Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 0
Nov 13, 2024
Visit Reason
This inspection was conducted as a State Licensure annual grading survey of the facility in accordance with Nevada Administrative Code, Chapter 449, Requirements for Residential Facilities for Groups.
Findings
The facility was reviewed including ten resident records and four employee records, received a grade of A, and no regulatory deficiencies were identified.
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 2
Nov 14, 2023
Visit Reason
The inspection was conducted as a State Licensure annual grading survey in accordance with Nevada Administrative Code, Chapter 449, for Residential Facilities for Groups.
Findings
The facility received a grade of A but was cited for deficiencies including failure to ensure medications ordered by physicians were available and administered correctly for multiple residents, and failure to secure toxic substances from residents. Specific medication availability and administration issues were noted for several residents, and paint supplies were found accessible to residents.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure medications ordered by the physician were available for 4 of 9 residents and to ensure medication was administered according to physician orders for 1 of 9 residents. | Severity: 2 |
| Failure to ensure toxic substances were not accessible to residents; paint supplies were stored in the living room accessible to residents. | Severity: 2 |
Report Facts
Resident records reviewed: 9
Employee records reviewed: 8
Facility licensed beds: 10
Current census: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Augustine Farias | Administrator | Signed the report as the Laboratory Director or Provider/Supplier Representative |
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 0
Jul 27, 2023
Visit Reason
The inspection was an annual State Licensure survey conducted at the facility from 07/26/23 to 07/27/23 in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the survey. One complaint was investigated but could not be verified. The facility received a grade of A.
Complaint Details
One complaint (#NV00068785) was investigated but could not be verified after interviews and record reviews.
Report Facts
Sample size: 4
Sample size: 10
Inspection Report
Re-Inspection
Census: 9
Capacity: 10
Deficiencies: 3
Feb 1, 2023
Visit Reason
This inspection was a State Licensure mandatory grading resurvey conducted to assess compliance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. Deficiencies were identified related to incomplete background checks for one employee, missing annual tuberculosis testing documentation for one resident, and lack of documented initial cultural competency training for three employees.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure follow-up on an 'Undetermined' background check result for one employee (Employee #10). | Severity: 2 |
| Failed to ensure one resident (Resident #4) met tuberculosis testing requirements with missing annual TB tests for 2021 and 2022. | Severity: 2 |
| Failed to ensure three employees (#3, #4, and #6) had documented evidence of initial cultural competency training. | Severity: 2 |
Report Facts
Number of beds licensed: 10
Census: 9
Number of employees reviewed: 8
Number of resident files reviewed: 9
Number of employees with incomplete cultural competency training: 3
Number of employees with background check issues: 1
Number of residents with missing TB testing: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Prescila Barcelon | Administrator | Administrator acknowledged background check and TB testing deficiencies and cultural competency training issues. |
| Employee 10 | Caregiver | Background check not completed; 'Undetermined' status not followed up. |
| Employee 3 | Caregiver | Lacked documented evidence of initial cultural competency training. |
| Employee 4 | Caregiver | Lacked documented evidence of initial cultural competency training. |
| Employee 6 | House Manager/Caregiver | Lacked documented evidence of initial cultural competency training. |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 15
Nov 1, 2022
Visit Reason
The inspection was conducted as an annual and infection control State Licensure survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility was found deficient in multiple areas including caregiver training, elder abuse training, TB testing, background checks, first aid and CPR certification, annual physical exams for residents, safety standards for toxic substances, and various required employee trainings such as mental illness, chronic illness, dementia, and cultural competency. Several repeat deficiencies were noted from prior inspections.
Severity Breakdown
Severity 2 Scope 1: 1
Severity 2 Scope 2: 6
Severity 2 Scope 3: 7
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure 8 hours of annual Medication Management training was completed for 1 of 11 employees (Employee #6). | Severity 2 Scope 1 |
| Failed to ensure elder abuse training was completed for 9 of 11 employees. | Severity 2 Scope 3 |
| Failed to ensure an initial two-step tuberculosis (TB) test was completed for 5 of 11 employees and annual TB test for 2 of 11 employees; also failed to ensure pre-employment physical exams for 6 of 11 employees. | Severity 2 Scope 3 |
| Failed to ensure background checks were initiated and/or completed through the Nevada Automated Background Check System for 5 of 11 employees. | Severity 2 Scope 2 |
| Failed to ensure employees had current or initial first aid and CPR training for 7 of 11 employees. | Severity 2 Scope 3 |
| Failed to ensure an annual physical examination was completed for 3 of 9 residents. | Severity 2 Scope 2 |
| Failed to ensure 6 of 9 sampled residents met tuberculosis (TB) testing requirements. | Severity 2 Scope 3 |
| Failed to ensure toxic substances were inaccessible to residents; unlocked cabinet with cleaning supplies found. | Severity 2 Scope 3 |
| Failed to ensure 6 of 11 employees received four hours of initial caregiver training within 60 days of hire. | Severity 2 Scope 2 |
| Failed to ensure 8 hours of mental illness training was completed within 60 days of hire for 8 of 11 employees. | Severity 2 Scope 3 |
| Failed to ensure 4 hours of chronic illness training was completed within 60 days of hire for 7 of 11 employees. | Severity 2 Scope 3 |
| Failed to ensure 2 hours of Alzheimer's training was completed within 40 hours of employment for 4 of 11 employees. | Severity 2 Scope 2 |
| Failed to ensure 8 hours of Alzheimer's training was completed within 90 days of employment for 3 of 11 employees. | Severity 2 Scope 2 |
| Failed to submit an application for a cultural competency training program and failed to ensure 10 of 11 employees completed initial cultural competency training. | Severity 2 Scope 3 |
| Failed to obtain a Standard Physician Assessment and Placement Determination for 3 of 9 residents. | Severity 2 Scope 2 |
Report Facts
Employees: 11
Residents: 9
Licensed Capacity: 10
Deficiencies: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Prescila Barcelon | Administrator | Named as provider/supplier representative and signer of report |
| Employee #6 | House Manager/Caregiver | Named in medication management training deficiency and other training deficiencies |
| Employee #1 | Caregiver | Named in elder abuse training, TB testing, CPR, mental illness training deficiencies |
| Employee #3 | Caregiver | Named in elder abuse training, caregiver training, Alzheimer's training, cultural competency deficiencies |
| Employee #5 | Administrator | Named in multiple training deficiencies and background check deficiency |
| Employee #8 | Caregiver | Named in elder abuse training, TB testing, Alzheimer's training, cultural competency deficiencies |
| Employee #9 | Caregiver | Named in elder abuse training, TB testing, caregiver training, Alzheimer's training, cultural competency deficiencies |
| Employee #10 | Caregiver | Named in elder abuse training, TB testing, caregiver training, Alzheimer's training, cultural competency deficiencies |
Inspection Report
Re-Inspection
Census: 8
Capacity: 10
Deficiencies: 0
Feb 2, 2022
Visit Reason
This inspection was a mandatory grading resurvey conducted to assess compliance with Nevada Administrative Code, Chapter 449, Residential Facilities for Groups.
Findings
The facility received a grade of A with no regulatory deficiencies identified. The inspection reviewed eight resident files and seven employee files, confirming compliance with care and safety standards.
Report Facts
Licensed beds: 10
Residents present: 8
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 8
Nov 10, 2021
Visit Reason
The inspection was conducted as a result of a State Licensure annual survey, infection control survey, and complaint investigation at the facility on 11/10/21.
Findings
The facility was found deficient in multiple areas including failure to report an allegation of elder abuse within 24 hours, lack of initial activities of daily living assessments for some residents, unsecured sharp objects and toxic substances accessible to residents, and inadequate employee training in elderly care, mental illness, chronic illness, dementia care, and Alzheimer's care within required timeframes.
Complaint Details
One complaint (#NV00064979) with four allegations was investigated. One allegation was substantiated: the Administrator failed to report an allegation of elder abuse within 24 hours to Adult Protective Services. Other allegations regarding caregiver refusal to assist a resident, caregiver bruising a resident, and caregivers being rude were not substantiated based on interviews and observations.
Severity Breakdown
Level 2: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to report an allegation of physical abuse by an employee to appropriate authorities within 24 hours for 1 of 8 residents. | Level 2 |
| Failure to assess activities of daily living upon admission for 3 of 8 residents. | Level 2 |
| Failure to secure sharp items and tools from residents with Alzheimer's disease and/or dementia. | Level 2 |
| Failure to secure toxic substances from residents, including unsecured laundry detergent pods. | Level 2 |
| Failure to ensure 5 of 6 employees received four hours of initial training related to care of elderly and disabled residents within 60 days of hire. | Level 2 |
| Failure to ensure 6 of 6 employees received eight hours of mental illness training within 60 days of hire. | Level 2 |
| Failure to ensure 6 of 6 employees received four hours of chronic illness training within 60 days of hire. | Level 2 |
| Failure to ensure 5 of 6 employees completed eight hours of dementia training within three months of hire. | Level 2 |
Report Facts
Licensed beds: 10
Residents present: 8
Employee files reviewed: 6
Resident files reviewed: 8
Complaint allegations substantiated: 1
Deficiencies with Level 2 severity: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Theresa Brushfield | Assistant to Administrator | Named as the person signing the report and responsible for implementation of corrective actions |
| Administrator | Named in multiple findings related to failure to report abuse and employee training deficiencies |
Inspection Report
Abbreviated Survey
Census: 2
Capacity: 10
Deficiencies: 1
Nov 13, 2020
Visit Reason
This inspection was a COVID-19 focused infection control State Licensure survey conducted to assess compliance with infection control measures related to the COVID-19 pandemic.
Findings
The facility had implemented multiple infection control measures including visitor screening, use of PPE, hand hygiene, and cleaning protocols. However, the Administrator failed to ensure that staff were medically cleared and fit-tested for N95 respirators as required for infection control.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Administrator failed to obtain staff fit testing and medical clearance for use of N95 respirators as an infection control measure related to COVID-19. | Severity: 2 |
Report Facts
Licensed beds: 10
Current census: 2
Gloves available: 800
Disposable surgical masks: 150
N95 respirators: 3
Gowns: 10
Hand sanitizer bottles: 4
Isolation rooms: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Kittle | Managing Member | Facility Administrator who received guidance on infection control policy and was responsible for oversight |
Inspection Report
Original Licensing
Census: 1
Capacity: 10
Deficiencies: 0
Aug 10, 2020
Visit Reason
This State Licensure survey was conducted to add an Alzheimer care endorsement to the facility.
Findings
No regulatory deficiencies were identified during the survey. No further action was necessary.
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