Inspection Reports for Theresiane Adult Group Care
6620 Ellerhurst Drive, Las Vegas, NV 89103, NV, 89103
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 7
Capacity: 10
Deficiencies: 5
Feb 18, 2025
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to have multiple deficiencies including offensive odors in a resident bedroom, missing and broken electrical outlet covers, presence of dog feces and debris outside, broken windows and missing screens, bedroom and bathroom doors with locks requiring more than one motion to open, and failure to ensure all employees received annual infection control training.
Severity Breakdown
Level 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure premises were free from urine or foul odors in bedroom #2. | Level 2 |
| Missing electrical outlet cover in kitchen and broken outlet cover in bedroom #3; dog feces and debris scattered outside; broken window and missing window screens. | Level 2 |
| Residents' bedroom doors #2, #3, #4, and #5 had locks requiring more than one motion to open. | Level 2 |
| Resident bathroom doors near bedrooms #1 and #3 had locks requiring more than one motion to open. | Level 2 |
| One of four employees (Employee #1) lacked documented evidence of annual infection control training through a nationally recognized course. | Level 2 |
Report Facts
Licensed capacity: 10
Census: 7
Employee files reviewed: 4
Resident files reviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Caregiver | Named in infection control training deficiency; hired 02/08/10 |
| Belma Dizon | Owner | Facility owner acknowledged deficiencies and corrective actions |
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 1
Jul 8, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 2024-05-28 and completed on 2024-07-08, regarding medication administration at the facility.
Findings
The investigation found that the facility administrator failed to obtain and ensure administration of prescribed medications for one resident, resulting in serious health consequences including hospitalization for sepsis and acute renal failure.
Complaint Details
Complaint #NV00071028 was substantiated with deficiency related to medication administration failure for Resident #1.
Severity Breakdown
Severity: 3: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Administrator failed to obtain medications and ensure they were administered as prescribed to Resident #1. | Severity: 3 |
Report Facts
Census: 10
Sample size: 10
Complaint count: 1
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 0
Feb 21, 2024
Visit Reason
This inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the survey. The facility received a grade of A and no further action is necessary.
Report Facts
Resident files reviewed: 10
Employee files reviewed: 3
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 0
Feb 9, 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 Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the survey. The facility received a grade of A and no further action is necessary.
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 2
Jan 20, 2022
Visit Reason
The inspection was conducted as a State Licensure annual and infection control survey in accordance 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 employee background checks and resident tuberculosis testing compliance. Specifically, one employee failed to complete a required background check within five years, and one resident lacked documented evidence of annual TB testing.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 3 employees met background check requirements; Employee #3 had not completed an updated background check within five years. | Severity: 2 |
| Facility failed to ensure 1 of 10 residents met tuberculosis testing requirements; Resident #1 lacked documented evidence of annual TB testing. | Severity: 2 |
Report Facts
Number of resident files reviewed: 10
Number of employee files reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Caregiver | Named in deficiency for failure to complete updated background check |
| Marina Vaughn | Administrator | Signed report and responsible for monitoring compliance |
Inspection Report
Abbreviated Survey
Census: 10
Capacity: 10
Deficiencies: 0
Nov 24, 2020
Visit Reason
This inspection was a COVID-19 focused infection control State Licensure survey conducted to assess the facility's compliance with infection control measures during the pandemic.
Findings
The facility had no residents or staff positive with COVID-19 and implemented multiple infection control measures including visitor restrictions, screening, PPE use, social distancing, and sanitization protocols. No regulatory deficiencies were identified.
Report Facts
Gloves: 200
Disposable surgical style masks: 150
N-95 respirators: 5
Licensed beds: 10
Residents present: 10
Hand sanitizer: 2
Staff sanitization frequency: 3
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 2
Feb 6, 2020
Visit Reason
This inspection was conducted as an annual State Licensure survey to assess compliance with regulatory requirements for the facility licensed as a Residential Facility for Group beds for elderly and disabled persons.
Findings
The facility received a grade of A. Deficiencies were identified related to failure to ensure elder abuse training for 1 of 3 employees and failure to ensure resident medications were reviewed every six months for 2 of 9 residents.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure employees had required elder abuse training for 1 of 3 employees (Employee #3). | Severity: 2 |
| Failure to ensure resident medications were reviewed every six months for 2 of 9 residents (Resident #2 and Resident #3). | Severity: 2 |
Report Facts
Residents present: 9
Licensed capacity: 10
Employees reviewed: 3
Resident files reviewed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Named in elder abuse training deficiency |
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 2
May 30, 2019
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 5/30/19 regarding medication administration issues at the facility.
Findings
The facility failed to ensure timely administration of medications for 2 of 5 residents reviewed. Resident #1 did not receive prescribed Clozaril from 5/8/19 to 5/15/19 due to prescription authorization issues. Resident #2 was not administered aspirin from 5/21/19 to 5/24/19 without a written physician order to hold the medication.
Complaint Details
Complaint #NV00057166 was substantiated regarding failure to administer medication as prescribed. The allegation that case manager and staff were not notified of medication unavailability was unsubstantiated.
Severity Breakdown
Level 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure medication was filled in a timely manner for Resident #1. | Level 2 |
| Failed to administer medications according to physician's orders for Residents #1 and #2. | Level 2 |
Report Facts
Residents present: 10
Sample size: 5
Days medication not administered: 8
Days aspirin not administered: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marina Vaughn | Administrator | Named in relation to medication administration findings and interviews |
Inspection Report
Annual Inspection
Census: 7
Capacity: 10
Deficiencies: 0
Mar 12, 2019
Visit Reason
This inspection was conducted as a State Licensure annual survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to be in compliance with no deficiencies identified and received a grade of A.
Report Facts
Resident files reviewed: 7
Employee files reviewed: 5
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 2
Mar 20, 2018
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility on 03/20/18 to assess compliance with state regulations.
Findings
The facility received a grade of A but had deficiencies including improper refrigeration temperatures for perishable foods and failure to secure residents' health information. Corrective actions were implemented by 03/31/18.
Severity Breakdown
2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure proper food temperatures were maintained; refrigerator thermometer read 55 degrees Fahrenheit with perishable foods inside. | 2 |
| Facility failed to secure residents' health information; medical files were unsecured on a bookcase and in an unlocked office file cabinet. | 2 |
Report Facts
Resident files reviewed: 10
Employee files reviewed: 4
Severity level: 2
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Belma Dizon | Administrator | Signed the report and named in corrective actions |
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 0
Feb 16, 2017
Visit Reason
The inspection was conducted as an annual State Licensure survey of the facility on 2/16/17 by the Division of Public and Behavioral Health.
Findings
No deficiencies were identified during the survey. The facility received a grade of A and no further action was necessary.
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 0
Apr 7, 2016
Visit Reason
This visit was an annual State Licensure survey conducted on 4/7/16 by the Division of Public and Behavioral Health to assess compliance with state regulations.
Findings
No regulatory deficiencies were identified during the survey. The facility received a grade of A and no further action was necessary.
Report Facts
Resident files reviewed: 9
Employee files reviewed: 2
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 0
Mar 30, 2015
Visit Reason
This Statement of Deficiencies was generated as a result of an annual State Licensure survey conducted in the facility on 3/30/15 by the Division of Public and Behavioral Health.
Findings
The facility received a grade of A with no deficiencies identified and is in substantial compliance with the regulations.
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 0
Feb 11, 2014
Visit Reason
This document reports on a State Licensure annual grading survey conducted at Theresiane Adult Group Care on 02/11/2014 to assess compliance with state regulations.
Findings
The facility received a grade of A with no deficiencies identified during the survey, indicating full compliance with applicable regulations.
Report Facts
Resident files reviewed: 9
Employee files reviewed: 4
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 5
Feb 13, 2013
Visit Reason
The inspection was conducted as an annual State Licensure survey to assess compliance with health and safety regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A but had several deficiencies including unclean premises, missing window screens, incomplete fire safety checks, unlocked medication storage, and incomplete tuberculosis testing documentation. Some deficiencies were repeats from the prior year's survey.
Severity Breakdown
Severity: 2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure premises were clean and well maintained, including garbage cans without lids, debris in yard, broken closet doors, and food particles in microwave. | Severity: 2 |
| Facility failed to ensure 5 of 7 windows had screens to prevent entry of insects; repeat deficiency from prior year. | Severity: 2 |
| Facility failed to ensure monthly fire drills and smoke detector checks were conducted regularly; 3 of 6 emergency lights did not illuminate; State Fire Marshall referral made. | Severity: 2 |
| Facility failed to ensure medications were kept in a locked area; medication cabinet was unlocked with resident present. | Severity: 2 |
| Facility failed to ensure 1 of 10 residents complied with tuberculosis testing requirements; repeat deficiency from prior year. | Severity: 2 |
Report Facts
Resident files reviewed: 10
Employee files reviewed: 3
Repeat deficiencies: 2
Emergency lights not illuminating: 3
Windows without screens: 2
Garbage cans without lids: 2
Emergency lights replaced: 2
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 5
Feb 13, 2013
Visit Reason
This document is the result of an annual State Licensure survey conducted on 2/13/2013 to assess compliance with state regulations 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 unclean and poorly maintained premises, missing window screens, incomplete fire safety checks, unlocked medication storage, and incomplete tuberculosis testing documentation for one resident.
Severity Breakdown
2: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure the premises was clean and well maintained, including uncovered garbage cans, debris in yards, broken closet doors, incomplete window blinds, hanging cable cords, and a microwave with food particles. | 2 |
| Facility failed to ensure 5 of 7 windows had screens to prevent entry of insects. | 2 |
| Facility did not ensure monthly fire drills and smoke detector checks were conducted regularly for 1 of 12 months (missing January 2013), and 3 of 6 emergency lights did not illuminate when tested. | — |
| Facility failed to ensure medications were kept in a locked area; file cabinet containing medication was unlocked with resident present. | 2 |
| Facility failed to ensure 1 of 10 residents complied with tuberculosis testing requirements. | 2 |
Report Facts
Number of residents present: 10
Total licensed capacity: 10
Windows without screens: 5
Months missing fire drill/smoke detector checks: 1
Emergency lights not illuminating: 3
Residents non-compliant with TB testing: 1
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 5
Feb 22, 2012
Visit Reason
The inspection was conducted as an annual State Licensure survey to assess compliance with health and safety regulations at Theresiane Adult Group Care.
Findings
The facility was found to have multiple deficiencies including failure to keep premises free from insects and rodents, lack of screens on windows and doors to prevent insect entry, improper administration and storage of over-the-counter medications, and failure to ensure medications were kept in locked containers.
Severity Breakdown
Level 2: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure it was free of insects and rodents (roaches observed throughout the kitchen). | Level 2 |
| Facility failed to provide screen doors on all bedroom windows to prevent entry of insects. | — |
| Facility did not obtain physician orders to administer over-the-counter medications to 9 of 9 residents. | Level 2 |
| Facility failed to ensure medications were stored in a locked area that is cool and dry. | Level 2 |
| Facility failed to ensure medications for 2 of 8 residents were kept in locked containers with keys provided to the facility. | Level 2 |
Report Facts
Deficiencies cited: 5
Census: 9
Total Capacity: 10
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 4
Feb 22, 2012
Visit Reason
This document is a result of an annual State Licensure survey conducted at Theresiane Adult Group Care on 2/22/2012 to assess compliance with state regulations.
Findings
The facility received a grade of A but was found deficient in several areas including failure to keep the premises free of insects and rodents, lack of screens on bedroom windows, failure to obtain physician orders for over-the-counter medications for all residents, and improper medication storage.
Severity Breakdown
Severity: 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure the premises were free of insects and rodents (Roaches observed throughout the kitchen). | Severity: 2 |
| Facility failed to provide screen doors on all bedroom windows to prevent entry of insects. | — |
| Facility did not obtain physician orders to administer over-the-counter medications to 9 of 9 residents. | Severity: 2 |
| Facility failed to ensure medications for 2 of 8 residents were kept in a locked container. | Severity: 2 |
Report Facts
Census: 9
Total Capacity: 10
Residents without physician orders for OTC medications: 9
Residents with medications not stored in locked container: 2
Inspection Report
Complaint Investigation
Capacity: 10
Deficiencies: 0
Oct 20, 2011
Visit Reason
The inspection was conducted as a complaint investigation initiated by the Bureau of Health Care Quality and Compliance on 10/4/11 regarding allegations of verbal, physical, and sexual abuse at the facility.
Findings
The investigation found that allegations of verbal, physical, and sexual abuse by employees and residents were not substantiated based on interviews with residents, employees, caseworkers, and observations of interactions at the facility.
Complaint Details
Complaint #NV00029543 involved allegations of verbal abuse, physical abuse, and sexual harassment by employees and residents. The allegations were not substantiated after interviews and observations.
Report Facts
Licensed capacity: 10
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 2
Jan 31, 2011
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at the facility on 01/31/2011.
Findings
The facility received a grade of A but was found deficient in maintaining the premises free from offensive odors in 2 of 5 resident bedrooms and failed to ensure that 1 of 10 residents received an annual physical examination as required.
Severity Breakdown
2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure the premises was free from offensive odors in 2 of 5 resident bedrooms (Bedroom C had a strong smell of smoke and urine). | 2 |
| Facility failed to ensure that 1 of 10 residents received an annual physical examination (Resident #9). | 2 |
Report Facts
Resident files reviewed: 10
Employee files reviewed: 4
Resident census: 10
Total licensed capacity: 10
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