Inspection Reports for Spruce Oak Residential Care Facility

This inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.

The facility was found to have no deficiencies and received a grade of A. Six resident files and four employee files were reviewed during the survey.

This inspection was conducted as an annual State Licensure survey of the Spruce Oak Residential Care Facility to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.

The facility received a grade of A overall; however, a regulatory deficiency was identified related to medication management training. Specifically, one employee (the Administrator) had not completed the required annual medication management training.

The inspection was conducted as a complaint investigation triggered by Complaint #NV00068725, which was verified during the visit to Spruce Oak Residential Care Facility on 07/18/2023.

The facility failed to comply with admission policies by admitting and retaining a bedfast resident with a worsening stage 4 pressure ulcer without requesting an exemption waiver. Additionally, the facility failed to notify the responsible party of the resident's worsening condition. The investigation included interviews, clinical record reviews, and observations.

Complaint #NV00068725 was verified. The complaint involved admission of a bedfast resident with a worsening pressure ulcer without exemption waiver and failure to notify the responsible party of the resident's condition.

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.

The facility received a grade of A. One deficiency was identified related to failure to ensure annual tuberculosis (TB) testing for one of six sampled residents (Resident #6).

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.

The facility received a grade of A but was found deficient in ensuring that employees received required elder abuse training and caregiver training. Specifically, 2 of 3 employees lacked documented annual or initial elder abuse training, and 1 of 3 employees lacked documented initial caregiver training.

A focused COVID-19 infection control survey was conducted to assess regulatory compliance with infection control and prevention measures related to COVID-19 at the facility.

The facility failed to ensure employees wore masks properly, lacked N95 masks with at least one employee medically cleared and fit tested for N95 use, and had incomplete infection control policies regarding COVID-19, including staff fit testing and reporting procedures for suspected or positive COVID-19 cases.

This inspection was conducted as a State Licensure annual survey of the facility in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.

The facility received a grade of A but had several deficiencies including failure to post current menus, lack of hand drying items in one bathroom, and improper documentation of a medication dosage change on the Medication Administration Record (MAR).

The inspection was conducted as a result of a complaint investigation triggered by allegations made by residents regarding staff behavior at the facility.

The investigation included observations, interviews, and medical record reviews. No regulatory deficiencies were identified and the allegations could not be substantiated. No further action was necessary.

One complaint (NV00058656) was investigated with three allegations: a resident was locked in her room, a resident was denied water, and a resident was told to urinate on the floor. None of these allegations were substantiated.

The inspection was conducted as an Annual State Licensure Survey combined with a Complaint Investigation regarding an allegation of physical abuse/injury of unknown origin, which was not substantiated.

The facility received a grade of B. Deficiencies included failure to ensure proper oversight by the Administrator, failure to administer medications as ordered for a hospice resident with difficult behaviors, incomplete tuberculin testing for employees and residents, and failure to maintain proper personnel and resident files.

Complaint #NV00055943 alleging physical abuse/injury of unknown origin was investigated and found to be unsubstantiated after interviews and record reviews.

The inspection was conducted as an annual State Licensure survey to assess compliance with regulations for a residential facility for elderly and disabled persons and/or persons with mental illnesses.

The facility received a grade of A but was found deficient in medication storage and mental illness training. Medications were not stored in a locked area as required, and one employee lacked the required eight hours of mental illness training.

This inspection was conducted as an annual State Licensure survey of the Spruce Oak Residential Care Facility to assess compliance with state regulations.

The facility received a grade of A. Two deficiencies were identified: unsecured medication storage in the caregiver's room and failure to ensure one employee received the required eight hours of mental illness training.

This Statement of Deficiencies was generated as a result of a required grading re-survey conducted in the facility on 6/5/15.

No deficiencies were identified during this State Licensure re-survey. The facility received a re-survey grade of A.

The Division of Public and Behavioral Health conducted a survey at Spruce Oak Residential Care Facility on 02/19/15 which resulted in sanctions being imposed due to deficiencies found.

Sanctions are being imposed based on the severity and scope of deficiencies identified during the survey. An initial monetary penalty of $400.00 was assessed for a deficiency at TAG Y515 with a severity level of three and scope level of two or less.

The inspection was conducted as an annual State Licensure grading survey and complaint investigation to assess compliance with regulations for a residential facility for elderly and disabled persons.

The facility received a grade of D with multiple substantiated allegations including medication errors, insufficient food, and resident safety/falls. Several deficiencies were identified related to administrator oversight, personnel files, health and sanitation, nutrition, resident rights, medication administration, and supervision.

Complaint #NV00041879 contained four allegations; three were substantiated: medications not given per physician's order, insufficient food, and resident safety/falls. The allegation regarding insufficient supply of towels and pads was not substantiated.

The inspection was conducted as an annual State Licensure grading survey combined with a complaint investigation triggered by complaint #NV00041879 containing four allegations.

The facility received a grade of D with substantiated complaints regarding medication administration, insufficient food, and resident safety/falls. Multiple deficiencies were identified including failure to provide adequate staff oversight, incomplete employee training and background checks, poor facility maintenance, unsafe food handling, inadequate nutrition and supervision of residents, failure to notify administrators of incidents, incomplete medical and medication records, and failure to comply with tuberculosis testing requirements.

Complaint #NV00041879 contained four allegations: 1) Residents' medications were not given according to physician's order (substantiated), 2) Insufficient food (substantiated), 3) Resident safety/falls (substantiated), and 4) Insufficient supply of towels and pads (not substantiated).

This document is a required grading re-survey conducted as a State Licensure survey to assess compliance with regulations for a residential facility for elderly and disabled persons.

The facility received a re-survey grade of A. Deficiencies were identified related to elder abuse training and tuberculosis screening for employees, with documented failures to ensure required training and health screenings were completed for several employees.

This document is a required grading re-survey conducted as a State Licensure survey to assess compliance with regulations at Spruce Oak Residential Care Facility.

The facility received a re-survey grade of A. Deficiencies were identified related to lack of elder abuse training for 2 of 3 employees and failure to ensure 3 of 3 employees had required pre-employment physicals and two-step tuberculosis screenings. The administrator acknowledged these documentation deficiencies.

The inspection was conducted as a required re-survey and an annual State Licensure survey of a residential facility for elderly and disabled persons with mental illness.

The facility received a grade of D with multiple deficiencies identified related to elder abuse training, personnel files, health and sanitation, service of food, fire safety, oxygen equipment, physical examinations, medication administration, resident file storage, tuberculosis testing, and mental illness training. Several deficiencies were repeat findings from a prior survey.

This Statement of Deficiencies was generated as a result of a required grading re-survey and an annual State Licensure survey conducted on 05/29/2014 at Spruce Oak Residential Care Facility.

The facility received a grade of D with multiple deficiencies identified including failure to provide elder abuse training, incomplete personnel files, inadequate background checks, lack of first aid and CPR training, poor facility maintenance, incomplete documentation of special diets, expired fire extinguisher inspections, unsecured oxygen tanks, missing pre-admission physicals, inaccurate medication administration records, unsecured resident files, incomplete tuberculosis testing documentation, and insufficient mental illness training for employees.