Inspection Reports for Shiny Stars Home Care
1032 Silver Creek Ave., Las Vegas, NV 89183, NV, 89183
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Inspection Report
Annual Inspection
Census: 2
Capacity: 4
Deficiencies: 0
Sep 17, 2024
Visit Reason
This 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 with no regulatory deficiencies identified. Two resident files and four employee files were reviewed, and no further action is necessary.
Inspection Report
Annual Inspection
Census: 3
Capacity: 4
Deficiencies: 0
Sep 20, 2023
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 with no regulatory deficiencies identified. Three resident files and three employee files were reviewed, and no further action was necessary.
Report Facts
Resident files reviewed: 3
Employee files reviewed: 3
Inspection Report
Annual Inspection
Census: 2
Capacity: 4
Deficiencies: 0
Sep 28, 2022
Visit Reason
The inspection was conducted as a result of an annual State Licensure, infection control survey and complaint investigation at the facility.
Findings
The facility was found to be in compliance with no regulatory deficiencies identified. The complaint investigation with seven allegations was unsubstantiated based on observations, interviews, and record reviews.
Complaint Details
Complaint #NV00066994 with seven allegations was investigated and found unsubstantiated. Allegations included inadequate activities, inadequate care and supervision, soiled incontinence brief, resident staying in bed all day, lack of documentation, poor room temperature control, and wrongful termination of a bathing aide. All were unsubstantiated based on observations, interviews with residents and caregivers, and record reviews.
Report Facts
Licensed beds: 4
Residents present: 2
Complaint allegations: 7
Inspection Report
Annual Inspection
Census: 3
Capacity: 4
Deficiencies: 3
Oct 1, 2021
Visit Reason
The 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 but was found deficient in several areas including failure to obtain bedfast waivers for two residents, failure to ensure medication reviews every six months for two residents, and failure to provide required Alzheimer's care endorsement and physician placement forms for two residents with Alzheimer's disease or related dementia.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to obtain a bedfast waiver/exemption for two residents who were bedfast and required repositioning assistance every two hours. | Severity: 2 |
| Failed to ensure a medication review was completed at least once every six months for two of three sampled residents. | Severity: 2 |
| Failed to provide a standard physician placement form and endorsement for care of residents with Alzheimer's disease or related dementia for two residents. | Severity: 2 |
Report Facts
Licensed beds: 4
Residents present: 3
Residents reviewed: 3
Employee records reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rosario Ramirez | Administrator | Named as Laboratory Director's or Provider/Supplier Representative who signed the report |
| Employee #2 | Provided information confirming residents were bedfast and lack of bedfast waivers | |
| Caregiver | Acknowledged lack of six-month medication reviews and missing physician placement forms |
Inspection Report
Abbreviated Survey
Census: 4
Capacity: 4
Deficiencies: 0
Oct 21, 2020
Visit Reason
The inspection was conducted as a COVID-19 focused infection control survey at the facility from 10/14/20 through 10/21/20 in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Findings
The facility was found to have comprehensive infection control and prevention measures in place, including PPE supplies, staff training, screening protocols, and visitation policies. No regulatory deficiencies were identified during the survey.
Report Facts
PPE supplies: 30
PPE supplies: 1
PPE supplies: 10
PPE supplies: 1
PPE supplies: 900
Hand sanitizer bottles: 8
Handheld temporal thermometers: 2
N95 masks: 3
Residents observed: 2
Relief caregivers: 2
Inspection Report
Complaint Investigation
Census: 2
Deficiencies: 0
Jun 4, 2020
Visit Reason
The inspection was conducted as a result of a complaint investigation on the facility from 06/01/20 through 06/04/20 regarding two allegations.
Findings
The complaint investigation found both allegations unsubstantiated with no regulatory deficiencies identified. No further action was necessary.
Complaint Details
Complaint # NV00061157 with two allegations was investigated and found unsubstantiated: 1) inappropriate admission of a resident, 2) incomplete medical records lacking a pressure ulcer waiver.
Report Facts
Complaint allegations: 2
Sample size: 1
Inspection Report
Re-Inspection
Census: 3
Capacity: 4
Deficiencies: 13
Feb 27, 2020
Visit Reason
This inspection was conducted as a state licensure re-grading survey of the residential facility for groups, in accordance with Nevada Administrative Code Chapter 449.
Findings
The facility received a grade of A with no regulatory deficiencies identified. Several areas such as staffing schedules, personnel files, menus, activities for residents, medication administration, medication storage, and maintenance of resident files were reviewed with no deficiencies noted.
Severity Breakdown
C: 3
D: 4
E: 2
F: 5
Deficiencies (13)
| Description | Severity |
|---|---|
| Staffing Schedule - NAC 449.199 Staffing requirements 4. The administrator of a residential facility shall maintain monthly a written schedule that includes the number and type of members of the staff of the facility assigned for each shift. The schedule must be amended if any changes are made to the schedule. The schedule must be retained for at least 6 months after the schedule expires. | C |
| Personnel File - TB Screening - NAC 449.200 Personnel files. 1. Except as otherwise provided in subsection 2, a separate personnel file must be kept for each member of the staff of a facility and must include: (d) The health certificates required pursuant to chapter 441A of NAC for the employee. | E |
| Service of Food - Menus - NAC 449.2175 3. Menus must be in writing, planned a week in advance, dated, posted and kept on file for 90 days. | C |
| Activities for Residents - NAC 449.260 Activities for residents. (NRS 449.0302) 1. The caregivers employed by a residential facility shall: (g) Post, in a common area of the facility, a calendar of activities for each month that notifies residents of the major activities that will occur in the facility. The calendar must be: (1) Prepared at least 1 month in advance; and (2) Kept on file at the facility for not less than 6 months after it expires. | C |
| Exemption Requests - NAC 449.2736 Procedure to exempt certain residents from restrictions. (NRS 449.0302) 1. The administrator of a residential facility may submit to the Division a written request for permission to admit or retain a resident who is prohibited from being admitted to a residential facility or remaining as a resident of the facility pursuant to NAC 449.271 to 449.2734, inclusive. | D |
| Medication Administration - NRS 449.0302 - NAC 449.2742 - Administration of medication: Responsibilities of administrator, caregiver and employees of facility. (as amended by LCB File No. R109-18) 4. Except as otherwise provided in this subsection, a caregiver shall assist in the administration of medication to a resident if the resident needs the caregiver's assistance. A caregiver may assist the ultimate user of: (a) Controlled substances or dangerous drugs only if the conditions prescribed in subsection 6 of NRS 449.0302 are met. (b) Insulin using an auto-injection device only if the conditions prescribed in NRS 449.0304 and section 13 of this regulation are met. | D |
| Medication/OTCS, Supplements, Change Order - NAC 449.2742 - Administration of medication: Responsibilities of administrator, caregiver and employees of facility. 5. An over-the-counter medication or a dietary supplement may be given to a resident only if the resident's physician has approved the administration of the medication or supplement in writing or the facility is ordered to do so by another physician. The over-the-counter medication or dietary supplement must be administered in accordance with the written instructions of the physician. The administration of over-the-counter medications and dietary supplements must be included in the record required pursuant to paragraph (b) of subsection 1 of NAC 449.2744. 6. Except as otherwise provided in this subsection, a medication prescribed by a physician must be administered as prescribed by the physician. If a physician orders a change in the amount or times medication is to be administered to a resident: (a) The caregiver responsible for assisting in the administration of the medication shall: (1) Comply with the order; (2) Indicate on the container of the medication that a change has occurred; and (Previously Y 0879) (3) Note the change in the record maintained pursuant to paragraph (b) of subsection 1 of NAC 449.2744; (b) Within 5 days after the change is ordered, a copy of the order or prescription signed by the physician must be included in the record maintained pursuant to paragraph (b) of subsection 1 of NAC 449.2744; and (c) If the label prepared by a pharmacist does not match the order or prescription written by a physician, the physician, registered nurse or pharmacist must interpret that order or prescription and, within 5 days after the change is ordered, the interpretation must be included in the record maintained pursuant to paragraph (b) of subsection 1 of NAC 449.2744. | F |
| Administration of Medication Maintenance - NAC 449.2744 Administration of medication: Maintenance and contents of logs and records. (NRS 449.0302) 1. The administrator of a residential facility that provides assistance to residents in the administration of medications shall maintain: (b) A record of the medication administered to each resident. The record must include: (1) The type of medication administered; (2) The date and time that the medication was administered; (3) The date and time that a resident refuses, or otherwise misses, an administration of medication; and (4) Instructions for administering the medication to the resident that reflect each current order or prescription of the resident's physician. | F |
| Medication: Storage - NAC 449.2748 Medication: Storage; duties upon discharge, transfer and return of resident. (NRS 449.0302) 1. Medication, including, without limitation, any over-the-counter medication, stored at a residential facility must be stored in a locked area that is cool and dry. The caregivers employed by the facility shall ensure that any medication or medical or diagnostic equipment that may be misused or appropriated by a resident or any other unauthorized person is protected. Medications for external use only must be kept in a locked area separate from other medications. A resident who is capable of administering medication to himself or herself without supervision may keep the resident's medication in his or her room if the medication is kept in a locked container for which the facility has been provided a key. 2. Medication stored in a refrigerator, including, without limitation, any over-the-counter medication, must be kept in a locked box unless the refrigerator is locked or is located in a locked room. | F |
| Medication: Storage - NAC 449.2748 Medication: Storage; duties upon discharge, transfer and return of resident. (NRS 449.0302) 3. Medication, including, without limitation, any over-the-counter medication or dietary supplement, must be: (a) Plainly labeled as to its contents, the name of the resident for whom it is prescribed and the name of the prescribing physician; and (b) Kept in its original container until it is administered. | D |
| Maintenance and Contents of Separate File - NAC 449.2749 Maintenance and contents of separate file for each resident; confidentiality of information. (NRS 449.0302) 1. A separate file must be maintained for each resident of a residential facility and retained for at least 5 years after he or she permanently leaves the facility. The file must be kept locked in a place that is resistant to fire and is protected against unauthorized use. The file must contain all records, letters, assessments, medical information and any other information related to the resident, including, without limitation: (a) The full name, address, date of birth and social security number of the resident. (b) The address and telephone number of the resident's physician and the next of kin or guardian of the resident or any other person responsible for the resident. (c) A statement of the resident's allergies, if any, and any special diet or medication he or she requires. | F |
| Maintenance and Contents of Separate File - NAC 449.2749 Maintenance and contents of separate file for each resident; confidentiality of information. (NRS 449.0302) 1. A separate file must be maintained for each resident of a residential facility and retained for at least 5 years after he or she permanently leaves the facility. The file must be kept locked in a place that is resistant to fire and is protected against unauthorized use. The file must contain all records, letters, assessments, medical information and any other information related to the resident, including, without limitation: (e) Evidence of compliance with the provisions of chapter 441A of NRS and the regulations adopted pursuant thereto. | E |
| Maintenance and Contents of Separate File - NAC 449.2749 Maintenance and contents of separate file for each resident; confidentiality of information. (NRS 449.0302) 1. A separate file must be maintained for each resident of a residential facility and retained for at least 5 years after he or she permanently leaves the facility. The file must be kept locked in a place that is resistant to fire and is protected against unauthorized use. The file must contain all records, letters, assessments, medical information and any other information related to the resident, including, without limitation: (g) An evaluation of the resident's ability to perform the activities of daily living and a brief description of any assistance he or she needs to perform those activities. The facility shall prepare such an evaluation: (1) Upon the admission of the resident; (2) Each time there is a change in the mental or physical condition of the resident that may significantly affect his or her ability to perform the activities of daily living; and (3) In any event, not less than once each year. | D |
Report Facts
Licensed beds: 4
Census: 3
Inspection Report
Annual Inspection
Census: 3
Capacity: 4
Deficiencies: 13
Jan 2, 2020
Visit Reason
This inspection was a State licensure annual survey conducted to assess compliance with Nevada Administrative Code Chapter 449 for a residential facility for groups.
Findings
The facility received a grade of D with multiple deficiencies identified including failure to maintain a current staff schedule, lack of annual tuberculosis testing for employees, failure to post a current menu and activities schedule, missing bedfast exemption for a resident, medication administration issues including missing ultimate user agreement and unavailable medications, inaccurate medication administration records, unsecured medications and resident files, and incomplete resident assessments.
Severity Breakdown
C: 3
D: 4
E: 2
F: 3
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to ensure a current staff schedule was posted. | C |
| Failed to provide annual tuberculosis testing for two employees. | E |
| Failed to post a current menu. | C |
| Failed to ensure a current activities schedule was posted. | C |
| Failed to obtain a bedfast exemption for Resident #2. | D |
| Failed to provide a signed ultimate user agreement for medication administration for Resident #3. | D |
| Medications were not available on site for Residents #1 and #3; physician orders and medication labels did not match for Resident #3. | F |
| Medication administration records (MAR) were missing for December 2019 and January 2020 for all residents. | F |
| Medication cabinet was unsecured and not locked. | F |
| Medication (Fluticasone Propionate) was not kept in original container and Aspirin was not properly labeled. | D |
| Resident files were unsecured in an unlocked cabinet. | F |
| Failed to ensure initial two-step tuberculosis testing was completed and documented for Residents #2 and #3. | E |
| Failed to ensure an activities of daily living screening was completed upon admission for Resident #3. | D |
Report Facts
Residents present: 3
Total licensed capacity: 4
Deficiencies cited: 13
Severity 1 Scope 3: 2
Severity 2 Scope 3: 4
Inspection Report
Re-Inspection
Census: 3
Capacity: 4
Deficiencies: 12
Sep 10, 2019
Visit Reason
This inspection was a State Licensure required re-grading survey conducted on 09/10/2019 to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to have multiple deficiencies including failure to designate an employee in charge during administrator absence, failure to maintain clean and sanitary premises and kitchen, inadequate food storage, incomplete posting of license and rates, failure to obtain a medical exemption for a resident with wounds, and medication administration and storage issues.
Severity Breakdown
F: 5
C: 5
D: 1
E: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Administrator failed to designate one or more employees to be in charge during administrator absence with proper access and posting. | C |
| Facility failed to ensure premises were clean and well maintained. | F |
| Kitchen equipment was not clean or in good working condition. | F |
| Perishable foods were not refrigerated at required temperatures. | F |
| Insufficient and improperly packaged food storage. | F |
| Menus were not properly documented, dated, posted, and kept on file for 90 days. | C |
| Residents were not provided with written programs of activities. | C |
| Failure to post administrator license and rates conspicuously. | C |
| Facility failed to obtain a medical exemption for a resident with wounds as required. | D |
| Administrator failed to ensure medication regimen reviews and reports were conducted and maintained properly. | F |
| Medication containers were not plainly labeled or kept in original containers until administration. | E |
| Resident files lacked proper evaluations of activities of daily living upon admission. | C |
Report Facts
Licensed beds: 4
Resident census: 3
Re-survey grade: A
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rosario Ramirez | Administrator | Named as Administrator and signatory on the report |
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