Deficiencies per Year
24
18
12
6
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 1
Jul 31, 2025
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; however, a regulatory deficiency was identified related to maintaining a bedfast resident without an approved waiver, specifically for Resident #9 who was bedfast without a waiver.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to obtain a waiver to maintain a bedfast resident (Resident #9) who could not turn on their own and required assistance. | Severity: 2 |
Report Facts
Resident files reviewed: 10
Employee files reviewed: 4
Licensed capacity: 10
Census: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Wolfkill | Administrator | Administrator confirmed no approved bedfast waiver for Resident #9 |
Inspection Report
Annual Inspection
Census: 5
Capacity: 8
Deficiencies: 13
Mar 24, 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 caregiver training, elder abuse training, CPR and first aid training, health and sanitation, exemption requests, medication administration, maintenance of resident files, Alzheimer's care standards, care to persons with dementia, annual resident assessments, and infection control training. Several residents lacked required documentation and training for staff was incomplete or missing.
Severity Breakdown
2: 13
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to ensure annual Caregiver training was completed for 1 of 8 employees (Employee #5). | 2 |
| Failed to ensure annual Elder Abuse training was completed for 1 of 8 employees (Employee #5). | 2 |
| Failed to ensure 4 of 8 employees received the in-person component of CPR and first aid training (Employees #3, #4, #6, and #8). | 2 |
| Failed to ensure the premises were clean and well-maintained; multiple items cluttered the backyard. | 2 |
| Failed to ensure a screen was on the window in Resident #4's room to prevent insect entry. | 2 |
| Failed to submit medical exemption requests prior to admitting 2 residents (Residents #3 and #4) who were bedfast and required skilled nursing care. | 2 |
| Failed to ensure 5 residents or their guardians had signed Ultimate User Agreements for medication administration. | 2 |
| Medication Administration Record (MAR) was inaccurate for 2 residents (Residents #2 and #3). | 2 |
| Failed to ensure Resident #4 completed the second step of a 2-Step Tuberculosis test. | 2 |
| Failed to ensure the front door alarm was activated and audible at all times. | 2 |
| Failed to ensure 1 of 8 employees (Employee #5) received three hours of annual Alzheimer's disease training. | 2 |
| Failed to obtain initial placement assessments for 2 residents (Residents #3 and #4). | 2 |
| Failed to ensure 2 of 8 employees (Employees #3 and #4) obtained required infection control training for unlicensed caregivers. | 2 |
Report Facts
Residents present: 5
Total licensed capacity: 8
Employees reviewed: 8
Resident files reviewed: 5
Severity 2 deficiencies: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caprice Benson | Administrator | Named as Administrator and signatory on report |
| Employee #5 | Administrator | Failed annual caregiver, elder abuse, and Alzheimer's disease training documentation |
| Employee #3 | Caregiver | Failed to complete in-person CPR and first aid training and infection control training |
| Employee #4 | Caregiver | Failed to complete in-person CPR and first aid training and infection control training |
| Employee #6 | Caregiver | Failed to complete in-person CPR and first aid training |
| Employee #8 | Owner/Caregiver | Failed to complete in-person CPR and first aid training |
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 4
Mar 17, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #NV00073359, substantiated, involving concerns about resident care and financial exploitation at the facility.
Findings
The investigation found that the Administrator failed to provide adequate oversight to ensure residents received needed services and protective supervision. Resident #1 was exploited financially by the group home Manager who acquired the resident's property and vehicle under questionable circumstances. Additionally, personnel files were incomplete for one employee, and safety standards for securing the facility's front gate and door were not met.
Complaint Details
Complaint #NV00073359 was substantiated. The complaint involved allegations of financial exploitation of Resident #1 by the group home Manager (Employee #4), who acquired the resident's condominium and vehicle without proper authority. The resident was cognitively impaired and lacked capacity to make financial decisions. The Administrator failed to provide oversight to prevent this exploitation.
Severity Breakdown
Level G: 2
Level D: 1
Level F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight and direction to ensure residents received needed services and protective supervision for 1 of 5 sampled residents. | Level G |
| Facility failed to maintain a complete personnel file for Employee #4, the Manager. | Level D |
| Administrator failed to ensure residents were not exploited; Resident #1 was financially exploited by the group home Manager. | Level G |
| Facility failed to ensure front gate and front door were secured to activate alarms and prevent resident wandering. | Level F |
Report Facts
Census: 10
Sample size: 5
Checks written: 9
Rent amount: 5500
Property sale amount: 30000
Severity level: 3
Severity level: 2
Severity level: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca N Wolfkill | Administrator | Named in oversight failure and lack of awareness of billing and resident file documentation |
| Employee #4 | Manager / Group Home Manager | Involved in financial exploitation of Resident #1, managed billing, staffing, and resident transportation |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 1
Jul 31, 2024
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; however, a deficiency was identified related to the front gate of the facility being unlocked and open, which posed a safety risk to residents. The caregiver acknowledged the gate should have been locked.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to ensure the front gate leading to the street was closed and locked, allowing residents access to an unsecured area. | Severity: 2 |
Report Facts
Licensed beds: 10
Resident census: 9
Severity level: 2
Scope: 3
Inspection Report
Annual Inspection
Census: 4
Capacity: 8
Deficiencies: 0
Mar 25, 2024
Visit Reason
This inspection was conducted as an annual State Licensure inspection in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to have no regulatory deficiencies and received a grade of A. Four resident files and five employee files were reviewed during the inspection.
Report Facts
Resident files reviewed: 4
Employee files reviewed: 5
Inspection Report
Complaint Investigation
Census: 8
Deficiencies: 0
Oct 17, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 10/17/23, in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The complaint was verified without deficient practice. The investigation included observation of a fence in need of repair, interviews with the owner and caregivers, and review of documents showing a temporary fixed fence. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
One complaint (#NV00069622) was investigated and verified without deficient practice.
Report Facts
Complaint count: 1
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 2
Jul 3, 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
Two regulatory deficiencies were identified: a missing window screen in a resident's room allowing insect entry, and a non-operational alarm on an exit door leading to the garage. Both issues were acknowledged by the Administrator and corrective actions were planned or implemented.
Severity Breakdown
2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident #9's window was open and without a screen to prevent the entry of insects. | 2 |
| Exit door alarm leading to the garage was not operating. | 2 |
Report Facts
Resident census: 9
Total licensed capacity: 10
Deficiency count: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca N. Wolfkill | Administrator | Acknowledged deficiencies and involved in corrective actions |
Inspection Report
Annual Inspection
Census: 4
Capacity: 8
Deficiencies: 3
Mar 21, 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 a Residential Facility for Groups.
Findings
The facility received a grade of A; however, deficiencies were identified including failure to ensure annual medication administration training for one employee, failure to ensure annual elder abuse training for one employee, and failure to ensure annual tuberculosis testing for two residents.
Severity Breakdown
2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure eight hours of annual medication administration training was completed for 1 of 3 employees (Employee #1). | 2 |
| Failed to ensure 1 of 3 employees had completed an annual Elder Abuse training (Employee #3). | 2 |
| Failed to ensure 2 of 4 sampled residents met the requirements for tuberculosis (TB) testing in accordance with Nevada Administrative Code (NAC) 441A (Resident #1 and #2). | 2 |
Report Facts
Licensed beds: 8
Current census: 4
Employees reviewed: 3
Residents reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Owner/Caregiver | Named in medication administration training deficiency |
| Employee #3 | Caregiver | Named in elder abuse training deficiency |
Inspection Report
Complaint Investigation
Census: 9
Deficiencies: 0
Oct 11, 2022
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #NV00066930 involving four allegations concerning resident rights, missing property, visitation denial, and competency assessments.
Findings
The complaint investigation substantiated all four allegations but found no regulatory deficiencies. The facility received a grade of A, and no further action was necessary.
Complaint Details
Complaint #NV00066930 with four allegations was substantiated without deficiencies. Allegations included executor status of the owner, missing resident property including money and a refrigerator, denial of visitation to a family member, and competency assessment of a resident. The investigation confirmed the resident eloped and some money was not recovered, but facility staff were not responsible for missing items.
Report Facts
Sample size: 12
Complaint count: 1
Money stolen: 30000
Money withdrawn: 27000
Money unrecovered: 3000
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 1
Jul 7, 2022
Visit Reason
The inspection was conducted as an annual and infection control State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. One deficiency was identified related to the failure to securely store toxic substances, which were found unlocked in the garage area, posing a safety risk to residents.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure toxic substances were securely stored and inaccessible to residents; unlocked room and cabinet in garage contained hazardous materials. | 2 |
Report Facts
Resident files reviewed: 10
Employee files reviewed: 5
Severity Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca N Wolfkill | Administrator | Administrator acknowledged toxic substances should be stored securely and was involved in corrective actions |
Inspection Report
Re-Inspection
Census: 2
Capacity: 8
Deficiencies: 0
May 31, 2022
Visit Reason
This inspection was a State Licensure mandatory grading resurvey conducted from 05/27/22 through 05/31/22 to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to be in compliance with no regulatory deficiencies identified and received a grade of A. Guidance was provided on nondiscrimination policies, privacy protections, cultural competency training, and complaint policies.
Report Facts
Licensed beds: 8
Residents present: 2
Inspection Report
Annual Inspection
Census: 3
Capacity: 10
Deficiencies: 21
Feb 1, 2022
Visit Reason
Annual State Licensure and infection control survey conducted in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of D with multiple deficiencies including failure to ensure COVID-19 visitor screening, incomplete caregiver training and personnel files, lack of posted staffing schedule and activity calendar, medication administration errors, improper medication storage, missing tuberculosis testing, incomplete resident assessments, unsecured toxic substances, and failure to obtain required CLIA waiver for blood glucose testing.
Severity Breakdown
Level 1: 2
Level 2: 17
Deficiencies (21)
| Description | Severity |
|---|---|
| Failed to ensure COVID-19 screening was conducted upon entry of a visitor and lack of administrator oversight. | Level 2 |
| Failed to ensure eight hours of caregiver training was conducted annually for 3 employees. | Level 2 |
| Failed to ensure medication management training was conducted annually for 3 employees. | Level 2 |
| Failed to ensure elder abuse training was conducted for 3 employees. | Level 2 |
| Failed to ensure staffing schedule was posted and available. | Level 1 |
| Failed to ensure employee personnel files were completed and onsite for 3 employees. | Level 2 |
| Failed to ensure two fire extinguishers were checked and serviced annually. | — |
| Failed to ensure first aid and CPR training was documented for 3 employees. | Level 2 |
| Failed to ensure activity calendar was posted and available for residents. | Level 1 |
| Failed to ensure a bedfast resident was not allowed to remain without medical exemption. | Level 2 |
| Failed to ensure resident requiring insulin injections received injections from appropriately trained person. | Level 2 |
| Failed to ensure pharmacy review of medications was completed every six months for 2 residents. | Level 2 |
| Failed to ensure ultimate user agreement was signed prior to administering medications to a resident. | Level 2 |
| Failed to ensure Medication Administration Record (MAR) was complete, signed and available for 3 residents. | Level 2 |
| Failed to ensure refrigerated medications were locked and inaccessible to residents. | Level 2 |
| Failed to ensure medications were kept in original containers until administered for 2 residents. | Level 2 |
| Failed to ensure two-step tuberculosis testing was completed upon admission for 2 residents. | Level 2 |
| Failed to ensure Activities of Daily Living (ADL) assessments were completed upon admission for 3 residents. | Level 2 |
| Failed to ensure toxic substances were properly secured and inaccessible to residents. | Level 2 |
| Failed to ensure resident received daily glucose checks from appropriately trained person. | Level 2 |
| Failed to obtain Clinical Laboratory Improvement Amendment (CLIA) waiver to perform blood glucose testing. | Level 2 |
Report Facts
Facility licensed beds: 10
Resident census: 3
Deficiencies cited: 19
Severity 2 deficiencies: 17
Severity 1 deficiencies: 2
Inspection Report
Complaint Investigation
Census: 8
Deficiencies: 1
Sep 22, 2021
Visit Reason
The inspection was conducted as a result of a facility reported incident involving resident elopement, investigated during a State Licensure survey from 09/14/21 through 09/22/21.
Findings
The facility failed to ensure protective supervision was provided to a resident with dementia who left the facility unsupervised, contrary to the needs assessment and without proper release documentation. The psychiatrist's evaluation was misinterpreted regarding the resident's ability to leave unsupervised.
Complaint Details
Facility Reported Incident #4787 regarding resident elopement was substantiated. The resident left the facility without signing a release form and without a companion, despite the needs assessment requiring protective supervision. The Power of Attorney did not agree the resident could leave unsupervised. The psychiatrist evaluation was intended only to assess capacity to sign documents, not to determine ability to leave unsupervised.
Severity Breakdown
Severity: 3: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Administrator failed to provide oversight ensuring protective supervision for a resident with dementia who eloped from the facility unsupervised. | Severity: 3 |
Report Facts
Census: 8
Sample size: 5
Severity level: 3
Scope: 1
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 0
Aug 31, 2021
Visit Reason
The inspection was conducted as an Annual Grading and infection control survey at the facility in accordance with Nevada Administrative Code, Chapter 449, Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the survey. The facility received a grade of A and was provided guidance on nondiscrimination, privacy, cultural competency, and complaint policies.
Report Facts
Resident records reviewed: 9
Employee records reviewed: 5
Inspection Report
Original Licensing
Capacity: 8
Deficiencies: 0
Feb 19, 2021
Visit Reason
This inspection was conducted as an initial licensure and COVID-19 infection control survey for a Residential Facility for Groups requesting licensure for eight beds for elderly and disabled persons and/or persons with Alzheimer's disease.
Findings
The facility demonstrated compliance with infection control and prevention policies including PPE availability, screening procedures, social distancing, and staff training. No regulatory deficiencies were identified during the survey.
Report Facts
PPE stock: 200
PPE stock: 1000
PPE stock: 20
PPE stock: 8
PPE stock: 1
PPE stock: 100
licensed beds: 8
inspection start date: Feb 19, 2021
inspection completion date: Feb 23, 2021
Inspection Report
Routine
Census: 7
Capacity: 10
Deficiencies: 0
Sep 23, 2020
Visit Reason
The inspection was a COVID-19 focused infection control, State Licensure survey conducted to assess compliance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility had no residents or staff positive with COVID-19, practiced proper infection control measures including PPE use, social distancing, and sanitation. However, the facility lacked written policies and procedures for isolation, quarantine, aseptic practices, and dedicated staff for COVID-19 infected residents. No regulatory deficiencies were cited.
Report Facts
Hand sanitizer bottles: 5
Surgical style masks: 150
N95 masks: 2
P-95 respirator: 1
Gloves: 500
Gowns: 5
Plastic face shields: 3
Staff members: 3
Notice
Deficiencies: 1
Aug 23, 2016
Visit Reason
The document serves as a sanction notice informing the facility of imposed monetary penalties due to regulatory deficiencies identified during a survey.
Findings
The Division of Public and Behavioral Health is imposing a monetary penalty of $400 for a deficiency at TAG 997, based on the severity and scope of the deficiency as defined by Nevada regulations.
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiency at TAG 997 | severity level 3 or less |
Report Facts
Monetary penalty amount: 400
Penalty reduction percentage: 25
Days until sanctions effective: 11
Days to request hearing: 10
Days to pay penalty: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Minou Nelson | Health Facilities Inspector III | Signed the sanction notice |
| Paul Shubert | Acting Bureau Chief | Signed the sanction notice |
Inspection Report
Annual Inspection
Census: 7
Capacity: 10
Deficiencies: 3
Jul 12, 2016
Visit Reason
The inspection was conducted as a result of an annual State Licensure survey combined with a complaint investigation on 7/12/16.
Findings
The facility received a grade of A. One complaint was substantiated regarding a resident eloping. Deficiencies were identified related to personnel background checks, staff awake requirements, and facility safety including yard fencing and gate security.
Complaint Details
One complaint (#NV00046378) was investigated and substantiated regarding a resident eloping from the facility.
Severity Breakdown
Level 2: 2
Level 3: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 5 employees met background check requirements; caregiver's background check was undetermined. | Level 2 |
| Facility failed to ensure one member of staff was awake and on duty at all times; caregiver working hours were not documented. | Level 2 |
| Facility failed to ensure a gate leading from a secured area to an unsecured area was locked; gate was observed open creating a 2-3 foot opening allowing resident elopement. | Level 3 |
Report Facts
Number of residents present: 7
Total licensed capacity: 10
Number of employees reviewed: 5
Severity level 2 deficiencies: 2
Severity level 3 deficiencies: 1
Inspection Report
Annual Inspection
Census: 7
Capacity: 10
Deficiencies: 3
Jul 12, 2016
Visit Reason
The inspection was conducted as an annual State Licensure survey combined with a complaint investigation triggered by a substantiated complaint regarding a resident eloping.
Findings
The facility was found to have multiple deficiencies including failure to meet background check requirements for one employee, failure to ensure a staff member was awake at all times, and failure to secure the facility yard gate leading to resident elopements. The facility received a grade of A.
Complaint Details
Complaint #NV00046378 was substantiated. The allegation that a resident eloped was confirmed based on incident reports and observations.
Severity Breakdown
2: 2
3: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 5 employees met background check requirements; background checks came back undetermined with no documented challenge form submitted. | 2 |
| Failed to ensure at least one member of the staff was awake and on duty at all times; caregiver reported sleeping during night shift hours. | 2 |
| Failed to ensure the facility yard gate was locked; gate was observed open allowing residents to elope. | 3 |
Report Facts
Licensed capacity: 10
Census: 7
Employee files reviewed: 5
Resident files reviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver #1 | Named in findings related to background check failure and sleeping during night shift |
Inspection Report
Complaint Investigation
Census: 10
Capacity: 10
Deficiencies: 0
Sep 4, 2014
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #NV00040412 regarding an allegation that a resident with a positive PPD was admitted to the facility.
Findings
The complaint was not substantiated. The investigation included review of resident and hospital records, employee and resident TB test results, and an interview with the Administrator. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00040412 contained one allegation that a resident with positive PPD was admitted. The allegation was not substantiated after review of medical records, TB tests, and interviews.
Report Facts
Resident files reviewed: 10
Employee files reviewed: 5
Licensed capacity: 10
Census: 10
Inspection Report
Re-Inspection
Census: 10
Capacity: 10
Deficiencies: 0
Aug 12, 2014
Visit Reason
This Statement of Deficiencies was generated as a result of a required grading re-survey conducted in the facility on 08/12/2014 under the authority of NRS 449.150.
Findings
The facility received a grade of A with no deficiencies identified during the survey. No further action is necessary.
Inspection Report
Enforcement
Deficiencies: 0
Feb 14, 2014
Visit Reason
The Health Division is imposing sanctions on the facility due to deficiencies found in a prior survey dated 5/20/13, including monetary penalties for repeat deficiencies.
Findings
The report details the imposition of monetary penalties totaling $600 for repeat deficiencies at specific tags cited in the previous survey. It outlines the statutory authority, penalty amounts, appeal rights, and payment instructions.
Report Facts
Monetary Penalties: 600
Penalty per repeat deficiency: 300
Survey date: May 20, 2013
Inspection Report
Re-Inspection
Census: 10
Capacity: 10
Deficiencies: 7
Dec 6, 2013
Visit Reason
This inspection was conducted as a required grading re-survey and complaint investigation from 11/26/2013 through 12/13/2013 at Sunshine Care Home II, a residential facility for persons with Alzheimer's disease and/or chronic illness.
Findings
The facility received a re-survey grade of C. The complaint investigation found no substantiated allegations regarding catheter care, toileting, verbal intimidation, medication administration, phone charging, or water accessibility. Multiple deficiencies were cited including failure to provide elder abuse training to employees, poor facility maintenance, inadequate food storage, unsecured pool access, lack of Alzheimer's training, and unsafe access to dangerous items and toxic substances.
Complaint Details
Complaint #NV00037491 was investigated and not substantiated. Allegations included staff not flushing Foley catheter, improper toileting and changing, verbal intimidation, incorrect pain medication administration, refusal to charge cell phones or allow calls, and water inaccessibility. All were found unsubstantiated through interviews, observations, and record reviews.
Severity Breakdown
Severity: 2: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure 3 of 5 employees received annual elder abuse training. | Severity: 2 |
| Facility premises not clean or well maintained; blinds melted, landscaping unkempt, trash and debris outside. | Severity: 2 |
| Food stored inadequately; multiple ice cream containers stored without lids and damaged. | Severity: 2 |
| Pool fencing in disrepair allowing resident access to pool. | Severity: 2 |
| Failure to ensure 2 of 5 employees completed required Alzheimer's training. | Severity: 2 |
| Dangerous items such as razors, matches, scissors, and garden tools accessible to residents. | Severity: 2 |
| Toxic substances including WD-40, floor cleaner, pesticide, and rubbing alcohol accessible to residents. | Severity: 2 |
Report Facts
Facility licensed beds: 10
Census: 10
Employees reviewed: 5
Residents reviewed: 10
Deficiency severity count: 7
Inspection Report
Re-Inspection
Census: 10
Capacity: 10
Deficiencies: 7
Nov 26, 2013
Visit Reason
The inspection was conducted as a required grading re-survey and complaint investigation from 11/26/13 through 12/13/13 to assess compliance with state licensure regulations for a residential facility providing care to persons with Alzheimer's disease and chronic illness.
Findings
The facility received a re-survey grade of C with multiple deficiencies identified including failure to provide annual elder abuse training to staff, inadequate maintenance of premises, improper storage of food, failure to secure dangerous items and toxic substances, and failure to ensure safety of facility pools. The complaint investigation found no substantiated allegations regarding catheter care, resident toileting, staff intimidation, pain medication administration, cell phone use, or water accessibility.
Complaint Details
Complaint #NV00037491 was not substantiated after investigation including observation, interviews, and document review. Allegations regarding staff not flushing Foley catheter, resident toileting, staff intimidation, pain medication administration, cell phone use, and water accessibility were all found unsubstantiated.
Severity Breakdown
Severity 2: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Administrator failed to ensure 3 of 5 employees received annual elder abuse training. | Severity 2 |
| Facility failed to ensure premises were clean and well maintained; blinds melted, landscaping needed mowing, trash and debris present. | Severity 2 |
| Facility failed to ensure food was stored and packaged adequately; multiple ice cream containers stored without lids and damaged. | Severity 2 |
| Fencing separating pool from facility was in disrepair, providing resident access to pool. | Severity 2 |
| Facility failed to ensure annual Alzheimer's training was completed for 2 of 5 employees. | Severity 2 |
| Facility failed to ensure dangerous items (razors, scissors, matches) were inaccessible to residents. | Severity 2 |
| Facility failed to ensure toxic substances (WD-40, rubbing alcohol) were inaccessible to residents. | Severity 2 |
Report Facts
Census: 10
Total Capacity: 10
Employees reviewed: 5
Residents reviewed: 10
Deficiency Severity 2: 7
Inspection Report
Original Licensing
Capacity: 10
Deficiencies: 0
Jun 28, 2013
Visit Reason
The inspection was conducted as a result of a request to add the Chronic Illness endorsement to the facility's license.
Findings
The facility received approval to add the Chronic Illness endorsement to their current license. The owner and administrator must ensure caregivers receive additional Chronic Illness training within 60 days of hire, and current caregivers must begin this training immediately. Training will be verified during the next on-site survey.
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 12
May 20, 2013
Visit Reason
This document is a State Licensure annual survey conducted on 5/20/13 to assess compliance with regulations for a residential facility providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of D with multiple deficiencies identified, including failure to meet licensing requirements for care of residents with mental illness, inadequate personnel training, pest control issues, maintenance problems, incomplete physical examinations, medication administration errors, unsafe storage of medications, and unsafe conditions related to dangerous items and toxic substances.
Severity Breakdown
1: 1
2: 11
Deficiencies (12)
| Description | Severity |
|---|---|
| Facility cared for persons with mental illness without proper endorsement. | 2 |
| Personnel file lacked current CPR and first aid certification for one caregiver. | 2 |
| Facility failed to keep premises free from insects and rodents; live roaches and insect parts found. | 2 |
| Premises not clean and well maintained; kitchen cabinets greasy, dishwasher not working, burnt out light bulb, lint accumulation, wall damage, calcium and lime buildup. | 2 |
| Fire extinguisher not inspected yearly as required. | 2 |
| Two residents missing required physical examinations. | 2 |
| Medication administration errors including missing order change labels and incomplete PRN documentation for multiple residents. | 2 |
| Medication administration record inaccurate for three residents. | 1 |
| Medications not stored in locked containers; unlocked medications found in resident rooms and kitchen cabinet. | 2 |
| One resident missing required tuberculosis testing. | 2 |
| Dangerous items such as razors and scissors accessible to residents. | 2 |
| Toxic substances including pest control sprays, wound cleaners, carpet cleaner, and cleaning supplies not secured and accessible to residents. | 2 |
Report Facts
Residents present: 10
Licensed capacity: 10
Deficiency severity 2: 11
Deficiency severity 1: 1
Report
File
11.01.21
Report
File
Care
Report
File
Home
Report
File
II
Report
File
Letter
Report
File
mailed.docx.pdf
Report
File
Sanction
Report
File
Sanction_Sunshine
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