Inspection Reports for Golden Villa Care Home
1505 Duneville St., Las Vegas, NV 89146, NV, 89146
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 9
Deficiencies: 2
Jun 23, 2025
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 06/23/25, involving three complaints, one of which was substantiated.
Findings
The facility failed to follow the Activities of Daily Living (ADL) assessment for two residents, failed to maintain home health records for one resident receiving hospice care, and acknowledged deficiencies in hair care and documentation. One complaint was substantiated with deficiencies identified.
Complaint Details
Three complaints were investigated: Complaint #NV00074336 was substantiated with deficiencies; Complaint NV00073306 was substantiated without deficient practice; Complaint #NV00073978 was unsubstantiated.
Severity Breakdown
E: 1
D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to follow the ADL assessment for Resident #5 and Resident #6, including inadequate hair care. | E |
| Failed to maintain home health records for Resident #1 receiving hospice care. | D |
Report Facts
Complaints investigated: 3
Sample size: 8
Inspection Report
Complaint Investigation
Census: 7
Deficiencies: 0
Oct 15, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 10/15/24, in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
Three complaints were investigated, all of which were unsubstantiated with no regulatory deficiencies identified. The investigation included observations, interviews, and record reviews, concluding no further action was necessary.
Complaint Details
Three complaints were investigated: Complaint #NV00072407 had previously been investigated and was unsubstantiated; Complaint #NV00072223 and Complaint #NV00072167 could not be substantiated and no regulatory deficiencies were identified.
Report Facts
Complaints investigated: 3
Sample size: 8
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 1
Sep 5, 2024
Visit Reason
The inspection was conducted as a combined annual and complaint State Licensure survey at the facility on 09/05/2024 in accordance with Nevada Administrative Code Chapter 449. The visit included investigation of one complaint which was found unsubstantiated.
Findings
The facility received a grade of A. One deficiency was identified related to inaccurate documentation on the Medication Administration Record (MAR) for one resident's medication. The medication technician failed to initial the MAR for doses administered, resulting in incomplete documentation.
Complaint Details
One complaint (Complaint #NV00072071) was investigated and found to be unsubstantiated after observation, interviews, and record review.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to have accurate documentation on MAR for Resident #8's medication (Hydro/APAP 5-325mg); medication technician forgot to initial MAR documenting administration as prescribed. | 2 |
Report Facts
Licensed beds: 10
Residents present: 9
Resident files reviewed: 10
Employee files reviewed: 5
Deficiency severity: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joanne Misuraca | Administrator | Named as facility administrator and responsible for plan of correction |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 0
Feb 7, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation at the facility on 02/07/2024, in accordance with Nevada Administrative Code (NAC), Chapter 449, Residential Facilities for Groups.
Findings
No regulatory deficiencies were identified during the complaint investigation. The complaint was unverified and no further action was needed.
Complaint Details
One complaint was investigated (Complaint #NV00070229) but it could not be verified. The investigation included observations, interviews with residents and staff, and record reviews.
Report Facts
Sample size: 5
Number of complaints investigated: 1
Inspection Report
Complaint Investigation
Census: 7
Capacity: 10
Deficiencies: 4
Nov 20, 2023
Visit Reason
The inspection was conducted as a complaint investigation triggered by complaint #NV00069787, verified during the visit, to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The investigation identified multiple deficiencies including failure to maintain an accurate staffing schedule, incomplete personnel files for an employee, failure to complete required background check renewals, and inadequate review and reassessment of a resident's medical condition after a wandering incident. The facility received a grade of A despite these findings.
Complaint Details
Complaint #NV00069787 was verified. The complaint involved a resident (Resident #5) who wandered off the facility, was missing for several hours, and was later returned by police. The facility lacked a policy on wandering and did not reassess the resident's condition after the incident.
Severity Breakdown
Level 1: 1
Level 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to maintain an accurate monthly staffing schedule including shift times and amendments for changes. | Level 1 |
| Failed to maintain a personnel file for one employee including required documentation such as hire date and training records. | Level 2 |
| Failed to ensure an employee completed a five-year background check renewal as required. | Level 2 |
| Failed to obtain a reassessment of a resident's medical condition after a wandering incident to ensure appropriateness for the facility. | Level 2 |
Report Facts
Facility licensed beds: 10
Resident census: 7
Sample size: 5
Complaint count: 1
Severity 1 deficiencies: 1
Severity 2 deficiencies: 3
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 0
Oct 3, 2023
Visit Reason
The inspection was conducted as a combined annual and complaint State Licensure survey initiated on 10/03/23 and completed on 10/19/23 to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the survey. Two complaints were investigated: one was verified without deficient practice and the other was unverified. The facility received a grade of A.
Complaint Details
Two complaints were investigated: Complaint #NV00069488 was verified without deficient practice, and Complaint #NV00069589 was unverified.
Report Facts
Resident files reviewed: 9
Employee files reviewed: 3
Complaints investigated: 2
Inspection Report
Complaint Investigation
Census: 8
Capacity: 10
Deficiencies: 0
Mar 7, 2023
Visit Reason
The inspection was conducted as a complaint investigation in response to three complaints received regarding the facility, in accordance with Nevada Administrative Code Chapter 449.
Findings
No regulatory deficiencies were identified during the investigation. All three complaints were unsubstantiated after observations, interviews, and record reviews were completed.
Complaint Details
Three complaints were investigated: Complaint #NV00067758, Complaint #NV00067689, and Complaint #NV00067694. All were unsubstantiated with no regulatory deficiencies identified.
Report Facts
Sample size: 5
Complaints investigated: 3
Inspection Report
Annual Inspection
Census: 7
Capacity: 10
Deficiencies: 0
Dec 28, 2022
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
No regulatory deficiencies were identified during the survey. The facility received a grade of A and no further action was necessary.
Report Facts
Resident files reviewed: 7
Employee files reviewed: 3
Inspection Report
Complaint Investigation
Census: 7
Capacity: 10
Deficiencies: 0
Sep 23, 2022
Visit Reason
The inspection was conducted as a complaint investigation survey triggered by Complaint #NV00067050 alleging that employees routinely yell and make demeaning comments towards residents.
Findings
The complaint allegation was unsubstantiated based on observations, interviews with caregivers and residents, and review of medical and staff records. No regulatory deficiencies were identified and the facility received a grade of A.
Complaint Details
Complaint #NV00067050 with one allegation was unsubstantiated. The allegation that employees routinely yell and make demeaning comments towards residents was not supported by observations, interviews, or record reviews.
Report Facts
Beds licensed: 10
Residents present: 7
Employee files reviewed: 3
Resident files reviewed: 7
Inspection Report
Complaint Investigation
Census: 10
Capacity: 10
Deficiencies: 3
Jul 14, 2016
Visit Reason
The inspection was conducted as a complaint investigation triggered by complaint #NV00046410 regarding missing controlled medications.
Findings
The investigation substantiated the complaint of missing controlled medications and identified deficiencies related to medication administration, medication receipt logs, and medication administration records for three residents. The administrator failed to ensure proper monitoring and supervision of controlled substance medications.
Complaint Details
Complaint #NV00046410 was substantiated. The allegation of missing controlled medications was substantiated.
Severity Breakdown
Level 1: 2
Level 2: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| The administrator failed to ensure controlled substance medications of 3 of 5 residents were monitored and medication techs were supervised. | Level 2 |
| The facility failed to maintain a complete log of medications received for residents #1, #2, and #3. | Level 1 |
| The facility failed to ensure the Medication Administration Record (MAR) and documentation for 'as needed' medications were complete and accurate. | Level 1 |
Report Facts
Residents present: 10
Licensed capacity: 10
Medication tablets missing: 62
Medication tablets missing: 27
Medication tablets missing: 49
Medication tablets administered: 114
Medication tablets administered: 89
Medication tablets remaining: 72
Medication tablets administered: 14
Medication tablets remaining: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator failed to ensure proper medication monitoring and supervised medication techs; acknowledged findings; responsible for corrective actions |
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 2
Feb 23, 2016
Visit Reason
The inspection was an annual State Licensure 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 was found deficient in securing oxygen tanks and maintaining accurate medication administration records for residents. Specific deficiencies included unsecured oxygen tanks in the garage and inaccuracies in the medication administration record for one resident.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure oxygen tanks were secured in the garage. | Severity: 2 |
| Medication administration record (MAR) did not accurately reflect instructions for resident medications. | Severity: 2 |
Report Facts
Census: 9
Total Capacity: 10
Oxygen tanks observed unsecured: 3
Residents reviewed: 9
Employee files reviewed: 4
Inspection Report
Annual Inspection
Census: 9
Capacity: 10
Deficiencies: 2
Feb 23, 2016
Visit Reason
This inspection was conducted as an annual State Licensure survey of the Golden Villa Care Home facility on 2/23/2016 by the Division of Public and Behavioral Health.
Findings
The facility received a grade of A. Two deficiencies were identified: unsecured oxygen tanks in the garage and inaccuracies in the medication administration record (MAR) for one resident.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The facility failed to ensure oxygen tanks were secured; three large oxygen tanks were observed unsecured in the garage. | Severity: 2 |
| The medication administration record (MAR) was inaccurate for one resident, with discrepancies between the MAR and the actual medication orders. | Severity: 2 |
Report Facts
Resident census: 9
Total licensed capacity: 10
Deficiency scope: 3
Deficiency scope: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 confirmed observations of unsecured oxygen tanks and acknowledged MAR inaccuracies; no full name provided. |
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 1
Mar 11, 2015
Visit Reason
The inspection was conducted as a result of an annual State Licensure survey combined with a complaint investigation from 3/11/15 through 3/13/15.
Findings
The facility received a grade of A. The complaint investigation found no substantiated allegations of employee to resident abuse or lack of administrator oversight. However, deficiencies were cited related to employee compliance with written policies, specifically failure to ensure compliance with the emergency protocol policy regarding incident reporting of resident falls.
Complaint Details
Complaint #NV00042203 contained two allegations: 1) Employee to resident abuse - sexual and physical, which was not substantiated; 2) Administration/Personnel - Lack of Administrator Oversight, which was also not substantiated.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure compliance with the emergency protocol policy; incident report for resident fall lacked complete date and time. | Severity: 2 |
Report Facts
Resident census: 8
Total licensed capacity: 10
Resident files reviewed: 9
Employee files reviewed: 5
Severity level: 2
Scope: 1
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 1
Mar 11, 2015
Visit Reason
This inspection was conducted as an annual State Licensure survey combined with a complaint investigation initiated on 3/11/15 regarding allegations of employee to resident abuse and lack of administrator oversight.
Findings
The complaint allegations of employee to resident abuse and lack of administrator oversight were not substantiated. However, deficiencies were identified related to employee compliance with emergency protocol policies, specifically failure to complete incident reports for resident falls. The facility received a grade of A.
Complaint Details
Complaint #NV00042203 contained two allegations: employee to resident abuse (sexual and physical) and lack of administrator oversight. Both allegations were investigated and could not be substantiated.
Severity Breakdown
Severity: 2 Scope: 1: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure compliance with the emergency protocol policy, including not completing incident reports for resident falls. | Severity: 2 Scope: 1 |
Report Facts
Resident files reviewed: 9
Employee files reviewed: 5
Facility licensed capacity: 10
Facility census: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #4 | Interviewed regarding allegations and fall policy; reported bruises resulted from resident hitting themselves and that incident reports were sometimes forgotten. | |
| Employee #5 | Interviewed regarding allegations and fall policy; explained resident's fall and bruising, and that 9-1-1 was not called. |
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 1
May 13, 2014
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 5/13/14 at the facility.
Findings
The facility received a grade of A. One deficiency was identified related to tuberculosis testing documentation for one resident, where the facility failed to ensure the resident met tuberculosis testing requirements.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 8 residents met tuberculosis testing requirements; lacked documented evidence of a two step TB test for Resident #1. | Severity: 2 |
Report Facts
Residents present: 8
Total licensed capacity: 10
Deficiency count: 1
Inspection Report
Annual Inspection
Census: 8
Capacity: 10
Deficiencies: 1
May 12, 2014
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with state regulations for the residential facility.
Findings
The facility received a grade of A but was found deficient for failing to ensure one resident had documented evidence of a two-step tuberculosis test as required by state regulations.
Severity Breakdown
2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 8 residents had documented evidence of a two-step tuberculosis test. | 2 |
Report Facts
Resident files reviewed: 8
Employee files reviewed: 4
Inspection Report
Re-Inspection
Census: 10
Capacity: 10
Deficiencies: 0
Nov 30, 2012
Visit Reason
This document is a required grading re-survey conducted as a State Licensure survey from 11/8/2012 to 11/30/2012 to assess compliance and facility conditions.
Findings
No regulatory deficiencies were identified during the re-survey. The facility received a re-survey grade of A.
Report Facts
Resident files reviewed: 4
Employee files reviewed: 0
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 9
Jul 19, 2012
Visit Reason
The inspection was an annual State Licensure survey conducted to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility received a grade of D with multiple deficiencies identified including incomplete resident records, personnel file issues, health and sanitation problems, medication administration errors, improper medication storage, unsecured oxygen tanks, and failure to keep resident files locked.
Severity Breakdown
Level 1: 1
Level 2: 8
Deficiencies (9)
| Description | Severity |
|---|---|
| Administrator failed to ensure 7 of 10 resident records were complete, missing Standard Physician's Assessment and Cognitive Assessment forms. | Level 1 |
| Facility failed to ensure 1 of 5 employees complied with tuberculosis testing requirements. | Level 2 |
| Facility failed to maintain cleanliness and proper maintenance; mold in shower basin, uncovered trash can, and exposed nails in bathroom threshold. | Level 2 |
| Facility failed to secure 2 of 5 oxygen tanks in a rack or to the wall. | Level 2 |
| Medication administration errors including incorrect dosages, missing documentation, and medications not given as prescribed for multiple residents. | Level 2 |
| Medication storage was not locked; medications not properly logged or stored. | Level 2 |
| Facility failed to keep medications belonging to all 10 residents in a locked location. | Level 2 |
| Resident files were not kept in a locked location; files were stored in an unlocked cabinet. | Level 2 |
| Facility failed to ensure 4 of 10 residents complied with tuberculosis testing requirements, missing two-step TB skin tests. | Level 2 |
Report Facts
Residents present: 10
Total licensed capacity: 10
Deficiency count: 9
Resident records incomplete: 7
Employees missing TB testing: 1
Oxygen tanks unsecured: 2
Residents with medication errors: 8
Residents with files unsecured: 10
Residents missing TB compliance: 4
Inspection Report
Annual Inspection
Census: 10
Capacity: 10
Deficiencies: 8
Jul 19, 2012
Visit Reason
This document is the result of an annual State Licensure survey conducted at Golden Villa Care Home on 7/19/2012 to assess compliance with state regulations for residential care facilities.
Findings
The facility received a grade of D with multiple deficiencies identified including incomplete resident records, failure to comply with tuberculosis testing requirements, medication administration errors, inadequate health and sanitation maintenance, unsecured oxygen tanks, improper medication storage, and unsecured resident files.
Severity Breakdown
Level 1: 1
Level 2: 7
Deficiencies (8)
| Description | Severity |
|---|---|
| Administrator failed to ensure 7 of 10 resident records were complete, missing Standard Physician's Assessment and Cognitive Assessment forms. | Level 1 |
| Facility failed to ensure 1 of 5 employees complied with tuberculosis testing requirements (missing 2012 annual signs and symptoms review). | Level 2 |
| Facility failed to maintain premises clean and well maintained, including mold in shower, uncovered overflowing garbage can, and hazardous wooden threshold with exposed nails. | Level 2 |
| Facility failed to ensure 2 of 5 oxygen tanks were secured in a rack or to the wall. | Level 2 |
| Facility failed to ensure 8 of 10 residents received medications as prescribed, including missing medications, incorrect dosages, and incomplete medication administration records. | Level 2 |
| Facility failed to ensure medications belonging to 10 of 10 residents were kept in a locked location (medication closet was not locked). | Level 2 |
| Facility failed to ensure 10 of 10 resident files were kept in a locked location (files were in an unlocked cabinet). | Level 2 |
| Facility failed to ensure 4 of 10 residents complied with tuberculosis testing requirements (missing two step TB skin tests). | Level 2 |
Report Facts
Resident records incomplete: 7
Employees non-compliant with TB testing: 1
Oxygen tanks unsecured: 2
Residents with medication errors: 8
Residents with missing TB skin tests: 4
Residents census: 10
Facility capacity: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Named in deficiency for missing 2012 annual tuberculosis signs and symptoms review |
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