents. Additional deficiencies included presence of cockroaches in the kitchen, lack of a dryer, unclean and partially non-functional stove and oven, and refrigerators not maintaining proper temperatures.
Severity Breakdown
F: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Two caregivers failed to wear face masks properly in accordance with the facility's Infection Control and Prevention Plan and CDC guidelines. | F |
| Failure to ensure social distancing between residents during meal service; residents sat less than six feet apart. | F |
| Presence of cockroaches in the kitchen including garbage can and cupboards; grease accumulation and dried food residue in oven drawer. | F |
| No dryer available at the facility; dryer had been removed due to malfunction. | F |
| Oven and stove were not maintained in clean and functional condition; two stove burners not functional; grease and food residue present. | F |
| Refrigerators failed to maintain temperature at or below 40 degrees Fahrenheit; observed at 50 degrees Fahrenheit. | F |
Report Facts
Census: 4
Total licensed capacity: 10
PPE supply: 250
PPE supply: 10
PPE supply: 5
PPE supply: 35
PPE supply: 5
PPE supply: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tess Pascual | Manager Employee in Charge | Named as Facility Manager and Employee in Charge responsible for infection control and plan of correction |
Inspection Report
Complaint Investigation
Census: 7
Capacity: 7
Deficiencies: 5
Nov 3, 2020
Visit Reason
The inspection was conducted as a result of a COVID-19 focused infection control survey and a complaint investigation triggered by complaint #NV00062396 with three substantiated allegations.
Findings
The facility was found to have unprofessional and unsanitary modifications to kitchen plumbing, medication errors, and residents overdue or lacking physical examinations and tuberculosis testing. Additionally, infection control deficiencies were noted including lack of visitor screening per CDC guidelines, caregivers not using PPE, and absence of N95 respirators and fit testing.
Complaint Details
Complaint #NV00062396 with three allegations was substantiated: unprofessional and unsanitary kitchen plumbing modifications, medication errors, and residents overdue or lacking physical examinations and tuberculosis testing.
Severity Breakdown
2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Administrator did not ensure visitors were screened for COVID-19 according to CDC guidelines, staff did not follow infection control policy, and facility lacked N95 respirators and fit testing. | 2 |
| Kitchen sink plumbing was unprofessionally modified leading to unsanitary conditions and dirt in the side yard. | 2 |
| Facility failed to ensure initial and annual physical examinations were completed for 1 of 7 residents. | 2 |
| Facility failed to ensure prescribed medication (Acetaminophen ES 500 mg) was available for 1 of 7 residents. | 2 |
| Facility failed to ensure annual tuberculosis test results were available for 2 of 7 residents. | 2 |
Report Facts
Census: 7
Total Capacity: 7
Severity 2 Deficiencies: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tess Pascual | Manager Employee in Charge | Signed the report and mentioned as Administrator in findings |
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