Inspection Reports for St Jude Home Care
6880 Hathaway Dr, Las Vegas, NV 89156, NV, 89156
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Inspection Report
Annual Inspection
Census: 3
Capacity: 6
Deficiencies: 6
Jun 25, 2025
Visit Reason
This inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.
Findings
The facility was found deficient in multiple areas including failure to meet background check requirements for one employee, overdue fire extinguisher inspections, lack of physician orders for a resident discharged from hospice, missing Ultimate User Agreements and range orders for medications, and incomplete infection control training for designated staff and unlicensed caregivers.
Severity Breakdown
2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 employees met background check requirements; Employee #1 lacked a Nevada Automated Background Check System clearance letter for this facility. | 2 |
| Failed to ensure fire extinguishers were inspected annually; inspection tags on four extinguishers were overdue. | 2 |
| Failed to ensure a resident received medical care from a physician after discharge from hospice; no physician orders were acquired for continued medication administration. | 2 |
| Failed to ensure 2 of 3 residents had Ultimate User Agreements and 2 of 3 residents had range orders for medications. | 2 |
| Failed to ensure primary and secondary infection control staff completed required 15 hours of infection control training annually and initially. | 2 |
| Failed to ensure 1 of 4 unlicensed caregivers completed annual infection control training as required. | 2 |
Report Facts
Licensed beds: 6
Current census: 3
Employee files reviewed: 4
Resident files reviewed: 3
Fire extinguishers: 4
Deficiencies cited: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Cobb | Executive Director | Signed the inspection report |
| Employee 1 | Administrator | Failed background check and infection control training requirements |
| Employee 3 | Owner/Caregiver/Director | Primary infection control person; involved in medication administration and infection control training deficiencies |
| Employee 4 | Caregiver | Secondary infection control person; lacked required infection control training |
Inspection Report
Complaint Investigation
Census: 5
Deficiencies: 5
Sep 11, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 2024-08-06 and completed on 2024-09-11, focusing on observations of resident grooming, facility odors, cleanliness, staff-resident interactions, and facility temperatures.
Findings
The facility was found to have multiple deficiencies including failure to maintain odor-free and clean resident rooms, lack of window screens to prevent insect entry, failure to maintain facility temperatures within required limits, and failure to develop a person-centered service plan for a resident exhibiting problematic behaviors. The complaint was substantiated with severity levels mostly at Level 2.
Complaint Details
One complaint (NV00071607) was investigated and substantiated.
Severity Breakdown
Level 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure the room was free of urine and body odor for 1 of 5 residents; odors traveled through vents and were detected in the kitchen. | Level 2 |
| Facility failed to ensure 1 of 5 resident rooms had a screen on the bedroom window to keep out insects. | Level 2 |
| Facility failed to maintain temperatures below 82 degrees Fahrenheit throughout the home; multiple areas exceeded temperature limits. | Level 2 |
| Facility failed to develop a person-centered service plan for 1 of 5 residents to address behaviors and care needs. | Level 2 |
| Facility failed to ensure 1 of 5 residents was kept dry of urine and odor free; resident poured urine from urinal onto bed and care plan was lacking. | Level 2 |
Report Facts
Census: 5
Sample size: 5
Employee files reviewed: 4
Severity Level 2 Deficiencies: 5
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 2
Jun 6, 2024
Visit Reason
The 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 received a grade of A but had two deficiencies: inaccurate documentation on the Medication Administration Record for one resident and failure to complete an Activities of Daily Living (ADL) Assessment upon admission for the same resident.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The Medication Administration Record (MAR) included inaccurate documentation for one resident's medication dosage. | Severity: 2 |
| Failure to ensure an Activities of Daily Living (ADL) Assessment was completed upon admission for one resident. | Severity: 2 |
Report Facts
Licensed beds: 6
Census: 4
Inspection Report
Annual Inspection
Census: 3
Capacity: 6
Deficiencies: 0
Jun 13, 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
Licensed beds: 6
Resident census: 3
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 1
Jun 7, 2022
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 and was provided guidance on compliance with nondiscrimination, privacy, and cultural competency regulations. One regulatory deficiency was identified related to maintenance and contents of resident files, specifically failure to ensure one resident had completed annual tuberculosis testing.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 4 residents had completed annual tuberculosis (TB) testing; Resident #1's last TB test was dated 05/24/21. | Severity: 2 |
Report Facts
Licensed beds: 6
Resident census: 4
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria T N Acoba | Administrator | Named as person responsible for corrective action and signature on report |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 1
Aug 17, 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. A deficiency was identified related to failure to conduct COVID-19 screening and temperature checks for visitors upon entry. The administrator issued a memorandum and retrained employees to correct this issue.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to conduct a COVID-19 screening and temperature check for visitors upon entry into the facility. | Severity: 2 |
Report Facts
Licensed beds: 6
Current census: 4
Employee files reviewed: 5
Resident files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria T. N. Acoba | Administrator | Named as person responsible for corrective action and signed the report |
Inspection Report
Abbreviated Survey
Census: 4
Capacity: 6
Deficiencies: 0
Sep 25, 2020
Visit Reason
The inspection was conducted as a Focused COVID-19 Infection Control survey at the facility to assess compliance with infection control practices during the pandemic.
Findings
The facility demonstrated appropriate COVID-19 screening, PPE use, sanitation, and infection control procedures with no residents or employees showing symptoms or positive test results. No regulatory deficiencies were identified.
Report Facts
PPE supply: 12
PPE supply: 16
PPE supply: 100
Thermometers: 3
Hand sanitizer containers: 3
Hand sanitizer container: 1
Relief staff: 2
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 4
Jan 8, 2020
Visit Reason
This inspection was conducted as a State Licensure annual survey of the facility to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but was cited for several deficiencies including failure to complete fingerprinting and background checks every five years for one employee, failure to provide group activities for residents, failure to request a bedfast exemption for one resident, and failure to complete annual activities of daily living assessments for two residents.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure fingerprinting and background check were completed every five years for 1 of 4 employees. | Severity: 2 |
| Failed to provide group activities that provide mental and physical stimulation and develop creative skills and interests to 5 of 5 residents. | Severity: 2 |
| Failed to request a bedfast exemption for 1 of 5 residents who was unable to turn in bed without assistance. | Severity: 2 |
| Failed to ensure annual activities of daily living (ADL) assessments were completed for 2 of 5 residents. | Severity: 2 |
Report Facts
Residents present: 5
Total licensed capacity: 6
Employees reviewed: 4
Resident files reviewed: 5
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 12
Apr 26, 2019
Visit Reason
This inspection was a State Licensure re-grading survey conducted in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facilities for Groups.
Findings
The facility received an annual survey grade of A. Several deficiencies were identified related to health and sanitation, kitchen equipment and food storage, activities for residents, oxygen monitoring, medication storage, and Alzheimer's endorsement requirements. All deficiencies were corrected by specified completion dates.
Severity Breakdown
F: 6
D: 4
E: 1
C: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Health and Sanitation - Accumulations of dirt, garbage and other refuse. | F |
| Health and Sanitation - Facility premises must be clean and well maintained. | D |
| Kitchens - Equipment must be clean, sanitary, and in good working condition. | F |
| Storage of Food - Sufficient storage and appropriate packaging required. | E |
| Service of Food - Menus must be in writing, planned a week in advance, dated, posted and kept on file for 90 days. | C |
| Service of Food - Ill Resident meals served in bedroom must be documented and limited to 14 consecutive days. | D |
| Bathrooms and Toilet Facilities - Residents must have individual toilet articles and towels changed at least weekly. | F |
| Activities for Residents - Facility failed to ensure activities were offered and encouraged. | F |
| Activities for Residents - Provide at least 10 hours each week of scheduled activities suited to residents' interests and capacities. | F |
| Oxygen - Caregivers must monitor resident's ability to operate oxygen equipment and ensure safety measures. | D |
| Medication Storage - Medication must be stored in locked, cool, dry areas with proper safeguards. | F |
| Alzheimer's Endorsement - Facility must obtain endorsement to provide care for residents with Alzheimer's disease. | D |
Report Facts
Licensed beds: 6
Residents present: 4
Resident files reviewed: 3
Annual survey grade: A
Activities hours per week: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria T Acoba | Administrator | Named as Administrator in relation to findings and plan of correction |
Inspection Report
Annual Inspection
Census: 4
Deficiencies: 12
Feb 26, 2019
Visit Reason
This inspection was conducted as a State Licensure annual survey of the residential facility on 02/26/2019 to assess compliance with applicable regulations.
Findings
The facility received an annual survey grade of D with multiple deficiencies identified including issues with cleanliness, sanitation, food storage and labeling, lack of dining menus, inadequate documentation of residents eating in bed, lack of paper towels in bathrooms, insufficient resident activities, oxygen equipment availability, medication storage, and failure to obtain Alzheimer endorsement for residents diagnosed with dementia.
Severity Breakdown
Severity: 1: 1
Severity: 2: 9
Severity: 3: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Accumulation of dust and dirt in kitchen and living room areas. | Severity: 2 |
| Backyard not free of garbage and debris including broken bed frame. | Severity: 2 |
| Kitchen food preparation area not clean; food debris and grease noted. | Severity: 2 |
| Improper labeling and storage of food items in kitchen and refrigerator. | Severity: 2 |
| Dining menu not provided to residents. | Severity: 1 |
| Failure to document resident eating meals in bed for greater than 14 consecutive days. | Severity: 2 |
| No paper towels or individual hand towels in two restrooms for hand drying. | Severity: 2 |
| Failure to provide appropriate activities for residents; activities limited to watching TV. | Severity: 2 |
| Failure to provide at least 10 hours of scheduled activities per week. | Severity: 2 |
| No full oxygen tank available for resident requiring oxygen. | Severity: 2 |
| Medication improperly stored in unlocked refrigerator; medication of discharged resident not disposed. | Severity: 3 |
| Facility failed to obtain Alzheimer endorsement for residents diagnosed with dementia. | — |
Report Facts
Census: 4
Deficiency count: 12
Activity hours: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria T Acoba | Administrator | Named as responsible person for corrective actions and monitoring compliance |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 3
Apr 18, 2016
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A but had deficiencies related to cleanliness and maintenance of the premises, kitchen equipment cleanliness, and medication administration errors.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility was not clean and well-maintained; issues included dust and lint buildup in laundry room, missing vanity light bulbs, dirty toilet paper holder, dirty fire sprinkler head, and non-functioning emergency lights. | Level 2 |
| Kitchen cabinets and appliances were not clean or in good condition; grease and grime on cabinet doors, malfunctioning cabinet doors, grease trap buildup, and dirty dishwasher buttons. | Level 2 |
| Resident medication administration errors; expired hydrocortisone cream was present, medication administration record did not list the medication, and lack of physician's order to discontinue the medication. | Level 2 |
Report Facts
Deficiencies cited: 3
Census: 4
Total capacity: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named as responsible individual for addressing deficiencies and acknowledged findings |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 3
Apr 18, 2016
Visit Reason
The inspection was conducted as an annual State Licensure survey to assess compliance with regulatory requirements for a residential facility for group beds for elderly and disabled persons.
Findings
The facility received a grade of A but had several deficiencies including cleanliness and maintenance issues in the facility interior and exterior, kitchen sanitation problems, and medication administration errors related to expired medication and lack of physician orders.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility was not clean and well-maintained; dust and lint buildup in laundry room, dust on air vents, missing light bulbs, dirty toilet paper holder, dirty fire sprinkler head, and emergency lights not working. | Severity: 2 |
| Kitchen cabinets and appliances were not clean or in good condition; stained cabinet doors, cabinet doors not latching, grease buildup on grease trap, and dirt residue on dishwasher. | Severity: 2 |
| Medication administration failure: expired Hydrocortisone cream found in resident's medication box without physician order to discontinue; medication label had incorrect instructions. | Severity: 2 |
Report Facts
Deficiencies cited: 3
Facility licensed capacity: 6
Resident census: 4
Inspection Report
Annual Inspection
Census: 3
Capacity: 6
Deficiencies: 4
May 21, 2014
Visit Reason
This document is a statement of deficiencies generated as a result of an annual State Licensure survey conducted on 5/21/14 at a residential facility for elderly or disabled persons.
Findings
The facility received a grade of A. Deficiencies were identified related to personnel files, periodic physical examinations of residents, and medication administration and documentation.
Severity Breakdown
Level 2: 3
Level 1: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 3 employees met the requirements of a pre-employment physical; physician wrote the wrong year on the physical. | Level 2 |
| Facility failed to ensure 1 of 3 residents received a physical examination prior to admission; late physical examination date acknowledged. | Level 2 |
| Facility failed to ensure a prescription change for 1 of 3 residents was indicated on the medication container. | Level 2 |
| Facility failed to ensure medication administration record (MAR) was accurate for 3 of 3 residents; morning medications were not initialed as given. | Level 1 |
Report Facts
Residents present: 3
Licensed capacity: 6
Employees reviewed: 3
Resident files reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Lowers | Administrator | Signed the statement of deficiencies |
Inspection Report
Annual Inspection
Census: 3
Capacity: 6
Deficiencies: 4
May 21, 2014
Visit Reason
This document is the result of an annual State Licensure survey conducted on 5/21/2014 to assess compliance with state regulations for a residential facility for group beds for elderly or disabled persons.
Findings
The facility received a grade of A but had several deficiencies related to personnel files, resident physical examinations, medication administration, and medication record accuracy. Specific issues included an employee lacking a proper pre-employment physical, a resident not having a physical examination prior to admission, failure to indicate a prescription change on a medication container, and incomplete medication administration records.
Severity Breakdown
Level 2: 3
Level 1: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 3 employees met pre-employment physical requirements (Employee #1). | Level 2 |
| Failed to ensure 1 of 3 residents received a physical examination prior to admission (Resident #2). | Level 2 |
| Failed to ensure a prescription change for 1 of 3 residents was indicated on the medication container (Resident #3). | Level 2 |
| Failed to ensure the medication administration record (MAR) was accurate for 3 of 3 residents; morning medications were not initialed as given. | Level 1 |
Report Facts
Licensed capacity: 6
Census: 3
Deficiencies cited: 4
Notice
Deficiencies: 0
Jul 31, 2012
Visit Reason
The Bureau conducted a required grading re-survey of St Jude Care, LLC on 7/31/12, which led to the imposition of sanctions and monetary penalties.
Findings
The facility received a letter grade of A, but repeat deficiencies were cited resulting in monetary penalties totaling $600. The Plan of Correction submitted by the facility was reviewed and found acceptable.
Report Facts
Monetary penalties: 600
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna C. McCafferty | Health Facilities Inspector II | Signed the notice imposing sanctions. |
Inspection Report
Re-Inspection
Census: 5
Capacity: 6
Deficiencies: 3
Jul 31, 2012
Visit Reason
This document is a required grading re-survey conducted as a State Licensure survey to assess compliance with regulations at a residential facility for elderly and disabled persons.
Findings
The facility received a re-survey grade of A. Several deficiencies were identified including failure to ensure pre-employment physical examinations for employees, inadequate laundry equipment maintenance, and unsecured refrigerated medications. These deficiencies were repeat findings from prior surveys.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure pre-employment physical examinations for employees as required by NAC 441A. | Severity: 2 |
| Laundry equipment not kept in good repair; washing machine leaking water onto laundry room floor. | Severity: 2 |
| Failure to ensure refrigerated medications were secured in a locked container; lock box found unlocked in refrigerator. | Severity: 2 |
Report Facts
Licensed beds: 6
Resident census: 5
Deficiency repeat count: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Named in deficiency related to failure to comply with pre-employment physical examination requirements | |
| Susan L. Somers | Administrator | Signed the report and noted as responsible for monitoring compliance |
Inspection Report
Re-Inspection
Census: 5
Capacity: 6
Deficiencies: 3
Jul 31, 2012
Visit Reason
This document is a required grading re-survey conducted as a State Licensure survey to assess compliance with regulatory standards at the facility.
Findings
The facility received a re-survey grade of A but had repeat deficiencies including failure to ensure employee pre-employment physical examinations, laundry equipment maintenance issues, and unsecured refrigerated medications.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 employees complied with NAC 441A.375 regarding pre-employment physical examinations (Employee #3). | Severity: 2 |
| Failed to keep the laundry equipment in good repair; the washing machine was leaking water onto the laundry room floor. | Severity: 2 |
| Failed to ensure refrigerated medications were secured in a locked container; the lock box was without a key and found unlocked in the refrigerator. | Severity: 2 |
Report Facts
Licensed beds: 6
Residents present: 5
Employees reviewed: 4
Resident files reviewed: 5
Inspection Report
Enforcement
Deficiencies: 0
May 8, 2012
Visit Reason
The Bureau conducted a required grading re-survey on Saint Jude Home Care on 5/08/12, which served as the basis for imposing sanctions and monetary penalties.
Findings
The facility received a letter grade of D based on the Statement of Deficiencies. Monetary penalties totaling $600 were imposed for repeat deficiencies cited in prior surveys dated 2/21/12 and 5/17/11. The Plan of Correction submitted by the facility was reviewed and found acceptable.
Report Facts
Monetary penalties: 600
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna C. McCafferty | Health Facilities Inspector III | Signed the enforcement notice |
| Wendy Simons | Bureau Chief | Referenced as Bureau Chief in the enforcement notice |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 14
May 8, 2012
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 5/8/12 to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of D with multiple deficiencies identified, including caregiver qualifications, training, staffing levels, personnel file compliance, health and sanitation issues, housing for staff, admission policy, medication administration and storage, and tuberculosis testing. Several deficiencies were repeat findings from previous surveys.
Severity Breakdown
Severity: 1: 1
Severity: 2: 13
Deficiencies (14)
| Description | Severity |
|---|---|
| Caregiver did not possess appropriate knowledge, skills, and abilities to meet resident needs. | Severity: 2 |
| Caregiver failed to receive required 8 hours of annual training. | Severity: 2 |
| Insufficient number of caregivers on duty to provide care and supervision. | Severity: 2 |
| Personnel files missing required health certificates and background checks. | Severity: 2 |
| Facility failed to ensure premises were free of insects and rodents. | Severity: 2 |
| Laundry room not kept clean; lint buildup and water leakage observed. | Severity: 2 |
| Insufficient housing for staff members; one staff sleeping on fold-up bed in living room. | Severity: 2 |
| Resident not restrained as required by admission policy. | Severity: 2 |
| Facility did not obtain physician orders for over-the-counter medications for one resident. | Severity: 2 |
| Medication records incomplete for two residents receiving PRN medications. | Severity: 1 |
| Medications not stored in locked containers; medication found unsecured in unlocked cabinet. | Severity: 2 |
| Refrigerated medications not secured in locked containers for two residents. | Severity: 2 |
| Medications not properly labeled for two residents. | Severity: 2 |
| Two residents missing second step of tuberculosis testing. | Severity: 2 |
Report Facts
Licensed capacity: 6
Census: 5
Severity 2 deficiencies: 13
Severity 1 deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Jones | Administrator | Signed the report on 6/8/12 |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 15
May 8, 2012
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 5/8/2012 at Saint Jude Home Care, a residential facility for group beds for elderly and disabled persons.
Findings
The facility received a grade of D with multiple deficiencies identified including caregiver qualifications, staffing levels, personnel file compliance, health and sanitation issues, medication administration and storage, housing for staff, admission policies, and resident file maintenance.
Severity Breakdown
Level 1: 1
Level 2: 13
Deficiencies (15)
| Description | Severity |
|---|---|
| Facility hired 1 of 2 caregivers lacking appropriate knowledge, skills, and abilities to meet resident needs. | Level 2 |
| One of three caregivers failed to receive the required eight hours of annual training. | Level 2 |
| Administrator failed to ensure sufficient number of caregivers on duty to provide care and supervision. | Level 2 |
| One of three employees failed to comply with tuberculosis testing and pre-employment physical examination requirements. | Level 2 |
| Two of three employees failed to meet background check requirements. | Level 2 |
| Facility failed to keep premises free from insects and rodents; insect body parts and a cockroach were observed. | Level 2 |
| Laundry room was not kept clean or in good repair; lint buildup behind dryer and water leakage from washing machine observed. | Level 2 |
| Facility failed to provide sufficient housing for one staff member residing on site. | Level 2 |
| One resident was restrained by use of a full bed rail, contrary to admission policy. | Level 2 |
| Facility did not obtain physician orders for administration of over-the-counter medication to one resident. | Level 2 |
| Medication records were incomplete for two residents receiving as needed medications. | Level 1 |
| Medications were not stored in locked containers; employee's husband's medication found unlocked. | Level 2 |
| Refrigerated medications for two residents were not secured in locked containers. | Level 2 |
| Medications were not plainly labeled for one resident; Centrum Silver bottle and Cortisone cream box unlabeled. | Level 2 |
| Two residents' files lacked evidence of compliance with tuberculosis testing requirements. | Level 2 |
Report Facts
Licensed capacity: 6
Census: 5
Employee files reviewed: 3
Resident files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Failed to meet tuberculosis testing, pre-employment physical, and background check requirements; scheduled for afternoon shift | |
| Employee #3 | Lacked appropriate caregiver skills; missing annual training; failed background checks; unable to provide sufficient care; medication storage violation; scheduled for morning shift; residing staff member with insufficient housing |
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