Inspection Reports for Billman House
3646 Billman Ave, Las Vegas, NV 89121, NV, 89121
Back to Facility ProfileDeficiencies (last 14 years)
Deficiencies (over 14 years)
15.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
118% worse than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
67% occupied
Based on a November 2024 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 4
Date: Nov 6, 2024
Visit Reason
The inspection was conducted as a result of an annual State Licensure and complaint investigation initiated on 2024-10-09 and completed on 2024-11-06, in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Complaint Details
One complaint (Complaint #NV00072276) was investigated and substantiated related to the nutritional quality and variety of meals provided to residents.
Findings
The facility was found deficient in several areas including failure to provide nutritious meals with adequate choices, failure to develop and maintain person-centered service plans for all residents, improper use of full bed rails as restraints, and failure to submit required medical exemption requests for residents with Foley catheters. One complaint was substantiated during the investigation.
Deficiencies (4)
Failed to ensure food was nutritious and prepared with regard for individual preferences; residents frequently served sandwiches instead of hot meals.
Failed to ensure person-centered service plans were developed and addressed treatment needs for all sampled residents.
Failed to ensure full bed rails were not used as a restraint for one resident.
Failed to submit medical exemption requests for residents with Foley catheters.
Report Facts
Licensed beds: 6
Residents present: 4
Resident files reviewed: 5
Employee files reviewed: 2
Complaints substantiated: 1
Severity 3 deficiencies: 1
Severity 2 deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helen Nicolas | Owner | Acknowledged deficiencies related to meal choices, missing service plans, use of bed rails as restraints, and missing medical exemption requests. |
Inspection Report
Re-Inspection
Census: 6
Capacity: 6
Deficiencies: 7
Date: Dec 26, 2023
Visit Reason
This inspection was a State Licensure mandatory grading resurvey conducted on 12/26/2023 in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A but had several deficiencies related to personnel files (missing TB screening, background checks, and first aid/CPR certification), health and sanitation maintenance, catheter care, medication administration accuracy, and cultural competency training.
Deficiencies (7)
Personnel File - TB Screening not documented as required.
Personnel Files - Background Checks not documented as required.
Personnel File - 1st Aid & CPR certification missing.
Health & Sanitation - Facility interior, exterior, and landscaping not well maintained.
Residents Requiring Indwelling Catheter - Caregiver did not follow required procedures.
Medication Administration - MAR was inaccurate for one resident; medication administered but not documented.
Cultural Competency Training not conducted as required.
Report Facts
Licensed beds: 6
Resident census: 6
Deficiencies cited: 7
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 8
Date: Oct 17, 2023
Visit Reason
This inspection was conducted as an annual State Licensure and infection control survey for a Residential Facility for Groups in accordance with Nevada Administrative Code Chapter 449.
Findings
The facility was found deficient in multiple areas including personnel files lacking required health certifications, background checks, CPR training, and cultural competency training for employees. Additionally, the facility failed to maintain the premises properly and had medication administration documentation inaccuracies. The facility received a grade of C.
Deficiencies (8)
Personnel file lacked documented evidence of physical examination and two-step TB test for Employee #3 upon hire.
Personnel file lacked documented evidence of fingerprints and completed background check for Employee #3.
Personnel files lacked documented evidence of CPR training for Employees #2 and #3.
Facility failed to ensure the interior and exterior were well maintained, including tall grass in backyard and rust stains in main bathroom toilet.
Facility failed to ensure catheter care training was documented for Employee #3 who emptied catheter bag of Resident #1.
Medication regimen review was not completed for Resident #3 within required 6-month period.
Medication Administration Record (MAR) was inaccurate for Resident #1; medication administered but not documented correctly.
Personnel files lacked documented evidence of cultural competency training within 30 days of hire for Employees #2 and #3.
Report Facts
Licensed beds: 6
Current census: 4
Employees reviewed: 3
Residents reviewed: 4
Deficiencies with severity Level 2: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helen Nicolas | Owner | Acknowledged deficiencies and signed report |
| Employee #3 | Caregiver | Named in multiple deficiencies including lack of TB testing, background check, CPR training, catheter care training, and cultural competency training |
| Employee #2 | Administrator | Named in deficiencies related to CPR training and cultural competency training |
Inspection Report
Complaint Investigation
Census: 4
Capacity: 6
Deficiencies: 1
Date: Apr 4, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation completed on 04/04/23 in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.
Complaint Details
One complaint (#NV00067890) was investigated and substantiated.
Findings
The facility was found to have a strong urine odor permeating multiple areas, which was acknowledged by the Owner/Operator and attributed to an incontinent resident. The complaint was substantiated and the facility received a grade of A.
Deficiencies (1)
Facility failed to ensure the premises were free from offensive urine odors affecting the living room, kitchen, and dining room.
Report Facts
Licensed beds: 6
Residents present: 4
Sample size: 5
Severity level: 2
Scope: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helen Nicolas | Owner | Named as Owner/Operator acknowledging the urine odor during the complaint investigation |
Inspection Report
Re-Inspection
Census: 5
Capacity: 6
Deficiencies: 6
Date: Dec 22, 2022
Visit Reason
This inspection was a State Licensure mandatory grading resurvey conducted to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A with several deficiencies identified, including failure to maintain the premises free of strong urine odor due to inadequate mattress protection, incomplete medical care records, and other documentation issues. The facility does not accept residents with Alzheimer's disease and does not discriminate against those needing assistance.
Deficiencies (6)
Facility failed to ensure the premises were free of a strong urine odor due to a resident soaking through incontinent briefs onto the mattress without a mattress protector.
Failure to obtain and maintain records of residents' physical examinations before admission and annually or more frequently as needed.
Failure to maintain separate locked files for each resident containing all required records, retained for at least 5 years.
Facility does not have endorsement to provide care for persons with Alzheimer's disease and will not admit such residents.
Facility does not discriminate against anyone who needs assistance.
Administrator and provider completed cultural competency training and will apply it to the facility.
Report Facts
Licensed beds: 6
Residents present: 5
Files reviewed: 5
Files reviewed: 2
Plan of correction completion date: Dec 28, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helen Nicolas | Owner | Signed as provider/supplier representative on the report |
Inspection Report
Complaint Investigation
Census: 3
Capacity: 6
Deficiencies: 4
Date: Apr 21, 2022
Visit Reason
The inspection was conducted as a State Licensure Complaint Investigation survey triggered by Complaint #NV00066007 with three allegations regarding menu accuracy, resident access to laundry facilities, and food variety.
Complaint Details
Complaint #NV00066007 with three allegations was investigated. Allegation #1 (menu issues) and Allegation #2 (lack of dryer access) were substantiated. Allegation #3 (lack of food variety) was unsubstantiated based on observations and interviews.
Findings
The investigation substantiated two allegations: the facility failed to provide accurate, dated menus reflecting actual meals served, and residents did not have access to the dryer and had to hang clothes on the clothesline including the Owner's clothes. The third allegation regarding lack of food variety was unsubstantiated based on observations and interviews. Additional deficiencies included failure to designate an employee in charge during the Administrator's absence and requiring residents to perform housekeeping and laundry duties without proper volunteer documentation.
Deficiencies (4)
Facility failed to provide written menus which were dated and accurately reflected the meals served to residents.
Administrator failed to designate an employee to be in charge with access to all areas during Administrator's absence.
Residents were required to perform cleaning and laundry duties normally performed by staff without documented volunteer statements.
Residents did not have access to the dryer and had to hang clothes on the clothesline, including the Owner's clothes.
Report Facts
Licensed beds: 6
Residents present: 3
Complaint allegations: 3
Ombudsman visits: 7
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 5
Date: Nov 1, 2021
Visit Reason
The inspection was conducted as a State Licensure annual survey and infection control survey in accordance with Nevada Administrative Code Chapter 449 for a residential facility for groups.
Findings
The facility received a grade of B with multiple deficiencies identified including failure to ensure infection control practices related to COVID-19, admission of a resident requiring a higher category of care, incomplete ultimate user medication agreements, incomplete tuberculosis testing documentation for multiple residents, and failure to complete a Standard Placement Determination form for a resident with mild neurocognitive disorder.
Deficiencies (5)
Facility failed to ensure infection control practices were implemented and maintained in response to the COVID-19 pandemic; no N95 masks available and no employees medically cleared and fit tested to wear N95 masks.
Facility admitted a resident who required a higher category of care than allowed (bedbound resident under hospice care).
Facility failed to ensure an ultimate user medication agreement was completed for one resident upon admission.
Facility failed to ensure tuberculosis testing requirements were met for 5 of 6 sampled residents, lacking documentation of required two-step TB tests.
Facility admitted and retained a resident with mild neurocognitive disorder without completing a Standard Placement Determination form.
Report Facts
Number of beds: 6
Resident census: 6
Deficiencies cited: 5
Severity level: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helen Nicolas | Owner | Acknowledged deficiencies related to infection control, resident care, and documentation during the inspection |
Inspection Report
Abbreviated Survey
Census: 4
Capacity: 6
Deficiencies: 0
Date: Nov 12, 2020
Visit Reason
A focused COVID-19 infection control survey was conducted to assess regulatory compliance with infection control and prevention measures at the facility.
Findings
The facility demonstrated compliance with infection control protocols including PPE use, temperature checks, social distancing, and cleaning procedures. No residents or staff exhibited COVID-19 symptoms or positive test results. No regulatory deficiencies were cited.
Report Facts
PPE stock: 300
PPE stock: 100
PPE stock: 10
PPE stock: 10
Residents tested: 4
Staff tested: 2
Hand sanitizer containers: 5
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 3
Date: Nov 26, 2019
Visit Reason
This inspection was conducted as a State Licensure annual survey in accordance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.
Findings
The facility received a grade of A but was found deficient in several areas including failure to ensure initial physical exams for some residents, lack of annual activities of daily living assessments for most residents, and failure to obtain required Alzheimer's care endorsements for residents diagnosed with dementia.
Deficiencies (3)
Failed to ensure 2 of 6 residents had initial physical exams completed.
Failed to ensure 5 of 6 residents had activities of daily living (ADL) assessments completed annually or initially.
Failed to obtain Alzheimer's endorsement for 2 of 6 residents diagnosed with dementia and lacked standard placement determination for 1 resident.
Report Facts
Residents reviewed: 6
Employee files reviewed: 3
Licensed beds: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helen Nicolas | Owner | Signed as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 7
Date: Jan 11, 2019
Visit Reason
Annual State Licensure survey conducted to assess compliance with Nevada Administrative Code for Residential Facility for Groups.
Findings
The facility received a grade of B with deficiencies identified related to medication administration, including failure to perform six-month medication reviews for two residents, failure to refill medication timely for one resident, failure to notify physician within 12 hours of missed medication, incomplete medication administration records, and failure to obtain Alzheimer's endorsement for residents with dementia.
Deficiencies (7)
Failed to ensure medication reviews were performed by a Physician, Pharmacist or Registered Nurse at least once every six months for 2 of 5 residents.
Failed to ensure a medication was refilled in a timely manner for 1 of 5 residents.
Failed to ensure over-the-counter medications were given only with physician approval and administered according to instructions.
Failed to ensure 1 of 5 residents received medication as prescribed.
Failed to notify physician within 12 hours after 1 of 5 residents missed medication administration.
Failed to document medication administration correctly on the Medication Administration Record for 1 of 5 residents.
Failed to obtain an Alzheimer's endorsement to provide care to residents with Alzheimer's Disease or related dementia for 3 of 6 sampled residents.
Report Facts
Residents present: 5
Total licensed beds: 6
Deficiencies cited: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helen Nicolas | Owner | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Employee #1 | Confirmed medication review deficiencies and medication administration issues for Resident #2 and #3 |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 2
Date: Jun 20, 2016
Visit Reason
This inspection was a mandatory State Licensure grading re-survey conducted on 6/20/16 in accordance with NRS 449.0307, Powers of the Health Division.
Findings
The facility received a grade of A but had repeat deficiencies including failure to maintain evidence of employee background checks for 3 employees and failure to ensure the kitchen and food preparation area were clean, with grease and dust buildup observed.
Deficiencies (2)
Failed to maintain evidence of compliance for 3 of 3 employees' completion of the Nevada Automated Background Check System (NABS).
Failed to ensure the kitchen and food preparation area were clean; stove, oven, countertops soiled with grease and debris; oven hood missing with grease and dust buildup; cabinets soiled with grease splatter and dust.
Report Facts
Number of residents present: 6
Total licensed capacity: 6
Number of employee files reviewed: 3
Number of resident files reviewed: 6
Scope: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Acknowledged findings related to missing NABS clearance letter and kitchen cleanliness | |
| Employee #2 | File lacked documented evidence of NABS clearance letter | |
| Employee #3 | Administrator | File lacked documented evidence of NABS clearance letter |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 20, 2016
Visit Reason
The document is related to a grading re-survey conducted at the facility on 6/20/16, resulting in a re-survey grade of A. It serves as a Statement of Deficiencies and Plan of Correction.
Findings
The document outlines instructions for submitting a Plan of Correction for deficiencies found during the re-survey. It also details the sanctions that may be imposed for deficiencies with high severity and scope scores.
Report Facts
Re-survey date: Jun 20, 2016
Sanction application fee: 600
Plan of Correction submission deadline: 10
Placard display deadline: 1
Re-survey grade date: Jun 20, 2016
Sanction application submission deadline: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kyle Parkson | Health Facilities Inspector I | Signed the letter regarding the Plan of Correction and sanctions |
| Kyle Devine | Bureau Chief | Referenced as Bureau Chief in the letter |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 2
Date: Jun 20, 2016
Visit Reason
This inspection was a mandatory State Licensure grading re-survey conducted on 6/20/16 to assess compliance with licensing requirements for a residential facility for elderly or disabled persons.
Findings
The facility received a grade of A. Deficiencies were identified related to missing Nevada clearance letters for employees and cleanliness issues in the kitchen area, including grease and dust on equipment and missing oven hood above the stove.
Deficiencies (2)
Employee files lacked documented evidence of Nevada clearance letters for three employees, including the administrator.
Kitchen area, including stove, oven, and countertops, were soiled with grease and debris; oven hood was missing and area soiled with grease and dust; cabinets next to oven/stove were soiled with grease splatter and dust.
Report Facts
Facility licensed beds: 6
Resident census: 6
Severity level 2 deficiencies: 2
Scope: 3
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 12
Date: Apr 12, 2016
Visit Reason
This inspection was an annual State Licensure survey conducted to assess compliance with state regulations for a residential facility for elderly and disabled persons and/or persons with mental illness.
Findings
The facility received a grade of D with multiple deficiencies identified including failure to provide adequate oversight by the administrator, incomplete employee tuberculosis testing and background checks, unsanitary conditions in the facility and kitchen, inadequate food storage, failure to provide required resident activities, incomplete annual physical examinations for residents, and medication administration record inaccuracies.
Deficiencies (12)
Administrator failed to provide oversight and supervision to staff, ensure residents' safety, maintain cleanliness, and ensure employees completed required background checks and tuberculosis testing.
Facility failed to ensure 3 of 4 employees met tuberculosis testing requirements.
Facility failed to ensure 4 of 4 employees had background checks at least every 5 years and failed to participate in the Nevada Automated Background Check Screening System (NABS).
Facility failed to maintain clean and well-maintained interior and exterior premises, including cigarette butts, deflated mattress, broken items, dust buildup, and inoperable dishwasher.
Facility failed to ensure kitchen and food preparation areas were clean; stove, oven, and counters soiled with grease and food debris; missing oven hood; cabinets soiled.
Facility failed to ensure perishable foods were refrigerated at proper temperatures; observed un-refrigerated eggs and moldy food items.
Facility failed to ensure sufficient storage and proper packaging of food; observed uncovered rice, moldy produce, and improper storage.
Facility failed to provide at least 10 hours of scheduled activities per week for residents.
Facility failed to ensure 1 of 6 residents had an annual physical examination.
Facility failed to ensure medication administration records (MAR) were accurate for 6 of 6 residents; multiple medications not signed for as given.
Facility failed to ensure medications were stored securely; medication cabinet was unlocked with prescription bottles unsecured.
Facility failed to maintain separate resident files locked and protected against unauthorized use for at least 5 years; failed to ensure tuberculosis testing documentation for 2 of 6 residents.
Report Facts
Residents present: 6
Total licensed capacity: 6
Employees reviewed: 4
Residents reviewed: 6
Deficiencies cited: 12
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 12
Date: Apr 12, 2016
Visit Reason
This document is an annual State Licensure survey conducted on 4/12/2016 to assess compliance with state regulations for a residential facility for group beds for elderly and disabled persons and/or persons with mental illness.
Findings
The facility received a grade of D with multiple deficiencies identified including failure to provide adequate oversight by the administrator, incomplete tuberculosis testing and background checks for employees, poor facility cleanliness and maintenance, inadequate kitchen sanitation and food storage, insufficient scheduled activities for residents, missing annual physical exams for residents, inaccurate medication administration records, unsecured medication storage, and incomplete resident tuberculosis documentation.
Deficiencies (12)
Administrator failed to provide oversight and supervision to staff, ensure residents' safety, maintain cleanliness, and ensure required employee background checks and tuberculosis testing.
Facility failed to ensure 3 of 4 employees met tuberculosis testing requirements.
Facility failed to ensure 4 of 4 employees had background checks performed at least once every 5 years and failed to participate in the Nevada Automated Background Check Screening System (NABS).
Facility failed to ensure the interior and exterior of the facility was clean and well maintained, including cigarette butt litter, broken furniture, dust buildup, and inoperable appliances.
Facility failed to ensure the kitchen and food preparation area were clean, with grease and food debris on stove, oven, countertops, and cabinets.
Facility failed to ensure perishable food was refrigerated at proper temperature; eggs were stored unrefrigerated.
Facility failed to ensure food was properly stored and packaged; uncovered rice, moldy produce, and open food containers were observed.
Facility failed to provide at least 10 hours of scheduled activities per week suited to residents' interests and capacities; activity schedule was inaccurate.
Facility failed to ensure 1 of 6 residents had an annual physical examination.
Facility failed to ensure Medication Administration Records (MARs) were accurate for 6 of 6 residents, including missing signatures, undocumented medications, and incomplete PRN medication records.
Facility failed to ensure medications were stored securely; medication cabinet and prescription bottles were unlocked.
Facility failed to ensure 2 of 6 residents met tuberculosis testing requirements; missing second step TB tests.
Report Facts
Facility licensed beds: 6
Census: 6
Employee files reviewed: 4
Resident files reviewed: 6
Deficiency severity: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Acknowledged deficiencies related to tuberculosis testing, background checks, facility cleanliness, medication administration, and medication storage. | |
| Employee #2 | Mentioned in tuberculosis and background check deficiencies. | |
| Employee #3 | Mentioned in tuberculosis and background check deficiencies. | |
| Employee #4 | Administrator | Mentioned in background check deficiency and oversight failure. |
Inspection Report
Complaint Investigation
Census: 4
Capacity: 6
Deficiencies: 0
Date: Sep 23, 2014
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding an allegation that a resident with Alzheimer's disease was admitted to the facility without an Alzheimer's endorsement.
Complaint Details
Complaint #NV00040598 contained one allegation that a resident with Alzheimer's disease was admitted without an Alzheimer's endorsement. The allegation was not substantiated based on hospital records and resident interview.
Findings
The complaint contained one allegation which was not substantiated after review of hospital records and an interview with the resident. No regulatory deficiencies were identified and no further action was necessary.
Report Facts
Licensed beds: 6
Resident census: 4
Inspection Report
Renewal
Capacity: 6
Deficiencies: 0
Date: Aug 3, 2014
Visit Reason
This Statement of Deficiencies was generated as a result of a mandatory State Licensure re-grading survey conducted in the facility on 8/3/14, in accordance with NRS 449.0307, Powers of the Health Division.
Findings
No regulatory deficiencies were identified. The facility received a grade of A.
Report Facts
Licensed beds: 6
Census: 0
Inspection Report
Complaint Investigation
Census: 4
Capacity: 6
Deficiencies: 22
Date: Jul 15, 2014
Visit Reason
The inspection was conducted as a complaint investigation initiated by the Division of Public and Behavioral Health on 2014-07-10, following complaint #NV00039826 alleging multiple deficiencies at the facility.
Complaint Details
Complaint #NV00039826 was substantiated. The complaint investigation was initiated on 2014-07-10 by the Division of Public and Behavioral Health. The complaint contained eight allegations, six of which were substantiated including lack of water pressure, mildew and mold, lack of food, unqualified caregiver, improper medication administration, and bed bugs. Two allegations were not substantiated.
Findings
The investigation substantiated multiple allegations including lack of water pressure, mildew and mold, lack of food, unqualified caregiver on-site, improper medication administration, and bed bugs. The facility was found to be over-census and had numerous deficiencies related to staffing, sanitation, resident rights, nutrition, medication management, and safety.
Deficiencies (22)
Facility does not have water pressure
Mildew and mold around the kitchen sink
Lack of food
Facility was over-census
No qualified caregiver on-site
Medications were not administered properly
Bed bugs in the facility
Residents not allowed to leave the facility
Administrator failed to provide oversight and direction to staff
Facility failed to ensure adequate hot water pressure
Facility failed to be free of insects and rodents
Facility interior and exterior not well maintained
Nutrition and service of food inadequate
State Fire Marshal referral due to front door lock safety issue
Supervision of residents inadequate
Protective supervision not provided for one resident
Activities for residents not provided
Resident rights violations including verbal and mental abuse
Residents with diabetes not provided appropriate meals
Medication administration and record keeping deficiencies
Medication storage not secure
Medication container labeling and count issues
Report Facts
Census: 4
Total Capacity: 6
Sample Size: 5
Number of Allegations: 8
Severity 2 Deficiencies: 18
Severity 3 Deficiencies: 2
Inspection Report
Complaint Investigation
Census: 4
Capacity: 6
Deficiencies: 15
Date: Jul 15, 2014
Visit Reason
Complaint investigation initiated due to eight allegations including lack of water pressure, mildew and mold, lack of food, unqualified caregiver on-site, improper medication administration, bed bugs, and residents not allowed to leave the facility.
Complaint Details
Complaint #NV00039826 was substantiated. The complaint contained eight allegations including lack of water pressure, mildew and mold, lack of food, unqualified caregiver on-site, improper medication administration, bed bugs, and residents not allowed to leave the facility (the last allegation was not substantiated).
Findings
The facility was found to have multiple deficiencies including inadequate water pressure, presence of bed bugs, poor sanitation and maintenance, insufficient nutritious food, lack of qualified caregivers on duty, improper medication administration and storage, inadequate protective supervision, lack of resident activities, verbal abuse by staff, and failure to comply with diabetic diet requirements.
Deficiencies (15)
Facility failed to provide oversight and direction to staff to ensure residents received needed services and protective supervision.
Failed to ensure a qualified caregiver was on duty at all times.
Failed to ensure 1 of 3 employees had required annual tuberculosis screening.
Failed to ensure adequate hot water pressure for residents.
Facility was infested with bed bugs despite treatment efforts.
Failed to maintain interior and exterior of facility in a clean and well-maintained condition.
Failed to provide nutritious meals suitable for residents; snacks not offered and residents often felt hungry.
Failed to ensure resident safety due to front door having a key lock on the inside.
Failed to provide adequate protective supervision for Resident #4 during pest control fumigation.
Failed to provide group activities for residents.
Failed to prevent verbal and mental abuse of residents by staff.
Failed to provide meals appropriate for diabetic diet for Resident #2.
Failed to maintain accurate medication logs and counts for Residents #2, #3, and #5.
Failed to store medications in locked containers; medications found unlocked in refrigerator.
Failed to keep medications in original containers and properly labeled for Residents #3 and #5.
Report Facts
Census: 4
Total Capacity: 6
Deficiencies cited: 15
Medication discrepancies: 3
Severity 2 deficiencies: 13
Severity 3 deficiencies: 1
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 1
Date: Dec 31, 2013
Visit Reason
This inspection was conducted as a State Licensure annual grading survey combined with a complaint investigation regarding allegations of resident neglect and malnourishment.
Complaint Details
Complaint #NV00037748 was investigated and found not substantiated. The allegation of resident neglect and malnourishment was not supported by document review and interviews.
Findings
The facility received a grade of A. The complaint was not substantiated. A deficiency was identified related to tuberculosis testing compliance for residents, which was a repeat deficiency from a prior survey.
Deficiencies (1)
Failure to ensure 4 of 6 residents complied with tuberculosis testing requirements, including missing two-step TB tests and annual TB tests.
Report Facts
Resident census: 6
Total licensed capacity: 6
Resident weight: 122
Resident weight: 125
Deficiency scope: 3
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 1
Date: Dec 31, 2013
Visit Reason
This inspection was conducted as a result of a State Licensure annual grading survey combined with a complaint investigation regarding allegations of resident neglect and malnourishment.
Complaint Details
Complaint #NV00037748 alleged a resident was neglected and malnourished. The complaint was investigated and not substantiated based on document review and interviews, including hospital records and staff interviews.
Findings
The facility received a grade of A. The complaint alleging resident neglect and malnourishment was not substantiated. However, deficiencies were identified related to tuberculosis testing compliance for 4 of 6 residents, which was a repeat deficiency from the prior year's survey.
Deficiencies (1)
Failed to ensure 4 of 6 residents complied with NAC 441A.380 regarding tuberculosis testing, including missing two-step TB tests and annual TB tests.
Report Facts
Resident files reviewed: 7
Employee files reviewed: 4
Resident weight at discharge: 122
Resident weight at hospital admission: 125
Repeat deficiency date: Dec 20, 2012
Notice
Deficiencies: 1
Date: Mar 29, 2013
Visit Reason
The Health Division is notifying Billman House of its intent to impose sanctions due to repeat deficiencies found in a prior survey dated 12/20/12.
Findings
The notice details the imposition of monetary penalties totaling $300 for a repeat deficiency at TAG Y920, explains the regulatory authority, and outlines the appeal process and penalty payment requirements.
Deficiencies (1)
Repeat deficiency at TAG Y920 cited in the survey dated 12/20/12
Report Facts
Monetary Penalties: 300
Working days for appeal: 10
Days for penalty payment: 15
Penalty reduction percentage: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dorothy Sims | Health Facilities Inspector III | Signed the notice regarding sanctions |
Inspection Report
Re-Inspection
Census: 5
Capacity: 6
Deficiencies: 3
Date: Feb 27, 2013
Visit Reason
This visit was a required grading re-survey conducted as a State Licensure survey to assess compliance and assign a re-survey grade.
Findings
The facility received a re-survey grade of A. Deficiencies were identified related to administrator responsibilities, medication storage, and resident file storage. Some deficiencies were repeat from a prior annual survey.
Deficiencies (3)
Administrator failed to ensure that the current grading placard was displayed conspicuously in a public area.
Facility failed to ensure medications belonging to a caregiver were kept in a locked container; medications were found in an unlocked hall closet.
Facility failed to ensure resident discharge files, caregiver file information, and other facility statements were accessible only to authorized persons; files were found in unlocked locations.
Report Facts
Licensed beds: 6
Resident census: 5
Severity 2 deficiencies: 3
Scope: 3
Scope: 1
Inspection Report
Re-Inspection
Census: 5
Capacity: 6
Deficiencies: 3
Date: Feb 27, 2013
Visit Reason
This document is a Statement of Deficiencies generated as a result of a required grading re-survey conducted on 2/27/2013 at Billman House, a residential facility for group beds for elderly and disabled persons and/or persons with mental illness.
Findings
The facility received a re-survey grade of A but had several deficiencies including failure to conspicuously display the current grading placard, improper medication storage where caregiver medications were not locked, and failure to secure resident discharge files and caregiver personnel information from unauthorized access.
Deficiencies (3)
Administrator failed to ensure the current grading placard was displayed conspicuously in a public area; placard was found behind a safe on a small counter top.
Facility failed to ensure medications belonging to a caregiver were kept in a locked container; a large paper bag with caregiver supplements and prescription medications was found in an unlocked hall closet.
Facility failed to ensure resident discharge files, caregiver file information, and other facility statements were not accessible to residents and others; files found in unlocked cabinet and unlocked dresser drawer.
Report Facts
Licensed capacity: 6
Census: 5
Deficiency repeat: 1
Severity score: 2
Scope score: 3
Scope score: 1
Inspection Report
Complaint Investigation
Census: 4
Capacity: 6
Deficiencies: 0
Date: Dec 28, 2012
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated by the Bureau of Health Care Quality and Compliance on 2012-12-17 regarding allegations of failure to notify a resident's responsible party upon discharge and change of condition.
Complaint Details
Complaint #NV00033958 was not substantiated. The allegation that a resident's responsible party was not notified upon discharge and change of condition was not substantiated based on interviews with the facility owner, caregiver, and a physician, and review of transfer and discharge documents. The allegation regarding resident safety/falls was substantiated during a previous complaint investigation (Complaint #NV00033497).
Findings
The investigation found that the allegations regarding failure to notify the resident's responsible party upon discharge and change of condition were not substantiated based on interviews and document reviews. The allegation regarding resident safety/falls was previously substantiated in an earlier complaint investigation.
Report Facts
Licensed capacity: 6
Census: 4
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 9
Date: Dec 20, 2012
Visit Reason
This document is a State Licensure inspection report resulting from an annual State Licensure inspection conducted on 12/20/12 to assess compliance with regulatory requirements for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of C with multiple deficiencies identified, including caregiver medication training, personnel background checks, facility cleanliness, resident bed safety, physical examinations, medication storage, tuberculosis testing, and Alzheimer's endorsement compliance.
Deficiencies (9)
Failed to ensure 1 of 4 caregivers completed required medication management training.
Failed to ensure 1 of 4 employees met background check requirements.
Failed to ensure the premises was clean and well maintained; mold and grease buildup found in kitchen areas.
Failed to ensure 1 of 6 resident beds had full side bed rails.
Failed to ensure 3 of 4 residents received required physical examinations.
Failed to ensure 4 of 4 residents' medications were kept secured; medication cabinet unlocked and unsecured medications observed.
Failed to ensure 2 of 4 residents complied with tuberculosis testing requirements.
Failed to obtain Alzheimer's endorsement for 1 resident prior to admission.
Failed to ensure employees received annual training in recognition, prevention, and response to elder abuse.
Report Facts
Residents present: 4
Total licensed capacity: 6
Caregivers reviewed: 4
Employees reviewed: 4
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 9
Date: Dec 20, 2012
Visit Reason
This document is the result of an annual State Licensure inspection conducted at the facility to assess compliance with state regulations and licensing requirements.
Findings
The facility was found to have multiple deficiencies including failure to ensure caregiver medication training, incomplete employee background checks, poor facility cleanliness, unsecured medication storage, missing resident physical exams, incomplete tuberculosis testing, lack of Alzheimer's endorsement, and failure to provide annual elder abuse training to employees.
Deficiencies (9)
Failed to ensure 1 of 4 caregivers completed required medication management training (Employee #1).
Failed to ensure 1 of 4 employees met background check requirements (Employee #4).
Facility premises were not clean or well maintained; moldy pie, grease buildup on stove and microwave.
Failed to ensure 1 of 6 resident beds had full side bed rails (repeat deficiency).
Failed to ensure 3 of 4 residents received required physical examinations.
Failed to ensure medications for 4 of 4 residents were stored securely.
Failed to ensure 2 of 4 residents complied with tuberculosis testing requirements.
Failed to obtain Alzheimer's endorsement prior to admitting 1 resident with Alzheimer's Disease.
Failed to ensure employees received annual training on elder abuse recognition, prevention, and response (Employee #1).
Report Facts
Licensed beds: 6
Current census: 4
Caregivers reviewed: 4
Employee files reviewed: 4
Residents reviewed: 4
Repeat deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Named in medication management training deficiency and elder abuse training deficiency | |
| Employee #4 | Named in background check deficiency |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 2
Date: Nov 30, 2012
Visit Reason
This inspection was conducted as a complaint investigation from 11/20/2012 through 11/30/2012 regarding concerns about the facility's care for residents with Alzheimer's disease.
Complaint Details
Complaint #NV00033497 was substantiated. The facility failed to provide protective supervision to Resident #1, an 84-year-old female with severe Alzheimer's disease, who eloped through the front door on 10/18/12 and suffered a bruised hip and black eye.
Findings
The facility was found to be caring for a resident with severe Alzheimer's disease without the appropriate endorsement or training and failed to provide protective supervision, resulting in the resident eloping and sustaining injuries. The complaint was substantiated with deficiencies noted.
Deficiencies (2)
Facility cared for a resident with Alzheimer's disease without appropriate endorsement and failed to obtain necessary training.
Facility failed to provide protective supervision to a resident with Alzheimer's disease who eloped and suffered injuries.
Report Facts
Residents present: 6
Total licensed capacity: 6
Severity 2 deficiencies: 1
Severity 3 deficiencies: 1
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 2
Date: Nov 20, 2012
Visit Reason
This Statement of Deficiencies was generated as a result of a complaint investigation conducted on the facility from 11/20/12 through 11/30/12.
Complaint Details
Complaint #NV00033497 was substantiated.
Findings
The facility was found to be caring for a resident with Alzheimer's disease without the appropriate endorsement or training, resulting in inadequate protective supervision. The resident eloped, suffered a fall, and sustained injuries. The facility is not licensed to care for residents with Alzheimer's disease.
Deficiencies (2)
The facility was caring for a resident with Alzheimer's disease without the appropriate endorsement and failed to obtain necessary training to care for such persons.
Failure to provide protective supervision to a resident with Alzheimer's disease, resulting in the resident eloping and sustaining injuries including a fall with a bruised hip and black eye.
Report Facts
Residents cared for with Alzheimer's disease: 1
Facility licensed capacity: 6
Current census: 6
Inspection Report
Enforcement
Deficiencies: 1
Date: Jan 5, 2012
Visit Reason
The Bureau conducted a required follow-up survey on Billman House from January 5 to January 11, 2012, which led to the imposition of sanctions due to deficiencies found during the survey.
Findings
The Health Division imposed sanctions on Billman House based on the severity and scope of deficiencies identified during the follow-up survey. A monetary penalty of $800 was assessed for a deficiency at TAG Y999 with a severity level of three and scope level of three.
Deficiencies (1)
Deficiency at TAG Y999 with a severity level of three and scope level of three
Report Facts
Monetary penalty: 800
Timeframe for training: 12
Follow-up survey dates: Survey conducted from 2012-01-05 through 2012-01-11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna C. McCafferty | Health Facilities Surveyor III | Signed the enforcement notice |
Inspection Report
Follow-Up
Census: 6
Capacity: 6
Deficiencies: 1
Date: Jan 5, 2012
Visit Reason
This document is a follow-up survey conducted between 2012-01-05 and 2012-01-11 to verify correction of previous deficiencies at Billman House, a residential facility licensed for six elderly and disabled persons.
Findings
The facility was found to be over census from 03/03/11 through 12/15/11, exceeding its licensed capacity of six residents. Interviews and record reviews confirmed that Resident #7 remained at the facility despite plans to move out, and the administrator failed to ensure compliance with the licensed capacity.
Deficiencies (1)
The administrator failed to ensure the facility did not provide care to more residents than it was licensed for, resulting in over census from 03/03/11 through 12/15/11.
Report Facts
Licensed capacity: 6
Census at time of survey: 6
Resident files reviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Interviewed regarding Resident #7 and admitted fault for the incident of over census |
Inspection Report
Follow-Up
Census: 6
Capacity: 6
Deficiencies: 1
Date: Jan 5, 2012
Visit Reason
This follow-up survey was conducted to verify compliance with previous deficiencies and to ensure the facility did not provide care to more residents than it was licensed for.
Findings
The facility was found to have been over census from 3/3/11 through 12/15/11, caring for more residents than its licensed capacity of six. Interviews and record reviews confirmed that Resident #7 lived at the facility during this period despite the licensed capacity, and the resident was discharged on 12/15/11 to another licensed group home.
Deficiencies (1)
The administrator failed to ensure the facility did not provide care to more residents than it was licensed for.
Report Facts
Licensed capacity: 6
Census at time of survey: 6
Over census period: 287
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 2
Date: Nov 3, 2011
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with licensing requirements for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A. Two deficiencies were cited: failure to obtain necessary endorsement for caring for residents with mental illnesses, and failure to ensure one resident was not restrained with the use of full side bed rails. Both deficiencies were repeat issues from prior complaint investigations.
Deficiencies (2)
Facility was caring for 2 of 6 persons with mental illnesses without an endorsement and failed to obtain the necessary endorsement.
Facility failed to ensure 1 of 6 residents was not restrained with the use of full side bed rails (Bedroom #3 had a full bed rail).
Report Facts
Residents present: 6
Licensed capacity: 6
Severity 2 deficiencies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helios Nicole | Owner | Signed as Laboratory Director or Provider/Supplier Representative |
Inspection Report
Annual Inspection
Census: 6
Capacity: 6
Deficiencies: 2
Date: Nov 3, 2011
Visit Reason
The inspection was conducted as an annual State Licensure survey to assess compliance with licensing requirements for the facility.
Findings
The facility was found to be caring for 2 of 6 persons with mental illnesses without the required endorsement and failed to obtain necessary training. Additionally, 1 of 6 residents was restrained with the use of full side bed rails, which was not in compliance with regulations. The facility received a grade of A.
Deficiencies (2)
Facility was caring for 2 of 6 persons with mental illnesses without an endorsement and failed to obtain necessary training.
Facility failed to ensure 1 of 6 residents were not restrained with the use of full side bed rails.
Report Facts
Residents present: 6
Licensed capacity: 6
Inspection Report
Annual Inspection
Census: 5
Capacity: 6
Deficiencies: 1
Date: Dec 16, 2010
Visit Reason
This document is the result of an annual State Licensure survey conducted at the facility on 12/16/2010 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. One deficiency was found related to caregiver qualifications, specifically that 1 of 3 caregivers did not receive the required eight hours of annual training.
Deficiencies (1)
Facility failed to ensure that 1 of 3 caregivers received eight hours of annual training (Employee #1).
Report Facts
Licensed beds: 6
Residents present: 5
Caregivers reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Named in deficiency for not receiving required annual training |
Notice
Deficiencies: 0
Date: Sep 21, 2010
Visit Reason
The notice informs Billman House that the Health Division intends to impose sanctions based on a complaint investigation conducted on 5/3/10 and completed on 5/12/10, with deficiencies detailed in an attached Statement of Deficiencies.
Complaint Details
The Bureau conducted a complaint investigation on Billman House on 5/3/10 and completed it on 5/12/10. Specific factual findings are detailed in the Statement of Deficiencies (SOD) in Attachment A.
Findings
The Health Division is imposing monetary penalties of $400 for deficiencies at Billman House, with the severity and scope of deficiencies defined by Nevada Administrative Code. The Plan of Correction submitted by the facility was reviewed and accepted.
Report Facts
Monetary Penalty: 400
Timeframe for appeal: 10
Timeframe for penalty payment: 15
Penalty reduction: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna C. McCafferty | Health Facilities Surveyor III | Signed the notice regarding sanctions |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 11
Date: May 3, 2010
Visit Reason
This inspection was conducted as a complaint investigation based on Complaint #NV00025222, carried out from 05/03/2010 to 05/12/2010 at Billman House, a residential facility for elderly and disabled persons.
Complaint Details
Complaint #NV00025222 was substantiated.
Findings
The facility was found to have multiple deficiencies including over census for five months, failure to ensure employee tuberculosis testing, background checks, CPR training, privacy violations, lack of emergency drill records, and insufficient mental illness training for employees. The complaint was substantiated and the facility received a grade of C.
Deficiencies (11)
Facility was caring for 1 of 7 persons with mental illnesses without an endorsement.
Facility was over census for five months, exceeding licensed capacity of six residents.
Failure to ensure 1 of 4 employees complied with tuberculosis testing requirements.
Employee #2 had no evidence of a two-step TB skin test.
Failure to ensure 1 of 4 employees met background check requirements within 10 days of hire.
Employee #2 had no fingerprints or evidence that state and FBI background checks were initiated.
Failure to ensure 1 of 4 caregivers had current training in first aid and CPR.
Employee #2 had no proof of current CPR/first aid training.
Facility failed to ensure privacy for 1 of 6 residents sharing a bedroom licensed for two residents.
Facility did not ensure monthly evacuation drills were conducted on an irregular schedule for the past 6 months; no fire drill records for April 2010.
Facility failed to ensure 4 of 4 employees received 8 hours of mental illness training within 60 days of employment.
Report Facts
Licensed capacity: 6
Census at time of survey: 6
Over census duration: 5
Employees reviewed: 4
Resident files reviewed: 6
Employees not compliant with TB testing: 1
Employees not compliant with background check: 1
Employees lacking CPR training: 1
Employees lacking mental illness training: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Failed to comply with tuberculosis testing, background check, and CPR training requirements. | |
| Employee #1 | Reported Resident #6 would call 911 stating 'wanted to die.' |
Inspection Report
Complaint Investigation
Census: 6
Capacity: 6
Deficiencies: 8
Date: May 3, 2010
Visit Reason
The inspection was conducted as a complaint investigation triggered by complaint #NV00025222, substantiated during the visit.
Complaint Details
Complaint #NV00025222 was substantiated.
Findings
The facility was found to be caring for a resident with mental illness without proper endorsement, was over census for five months, and had multiple personnel file deficiencies including lack of TB testing, background checks, and CPR/first aid certification. Privacy issues and failure to conduct monthly fire drills were also noted. The facility received a grade of C.
Deficiencies (8)
Facility caring for 1 of 7 persons with mental illnesses without an endorsement.
Facility was over census by one resident for five months.
Failed to ensure 1 of 4 employees complied with tuberculosis testing requirements.
Failed to ensure 1 of 4 employees met background check requirements within 10 days of hire.
Failed to ensure 1 of 4 caregivers had current training in first aid and CPR.
Failed to ensure privacy for 1 of 6 residents due to bed sharing with owner/employee.
Failed to ensure monthly evacuation drills were conducted on an irregular schedule for 1 of 6 months (April 2010).
Failed to ensure 4 of 4 employees received 8 hours of training concerning care for residents with mental illnesses.
Report Facts
Licensed beds: 6
Census: 6
Over census duration: 5
Employees reviewed: 4
Residents reviewed: 6
Discharged resident files reviewed: 1
Training hours required: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Named in findings related to lack of TB testing, background check, CPR/first aid training, and privacy issues. | |
| Employee #1 | Reported Resident #6 would call 911 stating she wanted to die. |
Notice
Deficiencies: 1
Date: May 26, 2009
Visit Reason
The Health Division is notifying the facility of its intent to impose sanctions based on a repeat deficiency cited in a prior survey dated August 21, 2007.
Findings
The notice details the imposition of monetary penalties totaling $300 for a repeat deficiency at TAG Y936, referencing the severity and scope of the deficiency as defined by Nevada Administrative Code.
Deficiencies (1)
Repeat deficiency at TAG Y936 cited in the survey dated August 21, 2007
Report Facts
Monetary Penalties: 300
Working days until sanctions effective: 11
Penalty reduction percentage: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Chambers | Health Facilities Surveyor III | Signed the notice |
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 18
Date: Dec 19, 2008
Visit Reason
The inspection was conducted as an annual state licensure survey combined with a complaint investigation at the facility on 12/19/08.
Complaint Details
Complaint #NV00017024 was substantiated. The complaint involved multiple deficiencies including failure to provide adequate care and training related to residents with dementia and Alzheimer's disease, medication administration issues, and financial handling of residents' money.
Findings
The facility was found to have multiple regulatory deficiencies including failure to provide necessary training for staff, inadequate oversight by the administrator, incomplete personnel files and training records, failure to maintain proper medication administration and documentation, and issues with facility safety such as fire extinguisher inspections and smoke detector maintenance. The complaint investigation was substantiated.
Deficiencies (18)
Facility failed to provide necessary training to care for residents with mental illnesses and Alzheimer's disease.
Administrator failed to provide oversight to ensure residents received needed services and protective supervision.
Caregivers failed to complete required medication management refresher training every three years.
Personnel files lacked documentation of required training hours and medical certifications.
Facility failed to ensure Bureau of Licensure and Certification insurance endorsement was current.
Facility was not free of hazards; broken glass door, missing window screens, and bed placement near fireplace.
Facility failed to provide weekly menus and document menu substitutions.
Fire extinguishers were not inspected annually as required.
Smoke detectors were not tested monthly and maintained properly.
First aid kit was missing a mask or shield for cardiopulmonary resuscitation.
Facility failed to plan recreational activities suited to residents' interests.
Facility failed to ensure blood glucose testing was performed by diabetic resident without assistance.
Facility failed to obtain required physical examinations and tuberculosis testing for employees and residents.
Facility failed to maintain accurate and complete medication administration records and physician orders.
Facility failed to maintain medication labeling and storage according to regulations.
Facility failed to maintain signed ultimate user agreements for administration of medications for all residents.
Facility failed to maintain signed statements allowing handling of residents' money and proper accounting.
Facility failed to provide Alzheimer's endorsement and training for staff.
Report Facts
Total licensed beds: 6
Residents present: 4
Complaint count: 1
Deficiency severity counts: 18
Inspection Report
Annual Inspection
Census: 4
Capacity: 6
Deficiencies: 30
Date: Dec 19, 2008
Visit Reason
The inspection was conducted as a result of the annual state licensure survey and complaint investigation at the facility.
Complaint Details
Complaint #NV00017024 was substantiated with multiple deficiencies cited related to medication administration, staff training, resident care, and facility compliance.
Findings
The facility was found to have multiple regulatory deficiencies including failure to obtain necessary endorsements for care of residents with dementia, inadequate staff training, missing or incomplete medical and personnel records, medication administration issues, safety hazards, and failure to maintain required documentation such as menus and fire safety inspections.
Deficiencies (30)
Facility cared for residents with mental illnesses and Alzheimer's disease without proper endorsement and training.
Administrator failed to provide oversight ensuring residents received needed services and protective supervision.
Caregivers failed to complete required medication management refresher training every three years.
Facility failed to ensure employees received at least 8 hours of annual training related to resident needs.
Personnel files lacked required tuberculosis screening documentation and health certificates.
Background check requirements for criminal history not met for one employee.
One caregiver lacked current certification in first aid and CPR.
Facility failed to provide Bureau of Licensure and Certification endorsement on insurance policy.
Facility premises not free of hazards including bed placement near gas fireplace, missing window screens, and broken glass door.
Facility failed to provide weekly menus and document menu substitutions.
Fire extinguishers not inspected annually.
Smoke detectors not tested monthly and no documentation of testing.
First aid kit missing CPR mask or shield.
Facility failed to provide activities suited to residents' interests and capacities.
Blood glucose testing for diabetic resident was performed by staff instead of resident himself.
Facility failed to obtain initial and annual physical examinations for several residents.
Medication profile reviews not performed at least every six months for residents on medications.
Facility failed to ensure ultimate user agreements were signed for all residents receiving medication assistance.
Physician orders missing for over-the-counter medications for several residents.
Medications not administered as prescribed, including incorrect dosages and discontinued medications still given.
Employee drew medication into syringe for resident without proper authorization.
Facility failed to maintain medication receipt logs for all residents.
Medications not plainly labeled with resident name and prescribing physician.
Medications not kept in original containers until administration.
Physician statements concerning residents' medical conditions were missing for several residents.
Facility failed to comply with tuberculosis screening and testing requirements for all residents.
Initial assessments of residents' ability to perform activities of daily living were missing for some residents.
Annual evaluations of residents' ability to perform activities of daily living were missing for residents residing longer than one year.
Facility lacked license endorsement to provide care to persons with Alzheimer's disease.
Facility failed to obtain signed written statement allowing handling of resident's money.
Report Facts
Total licensed beds: 6
Current census: 4
Employees reviewed: 3
Resident files reviewed: 4
Closed resident files reviewed: 2
Medication counts: 110
Medication counts: 67
Medication counts: 14
Medication counts: 63
Medication counts: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Named in medication management training and tuberculosis screening deficiencies | |
| Employee #2 | Named in multiple findings including medication administration, training, safety hazards, and resident care | |
| Employee #3 | Named in medication management training and tuberculosis screening deficiencies |
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