Inspection Reports for Golden Valley Group Care
2690 Margaret Dr, Reno, NV 89506, NV, 89506
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Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 6
Mar 17, 2025
Visit Reason
The inspection was conducted as a result of a State Licensure annual grading survey and complaint investigation in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of C with multiple deficiencies identified including failure to develop person-centered service plans for some residents, incomplete medication administration records and physician orders, lack of infection control program and policies, incomplete personnel and resident records, failure to maintain premises free of hazards, and failure to comply with preferred name and pronoun policies.
Complaint Details
One complaint investigated (Complaint #NV00073329) with allegations that the facility did not have enough food for residents and was billing for deceased residents. The allegations could not be substantiated due to lack of evidence after observations, interviews, and document reviews.
Severity Breakdown
Level 1: 1
Level 2: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure a person-centered service plan was developed for 3 of 10 residents reviewed. | Level 2 |
| Failed to ensure a physician's order was obtained for administration of medications for 3 of 8 residents. | Level 2 |
| Medication Administration Record (MAR) did not document current and active medications for 5 of 8 residents. | Level 2 |
| Failed to develop and carry out a complete infection control program and policies. | Level 2 |
| Failed to ensure resident records reflected preferred name, pronoun, gender identity or expression, and sexual orientation for 8 of 8 residents. | Level 1 |
| Failed to maintain backyard free from non-usable furniture and hazards posing risk to residents. | Level 2 |
Report Facts
Deficiencies cited: 6
Facility licensed capacity: 10
Resident census: 8
Inspection date: Mar 17, 2025
Plan of Correction completion dates: Mar 31, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Warlito Pizarro | Administrator | Named in relation to findings and responsible for implementing plans of correction. |
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 14
Nov 14, 2024
Visit Reason
This inspection was conducted as a result of a State Licensure annual grading survey combined with a complaint investigation at the facility on 11/14/2024.
Findings
The facility received a grade of D with multiple deficiencies identified including incomplete and inaccurate resident records, late TB testing for employees, non-functional ventilation fan, hazardous backyard conditions, lack of person-centered service plans for all residents, missing initial physical exams, incomplete medication reviews, medication administration and storage issues, missing tuberculosis testing for residents, lack of preferred name/pronoun documentation, incomplete annual assessments, and deficiencies in infection control program designation and training.
Complaint Details
Two complaints were investigated: Complaint #NV00072649 and Complaint #NV00071870. Both complaints could not be substantiated due to lack of evidence.
Severity Breakdown
Level 2: 14
Deficiencies (14)
| Description | Severity |
|---|---|
| Owner failed to ensure complete and accurate medication records for Resident #5, including falsifying medication administration records. | Level 2 |
| Facility failed to ensure timely tuberculosis (TB) testing for Employee #3. | Level 2 |
| Ventilation fan in resident restroom was non-functional and backyard contained hazardous debris and non-operational vehicles. | Level 2 |
| Facility failed to develop person-centered service plans for all 10 residents. | Level 2 |
| Resident #8 lacked documented initial physical examination upon admission. | Level 2 |
| Medication profile reviews were not completed every six months for Residents #3 and #5. | Level 2 |
| Medication Senna Docusate Sodium was not available on-site for Resident #9 and was discontinued without physician order. | Level 2 |
| Medication Administration Record (MAR) lacked documentation of Nystatin Powder for Resident #9. | Level 2 |
| Medications belonging to a caregiver were unsecured and accessible to residents. | Level 2 |
| Resident #7 lacked documented evidence of initial two-step TB test upon admission. | Level 2 |
| Facility failed to include residents' preferred names and pronouns in records according to gender identity or expression for all residents. | Level 2 |
| Residents #1 and #4 lacked annual Standard Placement Determinations for 2024; Resident #10 lacked initial Standard Placement Determination upon admission. | Level 2 |
| Facility lacked designation of primary and secondary persons responsible for infection control program. | Level 2 |
| Primary and secondary infection control persons lacked required infection control training. | Level 2 |
Report Facts
Facility licensed beds: 10
Resident census: 10
Grade received: D
Resurvey fee: 600
Number of resident files reviewed: 10
Number of employee files reviewed: 3
Severity 2 deficiencies: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Warlito Pizarro | Administrator | Named in relation to medication record falsification and overall facility administration. |
| Patricia Lite | Primary Person Responsible for Infection Control | Designated as primary person responsible for infection control in the facility. |
Inspection Report
Annual Inspection
Census: 4
Capacity: 10
Deficiencies: 2
Mar 21, 2024
Visit Reason
The inspection was conducted as a result of a State Licensure annual grading survey combined with a complaint investigation at the facility.
Findings
The facility received a grade of A. One complaint was investigated but not substantiated. Two deficiencies were identified: failure to ensure annual elder abuse prevention training for one employee, and failure to ensure medication profile reviews were performed every six months for one resident.
Complaint Details
One complaint (#NV00069733) was investigated with allegations of unclean environment and verbal abuse. Both allegations were not substantiated due to lack of evidence after observations, interviews, and document review.
Severity Breakdown
Level 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 3 sampled employees received annual elder abuse prevention training. | Level 2 |
| Administrator failed to ensure a medication profile review was performed by a physician, pharmacist, or registered nurse at least once every six months for 1 of 4 sampled residents. | Level 2 |
Report Facts
Licensed beds: 10
Residents present: 4
Employees reviewed: 3
Resident files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Caregiver | Named in elder abuse training deficiency; hired 04/14/20; lacked 2023 elder abuse training documentation |
| Warlito Pizarro | Administrator | Confirmed elder abuse training deficiency and medication review deficiency |
Inspection Report
Annual Inspection
Census: 7
Capacity: 10
Deficiencies: 6
Apr 10, 2023
Visit Reason
The inspection was conducted as a result of a State Licensure annual grading survey combined with a complaint investigation at the facility on 04/10/23.
Findings
The facility received a grade of B with multiple deficiencies identified including failure to maintain staff schedules for six months, incomplete preemployment physical examination for a caregiver, admission of residents receiving skilled nursing services without proper authorization, medication administration reviews not conducted every six months, incomplete tuberculosis testing documentation for residents, and failure to obtain an initial Physician Placement Determination Statement for a resident.
Complaint Details
One complaint (#NV00067326) was investigated with allegations that staff did not assist a resident with bathing, dressing, and personal care; insufficient staff to assist with transferring a resident; and a resident's room was hot due to lack of air conditioning. The complaint was not substantiated due to lack of evidence.
Severity Breakdown
Level 1: 1
Level 2: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to maintain a monthly written staff schedule for at least six months. | Level 1 |
| Caregiver provided care prior to completing preemployment physical examination. | Level 2 |
| Admitted residents receiving skilled nursing services without documented eligibility or waiver. | Level 2 |
| Medication profile reviews not performed at least once every six months for two residents. | Level 2 |
| Failed to ensure tuberculosis testing documentation included date and time of administration and reading for four residents. | Level 2 |
| Failed to obtain an initial Physician Placement Determination Statement for one resident. | Level 2 |
Report Facts
Licensed beds: 10
Residents present: 7
Deficiency severity counts: 1
Deficiency severity counts: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Warlito Pizarro | Administrator | Named as Administrator responsible for facility and plan of correction |
| Employee #3 | Caregiver | Failed to complete preemployment physical examination prior to providing care |
Inspection Report
Complaint Investigation
Census: 7
Capacity: 10
Deficiencies: 1
Sep 26, 2022
Visit Reason
This inspection was conducted as a result of a complaint investigation regarding the facility's failure to provide information or a copy of the most recent state investigation report.
Findings
The Administrator failed to disclose or maintain a copy of the most recent investigation completed by the State agency, which was substantiated as a deficiency.
Complaint Details
Complaint #NV00066774 with the allegation that the facility did not provide information included in or a copy of the facility's most recent investigation completed by the State was substantiated.
Severity Breakdown
Severity: 1: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The Administrator of the facility failed to disclose the findings or provide a copy of the most recent investigation completed by the State agency. | Severity: 1 |
Report Facts
Licensed capacity: 10
Census: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Warlito Pizarro | Administrator | Named in deficiency related to failure to maintain and provide investigation report |
Inspection Report
Annual Inspection
Census: 7
Capacity: 10
Deficiencies: 8
Apr 12, 2022
Visit Reason
The inspection was conducted as a result of a State Licensure annual grading survey combined with a complaint investigation at the facility.
Findings
The facility received a grade of B with deficiencies identified including maintenance issues, sanitation problems, failure to screen visitors for COVID-19 symptoms, failure to submit exemption requests for bedfast residents, unsecured oxygen tanks, medication administration errors, incomplete resident files, and missing tuberculosis testing documentation.
Complaint Details
Two complaints were investigated: Complaint #NV00065735 alleging urine odor, lack of assistance for bedbound residents, and insufficient caregivers was not substantiated. Complaint #NV00066176 alleging a resident was bedfast with wounds was substantiated.
Severity Breakdown
Level 2: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Ceiling of shared bathroom had peeling paint and exposed drywall due to roof leakage. | Level 2 |
| Dishwasher was unclean, had standing water with green mold-like substance, and was not working. | Level 2 |
| Visitors were not screened for temperature and COVID-19 symptoms upon entry. | Level 2 |
| Facility failed to obtain exemption request to retain a bedfast resident receiving wound care. | Level 2 |
| Oxygen tanks were not secured in a stand or to a wall. | Level 2 |
| Resident received medication nightly without a physician's order authorizing the change from as needed. | Level 2 |
| Physician Placement Determination form was incomplete and lacked facility type determination for a resident. | Level 2 |
| Resident file lacked documented evidence of two-step tuberculosis testing or chest x-rays to rule out active TB infection. | Level 2 |
Report Facts
Licensed beds: 10
Residents present: 7
Complaints investigated: 2
Resident files reviewed: 7
Employee files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Warlito C Pizarro | Administrator | Named in relation to corrective actions and plan of correction |
Inspection Report
Re-Inspection
Census: 6
Capacity: 10
Deficiencies: 0
Nov 9, 2021
Visit Reason
This inspection was conducted as a result of a mandatory regrading and complaint investigations at the facility on 11/09/2021.
Findings
Two complaints were investigated but neither was substantiated due to lack of evidence. No regulatory deficiencies were identified and the facility received a regrading/complaint investigation grade of A.
Complaint Details
Complaint #NV00064065 alleging a resident was moved without guardian notification was not substantiated. Complaint #NV00065079 alleging mold under bathroom sink and discolored water in guest bathroom was not substantiated.
Report Facts
Licensed beds: 10
Resident census: 6
Complaints investigated: 2
Inspection Report
Complaint Investigation
Census: 6
Deficiencies: 1
May 24, 2021
Visit Reason
The inspection was conducted as a result of complaint investigations initiated at the facility on 05/24/21, involving three complaints regarding resident care and facility practices.
Findings
The investigation substantiated one complaint regarding the transfer of a resident without guardian permission. Other allegations related to resident treatment, medication, and facility cleanliness were not substantiated due to lack of evidence. The facility failed to obtain documented approval from the resident's guardian for a transfer to another facility.
Complaint Details
Three complaints were investigated. Complaint #NV00063900 regarding unauthorized resident transfer was substantiated. Complaints #NV00063747 and #NV00063817 with multiple allegations were not substantiated due to lack of evidence.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to receive permission from the resident's guardian to move a resident to a different facility. | SS= D |
Report Facts
Number of complaints investigated: 3
Resident census: 6
Sample size: 3
Resident involved in deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Warlito Pizarro | RFA | Caregiver/Administrator in Charge involved in confirming lack of guardian approval for resident transfer |
Inspection Report
Abbreviated Survey
Census: 8
Capacity: 10
Deficiencies: 5
Mar 16, 2021
Visit Reason
A focused COVID-19 infection control survey was conducted to assess regulatory compliance with infection control and prevention measures in accordance with Nevada Administrative Code Chapter 449.
Findings
The facility failed to provide a safe environment by not screening visitors for COVID-19 symptoms and temperatures, lacking documented staff training on PPE use and handwashing, not following the N-95 respirator fit testing program, failing to track PPE inventory, and lacking a documented cohorting plan for COVID-19 positive residents.
Severity Breakdown
Severity: 2 Scope: 3: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Did not ensure visitors were screened for temperature and signs and symptoms of COVID-19. | Severity: 2 Scope: 3 |
| Did not have documented staff training on CDC recommended PPE donning/doffing and proper handwashing. | Severity: 2 Scope: 3 |
| Did not follow documented facility N-95 Respirator Program and Policy to have staff fit tested for N-95 masks. | Severity: 2 Scope: 3 |
| Did not ensure PPE was properly tracked to determine available quantities in case of a COVID outbreak. | Severity: 2 Scope: 3 |
| Did not ensure a proper cohorting plan was created for residents testing positive for COVID-19. | Severity: 2 Scope: 3 |
Report Facts
Licensed beds: 10
Census: 8
PPE inventory: 12
PPE inventory: 3
PPE inventory: 2
PPE inventory: 3
PPE inventory: 1
Residents vaccinated: 6
Residents refused vaccine: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Warlito Pizarro | Administrator | Named as Administrator who verbalized facility practices and deficiencies |
Inspection Report
Complaint Investigation
Census: 7
Deficiencies: 8
Dec 3, 2020
Visit Reason
The inspection was conducted as a result of complaint investigations initiated on 2020-09-11 and completed on 2020-12-03, involving four complaints regarding resident care and facility compliance.
Findings
The facility was found to have substantiated complaints related to resident elopement and failure to notify guardians, failure to post current administrator license, failure to provide protective supervision to prevent elopement for two residents, failure to observe medication administration for one resident, failure to maintain accurate medication administration records, failure to complete annual activities of daily living assessments for two residents, and failure to display the current letter grade placard from the last annual survey.
Complaint Details
Four complaints were investigated. Complaint #NV00061922 and #NV00062589 were substantiated involving resident elopement and failure to notify guardians. Complaint #NV00061952 was substantiated regarding failure to post current administrator license. Other allegations including abuse, neglect, and hygiene issues were not substantiated.
Severity Breakdown
Level 1: 2
Level 2: 6
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to contact Bureau of Health Care Quality and Compliance regarding change in administrator within 10 days and provide name of new licensed administrator. | Level 1 |
| Failed to provide protective supervision to prevent elopement for 2 of 7 residents. | Level 2 |
| Failed to ensure residents complied with sign in/out log policy for leaving the facility. | Level 2 |
| Failed to ensure resident notified staff of overnight or extended absence. | Level 2 |
| Failed to observe resident taking medications administered. | Level 2 |
| Medication Administration Record was inaccurate for one resident; initials did not reflect actual administration. | Level 2 |
| Failed to ensure annual activities of daily living assessments were completed for two residents. | Level 2 |
| Failed to display current letter grade placard from last annual survey. | Level 1 |
Report Facts
Number of residents at time of survey: 7
Number of complaints investigated: 4
Severity 1 deficiencies: 2
Severity 2 deficiencies: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julieta Iban | Administrator | Named in relation to findings on medication administration and facility supervision |
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 0
Jan 31, 2018
Visit Reason
The inspection was conducted as a complaint investigation based on allegation #NV00051973 that an employee struck a resident, pulled her hair, prevented the resident from calling 911, and attempted to stop the resident from leaving the facility.
Findings
The investigation included observations, interviews, and medical record reviews, and concluded that the allegation could not be substantiated. No deficiencies were identified during the investigation.
Complaint Details
Complaint #NV00051973 alleged employee struck resident, pulled hair, prevented resident from calling 911, and attempted to stop resident from leaving. The allegation was not substantiated.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 2
Jul 13, 2016
Visit Reason
The inspection was conducted as a complaint investigation following a complaint alleging offensive odors, missing personal items, and improper medication administration at the facility.
Findings
The complaint allegations were not substantiated. However, deficiencies unrelated to the complaint were identified, including failure to document discontinued medications for one resident and failure to evaluate two residents for their ability to perform activities of daily living (ADLs).
Complaint Details
Complaint #NV00046206 was investigated and found to be unsubstantiated. Allegations included offensive odors, missing personal items, and medications not given according to physician instructions.
Severity Breakdown
2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure discontinued medications/completed medications for 1 of 5 residents were documented. | 2 |
| Failure to provide evidence that 2 of 4 residents were evaluated for their ability to perform Activities of Daily Living (ADLs). | 2 |
Report Facts
Complaint count: 1
Sample size: 5
Residents evaluated for ADL: 2
Residents with medication documentation issue: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Warlito Pizarro | Administrator | Named as responsible for medication management and resident file monitoring |
Inspection Report
Complaint Investigation
Census: 10
Deficiencies: 2
Jul 13, 2016
Visit Reason
The inspection was conducted as a result of a complaint investigation triggered by Complaint #NV00046206.
Findings
The complaint allegations regarding offensive odors, missing personal items, and medication administration were not substantiated. However, two deficiencies unrelated to the complaint were identified involving medication documentation and resident ADL evaluations.
Complaint Details
Complaint #NV00046206 was investigated and could not be substantiated. Allegations included offensive odors, missing personal items, and improper medication administration.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure discontinued medications/completed medications for 1 of 5 residents were documented. | Severity: 2 |
| Facility failed to provide evidence that 2 of 4 residents were evaluated for their ability to perform Activities of Daily Living (ADLs). | Severity: 2 |
Report Facts
Census: 10
Sample size: 5
Residents evaluated for ADL: 2
Residents reviewed for medication documentation: 5
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 1
Feb 1, 2016
Visit Reason
This inspection was conducted as an annual State Licensure survey to assess compliance with regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of A. One deficiency was identified related to medication storage, where medications were not secured properly as required by regulation.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure medications were stored securely; medications for Resident #4 were found unsecured in a baggie on the kitchen table. | Severity: 2 |
Report Facts
Resident files reviewed: 8
Employee files reviewed: 3
Deficiency severity scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 acknowledged medications were not secure |
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 1
Feb 1, 2016
Visit Reason
This Statement of Deficiencies was generated as a result of an annual State Licensure survey conducted in the facility on 2/1/16 by the Division of Public and Behavioral Health.
Findings
The facility received a grade of A. A deficiency was identified related to medication storage where medications for Resident #4 were found unsecured on the kitchen table, violating regulations requiring medications to be stored in locked areas.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medication storage was not secure; medications for Resident #4 were found in a baggie on the kitchen table. | 2 |
Report Facts
Resident files reviewed: 8
Employee files reviewed: 3
Severity level: 2
Scope: 3
Inspection Report
Complaint Investigation
Capacity: 10
Deficiencies: 0
Oct 10, 2014
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding Quality of Care/Treatment at the facility.
Findings
The allegation regarding Quality of Care/Treatment was not substantiated through document review, interviews with resident, and observations.
Complaint Details
Complaint #NV00040447 regarding Quality of Care/Treatment was investigated and found not substantiated.
Inspection Report
Complaint Investigation
Capacity: 10
Deficiencies: 0
Jul 10, 2014
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding Administration/Personnel related to financial contracts and agreements.
Findings
The complaint contained one allegation which was investigated by reviewing personnel records, policies, and conducting interviews. The complaint could not be substantiated as the facility followed policies and admission agreements were properly signed.
Complaint Details
Complaint #NV00038818 contained one allegation related to Administration/Personnel-Financial contracts and agreements. The complaint was investigated and found to be unsubstantiated.
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 0
Mar 21, 2014
Visit Reason
This document reports on a State Licensure annual grading survey conducted at the facility from 2014-03-13 to 2014-03-21 by the Division of Public and Behavioral Health.
Findings
The facility received a grade of A with no regulatory deficiencies identified. No further action was necessary.
Report Facts
Resident files reviewed: 9
Employee files reviewed: 2
Inspection Report
Complaint Investigation
Census: 8
Capacity: 10
Deficiencies: 0
Jul 19, 2013
Visit Reason
This inspection was conducted as a complaint investigation following allegations regarding facility staffing, resident safety, administrator's license status, and facility license currency.
Findings
The complaint was found to be unsubstantiated after review of documents, interviews with staff and residents, and observations. The facility was clean, residents were in good condition, and all licenses were current. No deficiencies were noted.
Complaint Details
Complaint #NV00035833 was unsubstantiated. Allegations regarding facility staffing, resident safety, administrator's license not up to date, and facility license not current were not substantiated.
Report Facts
Facility licensed capacity: 10
Facility census: 8
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 4
Mar 21, 2013
Visit Reason
This document is a State Licensure survey conducted as an annual inspection of the Golden Valley Group Care facility to assess compliance with state regulations.
Findings
The facility received a grade of A but had several deficiencies including caring for a resident with mental illness without proper endorsement or training, failure to ensure tuberculosis testing compliance for an employee, poor maintenance and cleanliness of the premises, and lack of elder abuse prevention training for caregivers.
Severity Breakdown
Severity: 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility cared for a resident with mental illness without appropriate endorsement and training (Resident #7). | Severity: 2 |
| Failed to ensure 1 of 2 employees complied with tuberculosis testing requirements (Employee #2 missing annual TB skin test). | Severity: 2 |
| Facility failed to maintain clean and well-maintained premises; cleaning chemicals stored improperly and toilets dirty. | Severity: 2 |
| Failed to provide training in prevention, recognition, and response to elder abuse to 2 of 2 caregivers (Employees #1 and #2). | — |
Report Facts
Licensed beds: 10
Resident census: 9
Employee files reviewed: 2
Resident files reviewed: 9
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