Inspection Reports for Golden Lake Care Home

The inspection was conducted as a result of a complaint investigation triggered by two complaints, one of which was substantiated with deficient practice and the other substantiated without deficient practice.

The facility failed to report suspected abuse to the local office of Aging and Disability Services (ADSD) as required by regulation. Specifically, an employee threw a metal knife at a resident, which was witnessed and reported by other residents, but the facility did not submit a timely report to ADSD. The facility's Elder Abuse Policy was revised to include notification requirements to APS/ADSD within 24 hours of any elder abuse.

Two complaints were investigated: Complaint #NV00074743 was substantiated with deficient practice related to failure to report abuse; Complaint #NV00074519 was substantiated without deficient practice.

The inspection was conducted as a result of an annual state licensure survey combined with a complaint investigation at the facility on 05/20/25, in accordance with Nevada Administrative Code Chapter 449.

The facility was found to have two substantiated complaints and received a grade of A. Deficiencies included failure to ensure annual tuberculosis screening for one employee and improper use of bed rails as restraints for two cognitively impaired residents who could not lower the rails without assistance.

Two complaints were investigated: Complaint #NV00074074 was substantiated; Complaint #NV00073293 was unsubstantiated with no regulatory deficiencies identified. The bed rail use deficiency was related to Complaint #NV00070483.

The inspection was conducted as a complaint investigation following a complaint received by the facility.

The complaint was unsubstantiated with no regulatory deficiencies identified. Observations, interviews, and record reviews were conducted, and no further action was necessary.

One complaint (#NV00072941) was investigated and found to be unsubstantiated with no regulatory deficiencies identified.

The inspection was conducted as a mandatory State Licensure grading resurvey combined with a complaint investigation at the facility.

No regulatory deficiencies were identified during the inspection. The complaint investigated was unsubstantiated, and the facility received a grade of A.

One complaint (#NV00072725) was investigated and found to be unsubstantiated. The investigation included observations, interviews with residents, caregivers, and a hospice nurse, and record reviews.

The inspection was conducted as a result of a complaint investigation initiated on 08/23/24 and completed on 08/29/24, involving three substantiated complaints regarding resident care and facility conditions.

The facility failed to provide adequate oversight and staffing to ensure residents received necessary incontinence care, especially at night. There were insufficient caregivers on duty, with one caregiver physically unable to provide required care. The facility also had issues with offensive odors, poor sanitation, expired and inadequate food supplies, and failure to post meal substitutions.

Three complaints were investigated and substantiated: Complaint #NV00072062, #NV00072011, and #NV00071958. The investigation included observations, interviews with residents and staff, and record reviews. The complaints involved inadequate care, staffing issues, sanitation problems, and food safety concerns.

The inspection was conducted as an annual state licensure survey combined with a complaint investigation at the facility on 05/29/2024, in accordance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups.

The facility was found to have multiple deficiencies including rodent infestation and unsanitary conditions, failure to develop person-centered service plans for all residents, failure to obtain required medical exemptions for a bedfast resident and a resident with wounds, and inadequate infection control training for staff. Three complaints were investigated, two substantiated and one unsubstantiated.

Three complaints were investigated: Complaint #NV00071294 and Complaint #NV00070902 were substantiated; Complaint #NV00070924 was unsubstantiated.

This inspection was conducted as an annual state licensure survey in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.

The facility received a grade of A but was found deficient in providing adequate activities for residents and lacking a Clinical Laboratory Improvement Amendment (CLIA) waiver for blood glucose testing for one resident. The scheduled group activity did not occur, and residents reported lack of individualized activities.

Annual state licensure and infection control survey conducted in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.

The facility received a grade of A but was cited for deficiencies related to elder abuse training, tuberculosis screening, and medication management training for employees. Several employees had expired or missing training certificates and screenings.

The inspection was conducted as a complaint investigation triggered by Complaint #NV00065581 regarding visitation restrictions during a COVID-19 outbreak.

The complaint was substantiated without regulatory deficiencies. The facility temporarily closed in-person visitation due to COVID-19 but allowed alternative visitation methods and maintained visitation policies updated per pandemic protocols. No regulatory deficiencies were identified.

Complaint #NV00065581 with one allegation was substantiated without regulatory deficiencies. The allegation concerned the facility closing in-person visitation due to a COVID-19 outbreak, which was confirmed but found compliant with regulations.

The inspection was conducted as an annual grading, infection control State Licensure survey and complaint investigation at the facility on 09/07/21.

The facility received a grade of A with no regulatory deficiencies identified. One complaint with ten allegations was investigated and found to be unsubstantiated except for one allegation related to COVID-19 visitor restrictions, which was substantiated without deficiencies.

Complaint #64466 with ten allegations was investigated. Nine allegations were unsubstantiated based on interviews, record reviews, and observations. One allegation regarding the facility's no visitor policy due to COVID-19 was substantiated without deficiencies.

The inspection was conducted as an annual State Licensure survey combined with a complaint investigation initiated at the facility on 12/19/18, in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.

The facility was found to have multiple deficiencies including failure to maintain clean and well-maintained premises, inadequate housing for staff members, failure to ensure physician orders for oxygen therapy were followed for residents, improper medication storage, and failure to obtain an Alzheimer's endorsement for care of residents with Alzheimer's disease. The facility received a grade of B.

The inspection included a complaint investigation initiated on 12/19/18. The complaint involved concerns about cleanliness, housing for staff, medication administration, and care for residents requiring oxygen therapy and Alzheimer's care.

This inspection was conducted as a complaint investigation from 7/15/16 through 7/19/16 by the authority of NRS 449.0307. Two complaints were investigated regarding alleged verbal and physical abuse by caregivers.

The investigation substantiated verbal abuse by a caregiver towards residents and failure to report the abuse. Additional deficiencies included missing background checks for an employee and failure to allow a resident to smoke according to facility policy. The verbally abusive employee was dismissed during the investigation.

Two complaints were investigated: Complaint #NV00046462 was substantiated for verbal abuse by a caregiver; physical abuse allegations were not substantiated. Complaint #NV00046450 was not substantiated. The primary caregiver failed to report the verbal abuse to authorities.

This inspection was conducted as an annual State Licensure survey of the facility on 1/14/16 to assess compliance with state regulations.

The facility received a grade of A but was found deficient in maintaining proper background checks for employees, specifically failing to ensure that one of four employees had State and FBI background checks as required.

This Statement of Deficiencies was generated as a result of an annual State Licensure survey conducted in the facility on 1/14/16 by the Division of Public and Behavioral Health.

The facility received a grade of A. One deficiency was identified related to personnel files lacking required State and FBI background checks for one employee, which was a repeat deficiency from a prior complaint investigation.

This is a repeat deficiency from the 10/1/15 complaint investigation survey.

This inspection was conducted as a complaint investigation triggered by complaint #NV00044030, which was substantiated regarding an incomplete background check.

The facility failed to ensure that 1 of 4 employees completed the required fingerprint-based background check. Specifically, Employee #1, hired as Administrator, had no documented evidence of State and FBI clearance reports despite fingerprint records. The Administrator acknowledged the missing report and planned to request it from DPS.

Complaint #NV00044030 was substantiated. The allegation of incomplete background check was substantiated.

The inspection was conducted as a complaint investigation triggered by complaint #NV00044030 regarding incomplete background checks for employees.

The investigation substantiated the complaint that the facility failed to ensure one of four employees completed the required fingerprint-based background check. Specifically, Employee #1's file lacked documented evidence of State and FBI clearance reports.

Complaint #NV00044030 was substantiated. The allegation of incomplete background check was substantiated.

The inspection was an annual State Licensure survey conducted to assess compliance with regulatory requirements for a residential facility for elderly or disabled persons and/or persons with mental illness and/or chronic illness.

The facility received a grade of A but had deficiencies related to personnel files, including lack of documented evidence of pre-employment physicals, expired CPR and First Aid certifications for an employee, and lack of documented evidence of a periodic physical examination for a resident prior to admission.

This document is a statement of deficiencies generated as a result of an annual State Licensure survey conducted at the facility on 1/20/2015.

The facility received a grade of A but had several deficiencies including failure to ensure a pre-employment physical for one employee, lack of current CPR and first aid certification for one employee, and failure to obtain a periodic physical examination prior to admission for one resident.

The inspection was conducted as a complaint investigation triggered by Complaint #NV 00039325 regarding resident safety and falls.

The complaint was unsubstantiated after review of medical records, interviews with the Administrator and two Caregivers, and evaluation of facility policies and procedures related to safety and falls, which were found to be appropriately followed.

Complaint #NV 00039325 contained one allegation regarding resident safety and falls. The complaint was investigated and found to be unsubstantiated.

The inspection was conducted as a complaint investigation initiated by the Bureau of Health Care Quality and Compliance on February 25, 2014, regarding allegations of inappropriate admission and inappropriate level of care.

The investigation found that the allegations were not substantiated based on record review, staff interviews, observation, and policy review. The facility was in substantial compliance with state regulations and no further action was necessary.

Complaint #NV00038361 alleged inappropriate admission and inappropriate level of care. The complaint was not substantiated after review of four resident records, including the resident of concern, and interviews with facility staff.