Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 6
Capacity: 8
Deficiencies: 0
Jul 10, 2025
Visit Reason
This inspection was conducted as a result of an annual State Licensure survey for the facility.
Findings
No regulatory deficiencies were identified during the survey. The facility received a grade of A and no further action is required.
Inspection Report
Complaint Investigation
Census: 7
Capacity: 8
Deficiencies: 1
Mar 13, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #NV00071556 regarding allegations of incomplete staff files, a black stain resembling mold in the facility hall shower, and an employee working without a background check.
Findings
The investigation substantiated the allegation that facility staff files were incomplete and missing required caregiver training. The allegations regarding the mold-like stain and an employee working without a background check were not substantiated. The facility failed to ensure that all employees received the required Tier 2 training within 60 days of hire and annually thereafter.
Complaint Details
Complaint #NV00071556 was substantiated for Allegation #1 regarding incomplete staff files and missing caregiver training. Allegations #2 and #3 were not substantiated. The complaint investigation included observations, interviews, and document reviews. The Owner/Administrator confirmed personnel lacked appropriate Tier 2 training and was unaware of topic requirements.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff files were incomplete and missing caregiver training as required by NAC 449.196 and LCB File No. R043-22 Qualifications and training of caregivers. | Severity: 2 |
Report Facts
Licensed beds: 8
Residents present: 7
Employees reviewed: 4
Training hours required: 4
Annual training hours required: 8
Inspection Report
Annual Inspection
Census: 8
Capacity: 8
Deficiencies: 6
Sep 9, 2024
Visit Reason
This annual State Licensure survey was conducted to assess compliance with NAC 449 for Residential Facility for Groups, focusing on regulatory adherence and resident care standards.
Findings
The facility received a grade of B with multiple deficiencies identified including failure to meet background check requirements for one employee, incomplete person-centered service plans for all residents, medication administration review lapses, late tuberculosis testing for one resident, and lack of required infection control training for several employees.
Severity Breakdown
Severity: 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 4 employees met background check requirements; fingerprint submission was beyond the 10-day requirement. | Severity: 2 |
| Facility failed to develop person-centered service plans addressing all required focus areas and interventions for 8 of 8 residents. | Severity: 2 |
| Administrator failed to ensure medication profile reviews were initialed within 72 hours for 3 residents and failed to notify providers within 72 hours for 2 residents. | Severity: 2 |
| Facility failed to ensure 1 of 8 residents had timely tuberculosis testing; annual test was given two and one-half months late. | Severity: 2 |
| Facility lacked a designated secondary infection control person with required training, affecting all residents. | Severity: 2 |
| Two employees lacked documented evidence of required infection control training concerning control and prevention of infectious diseases. | Severity: 2 |
Report Facts
Residents reviewed: 8
Employee files reviewed: 4
Facility licensed beds: 8
Facility census: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Castillo | Administrator | Named in relation to findings and plan of correction |
Inspection Report
Renewal
Census: 4
Capacity: 8
Deficiencies: 10
Jul 19, 2023
Visit Reason
This inspection was a State Licensure regrading survey conducted as part of the facility's license renewal process.
Findings
The facility received a grade of A, but several regulatory deficiencies were identified including failures in medication security, maintenance of resident files, and administrator responsibilities. Medications were found unsecured, and documentation and maintenance issues were noted.
Severity Breakdown
D: 6
F: 2
E: 1
C: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Administrator failed to ensure that the records of the facility are complete and accurate. | D |
| Facility failed to maintain health and sanitation; premises were not well maintained. | D |
| Written policy on admissions not properly followed regarding eligibility for residency. | F |
| Medication administration policies not fully implemented including accuracy, reporting, and planning. | E |
| Medication administration plan not adequately developed or maintained. | D |
| Over-the-counter medications and supplements not administered according to physician's written instructions. | D |
| Medications were not properly secured; unlocked medications found in refrigerator and medication closet accessible to residents. | F |
| Maintenance and contents of separate resident files were not properly maintained and secured. | D |
| Care for persons with mental illnesses endorsement and training requirements not fully met. | D |
| Failure to display placard conspicuously within 24 hours after receipt. | C |
Report Facts
Licensed beds: 8
Resident census: 4
Severity 2 Scope 3: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Castillo Jr. | Administrator | Named as Administrator and signer of the report |
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 10
Jan 30, 2023
Visit Reason
The inspection was conducted as a result of a State Licensure annual grading survey combined with a complaint investigation regarding an allegation of inappropriate discharge of a resident.
Findings
The facility received a grade of D with multiple deficiencies identified including incomplete clinical records, failure to secure medications, failure to conduct timely medication reviews, failure to obtain required endorsements for residents with mental illness, failure to properly document resident discharges, and failure to display the current survey grade placard. One complaint was substantiated regarding inappropriate discharge.
Complaint Details
One complaint (#NV00063361) alleging inappropriate discharge of a resident was investigated and substantiated.
Severity Breakdown
Level 2: 9
Level 1: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Administrator failed to ensure clinical records were complete for 1 of 7 residents (Resident #7) missing admission packet, Resident Rights, Ultimate User Agreement, History and Physical, ADL Assessment, Physician Placement Determination, and two-step Tuberculosis test. | Level 2 |
| Facility failed to ensure items were not stored on the front porch, including walker, bedside commode, and trapeze bar. | Level 2 |
| Facility failed to ensure residents receiving skilled nursing services were not admitted or retained without proper waivers for 4 of 7 residents. | Level 2 |
| Facility failed to ensure medication profile reviews were conducted at least every six months for 2 of 7 residents. | Level 2 |
| Administrator failed to ensure physician notification of pharmacist recommendations was documented for 1 of 7 residents. | Level 2 |
| Facility failed to ensure medications were administered per physician's order for 1 of 7 residents (Resident #3) with Prednisone not administered or documented. | Level 2 |
| Facility failed to ensure medications were secured for 7 of 7 residents; medications were found unsecured in an unlocked medication box in a refrigerator. | Level 2 |
| Administrator failed to maintain a complete discharge document for 1 discharged resident (Resident #8) lacking date, time, discharge location, and summary of circumstances. | Level 2 |
| Facility failed to obtain endorsement for Mental Illness and admitted and retained a resident with a mental illness diagnosis (Resident #4). | Level 2 |
| Facility failed to conspicuously display the current letter grade placard; the placard from the last survey was outdated. | Level 1 |
Report Facts
Licensed beds: 8
Resident census: 7
Grade: D
Medication profile review delay: 21
Deposit amount: 4200
Temporary absence rate: 140
Resurvey fee: 600
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Castillo Jr. | Administrator | Named in relation to facility administration and plan of correction. |
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 2
Dec 13, 2021
Visit Reason
This inspection was conducted as a State Licensure annual grading survey of the facility on 12/13/2021 by the Division of Public and Behavioral Health in accordance with NAC 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. Deficiencies were identified related to incomplete tuberculosis (TB) screening for 2 of 5 employees and failure to administer medications as prescribed for 1 of 10 residents.
Severity Breakdown
Level 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The facility failed to ensure tuberculosis (TB) screening was completed in accordance with Nevada Administrative Code 441A for 2 of 5 employees, including improper timing of TB test readings. | Level 2 |
| The facility failed to administer medications as prescribed for 1 of 10 residents; acetaminophen and ibuprofen were given only three times daily instead of four as ordered by the physician. | Level 2 |
Report Facts
Employees reviewed: 5
Resident files reviewed: 7
Residents present: 7
Licensed capacity: 8
Residents with medication error: 1
Employees with TB screening deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Castillo Jr. | Administrator | Named as the Administrator who confirmed TB screening deficiencies and medication administration issues |
Inspection Report
Annual Inspection
Census: 6
Capacity: 8
Deficiencies: 0
Oct 19, 2020
Visit Reason
This inspection was conducted as a State Licensure COVID-19 Infection Control and Prevention Plan and annual grading survey of the facility.
Findings
The facility was found to have a comprehensive Infection Control and Prevention Plan with all required components documented and ready for implementation. No regulatory deficiencies were identified and the facility received a grade of A.
Report Facts
Resident files reviewed: 6
Employee files reviewed: 5
Inspection Report
Complaint Investigation
Census: 6
Deficiencies: 3
Feb 28, 2020
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 2020-01-30 and finalized on 2020-02-28 regarding a resident eloping from the facility.
Findings
The facility failed to provide protective supervision to prevent a resident from eloping, and failed to maintain a discharged resident's file for at least five years as required. The resident who eloped was transferred to a locked unit at a sister facility with family consent.
Complaint Details
Complaint #NV00060082 was substantiated with the allegation that a resident had eloped from the facility. The complaint was investigated with a severity level of 2 and scope of 1.
Severity Breakdown
Severity: 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide protective supervision to prevent a resident from eloping. | Severity: 2 |
| Failed to ensure caregivers could meet the needs of a resident by not preventing elopement. | Severity: 2 |
| Failed to maintain a discharged resident's file for at least five years after the resident permanently left the facility. | Severity: 2 |
Report Facts
Census: 6
Sample size: 5
Complaint count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Castillo Jr. | Administrator | Named in relation to the plan of correction and facility oversight |
Inspection Report
Complaint Investigation
Census: 8
Capacity: 8
Deficiencies: 0
Aug 6, 2019
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding alleged lack of supervision of a resident.
Findings
The complaint was investigated through observations, interviews, and record reviews, and the allegation of lack of supervision could not be substantiated. No regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Complaint #NV00058020 alleged lack of supervision of a resident; the allegation was not substantiated.
Report Facts
Sample size: 5
Inspection Report
Annual Inspection
Census: 6
Capacity: 8
Deficiencies: 2
Jul 9, 2019
Visit Reason
This inspection was conducted as a State Licensure annual grading survey of the facility to assess compliance with regulations for Residential Facility for Groups.
Findings
The facility received a grade of A. Two deficiencies were identified: one related to failure to ensure employee background checks were renewed every five years, and another related to a late medication profile review for a resident.
Severity Breakdown
Severity: 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 4 employees met background check renewal requirements, including fingerprints and clearance letters renewed at least every five years. | Severity: 2 |
| Failure to ensure a medication profile review was performed at least once every six months for 1 of 6 residents; the 2019 review was one month late. | Severity: 2 |
Report Facts
Resident files reviewed: 6
Employee files reviewed: 4
Facility licensed capacity: 8
Current census: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Castillo Jr. | Administrator | Named as Laboratory Director's or Provider/Supplier Representative who signed the report |
| Employee #1 | Caregiver and Assistant Administrator | Named in deficiency related to background check renewal |
Inspection Report
Annual Inspection
Census: 5
Capacity: 8
Deficiencies: 0
Jul 9, 2018
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility.
Findings
The facility received a grade of A with no deficiencies noted during the survey.
Report Facts
Resident files reviewed: 5
Employee files reviewed: 3
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 0
Jul 5, 2017
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility.
Findings
No deficiencies were noted during the survey. The facility received a grade of A.
Report Facts
Resident files reviewed: 7
Employee files reviewed: 3
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 3
Jul 11, 2016
Visit Reason
The inspection was conducted as an annual grading survey and re-licensure of the facility.
Findings
The facility received a survey grade of A but had deficiencies including failure to maintain the exterior premises clean and maintained, incomplete medication instructions for PRN medications for 3 residents, and failure to ensure an initial or annual physical examination for 1 resident.
Severity Breakdown
2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure the exterior was clean and maintained; building materials, unassembled shelving units, and trash were observed surrounding a shed. | 2 |
| Medication instructions for 3 of 7 residents were incomplete, lacking symptoms for which the medication was prescribed. | 2 |
| Facility failed to ensure 1 of 7 residents had an initial and/or annual physical examination. | 2 |
Report Facts
Residents reviewed: 7
Employee files reviewed: 4
Survey grade: A
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Castillo | Administrator | Acknowledged findings related to exterior maintenance and medication instruction deficiencies |
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 2
Jul 11, 2016
Visit Reason
This annual grading survey was conducted as a State Licensure survey by the Division of Public and Behavioral Health to assess compliance with regulatory standards for the facility.
Findings
The facility received a survey grade of A. Deficiencies were identified related to exterior cleanliness and maintenance, and incomplete medication instructions for PRN medications for three residents.
Severity Breakdown
2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure the exterior was clean and maintained, with building materials, unassembled shelving units, and trash observed surrounding a shed. | 2 |
| Medication instructions for PRN medications for 3 of 7 residents were incomplete, lacking symptoms for which the medication was prescribed. | 2 |
Report Facts
Residents reviewed: 7
Employee files reviewed: 4
Licensed capacity: 8
Current census: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Employee #4 acknowledged findings related to exterior maintenance and medication instruction deficiencies |
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 4
Jul 9, 2015
Visit Reason
This inspection was conducted as an annual survey of the facility to assess compliance with state licensure requirements for a residential facility for elderly or disabled persons.
Findings
The facility received a survey grade of A. Several deficiencies were identified related to personnel files, medication administration records, medication storage, and tuberculosis testing compliance.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure 1 out of 4 employees met tuberculosis and pre-employment physical examination requirements. | Severity: 2 |
| Failure to ensure the medication administration record (MAR) was accurate for 1 of 7 residents. | Severity: 2 |
| Failure to ensure medications were kept in a locked container as required. | Severity: 2 |
| Failure to ensure 1 of 7 residents complied with tuberculosis testing requirements. | Severity: 2 |
Report Facts
Residents present: 7
Total licensed capacity: 8
Employees reviewed: 4
Resident files reviewed: 7
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 4
Jul 9, 2015
Visit Reason
This annual grading survey was conducted as a State Licensure survey by the authority of NRS 449.0307 to assess compliance with regulations for the facility.
Findings
The facility received a survey grade of A. Deficiencies were identified related to personnel files lacking required tuberculosis documentation, inaccurate medication administration records for one resident, unlocked medication storage, and incomplete tuberculosis testing documentation for a resident.
Severity Breakdown
Severity: 2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 4 employees met tuberculosis and pre-employment physical examination requirements. | Severity: 2 |
| Medication administration record (MAR) was inaccurate for 1 of 7 residents due to documentation errors in medication administration. | Severity: 2 |
| Medications were not stored in a locked container; medication cabinet was found unlocked. | Severity: 2 |
| Facility failed to ensure 1 of 7 residents complied with tuberculosis testing requirements; missing documented evidence of 2nd Step TB test. | Severity: 2 |
Report Facts
Residents present: 7
Total licensed capacity: 8
Employees reviewed: 4
Resident files reviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Caregiver | Named in tuberculosis and pre-employment physical examination deficiency |
| Employee #3 | Acknowledged medication administration record and medication storage deficiencies | |
| Employee #4 | Acknowledged medication storage and tuberculosis testing deficiencies |
Inspection Report
Annual Inspection
Census: 5
Capacity: 8
Deficiencies: 6
Jul 24, 2014
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 7/24/14 to assess compliance with state regulations for a residential facility for elderly and disabled persons.
Findings
The facility was found to have multiple deficiencies including failure to ensure caregivers completed required medication management training, incomplete employee physical and tuberculosis documentation, failure to maintain a clean and maintained exterior environment, missing annual physical examinations for residents, incomplete medication administration records, and unsecured resident files.
Severity Breakdown
1: 1
2: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 4 caregivers completed required 8 hours of annual medication management refresher training. | 2 |
| Failed to ensure 1 of 4 employees met tuberculosis and pre-employment physical examination requirements. | 2 |
| Failed to maintain a clean and maintained exterior environment; observed mattresses, garbage, standing water, inoperable appliances, and miscellaneous items in backyard. | 2 |
| Failed to ensure 1 of 5 residents received an annual physical examination. | 2 |
| Failed to ensure medication administration records were accurate and complete for 2 of 5 residents receiving PRN medications. | 1 |
| Failed to ensure resident files were secure; files of discharged residents were left unlocked. | 2 |
Report Facts
Licensed capacity: 8
Census: 5
Caregivers reviewed: 4
Employee files reviewed: 4
Residents reviewed: 5
Inspection Report
Annual Inspection
Census: 5
Capacity: 8
Deficiencies: 6
Jul 24, 2014
Visit Reason
This inspection was conducted as an annual State Licensure survey of the facility 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 B with multiple deficiencies identified including failure to ensure caregivers completed required annual medication management training, incomplete employee health documentation, failure to maintain a clean and well-maintained exterior environment, missing annual physical examination for a resident, incomplete medication administration records for PRN medications, and unsecured resident files.
Severity Breakdown
E: 2
D: 2
B: 1
F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 4 caregivers completed the required 8 hours of annual medication management refresher training. | E |
| Failed to ensure 1 of 4 employees met tuberculosis and pre-employment physical examination requirements. | D |
| Failed to maintain a clean and maintained exterior environment with items such as mattresses, garbage, standing water, inoperable appliances, and a vehicle present in the backyard and driveway. | E |
| Failed to ensure 1 of 5 residents received an annual physical examination. | D |
| Failed to ensure medication records were accurate and complete for 2 of 5 residents receiving PRN medications, including missing dosage information and lack of documentation for administration. | B |
| Failed to ensure resident files were secure; discharged resident folders were found unsecured in a back office. | F |
Report Facts
Number of caregivers reviewed: 4
Number of caregivers non-compliant: 2
Number of employees reviewed: 4
Number of employees non-compliant: 1
Number of residents reviewed: 5
Number of residents non-compliant: 1
Number of residents with medication record issues: 2
Facility licensed capacity: 8
Facility census: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Named in findings for missing annual medication management training and missing pre-employment physical examination and TB documentation | |
| Employee #4 | Named in findings for missing annual medication management training |
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 1
Jun 7, 2013
Visit Reason
This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted from 6/5/13 through 6/7/13 at Golden Years Castle Home Care.
Findings
The facility received a grade of A. One deficiency was identified related to kitchen equipment cleanliness and sanitary conditions, specifically the crisper drawers in the refrigerator were not clean and free of old food debris.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The crisper drawers in the refrigerator were not clean and free of old food debris. | Severity: 2 |
Report Facts
Licensed capacity: 8
Census: 7
Severity level: 2
Scope: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| R. Carlucci | Administrator | Signed the Statement of Deficiencies as the Administrator |
Inspection Report
Annual Inspection
Census: 7
Capacity: 8
Deficiencies: 1
Jun 7, 2013
Visit Reason
This document is a result of an annual State Licensure survey conducted at the facility from 2013-06-05 through 2013-06-07 to assess compliance with state regulations.
Findings
The facility received a grade of A. One deficiency was identified related to kitchen sanitation: the crisper drawers in the refrigerator were not clean and free of old food debris.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility did not ensure the crisper drawers in the refrigerator were clean and free of old food debris. | Severity: 2 |
Report Facts
Resident files reviewed: 7
Employee files reviewed: 3
Facility grade: A
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