Inspection Reports for Golden Meadow Residential
4119 Meadowglen Cir, Las Vegas, NV 89121, NV, 89121
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 6
Capacity: 10
Deficiencies: 3
Dec 4, 2024
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility was found deficient in developing person-centered service plans for all six residents, ensuring required mental illness training for employees within 60 days of hire, and providing infection control training through a nationally recognized course for one employee. The facility received a grade of A overall.
Severity Breakdown
Severity: 1: 1
Severity: 2: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to develop a person-centered service plan for 6 of 6 residents. | Severity: 1 |
| Failed to ensure eight hours of mental illness training was completed within 60 days of hire for 3 of 5 employees. | Severity: 2 |
| Failed to ensure 1 of 5 employees received infection control training through a nationally recognized course. | Severity: 2 |
Report Facts
Residents reviewed: 6
Employee files reviewed: 5
Beds licensed: 10
Residents present: 6
Employees lacking required mental illness training: 3
Employees lacking infection control training: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Caregiver | Named in deficiency for lacking full mental illness training within 60 days of hire. |
| Employee #3 | Caregiver | Named in deficiency for lacking full mental illness training within 60 days of hire. |
| Employee #5 | Caregiver | Named in deficiency for lacking full mental illness training within 60 days of hire. |
| Employee #4 | Caregiver | Named in deficiency for lacking infection control training through a nationally recognized course. |
| Janet Roque | Administrator | Administrator responsible for corrective actions and monitoring compliance. |
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 0
Dec 13, 2023
Visit Reason
This inspection was conducted as an annual State Licensure inspection in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A with no regulatory deficiencies identified. No further action is necessary.
Inspection Report
Complaint Investigation
Census: 7
Deficiencies: 0
May 2, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 05/02/23, in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
One complaint was investigated and found to be unsubstantiated. No regulatory deficiencies were identified during the investigation, which included observations, interviews, and record reviews.
Complaint Details
One complaint (#NV000068218) was investigated and determined to be unsubstantiated. No regulatory deficiencies were found.
Report Facts
Complaints investigated: 1
Sample size: 7
Inspection Report
Routine
Census: 6
Capacity: 10
Deficiencies: 0
Dec 27, 2022
Visit Reason
This inspection was conducted as a 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 was necessary.
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 4
Dec 20, 2021
Visit Reason
This inspection was conducted as an annual State Licensure and infection control survey 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 including failure to designate an employee in charge during the administrator's absence, lack of current CPR training for one employee, poor maintenance of the facility's exterior and interior, and incomplete tuberculosis testing documentation for one resident.
Severity Breakdown
Level 1: 1
Level 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to designate in writing one or more employees to be in charge of the facility during the Administrator's absence; no written, posted designation available. | Level 1 |
| Failed to ensure current cardiopulmonary resuscitation (CPR) training was completed for 1 of 3 employees; CPR training expired for Employee #2. | Level 2 |
| Failed to ensure the exterior and interior of the facility was well maintained; bed frames, mattresses, and debris observed in backyard; hallway bathroom inoperable with toilet not flushing. | Level 2 |
| Failed to ensure 1 of 8 residents had completed two-step tuberculosis (TB) testing; Resident #2 lacked documented evidence of second step TB test. | Level 2 |
Report Facts
Number of resident files reviewed: 8
Number of employee files reviewed: 3
Facility licensed capacity: 10
Facility census: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janet Roque | Administrator | Named in relation to findings and responsible for compliance |
Inspection Report
Routine
Census: 8
Capacity: 10
Deficiencies: 0
Dec 9, 2020
Visit Reason
The inspection was a COVID-19 focused infection control survey conducted to assess compliance with infection control measures in the facility.
Findings
The facility was found to be in compliance with infection control policies and procedures related to COVID-19, including screening, PPE usage, social distancing, and sanitization. No deficiencies were identified during the survey.
Report Facts
Hand sanitizer bottles: 5
Gloves: 200
Surgical masks: 70
N-95 masks: 3
KN-95 masks: 5
Gowns: 20
Face shields: 14
Caregivers fit-tested and cleared for N-95 use: 3
Inspection Report
Annual Inspection
Census: 7
Capacity: 10
Deficiencies: 1
Jan 8, 2020
Visit Reason
This inspection was conducted as a State licensure annual survey of the facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility was found to have one deficiency related to failure to obtain a bedfast exemption for one resident who required assistance to reposition in bed. The facility received a grade of A.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to obtain a bedfast exemption for 1 of 7 residents who required assistance to reposition in bed. | Severity: 2 |
Report Facts
Resident files reviewed: 7
Employee files reviewed: 4
Licensed beds: 10
Current census: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janet Roque | Administrator | Named as the administrator responsible for corrective actions and signature on the report |
Inspection Report
Annual Inspection
Census: 10
Deficiencies: 5
Feb 5, 2019
Visit Reason
The inspection was a State Licensure annual survey conducted to assess compliance 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 blocked exit doors, improper linen storage posing infection control hazards, failure to ensure annual physical examinations for residents, incomplete medication reviews, lack of documentation for PRN medication purposes, and failure to obtain Alzheimer's endorsements for residents with dementia.
Severity Breakdown
2: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Hazards including obstacles blocking exit doors and linen stored on the floor posing infection control hazards. | 2 |
| Failure to ensure one of ten residents received an annual physical examination. | 2 |
| Failure to ensure medication reviews were completed every six months for six of ten residents. | 2 |
| Failure to ensure PRN medications for four of ten residents contained the purpose for use. | 2 |
| Failure to obtain Alzheimer's endorsement for three residents with dementia. | 2 |
Report Facts
Residents reviewed: 10
Employee files reviewed: 3
Deficiencies cited: 5
Severity level 2 deficiencies: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janet Rogue | Administrator | Named in relation to corrective actions and signature on the report |
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 0
Apr 7, 2017
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 04/05/17 and completed on 04/07/17 regarding allegations against the facility.
Findings
The complaint investigation found that two allegations against the facility could not be substantiated. No regulatory deficiencies were identified at the time of the survey.
Complaint Details
One complaint (#NV00048707) with two allegations was investigated and both allegations were not substantiated: Allegation #1 - The facility restrained a resident; Allegation #2 - The facility failed to provide the appropriate level of care to a resident.
Report Facts
Sample size: 5
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 0
Oct 24, 2016
Visit Reason
The inspection was conducted as an annual State Licensure survey of the facility on 10/24/16 by the Division of Public and Behavioral Health.
Findings
No deficiencies were identified during the survey. The facility received a grade of A after reviewing nine resident files and four employee files.
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 3
Oct 4, 2016
Visit Reason
This inspection was conducted as an annual State Licensure survey to assess compliance with regulatory requirements for a residential facility for group beds for elderly and disabled persons and/or persons with mental illnesses.
Findings
The facility received a grade of A but was found deficient in caregiver annual training, tuberculosis testing compliance, and criminal background check documentation for employees. Deficiencies were noted for failure to ensure annual caregiver training for some employees, incomplete tuberculosis screening documentation, and incomplete criminal background checks for all employees.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 employees received eight hours of annual caregiver training in 2016. | Level 2 |
| Failed to ensure 1 of 4 employees complied with tuberculosis testing/screening requirements. | Level 2 |
| Failed to ensure 4 of 4 employees complied with criminal background check requirements. | Level 2 |
Report Facts
Number of residents present: 8
Total licensed capacity: 10
Number of employee files reviewed: 4
Number of resident files reviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janet B. Roque | Administrator | Signed as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Renewal
Census: 10
Capacity: 10
Deficiencies: 1
Dec 2, 2015
Visit Reason
This document is a Statement of Deficiencies generated as a result of a State Licensure resurvey conducted on 12/2/15 to assess compliance with licensing requirements for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A but was found deficient in maintaining proper tuberculosis (TB) testing documentation for one of ten residents. Specifically, Resident #1's file lacked timely documentation of TB signs and symptoms evaluation and the TB test was initiated 13 days after admission.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure timely tuberculosis (TB) testing and documentation for Resident #1, including missing evidence of signs and symptoms evaluation upon admission and delayed TB test initiation. | Severity: 2 |
Report Facts
Residents reviewed: 10
Census: 10
Total capacity: 10
Inspection Report
Renewal
Census: 10
Capacity: 10
Deficiencies: 1
Dec 2, 2015
Visit Reason
This Statement of Deficiencies was generated as a result of a State Licensure resurvey conducted in the facility on 12/2/15 by the Division of Public and Behavioral Health.
Findings
The facility received a grade of A. One deficiency was identified related to tuberculosis screening: the facility failed to ensure that one of ten residents had documented evidence of a signs and symptoms evaluation upon admission and the TB test was initiated 13 days after admission.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 10 residents met tuberculosis requirements; missing documented evidence of signs and symptoms evaluation upon admission and delayed TB test initiation. | 2 |
Report Facts
Resident files reviewed: 10
Facility licensed capacity: 10
Current census: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 acknowledged the tuberculosis screening deficiency |
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 11
Sep 17, 2015
Visit Reason
This inspection was conducted as an annual State Licensure survey to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility was found deficient in multiple areas including licensing compliance, administrator responsibilities, health and sanitation, admission policy, oxygen monitoring, medication administration and storage, and resident file maintenance. Several repeat deficiencies were noted from prior surveys.
Severity Breakdown
Level 1: 2
Level 2: 9
Deficiencies (11)
| Description | Severity |
|---|---|
| Facility failed to comply with State business licensing; license expired on 3/31/15 and current copy was not provided during inspection. | Level 1 |
| Administrator failed to ensure 1 of 3 employee files were complete and accurate; CPR card was invalid and caregiver unaware of signature. | Level 2 |
| Facility failed to maintain clean and well-maintained interior and exterior; grease build-up, lint, dust, spider webs, and clutter observed. | Level 2 |
| Facility retained a bed-bound resident without a waiver as required by policy. | Level 2 |
| Facility failed to secure oxygen tanks in 1 of 10 resident bedrooms; unsecured oxygen tank observed. | Level 2 |
| Facility failed to ensure medication administration complied with physician orders; multiple residents had incomplete or missing medication orders and documentation. | Level 2 |
| Facility failed to destroy expired medications properly; expired medications found for residents #3 and #4. | Level 2 |
| Facility failed to maintain medication delivery logs for 8 of 8 residents. | Level 1 |
| Facility failed to maintain complete medication administration records (MAR) for 4 of 8 residents. | Level 2 |
| Facility failed to ensure medication storage was locked and secure; unsecured medications and storage deficiencies observed. | Level 2 |
| Facility failed to ensure tuberculosis testing was completed timely for resident #2; TB test administered past allowed timeframe. | Level 2 |
Report Facts
Census: 8
Total Capacity: 10
Severity 1 Deficiencies: 2
Severity 2 Deficiencies: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janet Rogue | Administrator | Named in relation to multiple deficiencies including licensing compliance, employee file accuracy, and medication administration |
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 11
Sep 17, 2015
Visit Reason
This annual State Licensure survey was conducted 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 expired business license, incomplete employee records, poor facility cleanliness, retention of a bedfast resident without waiver, unsecured oxygen tanks, medication administration errors, failure to destroy expired medications, incomplete medication logs and MARs, improper medication storage, and noncompliance with tuberculosis testing requirements.
Severity Breakdown
Level 1: 3
Level 2: 8
Deficiencies (11)
| Description | Severity |
|---|---|
| Facility failed to comply with State business licensing; Nevada State business license expired on 3/31/15. | Level 1 |
| Administrator failed to ensure 1 of 3 employee files were complete and accurate; CPR card with invalid provider. | Level 2 |
| Facility failed to ensure the interior and exterior were clean and maintained; grease, dust, dirt, trash buildup, broken blinds, leaking shower head, and cluttered storage areas observed. | Level 2 |
| Facility retained a bedfast resident without a waiver. | Level 2 |
| Facility failed to secure oxygen tanks in 1 of 10 resident bedrooms. | Level 2 |
| Facility failed to ensure 3 of 8 residents received medications as prescribed; missed doses, expired medications, and lack of physician orders. | Level 2 |
| Facility failed to destroy expired medications for 2 residents. | Level 2 |
| Facility failed to maintain a medication delivery log for 8 residents. | Level 1 |
| Facility failed to ensure medication administration records (MAR) were complete for 4 residents; missing documentation and incomplete labels. | Level 1 |
| Facility failed to ensure medications were stored in a locked container; suppositories found unsecured in refrigerator. | Level 2 |
| Facility failed to ensure 1 resident met tuberculosis testing requirements; TB test administered past allowed timeframe and improper timing of second step. | Level 2 |
Report Facts
Facility licensed capacity: 10
Census: 8
Deficiency severity count: 3
Deficiency severity count: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caregiver #2 | Reported on expired business license, acknowledged facility deficiencies, and medication administration issues | |
| Caregiver #3 | Involved in medication administration and employee file CPR card issue | |
| Administrator | Administrator | Unaware of invalid CPR card in employee file |
Inspection Report
Re-Inspection
Census: 10
Capacity: 10
Deficiencies: 1
Dec 18, 2014
Visit Reason
This inspection was a required grading re-survey conducted as a result of a previous State Licensure survey to verify compliance and correct deficiencies.
Findings
The facility was found deficient in maintaining proper resident files, specifically lacking documented evidence of two-step tuberculosis (TB) screening for two newly admitted residents. This was a repeat deficiency from a prior survey.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure 2 of 2 newly admitted residents had completed a two-step tuberculosis (TB) screening. | Severity: 2 |
Report Facts
Residents lacking documented two-step TB screening: 2
Facility licensed capacity: 10
Census at time of survey: 10
Scope: 3
Inspection Report
Re-Inspection
Census: 10
Capacity: 10
Deficiencies: 1
Dec 18, 2014
Visit Reason
This Statement of Deficiencies was generated as a result of a required grading re-survey conducted on 12/18/14 by the authority of NRS 449.0307.
Findings
The facility received a re-survey grade of A. Deficiencies were identified related to failure to ensure 2 of 2 newly admitted residents had completed a two-step tuberculosis screening. This was a repeat deficiency from the 10/28/14 State Licensure survey.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure 2 of 2 newly admitted residents had completed a two-step tuberculosis screening. | Severity: 2 |
Report Facts
Census: 10
Total Capacity: 10
Deficiency Scope: 3
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 9
Oct 28, 2014
Visit Reason
This document is a State Licensure survey conducted as an annual inspection of a residential facility for group beds for elderly or disabled persons and/or persons with mental illness.
Findings
The facility received a grade of D with multiple deficiencies identified including failure to maintain proper personnel files, incomplete pre-employment physicals, missing background checks, poor cleanliness of the facility and kitchen, inadequate documentation of menu substitutions, incomplete periodic physical examinations for residents, medication administration record errors, lack of tuberculosis testing documentation, and insufficient mental illness training documentation for employees.
Severity Breakdown
Severity: 1: 1
Severity: 2: 8
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure documentation of a pre-employment physical for 1 of 4 employees. | Severity: 2 |
| Failed to ensure evidence of compliance with background checks for 1 of 4 employees. | Severity: 2 |
| Failed to maintain cleanliness of interior and exterior of the facility. | Severity: 2 |
| Failed to maintain cleanliness of kitchen appliances for sanitary food preparation. | Severity: 2 |
| Failed to document, post, and file menu substitution changes. | Severity: 2 |
| Failed to ensure 2 of 8 residents received periodic physical examinations. | Severity: 1 |
| Failed to maintain accurate medication administration records for 3 of 8 residents. | Severity: 2 |
| Failed to ensure pre-admission and annual Tuberculosis testing documentation for 3 of 8 residents. | Severity: 2 |
| Failed to ensure documentation of initial training concerning care for residents with mental illness for 1 of 4 employees. | Severity: 2 |
Report Facts
Census: 8
Total Capacity: 10
Deficiency Count: 9
Employee Files Reviewed: 4
Resident Files Reviewed: 8
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 9
Oct 28, 2014
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at Golden Meadows Residential on 10/28/2014.
Findings
The facility received a grade of D with multiple deficiencies identified including failure to document pre-employment physicals and background checks for employees, failure to maintain cleanliness of the facility and kitchen appliances, inaccurate medication administration records for residents, lack of documentation of periodic physical exams and tuberculosis testing for residents, and failure to ensure mental illness training for employees.
Severity Breakdown
Level 1: 1
Level 2: 8
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure documentation of a pre-employment physical for 1 of 4 employees. | Level 2 |
| Failed to ensure documentation of background check compliance for 1 of 4 employees. | Level 2 |
| Failed to maintain cleanliness of the interior and exterior of the facility. | Level 2 |
| Failed to maintain cleanliness of kitchen appliances for sanitary food preparation. | Level 2 |
| Failed to document, post, and file menu substitution changes. | Level 1 |
| Failed to ensure 2 of 8 residents received periodic physical examinations. | Level 2 |
| Failed to ensure 3 of 8 residents' Medication Administration Records were accurate and consistent with medication label and doctor's order. | Level 2 |
| Failed to ensure pre-admission and annual Tuberculosis testing or screening was documented for 3 of 8 residents. | Level 2 |
| Failed to ensure documentation of initial mental illness training for 1 of 4 employees. | Level 2 |
Report Facts
Facility licensed beds: 10
Resident census: 8
Employee files reviewed: 4
Resident files reviewed: 8
Deficiency severity counts: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Acknowledged lack of documentation for pre-employment physical, background check, facility cleanliness issues, menu substitutions, physical exams for residents, and medication administration errors. | |
| Employee #2 | Subject of background check documentation deficiency. | |
| Employee #4 | Lacked documented evidence of initial eight hour mental illness training. |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 4
Oct 17, 2013
Visit Reason
This document is a State Licensure annual grading survey conducted to assess compliance with regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A but had several deficiencies related to medication administration, medication storage, and resident file documentation. Some deficiencies were repeat findings from the previous year's survey.
Severity Breakdown
Severity 1: 1
Severity 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Medication administration did not comply with required medical assessments before administration for 1 of 9 residents. | Severity 2 |
| Medication administration records (MAR) were inaccurate for 6 of 9 residents inspected. | Severity 1 |
| Medication storage was not secure; medications and files were observed unsecured. | Severity 2 |
| Resident file documentation for tuberculosis testing was incomplete for 1 of 9 residents. | Severity 2 |
Report Facts
Residents present: 9
Licensed capacity: 10
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Janet Roque | Administrator | Named in signature section related to plan of correction |
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