Inspection Report
Annual Inspection
Census: 23
Capacity: 30
Deficiencies: 19
Sep 16, 2024
Visit Reason
This inspection was a State Licensure annual grading survey conducted by the Division of Public and Behavioral Health in accordance with NAC 449 for a Residential Facility for Groups.
Findings
The facility received a grade of D with multiple deficiencies identified including failure to provide adequate oversight, incomplete caregiver training, expired CPR and medication technician licenses, expired food items, unsecured oxygen tanks, medication administration errors, incomplete personnel files, missing annual assessments, and incomplete infection control training.
Severity Breakdown
Level 1: 1
Level 2: 18
Deficiencies (19)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight and direction to ensure residents received needed services and protective supervision. | Level 2 |
| Failed to ensure 7 of 15 employees received required Tier 2 caregiver training within 60 days of hire and annually thereafter. | Level 2 |
| Failed to ensure 1 of 4 employees completed annual medication management training. | Level 2 |
| Failed to ensure 8 of 15 employees received initial elder abuse training prior to employment and annually thereafter. | Level 2 |
| Failed to ensure 2 of 15 employees had complete personnel files including reference checks and training documentation. | Level 2 |
| Expired food items were not removed from refrigerator and pantry. | Level 2 |
| Failed to ensure timely first aid and CPR training for 6 of 15 employees. | Level 2 |
| First aid kit in medication room lacked a thermometer. | Level 2 |
| Failed to post Administrator and designee contact information in a conspicuous place. | Level 1 |
| Oxygen tanks were stored unsecured in resident's closet. | Level 2 |
| Failed to ensure annual physical examinations and placement determinations were completed timely for residents with dementia. | Level 2 |
| Medications were administered without signed physician orders, medication not on site, missing medication change labels, and incomplete MARs for sampled residents. | Level 2 |
| Failed to ensure discontinued medications were destroyed properly in presence of witness and documented. | Level 2 |
| Resident self-administered medications and over-the-counter medications were not secured in locked containers or rooms. | Level 2 |
| Failed to ensure initial and annual Activities of Daily Living (ADL) assessments were completed for sampled residents. | Level 2 |
| Failed to ensure dementia training requirements were met for employees including Tier 2 training within 40 hours, 8 hours within 3 months, and 3 hours annually by anniversary date. | Level 2 |
| Failed to ensure cultural competency training was completed timely for 5 of 15 sampled employees. | Level 2 |
| Failed to ensure secondary infection control person completed required 15 hours of infection control training. | Level 2 |
| Failed to ensure 7 of 15 employees obtained required infection control training concerning control and prevention of infectious diseases. | Level 2 |
Report Facts
Facility licensed beds: 30
Current census: 23
Deficiencies cited: 19
Resurvey fee: 600
Employees sampled: 15
Residents sampled: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristy Lavey | Executive Director | Named in multiple findings and responsible for corrective actions |
| Business Office Manager | Provided personnel checklists, attestation of compliance, and acknowledged missing documentation | |
| Wellness Director | Involved in training, interviews, and corrective action responses |
Inspection Report
Annual Inspection
Census: 22
Capacity: 30
Deficiencies: 4
Jun 13, 2024
Visit Reason
This inspection was a State Licensure annual grading survey conducted by the Division of Public and Behavioral Health in accordance with NAC 449 for Residential Facility for Groups.
Findings
The facility received a grade of B with multiple deficiencies identified related to caregiver qualifications, personnel files, training requirements including first aid, CPR, dementia care, cultural competency, medication administration, and infection control. Several deficiencies were repeat findings from previous surveys.
Severity Breakdown
Level 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to initiate background check process within 10 days of hire for 3 of 9 sampled employees. | Level 2 |
| Failed to ensure timely first aid and CPR training for 6 of 9 sampled employees working greater than 30 days. | Level 2 |
| Failed to ensure 3 of 9 sampled employees received two hours of dementia training within the first 40 hours of employment. | Level 2 |
| Failed to ensure cultural competency training was completed timely for 9 of 9 sampled employees required to obtain it. | Level 2 |
Report Facts
Licensed beds: 30
Census: 22
Sampled employees: 9
Sampled residents: 6
Deficiency severity counts: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Resident Assistant | Named in background check, first aid/CPR, and cultural competency training deficiencies |
| Employee #2 | Resident Assistant | Named in background check, dementia training, and cultural competency training deficiencies |
| Employee #3 | Resident Assistant | Named in background check and cultural competency training deficiencies |
| Employee #4 | Resident Assistant | Named in first aid/CPR and cultural competency training deficiencies |
| Employee #5 | Resident Assistant | Named in dementia training and cultural competency training deficiencies |
| Employee #6 | Resident Assistant | Named in cultural competency training deficiency |
| Employee #7 | Resident Assistant | Named in cultural competency training deficiency |
| Employee #8 | Resident Assistant | Named in first aid/CPR and cultural competency training deficiencies |
| Employee #9 | Resident Assistant | Named in first aid/CPR, dementia training, and cultural competency training deficiencies |
| Wellness Director | Provided attestation of compliance and was involved in medication administration and personnel record reviews | |
| Business Office Manager | Provided personnel checklist and documentation during inspection | |
| Executive Director | Implemented corrective actions including hiring new Business Office Manager and scheduling trainings |
Inspection Report
Complaint Investigation
Census: 23
Capacity: 30
Deficiencies: 0
Apr 23, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding an allegation that the facility failed to provide protective supervision for a resident who eloped.
Findings
The complaint was unsubstantiated due to lack of evidence of noncompliance. Observations, interviews, clinical record reviews, and policy reviews were conducted, and no regulatory deficiencies were identified.
Complaint Details
Complaint #NV00070983 was investigated and found unsubstantiated. The allegation that the facility failed to provide protective supervision for a resident who eloped was not supported by evidence.
Report Facts
Licensed beds: 30
Resident census: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver | Interviewed during complaint investigation | |
| Medication Technician | Interviewed during complaint investigation | |
| Wellness Director | Interviewed during complaint investigation |
Inspection Report
Annual Inspection
Census: 22
Capacity: 30
Deficiencies: 17
Dec 20, 2023
Visit Reason
This inspection was a State Licensure annual grading survey conducted by the Division of Public and Behavioral Health in accordance with NAC 449 for Residential Facility for Groups.
Findings
The facility received a grade of D with multiple deficiencies identified including caregiver training, personnel file compliance, medication administration issues, infection control program deficiencies, and failure to meet tuberculosis testing requirements among others.
Severity Breakdown
Level 1: 1
Level 2: 15
Deficiencies (17)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 3 sampled employees received eight hours of annual training to care for elderly and disabled residents. | Level 2 |
| Failed to ensure an employee completed a physical examination and tuberculosis test prior to working for 1 of 15 employees. | Level 2 |
| Failed to initiate background check process within 10 days of hire for 3 of 15 sampled employees. | Level 2 |
| Failed to ensure timely first aid and CPR training for 6 of 14 sampled employees working greater than 30 days. | Level 2 |
| Failed to ensure kitchen and supportive dining services complied with NAC 446 standards; kitchen surfaces and floors were dirty and heavily soiled. | Level 2 |
| Failed to ensure a general physical examination was completed on or prior to admission for 1 of 10 sampled residents. | Level 2 |
| Failed to ensure medication profile review was reviewed and initialed by Administrator within 72 hours for 1 of 10 sampled residents. | Level 2 |
| Failed to ensure medications were on-site as prescribed for 2 of 10 sampled residents; medications administered not per physician's order for 1 resident; medication containers lacked change labels for 1 resident. | Level 2 |
| Failed to ensure 3 of 10 sampled residents met tuberculosis testing requirements per NAC 441A. | Level 2 |
| Failed to ensure Activities of Daily Living assessment was completed upon admission for 1 of 10 residents. | Level 2 |
| Failed to ensure 9 of 10 sampled employees had initial training in caregiving for elderly or disabled persons within 60 days of hire. | Level 2 |
| Failed to ensure 7 of 11 sampled employees received two hours of dementia training within first 40 hours of employment. | Level 2 |
| Failed to ensure 9 of 9 sampled employees received at least eight hours of dementia training within three months of hire. | Level 2 |
| Failed to ensure cultural competency training was completed timely for 5 of 15 sampled employees. | Level 2 |
| Failed to develop a comprehensive infection control program and corresponding policies to prevent and control infections affecting all residents. | Level 2 |
| Primary infection control staff and designee lacked required infection control training. | Level 2 |
| Failed to post Administrator's license and Administrator's designee contact information in a conspicuous place in the facility. | Level 1 |
Report Facts
Facility licensed beds: 30
Current census: 22
Employees sampled: 15
Residents sampled: 10
Inspection date: Dec 20, 2023
Inspection grade: D
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristy Lavey | Executive Director | Named in multiple findings and plan of correction responses |
| Employee #2 | Wellness Director | Named in training and personnel file deficiencies |
| Employee #7 | Executive Director | Named in personnel file deficiencies for physical exam and TB testing |
| Employee #4 | Resident Assistant/Medication Technician | Named in training deficiencies |
| Employee #8 | Resident Assistant | Named in training deficiencies |
| Employee #10 | Resident Assistant/Medication Technician | Named in training and medication administration deficiencies |
| Employee #12 | Resident Assistant | Named in background check and training deficiencies |
| Employee #13 | Resident Assistant | Named in training deficiencies |
| Employee #15 | Resident Assistant | Named in training deficiencies |
Inspection Report
Re-Inspection
Census: 20
Capacity: 30
Deficiencies: 12
May 30, 2023
Visit Reason
This inspection was a State Licensure grading re-survey conducted to assess compliance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.
Findings
The facility received a grade of A with several deficiencies identified, including failure to ensure a resident receiving skilled nursing services was not allowed to remain without a waiver, medication administration errors including missing orders and unavailable medications, and failure to destroy discontinued medications. Other areas such as laundry, kitchen equipment, first aid, and discrimination policies were found compliant or waived.
Severity Breakdown
Level 2: 3
Level E: 3
Level D: 4
Level F: 1
Level C: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident receiving skilled nursing services was not allowed to admit or remain without a waiver. | Level 2 |
| Failed to ensure a change label was affixed to medication labels, active orders were missing, and ordered medications were unavailable for 3 of 6 sampled residents. | Level 2 |
| Failed to ensure discontinued medication was destroyed timely for 1 of 6 sampled residents. | Level 2 |
| Elder Abuse Training requirements not fully met (waived). | Level E |
| Laundry and linen services requirements met (waived). | Level D |
| Kitchen equipment clean, sanitary, and functional (waived). | Level F |
| First Aid and CPR training and supplies requirements met (waived). | Level D |
| Residents requiring oxygen use requirements met (waived). | Level D |
| Medication administration reporting and restrictions requirements met (waived or deficient as noted). | Level D or E |
| Maintenance and contents of resident files requirements met (waived). | Level E |
| Discrimination prohibited policies and postings requirements met (waived). | Level C |
| Cultural competency training requirements met (waived). | Level E |
Report Facts
Licensed beds: 30
Resident census: 20
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristy Lavey | Executive Director | Named in relation to findings and plan of correction for skilled nursing admission and medication issues |
Inspection Report
Annual Inspection
Census: 19
Capacity: 30
Deficiencies: 15
Jan 24, 2023
Visit Reason
This inspection was a State Licensure annual grading survey conducted to assess compliance with NAC 449 for Residential Facility for Groups.
Findings
The facility received a grade of D with multiple deficiencies identified including failure to ensure timely elder abuse training, laundry lint trap maintenance, kitchen sanitation and food safety issues, timely first aid and CPR training, admission policy violations regarding skilled nursing residents, unsecured oxygen tanks, medication administration errors, incomplete resident assessments, and failure to post required nondiscrimination statements and complaint information.
Severity Breakdown
Level 1: 2
Level 2: 11
Level 3: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure 3 of 10 employees received initial elder abuse training prior to beginning work and annually thereafter. | Level 2 |
| Failed to ensure dryer lint trap was free from excessive lint. | Level 2 |
| Failed to ensure dented cans were not stored with non-dented canned food inventory and other kitchen sanitation issues. | Level 3 |
| Failed to ensure timely first aid and CPR training for 2 of 10 sampled employees. | Level 2 |
| Failed to ensure expired medications in first aid kits were destroyed. | Level 2 |
| Failed to ensure residents receiving skilled nursing services were not admitted or allowed to remain without required waivers. | Level 2 |
| Failed to ensure oxygen tanks were secured properly. | Level 2 |
| Failed to ensure six-month pharmacy review was completed timely for 1 of 10 sampled residents. | Level 2 |
| Failed to notify resident's physician within 72 hours of pharmacist's medication profile recommendation for 1 of 10 sampled residents. | Level 2 |
| Failed to ensure physician order was provided for medications on-site to administer as prescribed for 1 of 10 sampled residents. | Level 2 |
| Failed to ensure written instructions indicating specific symptoms for PRN medication were documented for 1 of 10 sampled residents. | Level 2 |
| Failed to ensure Activities of Daily Living (ADL) assessments were completed on or before admission for 3 of 10 sampled residents. | Level 2 |
| Failed to post a current nondiscrimination statement prominently in the facility and on any Internet website used to market the facility. | Level 1 |
| Failed to post prominently in the facility the State contact information to file a complaint for residents who may have experienced prohibited discrimination. | Level 1 |
| Failed to ensure cultural competency training was completed timely for 2 of 9 sampled employees required to obtain training. | Level 2 |
Report Facts
Facility licensed beds: 30
Current census: 19
Deficiency severity counts: 14
Inspection date: Jan 24, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Administrator | Named in elder abuse training and first aid/CPR training deficiencies |
| Employee #2 | Executive Director | Named in elder abuse training and cultural competency training deficiencies |
| Employee #3 | Wellness Director | Named in elder abuse training deficiency |
| Employee #6 | Executive Director | Named in cultural competency training deficiency |
| Employee #9 | Resident Assistant | Named in first aid/CPR training and medication order deficiencies |
Inspection Report
Re-Inspection
Census: 21
Capacity: 30
Deficiencies: 11
Jun 6, 2022
Visit Reason
This inspection was a State Licensure mandatory regrading survey conducted in accordance with NAC 449 for a Residential Facility for Groups.
Findings
The facility received a grade of A. Several deficiencies were identified related to elder abuse training, personnel file requirements, health and sanitation, food service permits, bedroom door locks, and medication administration including destruction of discontinued medications.
Severity Breakdown
D: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Elder Abuse Training requirements not fully met as per NRS 449.093. | D |
| Personnel files missing required TB screening documentation as per NAC 449.200. | D |
| Facility premises not adequately maintained in terms of interior, exterior, and landscaping as per NAC 449.209. | D |
| Failure to comply with food service permits and inspections requirements under NAC 446 and NAC 449.217. | D |
| Bedroom doors with locks not compliant with NAC 449.220 requirements. | D |
| Medication administration deficiencies including failure to review medication regimens every 6 months and maintain proper reports as per NAC 449.2742. | D |
| Failure to notify resident's physician within 72 hours of medication administration concerns as required by NAC 449.2742. | D |
| Improper administration and documentation of over-the-counter medications and dietary supplements as per NAC 449.2742. | D |
| Failure to timely remove and destroy discontinued medication for Resident #4, violating NAC 449.2742. | D |
| Restrictions on administration of 'as needed' medications not fully followed as per NAC 449.2746. | D |
| Maintenance and contents of separate resident files not fully compliant with NAC 449.2749. | D |
Report Facts
Licensed capacity: 30
Census: 21
Deficiency severity count: 11
Discontinued medication: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ilda Angulo | Executive Director | Signed as Laboratory Director's or Provider/Supplier Representative on report |
Inspection Report
Annual Inspection
Census: 21
Capacity: 30
Deficiencies: 10
Feb 22, 2022
Visit Reason
This inspection was a State Licensure annual grading survey conducted by the Division of Public and Behavioral Health in accordance with NAC 449, Residential Facility for Groups.
Findings
The facility received a grade of C with multiple deficiencies identified including failure to ensure annual elder abuse training for employees, incomplete pre-employment physicals, inadequate maintenance and sanitation issues, medication administration and documentation deficiencies, and failure to meet tuberculosis testing requirements.
Severity Breakdown
D: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to ensure employees completed annual elder abuse prevention training and initial training by date of hire. | D |
| Failure to ensure pre-employment physical examination was completed for 1 of 10 employees. | D |
| Failure to maintain clean and well-maintained exterior premises; doors and chair stored outside. | D |
| Failure to comply with food service permits and standards; improper quat sanitizer concentration and dirty kitchen floors. | D |
| Resident bedroom doors equipped with double-motion locks instead of single motion locks. | D |
| Failure to ensure medication profile reviews were initialed by the Administrator for multiple residents. | D |
| Failure to have medications onsite as prescribed for 1 of 15 residents. | D |
| Failure to remove and destroy discontinued medications in a timely manner. | D |
| Failure to document written instructions for administration of as-needed medications for 1 resident. | D |
| Failure to meet tuberculosis testing requirements for 1 resident; second step TB test read late. | D |
Report Facts
Facility licensed beds: 30
Resident census: 21
Survey date: Feb 22, 2022
Grade received: C
Deficiency severity count: 10
Fine for resurvey application: 600
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ERIC MAGER | Administrator | Named as Administrator responsible for compliance and plan of correction |
| Employee #4 | Failed to complete annual elder abuse prevention training for 2021 | |
| Employee #3 | Completed initial elder abuse prevention training late after hire date | |
| Employee #6 | Lacked documented evidence of pre-employment physical | |
| Employee #5 | Lacked documented evidence of pre-employment physical | |
| Business Office Manager | Confirmed training and physical exam deficiencies and took corrective actions | |
| Maintenance Director | Replaced unauthorized door locks | |
| Dining Director | Addressed food service deficiencies and sanitation | |
| Wellness Director | Involved in medication review and destruction corrective actions |
Inspection Report
Annual Inspection
Census: 17
Capacity: 30
Deficiencies: 7
Mar 30, 2021
Visit Reason
This inspection was conducted as a State Licensure annual grading survey to assess compliance with NAC 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but had deficiencies related to kitchen food service standards, including improper storage of utensils, cleanliness issues, inadequate lighting and ventilation, and medication administration errors for sampled residents.
Severity Breakdown
E: 3
2: 2
D: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Improper storage of disposable utensils with food contact surfaces pointing up. | E |
| Heavily soiled floors in multiple storage rooms including refrigeration, freezer, and dry storage rooms. | E |
| Equipment and kitchen essentials stored on crates placed directly on the floor. | E |
| Inadequate lighting in the Dry Storage room. | 2 |
| Inadequate ventilation in the Refrigeration room with excessive heat above 90 degrees F and no mechanical ventilation. | 2 |
| Failure to administer medication as ordered by the physician for Resident #6. | D |
| Failure to ensure symptoms for administering PRN medications were present for Residents #2 and #5. | D |
Report Facts
Licensed beds: 30
Current census: 17
Deficiency severity counts: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric Mager | Administrator | Signed report and responsible for oversight of corrective actions |
| Dining Director | Named in multiple findings related to kitchen utensil storage, cleanliness, and food storage | |
| Maintenance Director | Named in findings related to lighting and ventilation corrections | |
| Wellness Director | Named in findings related to medication administration and clarifications |
Inspection Report
Renewal
Census: 20
Capacity: 30
Deficiencies: 0
Sep 16, 2020
Visit Reason
This inspection was conducted as a State Licensure re-grading survey for a Residential Facility for Groups in accordance with Nevada Administrative Code Chapter 449.
Findings
The facility received a grade of A with no deficiencies identified during the survey. Six resident files were reviewed and all medication administration and record-keeping requirements were found to be in compliance.
Report Facts
Licensed beds: 30
Census: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric Mager | Administrator | Signed the report as Laboratory Director's or Provider/Supplier Representative |
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